The care and treatment of adult mentally ill offenders in the community has, all too often, been a "missing link" in California's criminal justice and mental health systems. The state's prisons now hold far more mentally ill offenders than its state mental hospitals. Additionally, an increasing number of inmates with severe mental disorders are being released to the community to an inadequate patchwork of supervision, treatment services, and assistance. This approach has been costly to taxpayers and public safety, because many of these offenders soon commit new crimes and return to jail or prison. In this analysis, we discuss several initiatives in the Governor's budget plan aimed at keeping the mentally ill out of the criminal justice system. Finally, we suggest that the Legislature consider a more comprehensive approach for addressing these complex problems.
As many as one in five Californians may have a diagnosable mental illness, according to one statistical study, and as many as one in 15 may have what is termed a serious mental disorder such as schizophrenia, bipolar disorder, or major depression. Some have additional complicating problems such as substance abuse addiction or need financial support, housing, and other forms of assistance.
More than 500,000 Californians annually receive services in the state's publicly funded mental health system. The state Department of Mental Health (DMH) operates 4,600 licensed beds located in its four hospitals, Atascadero, Metropolitan, Napa, and Patton.
Jail and Prison Populations Increasing. In increasing numbers and at a growing public cost, adults who are seriously mentally ill are receiving their treatment in state prisons and county jails. The number of mentally ill offenders at state prisons and jails now far eclipse the number of offenders held in state mental hospitals.
According to the state Board of Corrections, more than 10,400 persons who are diagnosed as seriously mentally ill are booked annually into county jails across the state, usually for a short length of stay. At any given time in 1998, the board indicated that more than 2,500 persons being held in jail were mental ill--a 118 percent increase over the number held in 1996.
The numbers of seriously mentally ill offenders receiving treatment in state prison have escalated dramatically over the last decade or more. A 1988 study found that less than 800 inmates identified as having psychiatric problems were receiving any significant level of treatment on the grounds of facilities operated by the California Department of Corrections (CDC). The 2000-01 budget plan allocates $139 million for providing more than 21,000 inmates with one of several levels of treatment services. The number of CDC inmates receiving such treatment has grown primarily because of court rulings requiring that the state to do a better job of identifying mentally ill offenders and a better job of providing services to those it has identified as needing treatment.
Inadequate Services in Communities for Offenders. The vast majority of mentally ill offenders are being held and punished for crimes resulting in determinate sentences--meaning that sooner or later they will be released from prison or jail to the community. Relatively few of the offenders are receiving a commitment to a state mental hospital, as allowed by state law for offenders meeting certain statutory criteria, at the end of their prison terms. Many mentally ill offenders are being released from prison or jail to a patchwork of supervision, treatment services, and assistance. For many, the provision of clinically effective and cost-effective community mental health services has been the missing link in the state's criminal justice and mental health treatment systems.
Parole Outpatient Clinics (POCs). At any given time, about 12,000 of the offenders released from prison with a documented history of psychiatric problems are on state parole caseloads. The CDC operates a statewide system of POCs that currently provides assistance to about 9,000 of these parolees. It is unclear why all 12,000 parolees with past psychiatric problems are not part of the POC caseload. It is clear, however, that the POCs are plagued by a number of problems.
Many of the 9,000 offenders who are on the POC caseload do not have a diagnosed serious mental disorder, having been assigned to POCs because of statutory requirements or internal CDC rules unrelated to any clinically based criteria. For example, CDC refers all parolees required to register as sex offenders to POCs, even though CDC may have determined they pose a low risk of reoffending and do not have a serious mental disorder. Meanwhile, the funding and staffing for POCs has not kept up over time with caseload growth. The predictable result of having POC caseloads clogged with parolees who are not seriously mentally ill, and limited treatment resources for POCs, is that seriously mentally disordered parolees receive infrequent and inadequate mental health services from clinicians struggling to handle caseloads of 160 to 1 or more.
The special needs of these offenders are rarely addressed. Few parolees who need it receive specialized assistance for substance abuse problems, despite evidence that as many as 70 percent of mentally ill offenders have a "dual diagnosis," meaning they also have a substance abuse problem. Resources are also limited to help those parolees who are homeless, and efforts are rarely made in advance of their release to the community to help them obtain federal Social Security Income, Social Security Disability Insurance, or federal veterans' benefits for which they may be eligible due to their illness, prior military service, or prior work history.
Conditional Release Program (CONREP). Some offenders released from state mental hospitals are receiving intensive supervision and mental health treatment in the community under CONREP. In some areas of the state, these services are provided by private providers, but in a number of locations they are provided by counties under contract with the DMH. Evaluations suggest that CONREP, while a relatively expensive program, has been clinically effective and has reduced criminal behavior by program participants.
However, only about 700 patients at any given time are on CONREP caseloads, and the vast numbers of offenders being released from county jails do not receive the intense level of supervision and treatment that CONREP offers. According to mental health experts, with some notable exceptions, homeless and mentally ill offenders are "falling through the cracks" in county mental health systems. One county mental health director estimated that less than half of the persons needing treatment in that county were receiving it. In many cases, initial treatment assistance is provided but, due to inadequate aftercare, offenders cease taking prescribed medications and soon relapse into severe mental health problems and erratic behavior.
Moreover, the CONREP model of close state-county coordination is often lacking for offenders released from state prisons to parole. State parole authorities complain that county mental health providers are often reluctant to provide mental health treatment services for parolees. Some county officials contend that parolees should be primarily a state responsibility and voice concern about the disruptions to local programs that parolees sometimes cause. The result is a serious gap in the provision of mental health services for parolees, especially offenders potentially posing the greatest public safety threat to the community given their past prison commitments.
The High Cost for Recidivism of Mentally Ill Offenders. Law enforcement authorities indicate that mentally ill offenders take up a disproportionate share of criminal justice resources. They are typically arrested and taken to jails, released due to their relatively minor crimes, then repeatedly brought back into the criminal justice system after being arrested for new offenses. A February 1999 California Research Bureau report noted that, within one month, 14 offenders in Sonoma County committed 96 misdemeanors and nonviolent felonies before being diagnosed in jail as mentally ill.
The DMH has cited data suggesting that involvement with the criminal justice system is much lower when mentally ill individuals are participating in treatment programs. For example, a 1997 statistical survey of mental health clients receiving treatment found that 98 percent had not been arrested in the prior six months.
The pattern is similar for mentally ill offenders under state parole supervision, who often continue to get into trouble, in some cases even before their first visit to POC clinicians. About 600 offenders each year are returned to state custody because they failed to show up for treatment at a POC or because of erratic behavior that deemed them a danger to themselves or others. No current CDC data are available on the overall recidivism rate for mentally ill parolees, but an informal 1991 survey conducted by CDC reportedly found that 94 percent of offenders receiving treatment in prison, then paroled to the POC program of community aftercare, had returned to prison within two years.
Not all of the crimes committed are nonviolent felonies and misdemeanors. The CDC data indicate that about 43 percent of the mentally ill offenders in its Enhanced Outpatient Program (EOP) are incarcerated for a violent crime. The most frequent offenses, in order, were robbery, assault with a deadly weapon, assault and battery, second-degree murder, and first-degree murder. Mentally ill offenders are more likely to be in prison for a violent offense than the inmate population as a whole.
In addition to the costs inflicted upon crime victims by this violence, the costs of housing 21,000 offenders with mental health problems in state prisons and 2,500 offenders in county jails probably exceeds $500 million annually. That sum does not include the additional and growing costs of their treatment while incarcerated or the significant costs to local law enforcement agencies and the courts to deal with mentally ill offenders caught in a revolving door of the criminal justice system.
The 2000-01 spending plan provides almost $28 million in additional funding and related staffing, as summarized below, for new and expanded state and county programs to keep adult mentally ill offenders out of the criminal justice system, as shown in Figure 1. We discuss the proposals in more detail below along with our recommendations for legislative action during the budget hearing process.
|Governor's Proposed Augmentations for Keeping Mentally Ill Offenders Out of Prison|
|(Dollars in Millions)|
|Department of Corrections|
|Improved mental health services for parolees released from state prisons||$6.0||
|Closer parole agent supervision of mentally ill parolees||1.9||23.7|
|Department of Mental Health|
|Continue and expand demonstration projects for homeless mentally ill and mentally ill offenders||20.0a||4.7|
|a One-time appropriation.|
The Governor's $6 million proposal to enhance services for mentally ill parolees is a good investment of state resources that offers the promise of reduced reincarceration rates for these offenders. However, we recommend modifications to address several weaknesses in its approach, including the redirection of some resources from services for low-risk offenders to enhanced services for those who pose a greater risk to public safety, and the establishment of separate treatment programs for high-risk sex offenders. We further recommend approval of the $1.9 million augmentation to provide closer parole supervision for seriously mentally disordered parolees.
Several Components to Parole Programs. As we discuss in our analysis of the CDC budget later in this chapter, the Governor exercised authority provided him by statute to shift $6 million allocated in the 1999-00 Budget Act for unrelated inmate and parole programs to establish two new programs to improve services for about 8,700 mentally ill parolees. The 2000-01 spending plan proposes to continue the implementation of these two programs.
Part of the funding--about $2.6 million in the budget year--would be spent for a new Transitional Case Management Program to provide services for about 1,500 severely mentally ill offenders annually who at the time of their release were housed in so-called EOPs within state prisons. This program thus targets offenders who will continue to require relatively intensive treatment services and support upon their release to the community.
The CDC would use the same approach the state has employed successfully in helping to transition inmates who have the AIDS disease, or who have tested HIV-positive for the AIDS virus, back into the community. The CDC studies have indicated that providing offenders intensive, short-term assistance in making the transition back into the community, through contracting with outside providers, has reduced the return-to-custody rate of the targeted offenders. Parolees in the new mental health program would receive assistance for up to 90 days from a team including a psychologist, a psychiatric social worker, a benefits counselor, and a clerical staffer to assist with benefits applications paperwork.
The Governor's budget includes a proposed $1.9 million augmentation to hire additional parole agents. The staffing increase would allow parole agents supervising this group of mentally ill parolees to have lower parole supervision caseloads. This means the agents would have more frequent contact with the parolees and more time to assist them with intensive prerelease planning and post-release services.
An additional $3.4 million would be spent to expand staffing at the existing network of POCs to provide improved services for about 7,200 severely mentally ill offenders annually who at the time of release were receiving treatment while in prison under the Correctional Clinical Case Management System (CCCMS). In effect, this program targets offenders whose mental health conditions were stabilized while in prison but who will continue to need less intensive treatment services and support upon their release to the community. The CDC proposes that these services be provided within the structure of its existing POC system, with most of the additional staffing proposed in the budget plan housed at POCs. Clinician staffing would be at levels allowing caseloads of 100 parolees to 1 staffer instead of the more than 160 to 1 caseloads now common at POCs. These treatment services would be provided on an ongoing basis during their period of parole.
Both of the new programs provide for planning efforts before an offender is released from prison, including the submission of applications on behalf of the parolee for federal benefits programs that could help support the offender in the community. Both also provide for arranging for long-term assistance to parolees by county social workers before they leave the care of the transitional assistance program vendors or the POCs. These elements increase the likelihood that the two new programs will enable mentally ill parolees to stabilize in the community and avoid problems that could result in their return to state prison.
The CDC Plans Have Some Weaknesses. Our analysis of the two new treatment programs indicates that there are some weaknesses that could make them less effective than intended:
Analyst's Recommendation. We recommend approval of the $6 million in funding and staffing for the two new programs proposed by the Governor. In addition, we recommend the adoption of supplemental report language directing the CDC to target its services in order to free up resources to improve its programs for mentally ill parolees. The proposed language follows:
It is the intent of the Legislature that:
Except as otherwise required by statute, the California Department of Corrections (CDC) shall immediately cease the practice of referring to Parole Outpatient Clinics (POCs) sex offenders who do not have a diagnosed serious mental disorder, who do not exhibit signs of serious mental illness, and who are not deemed to pose a high risk to the public of committing violent sex crimes.
Contingent upon the enactment of legislation establishing relapse prevention programs for parolees who pose a high risk to the public of committing violent sex crimes, and the provision of the necessary additional funding for any such programs, high-risk sex offenders who have a diagnosed serious mental disorder shall be removed from POC caseloads and instead placed in such programs.
The funding saved by removing the parolees cited above from POC caseloads shall be redirected toward the following purposes:
(1) establishing integrated substance abuse treatment services for mentally ill parolees with a dual diagnosis; (2) establishing a pilot program based upon the Wisconsin Community Support Program model for money management, dispensing of medications, housing referrals, and other assistance to mentally ill parolees completing the Transitional Case Management Program whose mental condition has been stabilized and do not need further intensive treatment at that time; and
(3) improving clinician-patient ratios for the remaining treatment caseload. The CDC shall provide a preliminary report to the Legislature by December 1, 2001, regarding its implementation of the funding shift and the effectiveness to date of the pilot program.
The CDC shall report to the Legislature by December 1, 2000, regarding a methodology for automatically adjusting the funding and staffing for mental health programs for parolees in keeping with future changes in the population of mentally ill parolees requiring such services.
We further recommend approval of the $1.9 million augmentation to provide closer parole supervision for seriously mentally disordered parolees.
We withhold recommendation on the $20 million proposed for the continuation and expansion of pilot programs to assist the homeless mentally ill, pending review of the statutorily required report (due May 1, 2000) on the effectiveness of the three existing projects. We further recommend that, if the Legislature does approve funding to expand the pilot projects to other counties, at least one of them be targeted primarily at providing assistance to parolees.
Legislation Initiated Projects. The DMH's current-year budget includes a one-time appropriation of $10 million from the General Fund for local assistance grants for demonstration projects targeting severely mentally ill adults who are homeless, recently released from jail or prison, or at risk of being homeless or incarcerated in the absence of mental health treatment. These grants are authorized by Chapter 617, Statutes of 1999 (AB 34, Steinberg).
The department formed an advisory committee to develop criteria for the award of grants and specific performance measures for evaluation purposes and, in November 1999, awarded $9.5 million for one-year demonstration projects in Los Angeles, Sacramento, and Stanislaus Counties. The remaining $500,000 is being used to administer and evaluate the projects. The department is to submit a report to the Legislature by May 1, 2000, on the effectiveness of the projects in reducing homelessness, substance abuse, and involvement by the participants with local law enforcement.
The 2000-01 budget proposes $20 million from the General Fund for the continuation of the three projects and expansion of the demonstration projects in three to six additional counties. Because the evaluation report due to the Legislature by May 1, 2000 should contain information helpful to the Legislature in evaluating this proposal, we withhold recommendation on this request.
Parolees Should Be High Priority. As noted in our analysis above, we are aware that county mental health departments are often reluctant to provide services to seriously mentally ill parolees. While Chapter 617 specifically includes parolees within its authorized target populations, only one of the pilot counties--Los Angeles--includes parolees as a target group.
Since parolees, as a group, tend to have a high risk of repeated incarceration, it is particularly important to overcome barriers to serving this population and develop effective strategies for their treatment and stabilization in the communities from which they come. Approval of another round of pilot projects would provide an opportunity to examine whether counties could effectively provide services to state parolees.
Related Pilot Projects. In addition to the Chapter 617 pilot projects administered by DMH, the Board of Corrections is administering a separate set of 15 grants amounting to more than $50 million under the Mentally Ill Offender Crime Reduction Grant Program authorized by Chapter 501, Statutes of 1998 (SB 1485, Rosenthal).
The stated purpose of the Board of Corrections grants is to support locally developed strategies for curbing recidivism among mentally ill offenders--an effort that clearly overlaps with the goal of the DMH grant program of reducing involvement of homeless mentally ill persons with the criminal justice system. Notably, all three counties that were awarded DMH grants--Los Angeles, Sacramento, and Stanislaus Counties--also have received grants from the board.
Given the overlapping target populations of the DMH and the board, we believe it is important that these two grant programs be carefully coordinated. The involved state agencies should ensure, for example, that counties receiving both types of grants can measure their effectiveness separately. The two state agencies should also establish common outcome measures that would allow comparisons between the projects operating in separate jurisdictions.
Analyst's Recommendations. We withhold recommendation on the proposed $20 million augmentation to continue and to expand the DMH pilot projects to assist the homeless mentally ill until the Legislature has had an opportunity to review an evaluation of the existing pilots which is due May 1, 2000.
Should the Legislature approve the funding for this expansion subsequent to receipt of the evaluation report, we recommend the adoption of budget bill language requiring DMH to award at least one of the new pilots for a program targeted primarily to parolees. This approach would permit a comparison of the effectiveness of providing treatment and services for parolees within the entirely state-run program discussed earlier in this analysis versus through contracting with counties for these purposes.
If this recommendation is adopted, we suggest the following language be included in Item 4440-001-0001:
Provision X. In awarding grants to expand the mentally ill homeless pilot projects, at least one grant shall be targeted to primarily serve offenders under state parole supervision.
Given the apparent barriers to county mental health services faced by severely mentally ill parolees, we further recommend that the DMH report to the Legislature regarding the extent of this problem. Accordingly, we recommend the adoption of the following supplemental report language:
It is the intent of the Legislature that the Department of Mental Health conduct a survey of an appropriate sample of county mental health providers and report to the Joint Legislative Budget Committee and the fiscal committees of both houses of the Legislature by December 1, 2000, regarding: (1) the degree to which parolees who are referred for treatment to county mental health providers fail to receive such assistance, and (2) the department's recommendations, if any, to improve access of persons under state parole supervision, particularly those parolees who are seriously mentally disordered, to county mental health services.
We further recommend that DMH and the Board of Corrections jointly report at budget hearings on the extent to which the Chapter 617 homeless mentally ill programs and the Chapter 501 Mentally Ill Offender Crime Reduction grants are being coordinated to ensure that counties receiving both types of grants can measure their effectiveness separately and that common outcome measures are being established to allow comparisons between the projects operating in separate jurisdictions.
We recommend that the Legislature consider a more comprehensive approach for addressing the complex problems involving mentally ill offenders and the criminal justice system. We discuss several key issues the Legislature may wish to consider.
A Broader Approach Needed. The Legislature and the administration have begun taking some significant steps toward implementation of strategies to divert more mentally ill offenders from the criminal courts, jails, and prisons and into appropriate treatment programs. While we agree that the development of these additional programs and services is warranted, we recommend that the appropriate budget and policy committees take a more comprehensive approach in thinking about how to address these complex problems.
We believe several key issues warrant further study and careful legislative consideration.
Treatment or Punishment? One of the first questions that must be addressed is whether the criminal justice system should focus more on punishment or more on providing treatment to mentally ill offenders.
The criminal courts can resolve cases involving proven wrongdoing by mentally ill offenders with guilty verdicts that send them to prison, and not guilty by reason of insanity verdicts or incompetent-to-stand-trial rulings that send them instead to mental hospitals. Local courts and prosecutors vary significantly in their use and acceptance of these options. The Legislature might wish to consider the establishment of a guilty-but-seriously-mentally-disordered verdict that separates the issues of the criminality and the mental competence of a defendant.
How these issues are resolved has important fiscal implications. For example, it could determine whether the state will need to invest more or less money in the future for expanding state mental hospitals, state prisons, or both.
State or Local Responsibility? The budget proposals discussed above simultaneously set in motion experimental programs at both the state and local level aimed at stemming criminal behavior by mentally ill offenders. As new programs are evaluated for their effectiveness, the Legislature should also consider whether the operation of the programs proven to be most effective should ultimately be a state or a local responsibility.
For example, the Legislature may wish to consider whether, in the long run, the state should create and operate a separate system of mental health treatment and aftercare for its parolees, or whether such operations should instead be consolidated with county mental health systems, the state's front-line providers of mental health care. Another option would be to modify parolee programs to operate along the lines of CONREP for offenders released from state mental hospitals. The CONREP is run by the state primarily through contracts with individual counties.
Targeting Public Resources. As it develops its strategy for addressing these issues, the Legislature may also wish to consider its priorities for intervention.
Research shows that programs such as substance abuse treatment aimed at curbing the criminal behavior of offenders are usually most cost-effective when they are targeted at an offender population that poses the highest risk of reoffending. However, it may also make strategic sense for the state to target less risky offenders who could be easily stabilized in the community with federally funded benefits and with relatively low-cost programs, such as community support programs. The results of the new state and local programs for assisting mentally ill offenders should be examined not just to see what programs work best, but for whom they work best.
The Legislature may also wish to reexamine the way it has targeted its existing programs for mentally ill offenders. One example is the Mentally Disordered Offender (MDO) program, which permits the state to transfer inmates nearing release on parole to state mental hospitals. State law permits an MDO commitment to occur if a seriously mentally ill offender's most recent crime involved force, violence, or injury to another. However, the MDO law does not allow such a state hospitalization to occur where the most recent criminal conviction was nonviolent but the offender has a prior record of violence. The Legislature may wish to reconsider what clinical and public safety criteria should apply to this and other state programs for mentally ill offenders.
Mandatory Treatment. As it examines the idea of expanding treatment services for mentally ill persons who are at risk of becoming involved with the criminal justice system, the Legislature may also wish to consider the extent to which it wishes to compel such persons not only to participate in treatment but also to take prescribed medications that could stabilize their mental condition in the community.
For example, the Legislature may wish to examine an ongoing experimental program in San Bernardino County through which a special "mental health court"--similar to existing drug courts--is diverting nonviolent mentally ill offenders from jail or prison through court orders mandating that they (1) take prescribed medications, (2) submit to close supervision by probation officers, and (3) live in board and care homes providing an appropriate and stable environment. The Legislature may also want to review whether appropriate, parallel mechanisms are available for mentally ill parolees subject to revocations by actions of the CDC parole division and Board of Prison Terms for parole violations.
Summary. For the reasons discussed above, we recommend that the Legislature undertake a more comprehensive approach toward addressing what is now a missing link of community care for mentally ill offenders. Development and funding of appropriate programs to fill that gap are important. We believe these new programs will have a greater clinical effect and that state money will be spent more cost-effectively if the other key issues we have outlined here are also addressed in a comprehensive fashion.