One County’s 20-Year Effort to Decriminalize Mental Illness
July 1, 2021
Many cities across the United States are reimagining the role of police in responding to mental health emergencies. Miami-Dade County has spent the last two decades revamping their policing — along with many other aspects of how their criminal justice system treats people in crisis. What lessons have they learned?
Listen to the full episode and read the transcript below, and scroll down for more information.
[Audio from police training]
Dan Gorenstein: What you are hearing is a recording Miami-Dade County uses to train police officers to respond to someone in a behavioral health crisis.
The goal is to help officers imagine how difficult it may be to follow orders if a person is hearing voices in their head.
Research from the Washington Post shows police have shot and killed 1,400 people with mental illness since 2015. Stats like that are helping fuel a push nationwide for a new approach to 9-1-1 calls involving people in a behavioral crisis.
San Francisco, LA, New York City and Greenville, North Carolina, have all launched pilot programs in recent months.
But some communities have spent years developing systems to keep these people safe and out of jail. Today, one county looks at the long game of decriminalizing mental illness.
From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein, and this is Tradeoffs.
By 2004, the Dade County Jail in Miami was housing ten times the number of people with mental illnesses than it had in the 1980s.
Across the state, Florida jails were holding more people with mental illness than the state’s psychiatric hospitals, according to a grand jury report.
That report, titled “A Recipe for Disaster,” condemned the state for effectively criminalizing mental illness.
Judge Steve Leifman: In Florida, if you got arrested for a misdemeanor and you were incompetent to stand trial, we would order a battery of evaluations. We were spending between one and two million dollars a year. And once we adjudicated them incompetent, we would release them back to the street without any treatment because that’s what the law said to do.
DG: Steve Leifman is a state judge in Miami-Dade County, Florida.
SL: There was no warm handoff to anybody. There was just nothing. And so this poor group would just recycle from homelessness to criminal justice to hospitalization with no one intervening to give them what they needed.
DG: In 2000, Judge Leifman invited leaders from across the county to talk about how to divert people with serious mental illness away from jail.
SL: We literally mapped out the intersection between the criminal justice system and the mental health system. And what we found is that we were embarrassingly dysfunctional, not the person who is sick; us, the system.
DG: So from that…came the Criminal Mental Health Project…I know, Judge, a huge part of it is something you call the Crisis Intervention Team, or CIT. How does the program actually work?
SL: It is a 40-hour training program that teaches law enforcement how to identify someone who’s in a mental health crisis, how to de-escalate the situation so it does not get escalated and deadly force or use of force gets used and then how and where to take the person if they’re in crisis, even if they’ve committed a low level offense.
And it has had a huge impact. And how do I know that? Because we keep data on every single city call the two largest departments make. That’s the city of Miami and Miami-Dade County.
DG: Based on data from the program, in the last decade, Miami and the Miami-Dade County police departments — the two largest — have received more than 105,000 mental health calls and made fewer than 200 arrests. And, Judge Leifman says, there were ZERO police shootings out of those departments in that time-period.
Judge, what’s something that you are doing in Miami-Dade County today that’s led to this sort of success that you were not doing when the program launched 15 years ago?
SL: We have over 7,600 officers trained at all 36 departments. So if a call goes out, what’s different now is the 911 call taker is going to start asking questions. Does this case involve someone with a serious mental illness? He or she will then hit a button to dispatch a law enforcement officer and could hit a button that will send out a CIT officer.
So they’ve been trained on how to identify that person, what distance they need to keep their tone, their words, their eye contact. They wear a pin that says CIT, which we found actually helps because believe it or not, a lot of the individuals with these illnesses recognize the pin, which immediately helps de-escalate the situation because they know they’re not going to get harassed.
DG: So, as far as diversion goes, how many people with mental illness are coming into Miami-Dade county jails now versus ten years ago?
SL: Our jail audit went from about 7,300 to 4,000. We actually closed three of our jails, including one large one. If you close the jail, then you see real savings. And for us, it was $12 million a year. It’s been seven years now. It’s $84 million in real savings and my county has been great about reinvesting this money. That’s the other part of it.
DG: Right, so a big part of that decrease is due to fewer people with mental illness getting locked up. And of course you want to make sure the county or the state keeps pouring that money into programs that support these people.
SL: 100 percent. The system is so under-resourced you don’t want ‘em to go, ‘Oh, we’re going to give people a tax cut now that we’ve saved that money.’ No, you have to reinvest it into the health care system to make sure that people are getting the services that they need so they don’t come back and get sick again and then, you know, bounce through these systems.
DG: Judge, researchers have found, in general, CIT programs tend to not reduce arrests.
Now, you’ve managed to keep arrests of mentally ill people very low, thanks in part to diverting like 66,000 people to social services.
But over the last decade…your arrest numbers are flat. Does that suggest that this program has hit a kind of wall?
SL: The problem has always been is there’s no capacity in the community for the most acutely ill…and we’ve been very successful with about 70 to 80 percent of the population. We have found that for 20 to 30 percent of the population, they keep recycling through the system. And it’s our belief that they’re just too sick and the level of services in the community just does not exist. And that’s why we’re building this first of its kind diversion facility to afford them what we believe they need and will work to break this cycle.
DG: Judge Leifman says that first-of-its-kind facility will have 208 beds and be called Miami Center for Mental Health and Recovery. It’s designed to work with these people who keep getting arrested, people with some of the most complex cases of mental illness and substance use.
These are also some of the most expensive cases in the criminal justice system. The judge says the Center, which is an example of the county reinvesting money back into health care, is on track to open early next year.
SL: We just treat this population — and not just in Miami, everywhere — so poorly that it becomes very difficult to get them what they need to recover. And then we blame them for not getting better. One of my mentors once said to me, you know, there’s no such thing as a treatment resistant person. We only have treatment resistant programs and we don’t set up the system for them to succeed and then they get blamed for not succeeding.
DG: Judge, thank you for taking the time to talk to us on Tradeoffs.
SL: Thank you, and I appreciate your interest.
DG: Other cities and counties are piloting programs that remove law enforcement from crisis calls. Critics point out police are more likely to escalate violence, especially against people of color.
And Congress tucked a provision into the American Rescue Plan this Spring that encourages states to pursue alternative behavioral health crisis approaches.
When we come back…Miami-Dade County learns that building effective on-the-ground support is as complicated as the cases cycling through its systems.
DG: Welcome back.
The criminal justice system in Miami-Dade County has spent much of the last two decades trying to shift law enforcement’s approach to mental health crisis calls.
This work has helped them realize that keeping people out of jail is only the first step, and that people need a range of services.
People like a man named Pedro…
Carol Caraballo: He was pretty much seconds from death when the police officers came across him.
DG: Carol Caraballo is with Thriving Mind South Florida, a state-funded nonprofit that, in part, works closely with police to help connect people involved in these crisis calls with social services.
Pedro — we’re not using his last name to protect his privacy — was homeless, struggling with anxiety, diagnosed with major depression, and had a drinking problem.
CC: He had drank four liters of vodka in a very short period of time.
DG: Back in the spring of 2017, an officer found him dirty and crumpled up on the sidewalk a few blocks from the beach, surrounded by empty bottles and food wrappers.
Police knew Pedro. In total, they’d arrested him 52 times. For things like…urinating in public, drinking in , panhandling and possession of alcohol.
CC: There was a lot of contact by police with him due to the nature of his substance use disorder, his mental health condition, all of it.
DG: For people keeping track at home, Pedro had been arrested by the Miami Beach Police Department…whose stats aren’t included in those from Judge Leifman earlier in the show.
Pedro ended up in the ICU that day. But Thriving Mind and the officer who found him stuck with him through his eight month recovery.
CC: Everything that he needed was being taken care of while we were also looking for housing for him…lots of work that went into Pedro, lots of love that went into Pedro…and I remember that day because it was the Fourth of July. So, you know, we kept saying this was Pedro’s Independence Day. He received the keys to his apartment.
DG: It would be nice if Pedro’s struggle ended there…but six months later, his landlord evicted him. And he spent the first five months of 2018 without a permanent place to live.
He’s back in an apartment today, thanks to on-going social service support, including help covering rent from Thriving Mind.
Pedro’s experiences illustrate the complications of the cases Thriving Mind and law enforcement are trying to triage.
In Carol’s world, Pedro is considered what’s known as a “frequent face” — people at the center of 911 crisis calls on a regular basis, either calling 911 themselves or, in Pedro’s case, other people calling 911 out of concern over their behavior.
Ideally, Carol says Thriving Mind could work with law enforcement and get every frequent face the support they need.
In reality: that extent of funding is lacking.
That’s why Carol and her team sought out a modest three-year $750,000 federal grant to build out a program to support ‘frequent faces,’ like Pedro.
Carol, what’s the like, name that you all are calling your frequent faces program?
CC: That’s the DACOTA grant, so um yeah, it stands for Data Access and Collaboration on Treatment Alternatives.
DG: Got it. I like, I thought, like the grant was coming from North Dakota or something.
CC: We literally sat in my office one day and my staff and I we did like a wordsmith. We threw, you know, literal words on the wall as to kind of what it is we were trying to do and we were trying to come up with some kind of acronym. And DACOTA was it. There was no magic behind it. It was just, OK, that’s what it is. And that’s what we’re calling it.
DG: You all are working with the Miami-Dade Police Department to monitor 911 calls coming in…watching for people who have made at least three calls over six months.
CC: Yes that’s how we are identifying those individuals so that those detectives…and the co-responder will be able to go out to those individuals and offer services in the hopes that we decrease the calls for service. They’re not calling police because they’re in crisis, because now they can call their case manager or their care coordinator, whomever that is, when they need help.
DG: Carol hopes she’ll be able to secure new grants to support this program, but regardless, she thinks it’s going to have a lasting impact.
That’s because they’re building a database to streamline communication between the police, health care providers and social services workers.
Right now, for example, when someone gets taken to the hospital in the wake of a crisis call, officers fill out a one-off paper form. The idea is to make these sorts of filings digital and help make sure people get the care they need.
CC: Law enforcement don’t share the same database. Hospitals don’t share the same database. So somebody can be taken to five different hospitals. And none of them knew that they were at a hospital a week ago and have received a change in medications; have received a change in their diagnosis. And that leads to that person not really getting better because they’re not really receiving that continuity of care.
DG: What data you have right now, Carol, and I realize it’s early. But do you have any information to suggest how well your frequent faces program is working?
CC: So, you know, and I always say this, you can’t measure prevention. You can’t measure what you stopped…I can’t give you a percentage or anything like that until we have that…everything again, we’re in the beginning stages of our, of our grant. But just from the thank yous that we’ve gotten or the amount of work that the detectives have done and the amount of phone calls that they get from the individuals that they are helping, that they call them instead of calling 911.
DG: Carol, thanks so much for taking the time to talk to us on Tradeoffs.
CC: Oh, thank you. I appreciate it. It’s been a fun time with you guys.
DG: The strategy behind the frequent faces approach and the 208-bed recovery center Judge Leifman talked about is to target people who utilize the system the most. A common tactic in health care.
And it’s tempting to think that providing support to people with the most difficult cases will significantly reduce the problem. But it will be a heavy lift for the county as few programs nationwide have been able to hit that goal.
That said, the Council of State Governments recently selected the Miami-Dade County Police Department as a national training site for all of its work in responding to crisis calls for people with serious mental illness.
It’s just one of 14 such sites in the country.
I’m Dan Gorenstein and this is Tradeoffs.
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Select Reporting and Research on Mental Illness and the Criminal Justice System:
How the American Rescue Plan Act will help cities replace police with trained crisis teams for mental health emergencies (Stuart M. Butler and Nehath Sheriff, Brookings, 6/22/2021)
Enlisting Mental Health Workers, Not Cops, In Mobile Crisis Response (Rob Waters, Health Affairs, 6/7/2021)
Behavioral Health Crisis Alternatives: Shifting from Police to Community Responses (Jackson Beck, Melissa Reuland and Leah Pope; Vera Institute; 11/2020)
The Definition of Insanity (PBS, 4/14/2020)
America’s Mental Health Crisis Hidden Behind Bars (Eric Westervelt, NPR, 2/25/2020)
Effectiveness of Police Crisis Intervention Training Programs (Michael S. Rogers, Dale E. McNiel and Renée L. Binder; Journal of the American Academy of Psychiatry and the Law; 9/2019)
All too often, California’s default mental institutions are now jails and prisons (Jocelyn Wiener, CalMatters, 2/4/2019)
The Tradeoffs theme song was composed by Ty Citerman, with additional music this episode by Blue Dot Sessions.
This episode was produced by Mary Franklin Harvin and mixed by Andrew Parrella.
Additional thanks to:
Jackson Beck, Tim Coffey, Officer Samuel Harris and OreGEN Digital, Habsi Kaba, John Newcomer, Carrie Perez and our stellar staff!