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People With Serious Mental Illness Need Housing, Not Jail

Daniel Ades and Virginia Barber Rioja

March 12, 2024

We should invest in cheaper, safer, more humane alternatives.

We should invest in cheaper, safer, more humane alternatives.

Jails are unpredictable and volatile. It’s hard to imagine a worse environment in New York City for someone suffering from serious mental illness than our jails — plagued by extreme violence and major operational obstacles to health care access, including challenges in consistently getting people to medical appointments. Yet, with about 1,200 people diagnosed with serious mental illness housed there, Rikers Island is the largest psychiatric provider in New York State. 

As a former public defender who has represented dozens of incarcerated clients with serious mental illness and the former co-chief of mental health for New York City Health + Hospitals Correctional Health Services, we have both seen firsthand the damage that incarceration can do to people with serious mental illness. 

We’ve also seen how news stories about random street violence have fueled a damaging myth about the relationship between mental illness and violence. The reality is that most people with serious mental illness are not violent and that most violence cannot be attributed to mental illness; violence correlates more with being a young male and using alcohol or substances than it does with mental illness alone. Decades of research have shown that people with mental illness usually engage in criminal behavior for the same reasons as those without mental illness.

So why is it that half of the roughly 6,000 people in our jails have a mental health diagnosis, and 20% of the jail population have a serious mental illness? And why do people receiving mental health treatment stay in jail almost twice as long as everyone else? 

Judges are understandably reluctant to release people who are charged with violent crimes, as a majority of individuals being held on Rikers currently are. Adding serious mental illness to that equation can make them even more cautious. And while most would agree that there should be a better option than jail for people who are sick, judges often feel like there is nowhere else for them to go. Often, there really isn’t. 

Even in cases where people suffering from serious mental illness are charged with violent crimes, there are better ways than jail to keep everyone safe. Take, for example, Alex, a client we both served years ago. Alex, who was around 19 at the time of his offense and had never been arrested before he got up in the middle of the night and hit his mother in the face and head with a heavy object, causing serious injuries, before his older brother stopped him. 

Most people with serious mental illness are not violent, and most violence cannot be attributed to mental illness.

According to his family, he had been acting strangely and having conversations with himself in his bedroom for a few years, but he had never seen a psychiatrist. Like many other people, Alex was not diagnosed with a mental illness until he ended up on Rikers and told doctors he had been hearing voices. Though his mother wanted him to get treatment, Alex was rejected from a mental health court because there was no place where he could live and get the kind of care that the judge was comfortable with. 

Mental health courts and other “problem-solving courts” that work with people with serious mental illness provide additional case management, supervision and support, and link incarcerated individuals with community providers that can meet their needs. And they work, even for people charged with violent crimes. Internal data show that Brooklyn Mental Health Court — where about half of the participants are accused of committing violent offenses, and half of its new participants are diverted to community treatment directly from jail every year — had 199 active participants in 2023. The Felony Alternative to Incarceration Court in Manhattan, though not specifically a mental health court, has diverted approximately 50 people suffering from a serious mental illness and charged with a felony — often a violent felony — directly from jail since 2022. 

Today, all of the city’s problem-solving courts are operating at or above capacity. Helpfully, Gov. Kathy Hochul’s preliminary budget proposes an increase in the resources available to mental health courts across the state. But as Alex’s case shows, these courts are only as good as the range and availability of services they can provide, and more often than not that comes down to stable housing that’s in terribly short supply. 

Alex got extremely lucky. His case was sent to a judge who was not a mental health court judge but who was willing to take a chance on him. With the consent of the district attorney, the judge agreed to release Alex to mandated outpatient care because we found a transitional psychiatric bed at Kingsborough Hospital. For a while, Alex took the subway to his program every day and stayed out of trouble. But after a few months, he began to show signs he was using K2 (synthetic marijuana), and the combination of his mental illness and substance use made the judge nervous. The judge put Alex back on Rikers for a few months until we could find a bed for him at the one residential facility in the city equipped to treat people with serious mental illness and substance use, the only option the judge would consider. Alex not only completed the program successfully; he decided to stay there after his court mandate until he could find a permanent place to live. 

If Alex were arrested today, he would have certainly ended up in prison after spending years on Rikers. The transitional psychiatric beds that he was originally placed in no longer exist. And without proof that he responded well to medication while he was receiving outpatient care, he would likely have been rejected by any residential program. The sad irony is that Alex had to start using substances in order to end up in the one place that could meet his mental health and housing needs. 

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For many judges, residential facilities provide a measure of comfort knowing that the person remains at a single location at all times, one where they can get treatment and staff can report back immediately if the person tries to flee or isn’t complying with the court mandate. But the residential facilities that exist, known as therapeutic communities, were designed to treat substance use, not serious mental illness, so clinicians are reluctant to recommend that type of setting for most people. As a result, there is not a single residential facility designed for people who have serious mental illness. 

To be clear, clinically speaking, most people who are currently held on Rikers and have a serious mental illness do not need to be in a residential facility if they have a safe and stable place to live and receive care. But some do, and judges who are also considering the public safety implications of diverting someone who is charged with a violent crime often want an added level of supervision.

If there were facilities designed specifically to offer housing and onsite care for people with serious mental illness, that could provide another option for judges. The key features of any such facility must be that it provide a safe place to sleep and appropriate mental health care, and cannot end up being just another place to warehouse people who could be safely managed in the community.

Some judges want even more, calling for the creation of a “semi-secure” setting that is a step down from jail but would have some mechanism for ensuring participants can’t just leave. The Greenburger Center for Social and Criminal Justice is on its way to establishing one such facility, called Hope House. Many advocates and defense attorneys believe that when you have a locked door, it amounts to jail by another name, and that judges will always default to a more restrictive setting even when it’s not necessary. To a certain extent, we agree. But if the only option is jail, it might be worth trying something else. 

In general, in order to be successful, the treatment model within any facility must be appropriate for people with mental illness, person-centered and trauma- and culturally informed, and the setting must be truly therapeutic. There must also be guardrails to ensure that only people who need to be in that kind of setting are sent there, because for most people with serious mental illness, a locked door isn’t really necessary, but a safe bed is. 

The city should also invest in transitional psychiatric beds that can provide temporary housing until more permanent housing can be identified.

In order to avoid legitimate civil liberties concerns, the best option would be a major expansion in the number of supportive housing beds dedicated to people who are currently incarcerated. These kinds of beds exist, but there aren’t enough of them, and more often than not they go to people who are not incarcerated. Even though everyone with a serious mental illness who is homeless has a supportive housing application submitted while they are in jail — a requirement of the settlement in a class-action lawsuit — almost none of them leave with a bed. 

The city should also invest in transitional psychiatric beds that can provide temporary housing until more permanent housing can be identified. 

In addition to significantly expanding its housing capacity, the city should give courts options for reducing the jail population for people who have a place to live by expanding access to intensive community supervision, including Assertive Community Treatment (ACT), Forensic Assessment Community Treatment (FACT) and Intensive Mobile Teams (IMT) for the jail population. These are outreach teams that provide a higher level of care than clinic-based outpatient treatment, offer rehabilitation and help reintegrate people into their community. Waitlists to these teams can be months long and the teams typically report feeling overworked and under-resourced. As with supportive housing, most teams are not reserved for the jail population. 

Inevitably, there will be some people with serious mental illness who cannot be diverted back to the community while they are waiting for their cases to be resolved. However, many can and should still get treatment in a secure therapeutic environment rather than a jail. In 2019, about 360 Outposted Therapeutic Housing beds were approved by the city to move people with serious health conditions who do not require inpatient admission to secure clinical units within city hospitals. A 104-bed facility was supposed to open at Bellevue Hospital in December 2022, but has not, and the future of the remaining beds at Woodhull and North Central Bronx hospitals is uncertain. 

Unfortunately, it is difficult to project how many people could be diverted from jail with more investment in these alternatives. Courts evaluate diversion eligibility on a case-by-case basis; there is no clear standard to approximate the percentage of those with serious mental illness who are appropriate for one solution or another. But judges and district attorneys alike are telling us clearly that they want to find more humane, safer options for people with mental health issues, too. Considering the absurd cost of incarcerating a person at Rikers, an investment in these resources would save the city money while providing people with the care they need, and in the process keep us all safer.