Statement of the Problem
     We have been advocating for some time that psychology become more involved in the public sector care and treatment of patients suffering from serious mental illness, such as schizophrenia, bipolar disorders and major depression.

     This large and very vulnerable population receives substandard care, as we all know. Deinstitutionalization, which was conceived in the humanitarianism and the idealism of the Community Mental Health Movement, has been a stark failure overall (although there have been some success stories here and there). With the clarity of 20/20 hindsight, we can see that there was insufficient investment in community-based care and psychological rehabilitation to make it work. There was also an over-reliance on psychoactive medications, which (again in retrospect) was terribly short-sighted given the lack of adequate care systems designed to prevent relapses due to non-compliance. In the end, the de-institutionalization movement succeeded in emptying the beds of the state mental hospitals and filling the streets and jails with chronic mental patients. Indeed, a recent article in the New York Times described the jail as the "new mental hospital".

     To give you some sense of the scope of the problem, consider these statistics. The Center of Crime, Communities, and Culture (1996) reports that 670,000 mentally ill people are admitted to U.S. jails each year, nearly eight times the number treated in public mental hospitals. The Department of Justice reports that nearly 12.5 percent of all prison inmates have serious psychiatric problems which require intermittent care, and that 7 percent have serious mental health problems (Federal Register: November 26, 1999). Other statistics indicate that 11% of the national female jail and prison population have serious mental disorders, with 70% of them demonstrating multiple problems including substance abuse and dependence, and that sixty percent (60%) are victims of abuse at some time in their lives prior to arrest.

     Mental Health Courts have arisen in response to this “trans-institutionalization” process, whereby the state hospitals were replaced by jails and prisons as the repositories for folks suffering from serious mental illness. Mental Health Courts are a new concept, arising out of the therapeutic jurisprudence movement, is similar to drug courts. The idea is to divert non-violent misdemeanants who are diagnosed with a serious mental illness into treatment programs.

     A recent federal resolution has called for the creation of a network of 100 Mental Health Courts across the nation based on the several successful model programs now in existence. The bill originated in the House, sponsored by Ted Strickland (D, OH), and was passed (but not funded) in the last Congressional session as S. 1865, sponsored by Senators DeWine and Domenici.

     This is a very important step. However, it doesn’t go far enough. Although Mental Health Courts can be effective in diverting mentally ill individuals who commit minor crimes from the criminal justice system, there is a dismal lack of resources to treat these people once they have been diverted. These folks have already been failed multiple times by state and local public mental health care systems, and as a result have only become much harder to treat. For example, consider a person diagnosed with schizophrenia in her early 20’s who is not adequately treated, goes on and off medication, exhibits unconventional behavior and refuses to follow rules, gets thrown out of housing, winds up living on the street, occasionally becomes so psychotic that she is sent to hospitals and crisis stabilization units and gets put back on medication for a short time, mostly self-medicates with alcohol and street drugs, prostitutes on occasion to gain money, gets victimized many times, and gets hits in head multiple times. Now we have a quintuply-diagnosed person: schizophrenia, substance abuse, post traumatic stress disorder, brain injury, and HIV/AIDS. How can anyone assume that the public sector care system that failed her at earlier and more treatable points in this trajectory can effectively treat her at this stage, following her diversion from jail?

     We urgently need specialized treatment programs to care for these fragile and complex persons who are now the subject of therapeutic jurisprudence and are being diverted from jails by mental health courts. The South Florida Medical Corrections Options (OPTIONS) program was one such program -- one that could develop models for other communities. OPTIONS focused on women, who are the most vulnerable and least well-served sector of this population. OPTIONS was funded by the Bureau of Justice Assistance. Unfortunately, funding was discontinued for FY 2001.

     At a time when the nation is about to embark on the creation of a large number of mental health courts, I thought it might be useful to report our experience with the first mental health court in the country and the OPTIONS program

The Development of the Mental Health Court
     We found that the situation in Broward County was, if anything, more severe than that in the rest of the country. The Broward Sheriff's Office (BSO) indicated over 2700 of the 4600 defendants housed in the four BSO facilities were seen for psychiatric consultation and 3500 were placed on psychotropic medication during the last six months of 1999. As in the rest of the nation, recidivism of mentally ill women defendants in Broward County is a serious problem with 40% having been arrested one or more times prior to the current arrest.

     In June 1997, after recommendations made by a committee of concerned professionals and citizens, including representatives from Nova Southeastern University (NSU), the Chief Judge of the Broward County Courthouse, issued an administrative order creating the first Mental Health Court in the United States. The mission was to provide access to treatment for the seriously mentally ill who were arrested for non-violent and non-drug related misdemeanor crimes. Like jails and prisons all over the United States, Ft. Lauderdale, Florida was detaining the mentally ill, sometimes because there was no other place for them.

     The Mental Health Court sees approximately 150 women per year, many of whom could use the services provided in the OPTIONS program. Their crimes were those often committed by the poor and homeless – trespassing, loitering, walking with an open bottle, public intoxication, getting into an argument, shoplifting and stealing food, etc. Many were from the minority communities with few resources. Some were recent immigrants from other countries, often having been exposed to wartime trauma. They often were abandoned by their families and had no friends or social support system. Those arrested who appeared mentally ill or had a history of mental illness were offered the opportunity to be transferred into the Mental Health Court where they could voluntarily agree to follow the judge’s orders into appropriate treatment. Within a short period of time it became clear that many of those arrested and diverted into treatment had major psychological needs. The public sector care institutions in our community, like in other communities around the country, were simply unable to properly treat the seriously mentally ill, particularly when they had multiple problems that included exposure to trauma and abuse, substance abuse, neurological complications, and medical conditions. The fragmented health and social systems had abandoned many of these clients, particularly women whose mental illnesses were often hidden under their depressions.

Development of the OPTIONS Program
     Recognizing the imperative need for a new kind of intervention program for women who were seriously mentally ill, the Center for Psychological Studies at NSU designed the South Florida Medical Corrections OPTIONS program. Our doctoral-level psychology students were already assisting the judge and attorneys in screening for mental illness, substance abuse, trauma responses and other diagnoses during the daily early morning appearances before the Magistrate through an assignment with the Broward Public Defenders Office and Courts. The OPTIONS program began in January 2000, funded by the Edward Byrne Memorial State and Local Law Enforcement Assistance Program, Bureau of Justice Assistance, U.S. Department of Justice. A demonstration project, it was designed to: 1. Divert mentally ill adult women from the criminal justice system; 2. Provide innovative mental health treatment designed especially for this community through careful evaluation; and arrange for medical treatment including psychopharmacological evaluation for this population; 3. Conduct research, outcome evaluation and cost benefit analysis, and 4. Disseminate program information to other communities.

     The program was a success with the community from the outset. Although designed with referrals from the Mental Health Court in mind, the OPTIONS program began to be deluged with requests from a variety of others in the court and mental health community. Probation officers referred clients needing similar treatment who had other contact with the criminal justice system. Parole officers referred clients being discharged from prison. Mental health workers referred clients being discharged from the psychiatric hospitals including the “Cottages”, a program designed for those within the Mental Health Court system needing immediate hospitalization. Judges inquired about referring women whose non-criminal cases were in front of them for dependency and neglect of children or even custody and access to children disputes in family court.

     NSU’s Center for Psychological Studies had the ability to design an innovative and integrated treatment program for a population that had been abandoned because of the difficulty in treating them. Homeless women often blend into the community, not being seen until there is a problem. While they may seek treatment at certain times, they may be unable to remain on stable medication routines without support. They may medicate themselves with alcohol and other drugs, often keeping away the pain from intrusive memories of abuse and trauma. They keep medical and mental health appointments when in crisis but are sporadic in their compliance when there are no critical problems. They live all over our community and rarely have transportation to get to the program if it is not provided for them. But, they liked the structure of our programs, were beginning to come regularly, and were empowering themselves by taking some responsibility for participating in their own health maintenance.

Results of the OPTIONS Program
     We worked with 64 women in our first year of operation even though our grant called for working with only 40 women. We began testing out new intervention techniques that provide comprehensive psychological, psychiatric and neuropsychological evaluation (comprehensive evaluation is critically important with a population this complex), integrated treatment including outpatient therapy, psychopharmacology, rehabilitation, and integration into the community. Our initial results are very positive. To effectively test all of our methods, we need a period of time of uninterrupted funding. The first five months the program was opened we had 38 clients ranging in age from 19 to 60 years old. Together they had 43 children although 14 women had none. Some who were still using alcohol and drugs were sent to a community detoxification center before they began the OPTIONS program. We are in the process of gathering outcome statistics on the total group. Very few of our women were rearrested after they began attending our program. Our staff helped the clients establish supportive relationships in the community. We work with the local chapter of the National Alliance for the Mentally Ill (NAMI), families of our clients, and the other agencies in our community. Staff attend court hearings with clients and help them meet the conditions they may have agreed to with the judge.

     The OPTIONS program is a critically important addition to dealing with this very difficult problem. The statistics cited above remind us that the mentally ill are in jails and prisons today and will not go away without treatment. Their recidivism rate is higher than in most other groups. Many are the silent women who do not cause problems although the rate of violence in the female population in the detention centers is reportedly increasing. In any case, there is great need for model programs that can both provide direct services and train new providers in a cost effective way. One of our students did part of her internship in the Seattle, Washington Mental Health Court. We anticipate working with Hawaii to collaborate with a university and court there to develop a similar program. NSU’s Center for Psychological Studies offers the advantages of a university-based program to design and develop such models. OPTIONS can serve as a model program that can be adapted by the 100 new mental health courts that were authorized by Congress this year.

     As always, we welcome your thoughts on this column. You can most easily contact us via email: (new address): levant@uakron.edu and DrLEWalker @aol.com.

     This column is based on a CE program that the authors presented at the Div 42 Midwinter meeting earlier this year in Miami Beach. In the program we included a role for independent practitioners in clinical and forensic psychology in the program.

Biographical Sketches

Ronald F. Levant, Ed.D., A.B.P.P., is in his second term as Recording Secretary of the American Psychological Association. He was the Chair of the APA Committee for the Advancement of Professional Practice (CAPP) from 1993-95, a member of the Board of Directors of Division 42 (1991-94), a member at large of the APA Board of Directors (1995-97), and APA Recording Secretary (1998-2000). He is Dean, Center for Psychological Studies, Nova Southeastern University, Fort Lauderdale, FL.

Lenore E. Walker, Ed.D., A.B.P.P. is currently President of APA Division 46, Media Psychology and President-Elect of APA Division 42, Society for the Independent Practice of Psychology. She was on the APA Council of Representatives elected from APA Division 35, Society for Women in Psychology from 1984-1989 and 1994-1998. She served on the APA Board of Directors from 1989-1990 when she chaired the APA Committee on Child Abuse Policy. She was Chair of the APA Presidential Task Force on Violence and the Family from 1994-1996 and continues to be an advisor to the ACT program in the Public Interest Directorate. She is currently Professor and Coordinator of the Forensic Psychology Concentration in the Center for Psychological Studies at Nova Southeastern University.

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