Jails as Psychiatric Facilities: Addressing Mental Illness in the Justice System with Judge Steve Leifman

Judge Steve Leifman, associate administrative judge of the Miami-Dade County Court Criminal Division and presiding
judge of its Criminal
Mental Health Project
, has worked at the intersection of mental health and the criminal justice system
in Miami-Date County for decades. In this podcast, he
outlines the challenges of addressing the high occurence of mental illness in Miami’s courts and prisons, the
fraught history of incarcerating those with mental health needs, and ways in which the justice system can change
its response to those living with mental illness.

Hello and welcome to the New Thinking podcast. This is Avni Majithia- Sejpal from the Center for Court Innovations.
Today, I’m joined by Judge Steve Leifman who is the Associate Administrative Judge at the Miami-Dade County
court in Florida and the presiding judge of Miami’s Criminal Mental Health Project. Welcome to our podcast,
Judge Leifman.

JUDGE STEVE LEIFMAN: Thank you very much.

wanted to start by talking about Miami. The statistics say that Miami has a very large population of people dealing
with mental illness, almost 10%, which is more than any other urban community in the U.S. You have said that the
county jail serves as the largest psychiatric facility in the state of Florida. Why do you say that?

Miami-Dade County has a very high prevalence of mental illness, as you’ve stated, with any urban area in the
United States. That really comes from a couple factors. One, we start with our own norm of mental illness such as
probably 3 to 5%. Then we pick-up a couple percent from our weather. A lot of times family members or people with
mental illnesses, they don’t want to be in Chicago or New York during the cold winters and so they end up coming
out to south Florida to escape the bad weather.

Then also during the Mariel Boatlift in the ’80s,
Castro literally emptied all the psychiatric facilities onto the boats, so the people that were actually fleeing
for political freedom from Cuba. Between the other factors and our own norm, it’s a very, very high prevalence.
Unfortunately, Florida also is very poor in its funding of mental health issues depending on the data anywhere from
48 to 50th per capita in mental health funding.

Only about 1% of the people in the county who
actually need services get access to the services that they need and so there’s a large unmet need. Many people,
unfortunately, will end up in the acute systems of care which sometimes means the Dade County jail.

When we say mental illness, what are we talking about?

LEIFMAN: We are not talking about sociopaths.
We are talking about people that have been diagnosed with an organic brain illness such as schizophrenia, bipolar
disorder, or major depression.

MAJITHIA-SEJPAL: Then I wanted to ask you about the 11th Judicial
Circuit Criminal Mental Health Project which you helped to establish in the year 2000. What’s the history behind
it, why was it created, and what does it do?

LEIFMAN: It actually started as a result of a case
that I had in 2000 where I had a defendant who turned out to be a Harvard educated psychiatrist who had an onset
of schizophrenia and had become homeless, and was recycling through the criminal justice system. It was really pretty
traumatic for all of us involved in the case. He had a full blown psychotic episode in my courtroom and it was an
eye-opener into how inadequate our community mental health system was as well as the court’s response for people
with mental illnesses.

If you had a serious mental illness and you were arrested on a low-level
misdemeanor charge, the court on the vast majority of cases, we were just releasing people back to the street telling
them to go see a psychiatrist for competency restoration. We are putting people who are very ill back out on the
street without any access to treatment and so I was able to bring together a meeting of all the traditional and non-traditional
stakeholders. We literally mapped out how our criminal justice system intersected with our community mental health
system and frankly it didn’t.

I think once we had mapped it out and realized how poor of
a response we had, we had an obligation and a responsibility to make some significant change. It was for everybody’s
sake to improve public safety, to spend our tax dollars more efficiently, and equally important to help people who
have illnesses have access to recovery.

We decided we needed a two-part approach. We needed to
stem the flow of people coming into the system that were coming in unnecessarily and we also needed to have an approach
where people that did penetrate the criminal justice system so that we could get them out if it was an appropriate
thing to do. We created a very expansive, what’s called, Crisis Intervention Team Police Program.

Over the years, we have actually trained over 4700 police officers including every single agency in Miami-Dade
County and it has made a startling difference. Between 2010 and 2015, we handled 48,669 mental health calls and only
made 109 arrests. It had a significant impact on the reduction of our jail. It actually helped us close one of our

We also realized that we also needed to set-up post arrest diversion program. We initially
set-up a misdemeanor diversion program whereby any individual with a serious mental illness who’s arrested for
a misdemeanor, if they meet criteria for involuntary hospitalization, generally within 3 days, we have them diverted
from our jail into one of our community crisis stabilization units.

We reset the case for a couple
weeks. During that period, A, we allow them to become more stable, but at the same time my team is working on lining
up their benefits, finding them housing, getting all these supports in place that people need for recovery and it’s
been phenomenally successful. Our recidivism rate dropped from over 70% to about 20% today. Our state attorney allowed
us to expand it to our non-violent felony cases.

We put into play about five years ago, a felony
diversion program and that program has a recidivism rate of only about 6% for those that complete the program which
is about 70%. The program alone has saved the county between 35 and 40 years of jail bed days. When we set-up the
third program, that diverts people from competency restoration hospitals and keeps them in a local facility. Instead
of just [inaudible] on the restoring competency, we actually focus on reintegrating them back into the community.

MAJITHIA-SEJPAL: Would you say that deincarceration is the way forward?

LEIFMAN: I think
jail should be the last resort for people with mental illnesses. It shouldn’t be the first entry point for people
with mental illness, which it has become. Our jails have become the de facto mental health facilities all around
the country and it’s really not fair. Most of these individuals have serious trauma issues and arrest often
re-traumatizes them.

Their lives are generally so fragile to begin with that even a day in jail
can help further the stigma against them, sever ties from employment, from housing, from family, and make it even
that much more difficult for them to reintegrate. Now there are some people that do commit crimes that are offensive
enough or dangerous enough that need to be in bars, so the program really is about identifying the people that don’t
need to be in jail and making sure that we get them out.

One of the things that we do now is we
use a risk assessment tool. We evaluate everybody that comes to our program and line-up the right services for each
individual. The key is to really understanding what the individual needs, doing our best to line-up the right services
for that particular individual, and then help reintegrate, reassociate them back into the community. If you do that
with all the supports and services that they need, this population can do very well.

In fact,
what most people don’t understand is that, number one is, people with mental illnesses are no more dangerous
than the general population and on medication they’re actually have a much lower propensity for any violent
crimes than people without mental illness. Sadly, they’re much more likely to be victims of violent crimes than

The other thing I don’t think people understand is that most people with mental
illnesses have much better recovery rates than actually people with diabetes and heart disease. The key to these
illnesses just like most illnesses is identifying them early and treating people early. I think the problem arises
when we ignore the problem and we see people who have been sick for many years, and have had many psychotic episodes.

What we’re trying to do in our community as well is working with our school system now to educate all
of our teachers so that they can do a better job identifying kids that are showing signs and symptoms of mental illness
so that we don’t wait for them to grow-up in our system to try to get them access to treatment at a much earlier
stage. We look at this as not as a court problem or a court solution, but really a community problem that requires
a community solution.

It really requires a community to come together and to make the structural
changes that are necessary that help access treatment for people.

courtroom, how do you balance responding to the treatment needs of defendants with the need for public safety?

LEIFMAN: If somebody commits a violent offense, now that is not someone that’s probably a good candidate
for our program. The people that we accept in our program are, A, generally charged with committing low-level non-violent
offenses nor do they have histories of committing violent offenses. There are very good risk assessment tools on
whether or not that they’re going to commit further crimes in the future and so we do use those.

may sound counterintuitive, but the people that are scoring moderate to high risk are the ones that we want in the
program because those are the ones you want to wrap your arms around, get them the right services, follow them more
closely and monitor them so that they’re not picking up new offenses. The people with low-risk don’t need
that kind of court supervision. They’re going to be absolutely fine back in the community and the chances of
them reoffending are very, very, very low.

I think as communities look to set-up these programs,
the key is to take the moderate and higher risk people who are going to get out of jail anyway, and make sure that
we’re appropriately monitoring them, and helping them change their ways, getting them housing, getting them
case management, getting them peer specialists so that we know that they are going to stay out of trouble and stop
committing offenses.

By doing that, you get better outcomes, you spend your dollars more wisely,
and you have a bigger, better impact on improving our public safety.

experience in dealing with mental illness in the justice system over the decades, have you seen a change in the justice
system response to mental illness?


LEIFMAN: That’s a great
question. Yes. There have been [inaudible] in how the courts are beginning to approach and deal with people with
mental illnesses. There’s a lot of initiatives that are going on and particularly since prevalence is just so
high in the criminal justice system.

We started several years ago, an organization called the
Judge’s Leadership Initiative and we created a parallel group called the Psychiatric Leadership Group. We now
go around the country training judges on how to identify people with mental illnesses, how to respond better in court,
and how the judge can be the community facilitator to bring people together to make the structural changes that are
necessary to have a better improved response.

There’s a national movement going on right
now. We’ve begun this initiative called Stepping Up. More than 250 counties in the United States representing
more than a third of the American population have passed these resolutions agreeing to step up to reduce the over
representation of people with mental illnesses.

The jails are now spending almost $70 billion
a year to partially deal with this problem and it’s enormously expensive. It cuts into infrastructure projects,
it affects our tax base, and it’s such an unnecessary waste of money because we don’t get good outcomes
from what we do today.

MAJITHIA-SEJPAL: I also wanted to talk to you about a very interesting
book called Crazy by the reporter, Pete Early, which was personal, but also investigative look at mental illness
in the justice system. He got access to the Miami-Dade County Jail for research. Were you involved in that decision?
Was it an easy decision to give him access or were there reservations about it?

I felt that it was incredibly important for someone to tell the story. While the focus was on the Miami-Dade County
Jail and some of the horrors that went on there, we could have been any jail in the United States. He did a brilliant
job documenting what goes on and I think it really was illuminating for a lot of people in the country, and helped
us take a critical look at our own system. We’ve been able to almost use his book as a blueprint on how to improve
our system.

The difference between today and when he wrote that book are night and day. We closed
down the horrible 9th floor that he highlights in his book. We opened up 2 jail floors that are just for people with
mental illnesses. Instead of sticking our heads in the dirt and resisting what was going wrong, we fixed it.

MAJITHIA-SEJPAL: Would you say that opening up the jail to scrutiny from a reporter has actually benefited

LEIFMAN: There is no doubt. It wasn’t just Pete. We also opened it up to our local
CBS affiliate. Inevitably the Justice Department came in and took a hard look at our jail, and all those things helped.
Since that day, we have special training for our corrections officers. There has been a significant reduction in
violence on those floors since we’ve made those changes and we’re getting people out of the system, and
not keeping them so long, so it’s less of a burden on the justice system and the jail system to begin with.

MAJITHIA-SEJPAL: I wanted to ask you about the state of mental illness in the justice system today, what
you think the challenges are, and what the future can perhaps look like.

LEIFMAN: I think we’re
turning a corner. We have a long way to go, but we have finally acknowledged and recognized that we have a problem.
It’s also interestingly pleasantly enough one of the only non-partisan issues that we have seen in my legislature
as well as in congress. Part of the problem that we have today is, aside from inadequate community resources to handle
some of these and the capacity to handle some of these problems, all of the laws regarding both treatment and financing
for mental health were really written 40 and 50 years ago.

These laws were all written at a time
when most people with serious mental illnesses were still in state hospital. It really requires a modernization of
the laws so that they better reflect the science, research, and medicine of psychiatry and mental health. As we begin
to do that, I think we’ll start to see this great change.

MAJITHIA-SEJPAL: On that note,
I think we will conclude this podcast. Thank you so much for your time, Judge Leifman.

Sure. Thank you for doing this.

MAJITHIA-SEJPAL: I’m Avni Majithia-Sejpal and you’ve
been listening to the New Thinking podcast. To hear more of our podcast, visit our website at www.courtinnovation.org.
Thanks so much for listening.