While attending a global mental health conference last fall, ACMI Vice President and Founding Director, Laurie Goldstein asked a psychiatrist from Trieste, Italy, “About how many persons with serious mental illness are in your jails?” The psychiatrist looked startled and replied, “We do not send our persons with mental illness to jail.” He went on to explain that if a person is experiencing a psychotic episode and the police are called, the police call the person’s psychiatrist, who treats the person until the person is stabilized. The Italian psychiatrist went on to explain that it is his “responsibility to prevent and also treat psychotic episodes, even if the person is jailed. Community providers remain engaged and accountable for their patients’ progress.
The Trieste Model, labeled by the World Health Organization (WHO) as one f the most progressive public psychiatry delivery systems, is now a collaborating center for mental health research with the WHO. The Trieste model manages to put the person at the center of the delivery system by 24-7 comprehensive treatment through a network of mental health centers that are “capable of dealing with the most severe conditions and of supporting clients in their daily life, with a view towards recovery and social inclusion.” https://zeroproject.org/practice/mental-health-department-whocc-italytrieste/ These 24-7 clinics not only replaced all psychiatric hospitals in Trieste, today fewer people go to jail because of the lack of continuity of care and cooperation between the law enforcement and mental health systems. The “sequential intercept model” enjoys deserved praise; Trieste shows that the first key intercept if effective clinical care.
Whether the Trieste Model is transferrable or sustainable elsewhere is debatable. But its existence and success generate food for thought about the relationship between the mental health and criminal justice systems in the United States and Arizona, specifically. Our communities experience high profile incidents in which an individual living with a serious mental illness commits a horrific crime, often resulting in death or serious injury. Often the individual is receiving services in the public behavioral health system, but in a psychotic state due to inadequate treatment either because of non-adherence or inadequate follow-up.
Reactions to these events are intense and sometimes polarized. Some believe the behavioral health industry “gets a pass” for poor management of potentially violent, seriously mentally ill “patients” who become “criminals.” Some contend that mental illness should never excuse criminal conduct. In terms of city, county and state fiscal accountability, there is no question that law enforcement and the corrections systems shoulder an increasing financial burden of caring for persons who commit a crime while they are enrolled in treatment in the behavioral health system.
Consider that the Maricopa County jail, one of the largest in the country, “books” (admits) approximately 100,000 individuals each year. Of these, approximately 8,200 (8.2%) of the total daily population are identified with SMI; another 16,000 (16%) have a significant mental health issue. Once incarcerated at the jail, the cost of care for these detainees shifts to Correctional Health Services (CHS) and Maricopa County https://www.maricopa.gov/5161/About-Correctional-Health-Services-CHS The Arizona Department of Corrections (ADC) has a similar patient population. In 2015, approximately 26.6% of all ADC inmates receive mental health services; of these, 4.7% are classified as SMI. Nicole Taylor and Karen Hellman, MENTAL “HEALTH DISORDERS AND THE CRIMINAL JUSTICE SYSTEM,” Arizona Dept. of Corrections (2015)
A defining difference in the “system” in Trieste, Italy, and Arizona (and the entire United States) is the presence of multiple payors and the involvement of private insurers in coverage decisions, rate setting, utilization management, and financing of health care services. Nonetheless, we can ask how behavioral health providers can be more responsible and accountable for the ongoing treatment of individuals in their care who become the justice system-involved and end up in jail or prison? Maybe dollars for care and services could “follow” the individual from clinic to jail or prison and back again? Maybe the county and state would bill the providers for treatment of incarcerated members? Maybe community providers would treat the person post-incarceration on a contract basis?
There are no easy answers but many fascinating questions for innovation in the delivery of services, especially person-centered services. The bureaucracies, payor systems, and pages of statutes and regulations are formidable obstacles. But there is an opportunity to examine ways to more equitably and effectively deploy resources of law enforcement, corrections, and the behavioral health system to accomplish two goals:
- Reduce the likelihood that individuals living with SMI will become “justice system involved” ––an obfuscation of saying “committed a crime” or “got arrested”
- More equitably distribute fiscal and clinical responsibility for treating individuals in jail or prison.
Laurie Goldstein’s question to the Italian psychiatrist was simple but provocative. “How many people with SMI are in your jail?” Maybe Arizona can find some answers in Trieste, Italy, which reduced these numbers through a truly person-centered community delivery system. Trieste, Italy does have a much smaller population that Maricopa County, so questions of scale and the intimacy of community is called into question. It may not be an fair comparison, but best practices may be applied in smaller clinical settings. In 2018, Trieste had a population of about 205,000 and it is the capital of the autonomous region Friuli-Venezia Giulia. The metropolitan population of Trieste is 410,000, with the city comprising about 240,000 inhabitants. Maricopa County is located in the south-central part of the U.S. state of Arizona. The U.S. Census Bureau estimated its population was 4,410,824 as of 2018, making it the state’s most populous county, and the fourth-most populous in the United States, containing more than half the population of Arizona. Wikipedia