by Sally A.M. Ho

When I was asked in December 2002 to serve as a consumer representative on the Jail Diversion Advisory Council, I was excited and honored. The Council was forming to create a program to divert individuals with mental health issues away from jail and into treatment, using funding from a federal SAMHSA grant awarded to Hawai’i State’s Adult Mental Health Division (AMHD). The grant specified a program for Hawai’i County (the Big Island), because it has the highest rates of unemployment, poverty, suicide, substance abuse, trauma, and child abuse in the state.

Clearly, the task was essential, but could I be of any real help?

Council members represented key stakeholders who had been selected with care from criminal justice, treatment, advocacy, mental health and state agencies, consumers and family members. Diverse though we were, we were united in our desire to implement a program that would work.

Our grant called for the design of a post-booking version of jail diversion. People who qualified for services had already been ‘booked’ into the criminal justice system on specific charges.

Cooperation among existing government agencies proved important from the beginning. For example, an initial screening by the Department of Public Safety would attempt to identify those who might also have mental health issues. We eased access to the Adult Mental Health database, so individuals already known to the system could be readily identified. Another agreement allowed for transfers from jail to a local hospital. Prosecuting and defense attorneys were urged to communicate with each other so as to present a united recommendation mandating diversion for an interested and eligible client.

But who was eligible? Criteria for enrollment, both psychiatric and legal, were scrutinized, rethought, and reworked. Having a diagnosis of a serious and persistent mental illness was one basic criterion. However, legal criteria had not been specified in the terms of the grant, so we needed to decide those. Our differing points of view led to passionate discussions. Public defenders wanted to include felons, because a person who had committed only a misdemeanor, for which the sentence might be several days in jail, would simply choose to “do the time,” rather than enroll in the lengthier jail diversion program. Prosecutors, however, were adamant that only those with non-violent misdemeanors be admissible. Many months later, we decided to expand our legal eligibility criteria, admitting certain individuals who had committed minor physical abuse (e.g., pushing a family member), especially if that incidence of violence were a passing symptom of untreated psychosis. Flexibility allowed our program to evolve.

Maintaining the safety of clients, law enforcement officers, and the general public was another important issue. At one point early on, I suggested that a consumer/survivor accompany the intake staff into the jail to talk with the potential client, so as to make a strong case for the life improvement that comes with recovery/treatment. I recall the public prosecutor looking at me aghast: “You mean, into the jail cell?” he asked incredulously. Others agreed that the safety issues raised by such integral consumer involvement were too great. Although it felt appropriate to me, the Council wasn’t ready for such a big step, so I let it go.

We discussed how completion of the program would be defined, and faced the tough realities of client non-compliance or even disappearance, once enrolled. Because jail diversion enrollment would include supervised case management for months longer than a misdemeanor jail sentence, we had to make the program attractive. We compromised on a six-month duration, long enough to allow for some real life changes; but we also decided that ‘graduates’ from the program should earn outright dismissal of their criminal charges. Consumers on the Council spoke about how peer mentoring could help motivate a client to do the hard work of recovery.

During those early monthly meetings, I frequently felt that the group was speaking a legal language unknown to me, and it required courage to speak up and ask questions. I hoped that others in the room were struggling, too. Sometimes after a meeting my head would be swimming, and a series of question marks would run down my agenda/notes pages. I kept telling myself that my neurons were growing back, evolving into a clear-thinking brain again.

Through the winter and spring of 2003, the Council worked closely with the federally funded TAPA Center (Technical Assistance Policy Analysis), which was created specifically to provide guidance to the newly forming programs, 17 of them across the country. We carefully documented every right and wrong turn in our program design. In addition to monthly consumer representative conference calls, the TAPA Center sponsored national conferences at which the jail diversion grantees were able to meet, share the particulars of one another’s programs, and learn about solutions and improvement possibilities.

By May 2003, the Hawai’i County Jail Diversion Program was up and running.

The following month, I attended the first TAPA conference in Bethesda, MD. The meetings with fellow consumer representatives were of particular value. Our major focus was how to make the consumer voice heard. How were we to insure that our experiences would lead to the creation of programs that would make a real difference?

We gained strength, confidence, and inspiration from one another. We learned, for example, that Victor from Iowa rode along in police cars; he kept reminding us to speak up, speak out, and insist. We shared stories of the power of stigma to block our voices; and we felt that familiar comfort in knowing we weren’t alone. At plenary sessions, Albert, from NYC, shared how his participation in the Howie the Harp program brought him back from facing a lifetime of imprisonment after a third felony conviction. Geneva courageously shared stories about her humiliating treatment, including transport to a mental facility while clothed only in a hospital gown.

I was astonished to learn that in Memphis and Miami, the Crisis Intervention Training (CIT) programs expose each officer to 40 hours of training in how to handle persons in mental health crisis. I must have audibly inhaled when I heard of a police officer who, after having been assaulted by an individual in the throes of a mental health ‘meltdown,’ did not press charges, so great were his compassion and understanding. “You can do it – Show me!” proclaimed our conference buttons.

I returned home to Kona reconvinced of the importance of the consumer viewpoint. Through the summer and fall of 2003, the Council continued its monthly meetings to work out the program’s kinks. For example, we saw the need to individualize the length of program enrollment; we pondered the gender gap in enrollees; we learned the importance of addressing trauma issues; we made police booking data available to our case managers; and we evaluated the challenges of ‘converting’ judges who weren’t yet familiar enough with the program to order it.

A missing piece in our jail diversion program was direct consumer input concerning proper police handling of a person in mental health crisis. There was a large gap between what I was hearing at the national level and what was actually happening at home. I’d heard a number of stories of inappropriate treatment of a consumer and in August 2004, an incident occurred that pushed me into action. A friend of mine was arrested, handcuffed, and taken away to spend a night in jail. She told me that the officers had pushed her to the ground, withheld her medications, and thrown her shoes at her in the cell.

She requested a misconduct hearing at which we both asked for more informed treatment of mental health consumers. However, the officers testified in closed session, so we couldn’t hear what they said. Based on their behaviors, I assumed that they had not understood that they had retraumatized my friend. She was never able to make a reality check of what she’d said and done. Without such feedback, she could neither clarify nor understand herself in ways that promote recovery. The officers were exonerated.

After my report of the incident, “officer training” became a regular agenda item at Council meetings, and everyone agreed there was a need, but nothing was done. Finally, I ‘got it’ – I was the one to take on the task, daunting though it was. If mistreatment in Hawai’i County was going to stop, I had to be part of trying to make that change happen. In February 2005, I volunteered to do it.

There was a hugely positive response by the Council. One of the program evaluators sent me a copy of the Miami-Dade County CIT program. I read more, interviewed Hawai’i consumers who’d been arrested, and did online research about incidents involving law enforcement officers and mental health consumers nationwide. I even talked to the police academy in Hilo – but nothing concrete happened. The grass roots approach still wasn’t working after six months. Finally, in the fall of 2005, Judge Ronald Ibarra, a leader in our group, looked over at me and asked, “Are you and your consumer panel ready to go?” Without hesitation, I replied, “Yes!” Within days, he had helped set up our first-ever-in-the-state consumer panel to train police recruits.

We were a hit that December at the Hilo Police Academy. Trainees’ feedback told us they benefited most from our personal testimony about mental illness. We had become full human beings to those recruits, who I knew would go out ‘on the street’ and do a better job because of their understanding. I had at last found an authentic and appropriate outlet for the consumer’s voice.

Our Jail Diversion Program continues to evolve. When our grant monies ran out after about two years and we shifted to State funding, salaries dropped, and we lost some staff. We remain a small program, with 35-40 people enrolled annually. Our screening process is very careful, but perhaps our eligibility criteria are still too narrow. In 2004, for example, of the 1,800 persons booked in Hilo (east side of the island), only 29 were eligible and 23 enrolled; in Kona (west side), 12 people enrolled. Three case managers (two in Hilo, one in Kona) work to meet the service needs of their clients, including housing, therapy, and medical care. For about a year, a certified peer specialist worked part-time in Hilo with clients, sometimes going to a doctor’s appointment or human services, and always counseling and modeling recovery, whether in the car, in court, or over a cup of coffee. We hope to reinstate a full-time peer specialist with adequate funding.

The Program is now state-wide, and that is a tremendous accomplishment. The Hawai’i County Jail Diversion Program Manual and our officers’ training manual are available. We hope to expand the scope of the consumer panel to include veteran police officers, and there are plans to film our presentation.

At the second TAPA Center conference in February 2004, Kathryn Power, Director of the Center for Mental Health Services, spoke of the need to make a jail diversion program recovery-based: It will succeed only if the individuals enrolled in it actually get better, meaning their lives change. Recovery is consumer- and family-driven; therefore we must ‘wrap’ the client in services. Evidence-Based Practices provide the foundation of change. Peer involvement is essential to the success of any program. In caring for each individual, we are taking care of our community. We are healing.