Susan Hawk's Mental-Health Reforms Are Good, but They're Only a Start

Now that she has returned from the lengthy mental-health sabbatical that put a bold-faced exclamation point on her remarkably tumultuous first several months in office, Dallas County District Attorney Susan Hawk is projecting an air of super-competence. Not only is she fielding the public’s questions (and quite deftly, by all accounts) at a town-hall meeting, she’s also personally prosecuting a murder case. The display might make people forget — or at least forgive — the past tumult she has caused. Or maybe it won’t. What seems more certain is that the episode will help accelerate a significant and sorely needed shift in the way the Dallas County criminal justice system deals with mental illness.

At Monday’s town hall, Hawk announced the creation of “one of the nation’s most comprehensive, DA-driven diversion units that will focus solely on steering young adults and mentally ill offenders away from incarceration and direct them into life-changing resources and services.” She hasn’t released details yet; her first assistant, Messina Madson, says in an email that Hawk will release a more detailed statement on the diversion program next week. But Hawk did offer the broad outlines and what she plans to do and why.

“The mental health aspect of this program is important to me personally,” she said, pausing to fight back tears, “because I know first-hand how an untreated illness can impact your life. I was blessed with the opportunity to treat my illness, but I believe that getting well is an opportunity everyone should have. We just can’t turn our back on the core issue by housing those with mental illness in our prisons.”

Indeed, that's what has been happening for the past half century. In 1955, state-run mental institutions housed 558,239 patients suffering with severe mental illnesses. That number dropped precipitously in the ensuing decades with the advent of better psychiatric drugs and the recognition that warehousing the mentally ill in frequently appalling conditions was ineffective and inhumane. By 2010, "deinstitutionalization," as the mass closure of state mental hospitals came to be known, had left only 43,318 beds at public psychiatric hospitals.

The theory behind deinstitutionalization — that most people with mental illness would be better served by community-based treatment rather than being relegated to bedlam —  was solid, says Sherry Cusumano, president of the National Alliance on Mental Illness-Dallas. The problem, says Cusumano, is that, "We didn't shift the funding to the communities when we decided to close down the state hospitals."

The result has been that hundreds of thousands of the seriously mentally ill people have been dropped into a society that lacks the mental-health resources to adequately treat them. Many became homeless. Many more were caught up in the criminal justice system, which has replaced the state hospitals as the default place to warehouse the mentally ill. A widely cited study published by the Bureau of Justice Statistics in 2006 reported that more than 49.2 percent of inmates in state prisons and 60.5 percent of local jail inmates had symptoms of a mental health disorder. This probably overstates the problem, given that the study relied on self-reporting by inmates rather than formal evaluation and diagnosis by mental-health professionals. The study's count of people with a "recent history of mental health problems," (i.e., those who've been diagnosed by a mental health professional, had an overnight hospital stay, been prescribed medication or participated in therapy) puts the number at 24.3 percent for state prisoners and 20.6 percent for local jail inmates, which is closer to Dallas County's estimate of 25 percent, which is based on a count of participants in NorthSTAR, the region's publicly funded mental health system. On its website, the Dallas County Sheriff's office notes almost boastfully that the second largest mental health facility in Texas is housed in Lew Sterrett. (The largest, naturally, is in Houston, at the Harris County Jail.)

This is an awful way to deal with mental illness, not just because it's cruel to punish human beings for losing the brain-chemistry lottery. This is one of those instances in which humanitarian concerns dovetail nicely with fiscal responsibility. Mentally ill inmates get longer sentences than other inmates. They are more likely to break the rules while they're locked up. They are more likely to keep getting arrested. Treating mental illness in communities is far, far cheaper than letting the criminal justice system deal with it. In Dallas County, the cost to taxpayers of treating mental illness through the criminal justice system is estimated at more than $47 million.

Over the past dozen years, Dallas County judges and prosecutors have taken modest steps to correct the problem by creating diversion courts, which steer offenders into treatment and keep them out of jail. In addition to specialty courts for prostitution, substance abuse and veterans, Dallas County has two diversion courts focused specifically on mental illness: Judge Kristin Wade's Misdemeanor Mental Health Court and ATLAS (Achieving True Liberty and Success), which Hawk established a decade ago when she was a district judge. Wade's court follows the traditional model: Offenders who complete a six-month course of therapy and supervision have their charges dropped. ATLAS is unique in its focus on serious offenders, convicted felons who are on the brink of having their probation revoked. Those who complete the yearlong program are allowed to remain free.

Hawk talked up the ATLAS program at her town-hall meeting. "Most importantly we were able to help individuals get back on track, reducing recidivism among this group of offenders by 70 percent." A 2010 study by researchers at the University of North Texas found more modest improvements. The researchers compared the rearrest rate of ATLAS participants (42 graduates and 37 failures) with a group of offenders processed through traditional criminal courts, carefully matched for sex, age, race, offense and other characteristics. A year after completion of the program, 14 percent of ATLAS participants had been rearrested compared with 22.6 percent in traditional courts. After two years, the number had jumped to 28.2 percent and 42.9 percent, respectively. Those numbers include all ATLAS participants, even those who flunked out. Counting only graduates, the rearrest rate was 9.5 percent after one year and 18.2 percent after two years.

Dallas County criminal justice director Ron Stretcher, who has a standing mandate to reduce the jail population, says he is "very glad to see Judge Hawk focus on mental health services." He declined to provide specifics of his conversations with Hawk and her office concerning the new diversion policy other than to say that "we've all identified a bit of a gap here, [which] is jail diversion for felony cases." Wade's misdemeanor court, as the name implies, doesn't handle felonies. The ATLAS court does, but only after the participant has been found guilty of the felony and violated the terms of probation. Missing is a way for mentally ill defendants to escape a felony conviction — and likely prison time — in exchange for treatment.

Such a program is unlikely to have a dramatic impact, other than on the people who get to stay out of prison, but it's of a piece with a broader push, spearheaded by Stretcher, to rationalize the way the mentally ill interact with the criminal justice system. Over the summer, the county signed on to the national Stepping Up initiative, which aims to reduce the number of people with mental illness who wind up in jail. The county has also recently partnered with the Meadows Mental Health Policy Institute to determine how to better identify, assess and divert to treatment people with severe mental illness at each point of contact with the criminal justice system, from their interaction with police to post-conviction re-entry and probation. Stretcher describes this as "mapping out our system." It will, he says, "fundamentally change the ways we screen for and react to people in our system who are mentally ill."

The expansion of diversion programs and the efforts to revamp how the criminal justice system addresses mental illness is all good news to NAMI-Dallas' Cusumano, but it does little to fix the fundamental structural problem, which is that community-based mental health treatment options are few and chronically underfunded. "Texas has always been one of the lowest in terms of per capita [mental-health] funding, and we haven't chosen to expand Medicaid," she says. She wonders where Hawk is going to find the money to pay for her new diversion program. (Dallas County's existing diversion courts are funded through state and federal grants.) It's important that the funding come from somewhere. "What these families are going through, there is some help for them, but we really need to put more resources into helping people," she says. "You have to provide the resources that people need."