Kristen Ochoa, Oona Appel, Viet Nguyen, and Elizabeth Kim
The insane criminal has nowhere any home: no age or nation has provided a place for him. He is everywhere unwelcome and objectionable. The prisons thrust him out; the hospitals are unwilling to receive him. And yet humanity and justice, the sense of common danger, and a tender regard for a deeply degraded brother-man, all agree that something should be done for him—that some plan must be devised different from, and better than any that has yet been tried, by which he may be properly cared for, by which his malady may be healed, and his criminal propensity overcome.
Jarvis E. Criminal insane: Insane transgressors and insane convicts. Am J Psychiatry. 1857;13:195–231.
A home and treatment. And not giving up on anybody. That is what we do in Los Angeles to decriminalize mental illness. Our model stands on philosophies of harm reduction and housing first. It is an admittedly basic approach, but has worked to remove thousands of persons with serious mental disorders from our vast jail system. This approach asserts that many persons are in jail because of a systematic failure to adequately care for them. It is an approach that recreates systems to provide permanent care, without rationing, for the lifetime of the patient. To accomplish this, the new system must say “Yes” with the same veracity and availability of a jail bed, and with the same ease and routine of a jail booking. It has to be flexible and forgiving; it has to be a commitment to “care first, jail last.”
This is not to say that we are not realists. We understand that not everyone can avoid jail, for some have crimes too serious. We also understand that, if sufficient community services existed, more than half of the jail mental health population could be released. On any given day, Los Angeles jails over 16,000 people. More than 5,000 of those reside in the mental health section of the jail. Providing an alternative place for those with serious mental disorders to live and thrive is a tremendous undertaking. Los Angeles has only begun to build a continuum of care to accommodate this need, but the concept proves that thoughtfully removing persons with serious mental disorders from the jail is possible and necessary for the health of both patients and community.
In addressing one of the greatest public health problems of our time, we can learn from other scientists. Consider ecologists, who are concerned with inter-relationships and their impact on the environment. When ecologists create reserves, they reconnect habitats that have been fragmented, allowing them to function as a whole rather than as a set of independent pieces. The Los Angeles model works to create that “reserve” through the Office of Diversion and Reentry (ODR), which connects institutions and justice partners on clinical matters and public health solutions. Through elaborate clinical interventions on behalf of persons with serious mental disorders in custody, connections are made between jail and court, community and hospital, clinic and housing, and back again.