The Miami model
As WFAE has been reporting in our series, “Fractured,” locking up defendants with serious mental illness can make their mental health worse. It’s expensive, and it's often not very effective at reducing crime. If former inmates don’t get treatment when released, they’re likely to get arrested again.
But in Miami, Fla., public officials have been managing defendants with mental illness very differently. A lot of places are paying attention, including North Carolina.
Ready for a change
We meet 61-year-old Alretha Toombs at the Miami-Dade courthouse. She has been booked into the Miami jail more than 70 times in the last 40 years. Most of the charges were for shoplifting and low-level thefts to support what she says was a lifelong crack habit.
Toombs has now been clean for more than a year. She’s turning her life around in other ways, too, including working as a prep chef for a Miami fast-food restaurant. Toombs credits much of her success to the court system.
It’s why she wanted to meet at the courthouse — to introduce me to the person she affectionately calls “my judge.”
“I came here because, if it weren’t for her, I wouldn’t be where I’m at today,” Toombs said. “She pushed me so hard … [Now] my recovery means more to me than drugs.”
Toombs dressed up for the occasion, wearing a sparkling silver sweater and matching boots. We sat for a while at the back of Judge Andrea Wolfson’s courtroom, but it was clear the judge was going to be busy for a while. We moved to the hallway, but it was hard to talk. Toombs seemed to know everyone.
“I’ve been coming here long enough,” she said.
Toombs last ended up in court in late 2020 on a low-level felony theft. Instead of going to jail and being punished for the offense, she opted to join a jail diversion program run by the Miami-Dade court. It required Toombs to stay off drugs for 15 months and go to therapy. There were regular check-ins with Wolfson before Toombs completed the program last December.
“I came in here for at least a whole year and a half in Judge Wolfson's courtroom,” Toombs said. “I dropped every Thursday. When I came in, I dropped clean. So if it weren't for her, I won't be where I am.”
“So you would be [drug] tested every week?” I asked.
“Every week,” she said.
The diversion project is for defendants with serious mental illnesses who are charged with misdemeanors or low-level felonies. Toombs says she has been diagnosed with schizophrenia and depression.
Defendants must stay in treatment and stay out of trouble for at least a year. Defendants also have scheduled check-ins with a judge, and they’re in regular contact with a court case manager who helps them transition to life in the community. A peer specialist — someone who’s successfully managing their own mental illness — encourages defendants to stay on track.
Toombs said she connected with the diversion program after she was released from a psychiatric hospital and had to face the charges.
“When I [would] go to court, they'd be in the courtroom waiting for me,” Toombs said.
“They” refers to representatives of the diversion program. The team helps defendants get food, clothing, and housing. They also help defendants apply for benefits and enroll in vocational rehabilitation, so they can pay for their care and support themselves. Three-quarters of those who complete the program won’t get rearrested within the next year, according to the program’s team leader, Alejandro Aristizábal. The court stops monitoring participants after graduation, but they can remain connected to treatment and services indefinitely.
Toombs said staying clean is harder than it sounds, even with the program’s support.
“I've been struggling with it for so long, for like, since I was 18. It's not easy,” Toombs said. “And when you've been on drugs a long time, it's really not easy. But if you really want, you can do it.”
We finally met Toombs’ judge by Zoom a few months later. Judge Wolfson said Toombs’ attitude had everything to do with her success.
“She was really ready to make some changes in her whole life,” Wolfson said. “And that's huge when it comes to the mental health diversion court.”
Wolfson said the program is rigorous. Defendants aren’t always willing to show up for all the requirements — which include therapy, 12-step meetings, drug testing and court appointments.
“Very often we have people who say, you know what, I don't want to do this anymore. I want to go back to the regular division and, you know, kind of roll the dice as to what my plea is going to be,” Wolfson said.
This is Toombs’ third time through the diversion program. One time, she was clean for three years, then slipped and ended up back in jail. But she was confident she would stay out this time.
“I have so much to gain,” Toombs said. “I'm working every day. I like the way I look. I like the way I'm living. I get to spend more time with my family.”
A sophisticated diversion system
The program is the brainchild of Miami-Dade Judge Steve Leifman, although he wouldn’t call it that. He’d say he’s just applying what’s been shown to work. It’s grown out of his decades-long mission to completely restructure the way the county’s criminal justice system handles mental illness.
“We have created a very sophisticated diversion system,” Leifman said. “We restructured our approach for people with mental illnesses, and it's at many different, different levels.”
“We” refers to the 11th Circuit Criminal Mental Health Project, which Leifman helped found in 2000.
Leifman first became concerned about the treatment of those with severe mental illness when he was a 17-year-old intern for a state legislator, he said. It was just as Florida and other states were shutting down many psychiatric hospitals and starting to “deinstitutionalize” the patients living there. Leifman was told to investigate a complaint about a local hospital – an assignment he still can’t believe he was given at such a young age.
“They took me downstairs to what looked like a dungeon,” Leifman said. “I found these men lying naked in their own feces while a guard stood there and washed them down like animals in a zoo. Seventeen years later, I was appointed to the bench. The hospital was closed, and those same people that were being mistreated at the hospital were now being mistreated in our jail.”
As psychiatric hospitals closed, Miami-Dade County Jail became Florida’s largest psychiatric institution. As a new judge in the mid-1990s, Leifman heard case after case involving seriously mentally ill people who kept cycling through the courts. A few years later, he organized a summit of mental health and justice professionals.
“I remember vividly looking at each other, asking ourselves who was more sick,” he said. We had “a so-called sane policy. [Was it the] healthy people that had designed a system that was truly designed to fail? Or [was it] these poor souls who are just sick? And we were not nearly giving them what they needed, and we were allowing them to cycle in and out of these very expensive acute systems of care.”
The group resolved to divert defendants charged with misdemeanors to treatment, bypassing the regular criminal justice system. Recidivism dropped from 75% to 20% the year following their release. That success convinced prosecutors, a local hospital and the Department of Corrections and Rehabilitation to sign on. The diversion program grew, adding defendants charged with non-violent felonies, like Toombs.
The project also has been training police to keep thousands of seriously mentally ill from being arrested in the first place. It started in 2010, and now it's training police in all 36 of the county’s municipalities to de-escalate conflict with the mentally ill. Over the next nine years, Miami-Dade police responded to just over 100,000 mental health crisis calls, but they made only 198 arrests, the project reports. Two-thirds went to crisis treatment. Taxpayers save about $39 million a year.
“So we deflect people from ever coming in on a pre-arrest basis by working with our law enforcement,” Leifman said. “And they have been amazing. They do hundreds of thousands of cases with very few arrests.”
Community care instead of restoration
Leifman has particularly harsh words for the wholesale practice of hospitalizing defendants who are too sick to understand their charges, then giving them just enough treatment to stand trial. It’s called “capacity restoration.” And its standard practice in North Carolina.
But in North Carolina, the wait for a psychiatric hospital bed is so long that people charged with misdemeanors and low-level felonies often don’t even get to a hospital. By law, they can’t be held longer than the maximum sentence for their alleged crimes. After that, they have to be released.
In Miami, those charged with misdemeanors go directly to treatment. Those with low-level felonies who are too mentally impaired to stand trial go to a special unit of the Jackson Behavioral Health Hospital.
Once defendants get stable with medication, they’re given a choice: Go to trial – or try to get the charges dropped by completing the diversion program. Defendants get help with housing and benefits. They’re connected to individual and group therapy and life skills classes. They even get help getting a job. The program costs one-third less than typical restoration, Leifman said.
Such comprehensive support is key, said Madeline Reyes, who runs the unit.
“You have no idea how many individuals come here [who] … haven’t heard from family in years,” Reyes said. “We just search everywhere, Facebook, social media. We contact them. We make sure that when [defendants] get out of here, they have all the support available.”
Leifman said at first they didn’t realize how difficult it would be to reach the most acutely ill, like the homeless people who cycle in and out of jail. Eventually, they got approval from the Florida Legislature for the ability to require court-ordered outpatient treatment for those too sick to realize they need care.
A lot of work still needs to be done, Leifman said. The project says the county spends $232 million a year incarcerating those with serious mental illness. He’s still trying to figure out how to help the sickest people who cycle in and out of the courts.
Leifman showed us his next big idea. It’s a 208-bed facility, which will serve as a one-stop shop for medical and psychiatric care for those who’ve been the hardest to help. Construction is almost complete. He warned visitors not to trip. When the facility opens, it will include a walled in-courtyard and a gym, and a kitchen to train residents for culinary jobs.
There are jail diversion programs throughout the country, including North Carolina, but few as comprehensive as Leifman’s. Last year, teams from 22 states traveled to Miami-Dade to hear about the programs. Dr. Bob Cochrane of North Carolina’s Department of Health and Human Services was part of North Carolina’s team.
“We're sold, and are committing our time and resources to moving this,” Cochrane said.
Judge Leifman will come to North Carolina in October to meet with North Carolina Chief Justice Paul Newby and health department officials. Cochrane’s hoping to start a misdemeanor diversion program in several North Carolina counties. But the planning is very preliminary.
“The core group of us are very committed to pushing this,” Cochrane said. “We're going to run into roadblocks. But we very much would like to see this happen because we see the potential benefits as quite, quite large.”
Funding may be one of the roadblocks. It’s taken 20 years for Leifman to build out support. And even then, it's hard to get all the funding in place. He’s hoping to get Columbia University and the University of South Florida to study the impact of the new center. Those studies could help others, like Cochrane, get funding. But Cochrane says the endorsements of Miami-Dade prosecutors and law enforcement help demonstrate that the program works.
“We know how to fix it,” Leifman said. “It takes political will, and it takes leadership to enforce it to happen. And if not, everyone's just going to go off like they do now and protect their own system and try to get more money into an existing system that doesn't work.”
It also takes commitment on the part of defendants like Toombs.
WFAE checked in with her a few days ago. She’d lost the job she loved but said she’s still clean. Her judge is glad to hear that but worries Toombs is vulnerable.
In the words of Judge Leifman, the people they’re helping need something to wake up for every day, just like everyone else.
Please note two corrections to the original story. Data on the impact of police training comes from both City of Miami police and Miami-Dade police. Judge Leifman hopes the University of Miami will study the impact of the upcoming Miami Center for Mental Health and Recovery, not the University of South Florida as originally reported.
This story is part of a collaboration with “FRONTLINE,” the PBS series, through its Local Journalism Initiative, which is funded by the John S. and James L. Knight Foundation and the Corporation for Public Broadcasting.
Julia Ingram and Mona Dougani contributed research to this report.