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Keeping the mentally ill out of prison 

Ronnie Cox speaks in a soft, gentlemanly voice. His thinning, curly black hair is speckled with white, and his left hand wobbles with a slight tremor when he talks. Cox, who is 64, spent 16 years in prison. He was addicted to heroin and cocaine, and he contracted hepatitis C, a viral infection that often results in liver failure.

"I started doing things that got me into trouble in 1974 and '75," Cox says. "I was around death or on the verge of death many times, because if you run the streets, that's what happens to you."

It was just about as easy to get drugs in prison as it was out on the street, Cox says, but he desperately wanted to stop using them. His addiction, however, was compounded by something else in his life that, at one point, landed him in Strong Memorial's psychiatric unit. Cox had been living with undiagnosed schizophrenia for much of his adult life.

"When I was using drugs, I knew I wanted to get off of them," he says, "but it wasn't known that I had a mental illness at the time. I can't say for sure if both went hand in hand."

Cox, who now lives with his sister, quit using drugs cold turkey, something he says he never wants to go through again. He hasn't been hospitalized for his mental illness in many years, nor has he committed any crime. And he was treated for hepatitis C and is now considered cured, he says.

"I finally stopped going against the system and started living within society," Cox says. "I live a pretty normal life, and I thank the Lord for that."

Cox's story is not unusual; plenty of research shows he's fairly typical of people with some forms of serious mental illness. People experiencing a mental health crisis in the US are more likely to encounter a police officer than to receive medical attention, according to the National Association of Mental Health. The result: roughly two million people with mental health issues are booked into jails every year.

They also cycle in and out of hospital emergency rooms regularly. Treatment, if they receive it, is too inconsistent to provide lasting relief.

Even though more health-care professionals are aware of the criminalization of people with mental illness, finding effective solutions has been a major challenge. For years, intervention programs designed to reduce criminal convictions and repeated hospitalizations have been tested in cities around the country, including Rochester. But the results have been mixed, says Dr. Steven Lamberti, professor of psychiatry at the University of Rochester Medical Center.

Lamberti has spent much of his career studying the problem. He led the research into a new treatment model that cuts convictions, jail time, and hospitalizations by as much as 50 percent. The treatment model – "Rochester Forensic Assertive Community Treatment," or R-FACT – is built around a highly coordinated team of mental health and criminal justice professionals. Cox participated in the study, and he credits much of his success to it.

"The whole idea of the R-FACT program is to keep you well and keep you out of prison," Cox says.

R-FACT is sort of a second generation of Lamberti's earlier efforts. He first saw what he calls a disconnect between the medical and criminal-justice communities a number of years ago, when he received a call from a panicked mother of one of his patients.

"It just hit me between the eyes: a mother called me and said that her son was in jail and nobody knew about it," says Lamberti. The patient had schizophrenia, and his mother was concerned that the staff at the jail was not giving him his medication, he says. "I had a person there say to me that some of the people here don't believe these people should be getting their happy pills."

The Rochester Psychiatric Center might have prevented cases like that when it was a larger operation, he says. But like many psychiatric hospitals throughout the county, RPC was being downsized through the 1980's and early '90's.

"At one time, RPC served about 3,000 people a year, and it's now down to about 100," Lamberti says.

Like many other mental health professionals during the 1990's, Lamberti believed that assembling a team of professionals that went out into neighborhoods and made house calls was the best way to help patients. ACT, a program Lamberti led out of the University of Rochester's Strong Ties Community Support Clinic, was the gold standard back then, he says.

"I like to call ACT 'doctors making house calls on steroids,'" he says. "It was psychiatrists, social workers, and health care professionals, this all-in team going right into people's homes or wherever they were at to get them treatment."

But he began to realize that at the very least, the program needed modifications, because many patients still ended up in the Monroe Country jail, some repeatedly. The ACT team was observing the same results that similar programs in other cities were seeing: careful monitoring of patients and their medication could reduce hospitalizations, but it wasn't reducing arrests and convictions. Recidivism rates were going up, not down.

"We were talking more about failures than our successes," Lamberti says.

A breakthrough came after Lamberti heard a lecture by a criminologist who talked about the "criminogenic risk factors" of people with mental illnesses: antisocial personality, criminal thinking, alcohol and substance abuse, and socializing in environments where criminal behavior is the norm, to name a few.

"If you look at these risk factors and what can happen when they become combined with psychiatric issues like paranoia and psychosis, you start to get a different picture," Lamberti says. "I reflected on our clinical experience with our patients, and I started to see that they had many of these same risk factors and we weren't being mindful of them."

People with some forms of mental illness have higher rates of criminogenic risk factors, Lamberti says. When the risk factors are paired with their illness, their response to some situations – like meeting a police officer, a figure of authority – is often completely inappropriate.

"If you suffered serious trauma, you will have trouble trusting people," he says. "If you suffer from paranoia, you're going to experience fear and suspicion of what an officer tells you to do. So once you're in trouble, it's harder to get out of trouble. Add those things together and it helps to explain why people with mental illnesses are four times as likely to be in prison."

The R-FACT study showed that patients not only need to be medically treated for their illness, but they also need highly targeted, individualized treatment for the criminogenic risk factors.

"We learned we needed to engage them in the things that drive recidivism," says Lamberti. "But one of the hardest parts of this whole thing is getting them engaged, because they often reject the help."

Cox, who is now studying to become a peer counselor, agrees.

"This is something you have to tell your heart," Cox says. "You're either going to do this or you're not. But you can't keep dipping and dabbing at it."

He also advises others to never look back. "Don't dwell on the past," he says, "and don't dwell on your injuries and continue to down yourself on the things you did. You won't have a clear outlook going forward."

Often it takes more than reasoning with them to engage them, Lamberti says. The other leg of R-FACT is leverage and collaborating with the justice system, he says, and that is key.

"When they refuse help, legal leverage is used to promote treatment and adherence," Lamberti says. But cultivating the right kind of help is critically important, and the mental health and criminal justice fields have only recently been learning how to collaborate with each other, he says. Both fields share some of the same values, he says.

"When it works, it's really amazing," Lamberti says. "There's this magic that can happen when mental health and criminal justice are working together."

Judges can be especially concerned about being seen as lenient on crime, and some just don't support the concept of this type of program, says Rochester City Court Judge Jack Elliott, who also participated in the study.

Elliott presides over a mental health court, which is similar in some respects to a drug court. He may see as many as 40 people a day who have either been arrested or have mandated court appearances. The goal is to use his leverage to keep them in treatment and out of incarceration.

"I have to listen to them and decide: Is this something they did because of their illness? Or no, this is just bad behavior," he says. "I always liken myself to a traffic cop. I don't decide what kind of help they need. The mental health professionals do that. Then I hold them to it, and if they don't do the things they need to do, they're accountable."

What he decides affects everyone around that person, too, Elliott says: "Their children, their parents, their husbands or wives – it's really challenging."

He says he has no doubt about whether R-FACT works. One of the biggest indications is the number of people he meets nearly every day who thank him for his help.

"I walk to work every day, and they stop me all of the time," Elliott says. "I get it constantly. I never had a job like this where I'm making a difference. It's a great thing."

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