Immigration Policy Center: Recommendations for Addressing Mental Illness and Disability Among Detained Immigrants

In light of May 2nd, the National Day of Action to End Family Detention, we will be discussing the detention of non-citizens, the policies governing it and how it can negatively impact the mental health of detained adults, children and families.

Close Dilley

The History of Immigrant Detention

The United States government, through the Department of Homeland Security and Immigration and Customs Enforcement (ICE), has increased its use of civil detention for non-citizens at an alarming rate since 1996  (American Civil Liberties Union, 2006).

Detention Watch Network, 2012
Detention Watch Network, 2012

The size of the immigrant detention system has increased 500% over the past 2 decades, from 6,280 beds in 1996 to 33,4000 beds in 2011 (Tan, 2011). In fact, , there was a 52.8% increase between 2005 and 2010 (Office of Immigration Statistics, 2011). Moreover, illegal immigration (46%) was the most common arrest offense across the nation in 2010 (Motivans, Bureau of Justice Statistics, 2013).

Immigration reform measures passed in the 1980s and 90s have resulted in drastic changes to the detention laws (Tan, 2011). In 1988, Congress passed the first mandatory detention statute, requiring the detention without bond of non-citizens convicted of an aggravated felony (Tan, 2011). In 1994, this statute was amended to widen the definition of aggravated felony and increase the number of non-citizens who could not be released on bond (Tan, 2011). Then, in 1996 the Antiterrorism and Effective Death Penalty Act was passed, which required the detention without bond of almost all non-citizens with criminal convictions including non-violent, misdemeanor charges (Tan, 2011). Finally, the Illegal Immigration Reform and Immigrant Responsibility Act made these changes to an aggravated felony retroactive; in other words, non-citizens who had already served time in jail or settled their court case could be detained after the fact (Tan, 2011).

ICE’s primary mission is to promote homeland security and public safety through the criminal and civil enforcement of federal laws governing border control, customs, trade and immigration.

According to ICE (2015), non-U.S. citizens who are apprehended and determined to need custodial supervision are placed in detention facilities. By law, immigration detention is different from criminal incarceration (Schriro, 2009). In fact, ICE does not classify detention as punitive, but instead categorizes it as a short-term administrative measure to ensure that non-citizens appear at their immigration hearing. Interestingly, an annual report published by the Office of Immigration Statistics (2010) defines detention as “the seizure and incarceration of an alien in order to hold him her while awaiting judicial or legal proceedings or return transportation to his/her country of citizenship.” Therefore, there are conflicting definitions of detention within the United States government and a clear contradiction between policy and practice.

While convicted prisoners are protected by the US Constitution and the 8th Amendment, which prohibits “cruel and unusual punishment,” detained immigrants are by definition non-citizens, and therefore are protected under the Constitution’s 5th Amendment, which affords everyone the right to “due process” (American Civil Liberties Union, 2006). However, up to 84% of detainees do not have lawyers, and due to policies like the Illegal Immigration Reform and Immigrant Responsibility Act, non-citizens are not guaranteed a basic form of due process, which is a prompt bond hearing before an independent judge to determine whether the detention is justified (Tan, 2011). Finally, under the Bush Administration, the Immigration and Naturalization Service department was abolished, and the Department of Homeland Security took over the process of monitoring immigration, whose sole mission is to protect American citizens from terrorism (Mukopadhayay, 2008). This shift in departmental control, as well as the above policies, have all contributed to the further criminalization of immigration.

Further, the U.S. Court of Appeals for the Ninth Circuit has held that conditions of confinement for civil detainees must be superior not only to convicted prisoners, but also to pre-trial criminal detainees (American Civil Liberties Union, 2006). Therefore, if civil detainees are confined to conditions identical, or similar, to those of convicted prisoners, then those conditions could be considered unconstitutional (American Civil Liberties Union, 2006). However, the majority of facilities used to detain non-citizens were originally built, and currently operate, as jails and prisons to confine pre-trial and sentenced felons (Schriro, 2009).

There are two types of detention facilities, one for detaining non-citizens for 72 hours or less and those for detaining non-citizens for 72 hours or more (Schriro, 2009). While 93% of facilities are for detaining immigrants for 72 hours or more, 66% of detained non-citizens were apprehended for non-criminal charges and 88% of immigration defendants were detained in 2010 (Motivans, 2013; Schriro, 2009). Further, 39% of cases terminated in the United States were immigration defendants (Motivans, 2013). In other words, two-fifths of immigrants detained were released with their cases dropped and no charges. This supports the argument that it would be more humane and cost-effective to allow immigrant defendants to stay within the community while awaiting legal or judicial proceedings.

Immigration Forum, 2013
Immigration Forum, 2013

The cost of detaining non-citizens is exorbitantly higher than alternatives to detention (ATD), such as monitoring immigrants within the community (Human Rights First, 2012; Tan, 2011). While ATDs cost approximately 40 cents to $14 a day per individual, detention centers cost between $266 and $300 a day per individual (Planas, 2014). The ICE spends approximately $2 billion per year on detention, which is 28x the budget for alternatives (Human Rights First, 2012). Moreover, more than 90% of immigrants in Alternatives to Detention (ATD) programs have participated successfully.

Immigrant Detention in Texas

This is not just an issue for the United States on a whole, but it is also incredibly pertinent to Texas. 24% of the total population detained by ICE are in Texas facilities (Human Rights First, 2012). In fact, Texas leads in the number of beds offered to ICE through private contractors (Detention Watch Network, 2012).

Detention Watch Network, 2012
Detention Watch Network, 2012

The video below discusses the T. Don Hutto family detention center in Taylor, Texas, which was originally a medium-security state prison, and was the largest family detention center in the country (Lutheran Immigration Refugee Service & the Women’s Refugee Commission, 2014). In 2009, the Obama administration ordered the T. Don Hutto detention center to close due to substantiated claims of substandard care.

In December 2014 a new family detention center was opened in Dilley, Texas. Immigrant advocacy groups are vehemently opposed to the Obama administration’s return to family detention practices since 98% of families are seeking protection within the United States, and are eligible for asylum (Lutheran Immigration Refugee Service & the Women’s Refugee Commission, 2014). In addition to allegations of substandard child care, medical care and legal assistance, there have also been allegations of sexual abuse between detention guards and detained women (Lutheran Immigration Refugee Service & the Women’s Refugee Commission, 2014). In light of these issues, a local community organization, Texans United for Families, has scheduled a protest at the Dilley Family Detention Center on May 2nd.

Mental Health Concerns within Detention Centers

As previously mentioned, the majority of non-citizens that are arriving in the United States are fleeing unsafe living conditions within their home countries, and are eligible for asylum (Lutheran Immigration Refugee Service & the Women’s Refugee Commission, 2014). Accordingly, it has been well-documented that non-citizens requesting asylum have been subjected to physical abuse, sexual violence and trauma prior to immigration, which all require appropriate mental health services (Sinnerbrick, Silove, Field, Steel & Manicavasagar, 1997). However, there have been numerous reports and publications documenting the severe lack of medical and mental health services for detained non-citizens (Mukopadhayay, 2008; Parker, 2010; Schriro, 2009; Tan, 2011). Reported problems include lack of a timely, or accurate, assessment, limited to no translation services, changes in mental health care, including changes to psychotropic medications due to lack of funds or accessibility, lack of appropriate treatment for serious mental illness and the segregation or isolation of those with mental illness or disability.

Research suggests that the longer a non-citizen is detained, the more significantly distressed they became, including symptoms of depression, post-traumatic stress disorder, anxiety or even suicidal thoughts (Robjant, Hassan & Katona, 2009). According to Keller et al. (2003) 86% of asylum seekers showed clinical levels of depression, 77% had clinical anxiety and 50% had clinical post-traumatic stress disorder. At follow-up, the mental health of those who were still detained had continued to deteriorate, while their were significant improvements in mental health among those who had been released.

Recently, the United States, along with other industrialized countries like the United Kingdom and Australia, have returned to the detention of children, through the advent of family detention centers, which directly opposes the UNCRC‘s policy that children should only be detained as a “last resort” and for the “shortest time possible.” Further, family detention centers are solely meant for mothers and children, and leads to the removal of fathers, even if they are apprehended together (Lutheran Immigration Refugee Service & the Women’s Refugee Commission, 2014). Therefore, these policies do not take into consideration the trauma imposed on children due to the separation of families and disruption of attachments (Newman, 2008).

Additionally, there has been a drastic increase in the number of unaccompanied children seeking asylum in the United States; in 2011, over 21,000 unaccompanied children from Latin countries like El Salvador and Guatamala entered the United States (United Nations High Commissioner for Refugees, 2013). According to this report, over half (58%) of unaccompanied children were eligible for international protection due to exposure to violence and 22% had experienced abuse in the home. Therefore, there are significant needs among detained, non-citizens to receive appropriate, and time sensitive, mental health care and serious concerns regarding the detention of families, and more specifically, children.

The Immigration Policy Center

The Immigration Policy Center (IPC) is a think-tank associated with the American Immigration Council. IPC’s mission is to “shape a rational conversation on immigration and immigrant integration.” The IPC researches a plethora of issues related to immigration including deportation, health care, employment and citizenship. Therefore, the IPC is an expert in the field of immigration, and has published multiple reports regarding deportation and detention.

Immigrant Detention Reform & Recommendations

According to a Special Report published by the Immigration Policy Center in 2010, detention centers are not meeting the current needs of non citizens with mental illness or disability. Therefore, the IPC recommends the following changes in order to improve the current mental health services:

1. Require that non-citizens are immediately screened on admission for mental disabilities by a healthcare professional.

2. Provide professional translation services to all non-English speaking

3. Improve the overall quality of mental health services within detention centers, including appropriate levels of staffing.

4. Develop and maintain electronic medical records in order to improve the identification and documentation of non-citizens with mental disability or mental illness.

5. When feasible, release non-citizens with mental illness or mental disability into the community under the care of a guardian or family member. If not feasible, provide access to appropriate mental health services such as the accurate dispensation of medications, and avoid the current practices of prolonged isolation or segregation.

6. Ensure that non-citizens with mental disabilities are providing appropriate legal representations or counsel, as well as an appointed guardian or family member for legal proceedings.

In conclusion, the United States is currently detaining almost half a million non-citizens per year, and spending approximately $2 billion on the venture. The current system raises serious concerns in terms of providing humane care for those who are awaiting legal proceedings regarding immigration, and many non-citizens are not afforded the constitutional rights that they are guaranteed. Alternatives to detention could significantly decrease the current budget, as well as improve the overall quality of life and mental health for detained adults, families and children.


American Civil Liberties Union. (2006). Conditions of Confinement in Immigrant Detention Facilities. Retrieved from

Detention Watch Network. (2012). Detention Centers. Retrieved from

Keller, A. S., Rosenfeld, B., Trinh-Shevrin, C., Meserve, C., Sachs, E., Leviss, J. A., Singer, E., Smith, H., Wilkinson, J., Kim, G., Alden, K. & Ford, D. (2003). Mental health of detained asylum seekers. The Lancet, 362(9397), 1721-1723.

Lutheran Immigration Refugee Service & the Women’s Refugee Commission. (2014). Locking Up Family Values, Again. Retrieved from

Motivans, M. (2013). Federal Justice Statistics, 2010. US Department of Justice: Office of Justice Programs, Bureau of Justice Statistics.

Mukhopadhyay, R. (2008). Death in detention: Medical and mental health consequences of indefinite detention of immigrants in the united states. Seattle Journal for Social Justice, 7(2), 693.

Newman, L. K., & Steel, Z. (2008). The child asylum seeker: psychological and developmental impact of immigration detention. Child and adolescent psychiatric clinics of North America, 17(3), 665-683.

Office of Immigration Statistics. (2011). Immigration Enforcement Actions: 2010. US Department of Homeland Security. Retrieved from

Packer, T. (2010). Non-citizens with mental disabilities: the need for better care in detention and in court. Immigration Policy Center. Retrieved from

Planas, R. (2014). Family Detention Center In Texas Is ‘Utterly Unnecessary,’ Says Immigration Attorney. Huffington Post Latino Voices. Retrieved from

Robjant, K., Hassan, R., & Katona, C. (2009). Mental health implications of detaining asylum seekers: systematic review. The British Journal of Psychiatry,194(4), 306-312.

Schriro, D. B. (2009). Immigration detention overview and recommendations. US Department of Homeland Security, Immigration and Customs Enforcement.

Sinnerbrink, I., Silove, D., Field, A., Steel, Z., & Manicavasagar, V. (1997). Compounding of premigration trauma and postmigration stress in asylum seekers. The Journal of psychology, 131(5), 463-470.

Tan, M. (2011). Locked Up Without End: The Indefinite Detention of Immigrants Will Not Make American Safer. Immigration Policy Center. Retrieved from

United Nations High Commissioner for Refugees. (2013). Children on the Run. Retrieved from


Any One of Us: Words from Prison

In this post we will discuss a community event, Any One of Us: Words from Prison, geared towards raising awareness about the domestic and sexual violence experienced by incarcerated women. We will also review national data regarding the incarceration of women and explore some relevant Texas legislation that is currently up for a vote at the Capital.

Eve Ensler, Tony Award winning playwright, performer, and activist, author of Any One of Us: Words from Prison.
Eve Ensler, Tony Award winning playwright, performer, and activist, author of Any One of Us: Words from Prison as well as The Vagina Monologues.

Any One of Us: Words from Prison by Eve Ensler

At the beginning of April two local non-profits, Empower Art and Conspire Theatre, put on a collaborative production entitled Any One of Us: Words from Prison by Eve Ensler. Any One of Us is part of V-Day, a global activist movement to end violence against women and girls. This play in particular is part of a community campaign to raise awareness about the issues of domestic violence, sexual violence and childhood trauma and how it relates to the incarceration of women.

Empower Art is a local non-profit that facilitates healing and empowerment for victims of domestic and/or sexual violence through creative expression while Conspire Theatre is an Austin-based theater company dedicated to working with incarcerated women and previously incarcerated women. Conspire Theatre has created a supportive community as well as a safe space for incarcerated women to explore their traumatic past through creative writing and theater arts. Even though Conspire Theatre works primarily with women in the Travis County Jail, the stories performed in Any One of Us: Words from Prison were actually a compilation of stories from incarcerated women across the US, namely Michigan, New York, Florida and California.

conspire_LOGO_final Screen Shot 2015-04-19 at 2.58.57 PM

National Data about the Female Prison Population

As previously discussed, the number of people being incarcerated in the United States has drastically increased since the 1980s primarily due to the War on Drugs. For example, drug offenses account for more than 50% of the current prison population growth (Snell & Morton, 1994). Consequently, the number of women in prison has grown at an astronomical rate between 1980 and 2010 (646%), even faster than the rate of incarceration among men (419%) (Guerino, Harrison & Sabol, 2011). Even more disturbing is the disproportionate rate at which women of color are incarcerated; black women are imprisoned at nearly three times the rate of non-hispanic, white women and hispanic women are imprisoned at nearly twice the rate of non-hispanic, white women (Guerino, Harrsion & Sabol, 2010).


As explored within Any One of Us: Words from Prison, the social and psychological circumstances that proceed the incarceration of women is somewhat different than men (Moloney & Muller, 2009). For example, the Department of Justice (1999) reported that 23-36.7% of incarcerated women have experienced sexual abuse during childhood, compared to 16.8% of the general population (Gorey & Leslie, 1997). Further, 34-43% of female inmates have experienced either physical or sexual abuse prior to incarceration, and of those who had experienced abuse, almost 50% experienced it at the hands of an intimate partner (Snell & Morton, 1991; James & Glaze, 2006). Another study found that 60% of incarcerated women in California had been physically assaulted during adulthood (Bloom, Chesney-Lind, & Owen, 1994). This all provides support for the creation of preventive policies and/or programs that provide economic, social or psychological services for women at risk.

The Continuation of Marginalization during Incarceration

Copyright: Conspire Theatre.
Copyright: Conspire Theatre.

One major issue explored within Any One of Us: Words from Prison is the prevalence of rape and sexual misconduct among female prisoners at the hands of male prison guards. In fact, in 2003, the Prison Rape Elimination Act (P.L. 108-79) was passed, which requires that the Bureau of Justice Statistics collect national data on the prevalence of sexual violence within correctional institutions (Beck, Harrison & Adams, 2007). According to Beck, Rantala & Rexroat (2014), 48% of substantiated incidents of sexual assault involved staff and inmates. And while women represent approximately 7% of all state or federal inmates, they account for 33% of staff-on-inmate incidents of sexual victimization (Beck, Rantala & Rexroat, 2014). While there have been some strides in terms of collecting information regarding sexual assault within prison, there is major criticism for the lack of consequences faced by perpetrators and overall impunity for prison guards (Buchanan, 2007). Scholars have been pushing for gender-appropriate policies since the 1990s, although little change has been enacted (Bloom, Owen & Covington, 2004). In fact, one paper argued that the sexual abuse of imprisoned women is a modern corollary to slavery, particularly due to the disproportionate arrest of women of color (Smith, 2005). Needless to say, this is still a major issue that needs to be addressed on a county, state and federal level.

Mental illness is another prevalent issue among inmates. The number of individuals with serious mental illness in prisons and jails now exceeds the number in state psychiatric hospitals tenfold (Torrey et al., 2014). One study found that 56%-64% of state and county inmates had some type of mental health problem, not included substance dependence or abuse (James & Glaze, 2006). Once substance abuse and dependence were included, rates jumped to 74%-76% of all state and jail prisoners (James & Glaze, 2006). A more recent study found that 34%-38% of female inmates had a serious mental illness (Steadman, Osher, Robbins, Case, & Samuels, 2009). However, only 17%-33% of state and county inmates with mental illness received some type of mental health services even though 42%-49% had previously received mental health services prior to incarceration (James & Glaze, 2006). 

Lifelong repercussions of incarceration

ywcaAfter the production of Any One of Us: Words from Prison, the producer of the show conducted a talk back with a panel that consisted of a program manager, social worker and counselor from the YWCA as well as a professor of Theater and Dance from Texas State University. One of the major issues discussed was the reintegration of formerly incarcerated women into the community, and the services that could be provided to improve the process. For example, the YWCA offers a group to women released from prison in order to create a supportive community and decrease recidivism rates. 

In the United States, people who are found guilty of a crime and sentenced to prison do not have the same rights as average Americans. For example, some states prohibit ex-offenders from voting or driving while federal restrictions include the inability to receive social welfare like food stamps or even public housing (depending on the crime) (Petersilla, 2005). While there are some safeguards in place to prevent employer discrimination of ex-offenders, research suggests that discrimination still occurs (Demleitner, 2002; Lam & Harcourt, 2003). Therefore, it is no surprise that rates of recidivism are as high as 68% within 3 years of release and 77% within 5 years of release (Durose, Cooper & Snyder, 2014).

Relevant Texas Legislation 

So why is a community event like Any One of Us: Words from Prison relevant to social policy? Social justice is a major component of social work, as it ensures that disenfranchised populations are given an opportunity to advocate for their needs. Many times this opportunity is provided during a legislative hearing in order to influence change within current policies. Therefore, understanding current state and federal policies is essential, since changes in social policy can improve the lives of hundreds or even thousands of people.

HB 1083: Mental health assessment for inmates

This piece of legislation has two major goals:

1) identify inmates with mental illness through standardized screening,

2) restrict the confinement or segregation of inmates with mental illnesses.

As mentioned above, mental illness and substance use disorders are highly prevalent among prisoners; therefore, it is imperative to screen all inmates in order to identify mental health issues, as well as provide access to appropriate treatment. Additionally, solitary confinement has been increasingly used as a way to manage difficult prisoners, sometimes for months or even years at a time (Metzner & Fellner, 2010). While isolation by itself can lead to significant or even severe psychological harm, solitary confinement also limits the services that an inmate can receive (Grassian, 2006; Metzner & Fellner, 2010).

HB 569: Providing inmates with reentry information

This piece of legislation proposes that jails and prisons should collaborate with organizations across the state of Texas that provide reentry programs in order to create county-specific resource guides for prisoners released on probation, parole or otherwise. While some counties already offer a resource guide (check out the Travis county guide here), it is important to make this a state wide requirement because there is not guarantee that someone serving time in a Travis county jail or prison will live in the Travis county area upon release.

As mentioned above, it can be very difficult for the formerly incarcerated to reintegrate back into society, and recidivism rates are as high as 37% within the first 6 months (Durose, Copper & Snyder, 2014). Therefore, it is important to “front load” post-prison services in order to decrease recidivism rates (Petersilla, 2005). Additionally, this type of legislation may lead to higher rates of mental health or substance abuse treatment for formerly incarcerated individuals that either did not receive adequate services during their sentence, or require a continuation of care (i.e./ medications, therapy, group interventions, etc.). If enacted, it would be important to keep track of any changes in recidivism rates to inform future policies or changes. 



Beck, A. J., Harrison, P. M., & Adams, D. B. (2005). Sexual violence reported by correctional authorities, 2004. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Beck, A. J., Rantala, R. R., & Rexroat, J. (2014). Sexual victimization reported by adult correctional authorities, 2009-11. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Bloom, B., Chesney-Lind, M., & Owen, B. (1994). Women in California prisons. San Francisco: Center on Juvenile and Criminal Justice.

Bloom, B., Owen, B., & Covington, S. (2004). Women Offenders and the Gendered Effects of Public Policy1. Review of Policy Research, 21(1), 31-48.

Buchanan, K. S. (2007). Impunity: Sexual Abuse in Women’s Prisons. Harv. CR-CLL Rev., 42, 45.

Demleitner, N. V. (2002). Collateral damage: no re-entry for drug offenders. Vill. L. Rev., 47, 1027.

Durose, M. R., Cooper, A. D., & Snyder, H. N. (2014). Recidivism of Prisoners Released in 30 States in 2005: Patterns from 2005 to 2010. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Gorey, K. M., & Leslie, D. R. (1997). The prevalence of child sexual abuse: Integrative review adjustment for potential response and measurement biases.Child abuse & neglect, 21(4), 391-398.

Grassian, S. (2006). Psychiatric effects of solitary confinement. Washington University Journal of Law & Policy, 22(24), 325-383.

Guerino, P., Harrison, P. M., & Sabol, W. J. (2011). Prisoners in 2010. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Harlow, C. W. (1999). Prior abuse reported by inmates and probationers. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Glaze, L. E., & James, D. J. (2006). Mental Health Problems of Prison and Jail Inmates. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Lam, H., & Harcourt, M. (2003). The use of criminal record in employment decisions: The rights of ex-offenders, employers and the public. Journal of Business Ethics, 47(3), 237-252.

Metzner, J. L., & Fellner, J. (2010). Solitary Confinement and Mental Illness in US Prisons: A Challengefor Medical Ethics. Journal of the American Academy of Psychiatry and the Law Online, 38(1), 104-108.

Moloney, K. P., & Moller, L. F. (2009). Good practice for mental health programming for women in prison: Reframing the parameters. Public health,123(6), 431-433.

Petersilia, J. (2005). Hard time: Ex-offenders returning home after prison.Corrections Today, 67(2), 66-71.

Smith, B. V. (2005). Sexual Abuse of Women in United States Prisons: A Modern Corollary of Slavery. Fordham Urb. LJ, 33, 571.

Snell, T. L., & Morton, D. C. (1994). Women in prison. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Steadman, H. J., Osher, F. C., Robbins, P. C., Case, B., & Samuels, S. (2009). Prevalence of serious mental illness among jail inmates.psychiaTric services, 60(6), 761-765.

Torrey, E. F., Kennard, A. D., Eslinger, D., Lamb, R., & Pavle, J. (2010). More mentally ill persons are in jails and prisons than hospitals: A survey of the states. Arlington, VA: Treatment Advocacy Center, 2010.

Throwback Thursday: Affordable Care Act of 2010

obama and aca

The Patient Protection & Affordable Care Act (ACA) was passed by Congress and then signed into law by President Barack Obama in March 2010. This is considered the largest overhaul of the US healthcare system since Medicaid and Medicare were passed in 1965 (Samora & Hettrich, 2012). In general, the ACA was passed in order to expand accessibility to health care coverage, as well as improve the quality of care provided. More specifically, the legislation required that “marketplaces” be set up in all states so that the uninsured can shop for individual plans. While most “blue” states have set up their own marketplace, most “red” states did not, and allowed the federal government to do so instead (Sanger-Katz, 2015). We will discuss why this has caused problems later in the blog post.


The Affordable Care Act has had three major implications in terms of the expansion and improvement of mental health care:

1. It has expanded mental health and substance abuse benefits to 62 million Americans.

2. Health care plans are now required to cover preventive measures like depression screenings or behavioral assessments, as well as provide mental health parity. In other words, many health insurance plans are now required to provide equal access to mental health care as provided for other chronic conditions like diabetes.

3. Health care plans and insurers can no longer deny coverage based on preexisting conditions, including mental illness.

Current research suggests that the Affordable Care Act has been effective in terms of decreasing the number of uninsured Americans and providing more affordable options (Sanger-Katz, 2015). However, more progress is needed as 12.9% of American adults are currently uninsured (Levy, 2015).

Current Controversy surrounding the ACA

Currently, middle and low income Americans can quality for federal subsidies in order to receive affordable healthcare through the Obamacare marketplace. Specifically families with an annual income between 100% and 400% of the federal poverty line can qualify for federal subsidies (Health Insurance Marketplace, 2015).

King v. Burwell is a Supreme court case regarding whether federal subsidies can go to all insurance purchasers, or just those managed by the state government (Sanger-Katz, 2015). This discrepancy has com from the ACA legislation as it stipulates that the health care subsidies should flow through the marketplace “established by the state.” However, only 13 states are currently managing their own marketplace, while 3 states have federally supported, state marketplaces and the remaining 34 are completely managed by the federal government. Therefore, this ruling could have a major impact on who can afford health insurance. The Kaiser Family Foundation (2015) estimates that approximately 7.5 million people in 34 states qualify for subsidies and some estimates suggest that approximately 7 million Americans could lose their subsidies if the Supreme court rules against the government (Sanger-Katz, 2015).

If the Supreme Court rules against the government, it could create a major problem by setting the precedence for reading each legislative bill literally. Intentionality of a law is the current standard for interpretation; often, constitutional lawyers will refer to the founding father’s ‘intentions,’ instead of literal interpretation. Further, some laws and policies are hundreds or even thousands of pages long and some politicians may not even read a bill, especially in its entirety. Therefore, this case could open a floodgate of additional lawsuits for any bill that is currently enacted.


Health Insurance Marketplace. (2015). Income levels that qualify for lower health coverage

Kaiser Family Foundation. (2015). Marketplace Enrollees Eligible for Financial Assistance as a Share of Subsidy-Eligible Population. Retrieved from

Levy, J. (2015). In U.S., Uninsured rate sinks to 12.9%. Gallup. Retrieved from

Samora, J. B. & Hettrich, C. M. (2012). Where the Candidates Stand on Healthcare. Retrieved from

Sanger-Katz, M. (2015). Is the Affordable Care Act Working? New York Times. Retrieved from

Sanger-Katz, M. (2015). Obamacare, Back at the Supreme Court: Frequently Asked Questions. New York Times.  Retrieved at

HB 2597: Jail Diversion Pilot Program in Fort Bend County


According to the Substance Abuse and Mental Health Services Administration (SAMHSA) (2015), 800,000 individuals with serious mental illness are incarcerated annually in the United States. Further, 72% of this population meets criteria for a co-occurring substance use disorder (SAMHSA, 2015). As discussed in a previous blog post, police officers and the criminal justice system have become the main provider of mental health services due to limited community mental health services and resources (SAMHSA, 2015). Additionally, the advent of the “War on Drugs” in 1968 by President Nixon led to the criminalization of drug use and addiction, leading to huge increases in the number of people incarcerated (Center for Health & Justice, 2013). For example, in 2008, the number of incarcerated people had increased 5-fold without comparable decreases in crime or drug use (Moore & Elkavich, 2008). However, incarceration is incredibly costly, and it is estimated that the lifetime cost of incarceration for 1 person in the Texas criminal justice system is $2 million (Hogg Foundation for Mental Health, 2011). Therefore, jail diversion programs are gaining popularity across the United States, and recently in Texas, as an economic alternative (Center for Health & Justice, 2013).


According to SAMHSA (2015), jail diversion refers to “programs that divert individuals with serious mental illness (and often co-occurring substance use disorders) away from jail and provide linkages to community-based treatment and support services.” There are generally two types of jail diversion programs: pre-booking and post-booking (Senate Committee on Criminal Justice, 2014). Pre-booking diversion programs involve the identification of people with serious mental illness and/or addiction by law enforcement agents before arrest, and transportation to a crisis intervention center instead of jail (Senate Committee on Criminal Justice, 2014). Therefore, mental health services are provided in lieu of criminal charges, and lowers the jail costs and court costs substantially (Drain & Solomon, 1999; Senate Committee on Criminal Justice, 2014). This model require partnership between law enforcement agents and mental health providers within the community, and would include programs previously discussed like Crisis Intervention Teams within local or county police departments (Center for Health & Justice, 2013).

Post-booking jail diversion, which is more widely used, identifies people with serious mental illness and/or addiction after they have been arrested and booked in jail (Senate Committee on Criminal Justice, 2014). This model is usually associated with speciality courts like drug court or mental health court, but it may also be associated with mental health assessment by correction officers or emergency services personnel within the jail (Drain & Solomon, 1999; Senate Committee on Criminal Justice, 2014). Therefore, post-booking diversion programs can range from deferred prosecution and community based treatment to arraignment, conviction and/or probation (Center for Health & Justice, 2013).

criminal justice process
(Center for Health and Justice, 2013)

Due to the variance in jail diversion programs, and a lack of overarching standards for collecting and publishing data,  there is limited literature on the effectiveness of jail diversion programs (Center for Health & Justice, 2013). However, some research suggests that jail diversion programs reduce the number of days spent in jail, increase the number of days spent in the community and leads to lower criminal justice costs (Steadman & Naples, 2005). However, a more recent literature review found that while jail diversion programs decrease the number of days in jail, they do not have any impact on rates of recidivism (Sirotich, 2009). Therefore, further research is needed to thoroughly examine common sets of performance measures like cost savings or reduced recidivism. Drain & Solomon (1999) suggest conducting a randomized trial that randomly assigns offenders to a diversion program or jail. However, this would necessitate considerable training of police officers to reliably assess inclusion and exclusion criteria in order to evaluate a pre-booking diversion program.

Texas Legislation

In 2004, the Texas House passed bill 2292, which states “a local mental health authority shall ensure the provision of assessment services, crisis services, and intensive and comprehensive services using disease management practices for adults with bipolar disorder, schizophrenia, or clinically severe depression and for children with serious emotional illnesses.”

Texas State pub_pie chartIn 2010, the Texas Department of State Health Services conducted a study to assess the efficacy of post-booking jail diversion programs for offenders currently in prison, on parole and on probation. According to the Texas Department of State Health Services (2010), approximately 23% of people in the Texas prison system have also been served by the mental health system. Refer to figure 5 for the breakdown of mental health diagnoses within the study population.

According to the Texas Department of State Health Services report (2010), 15% of those diverted to community mental health services had fewer psychiatric hospitalizations, 36% had less functional impairment, 32% had fewer employment problems, 31% had less housing instability and 28% had less co-occurring substance use. However, the report found that this type of diversion program should not be considered cost-saving, so much as cost-diverting (Texas Department of State Health Services, 2010). Therefore, in order to adequately execute jail diversion programs, an increase in community mental health service funding will also be necessary.

Interestingly, San Antonio and Bexar County have been implementing a jail diversion program since 2003 in order to reduce costs; in fact, it is estimated that the jail diversion program has saved the city more than $10 million annually (Moser, 2014). Cumulatively, this has diverted approximately 17,000 people from jails, reduced overcrowding and saved Bexar County approximately $50 million since it’s inception in 2003 (The Center for Health Care Services, 2015).

HB 2597: Incarceration Diversion Program for Fort Bend County

Currently, Fort Bend County, a county outside of Houston, is requesting $1 million in order to create a jail diversion program for 10-20 individuals. According to the proposed policy, HB 2597, the program must include the following components:

(1)  caseload management;
             (2)  multilevel residential services; and
             (3)  easy access to:
                   (A)  integrated health, mental health, and
chemical dependency services;
                   (B)  benefits acquisition services; and
                   (C)  multiple rehabilitation services.

Of note, the current policy proposal would be considered a post-booking jail diversion program, as it would provide social, clinical, housing and welfare services for people with mental illness upon release from jail. While this type of program is slightly different from the jail diversion programs reviewed so far, this type of program is essential as previously incarcerated individuals are extremely limited in terms of housing and employment options, which also limit access to social and mental health services.

While there are significant limitations and gaps in terms of empirical support for pre-booking and post-booking jail diversion programs, preliminary research suggests that these programs can improve clinical outcomes like functional impairment, as well as social outcomes like employment and housing. Further, research suggests that jail diversion programs can save tax payer dollars by decreasing criminal justice costs. While some argue that jail diversion programs actually divert costs to the mental health care system, one could argue that these costs are more justified as they led to the improvement of quality of life for both offenders and communities. In conclusion, we look forward to seeing more research support for jail diversion programs in the future, as evidence based interventions are a cornerstone to high-quality social work.


Center for Health and Justice. (2013). A National Survey of Criminal Justice Diversion Programs and Initiatives. Retrieved from

Drain, J., & Solomon, P. (1999). Describing and evaluating jail diversion services for persons with serious mental illness. Psychiatric Services, 50(1), 56-61.

Hogg Foundation for Mental Health. (2011). Crisis Point: Mental Health Workforce Shortages in Texas. Retrieved from

Moore, L. D., & Elkavich, A. (2008). Who’s using and who’s doing time: Incarceration, the war on drugs, and public health. American Journal of Public Health, 98(5), 782.

Moser, W. (2014). San Antonio Reduced Its Jail Population by Treating the Mentally Ill. Chicago Magazine. Retrieved from

Sirotich, F. (2009). The criminal justice outcomes of jail diversion programs for persons with mental illness: a review of the evidence. Journal of the American Academy of Psychiatry and the Law Online, 37(4), 461-472.

Steadman, H. J., & Naples, M. (2005). Assessing the effectiveness of jail diversion programs for persons with serious mental illness and co‐occurring substance use disorders. Behavioral sciences & the law, 23(2), 163-170.

Substance Abuse and Mental Health Services Administration. (2015). What is jail diversion? Retrieved from

Texas Department of State Health Services. (2010). Another Look at Mental Illness and Criminal Justice Involve in Texas: Correlates and Costs. Retrieved from

The Center for Health Care Services. (2015). Jail Diversion Program. Retrieved from

The Role of Police in Providing Mental Health Services

This week we will be reviewing an academic article, The Police and Mental Health. We will then discuss the role that the Austin Police Department plays in responding to psychiatric emergencies in the Texas capital.


In 1963, John F. Kennedy and the American Congress passed the Community Mental Health Act to support the deinstitutionalization of people with mental illness or intellectual disabilities. This led to a major shift away from long-stay, inpatient facilities, towards creating community-based outpatient facilities that upheld the dignity and self-determination of clients. The Americans with Disabilities Act (ADA) was passed in 1990 to further protect those with a physical or mental disability from discrimination. In fact, Olmstead vs. L.C. is a famous Supreme Court case which upheld the rights of people with disabilities and protected them from inappropriate institutionalization when outpatient services were available.

Due to this shift away from institutionalizing people with mental illness and fewer psychiatric hospitals, police departments and emergency dispatch have become the first line responders to mental health crises like suicidal outcries or psychotic episodes (Shapiro et al., 2014). These crises can be sensitive, or even dangerous, depending on the person’s mental status. However, the majority of police officers do not receive adequate training in working with people who have mental illnesses, which can lead to unnecessary arrest, the criminalization of mental illness or even the use of deadly force (Borum, 2000; Lamb, Weinberger & DeCuir, 2002).

Police officers have a large amount of discretion when deciding how to respond to people with mental illness. This problem is further exacerbated within communities that have limited community mental health services; in fact, a jail may be more equipped to provide mental health care than a community hospital or clinic can offer (Lamb, Weinberger & DeCuir, 2002). When police officers choose to arrest a mentally ill citizen due to lack of available mental health facilities, it is referred to as a “mercy booking” (Lamb, Weinberger & DeCuir, 2002; Shapiro et al., 2014). Accordingly, the three largest providers of inpatient psychiatric services in the US are jails (NPR, 2011).

In order to address the lack of mental health and crisis intervention training that police officers receive, police departments have started to collaborate with local mental health workers. Ideally, this collaboration would facilitate an accurate assessment of the person in crisis, and insure that people in distress are referred to the appropriate services. Additionally, the hope is that a mobile crisis team will not only reduce arrests, but also hospitalizations (Lamb, Weinberger & DeCuir, 2002).

A few different tactics are currently being implemented across the US, the Crisis Intervention Team (CIT) or “Memphis Model” being the most popular (Shapiro et al., 2014). The CIT model provides mental health training for designated police officers, who are then dispatched to respond to calls that involve a person with mental illness (Lamb, Weinberger & DeCuir, 2002). However, these designated police officers do not solely work with people with mental illness, and perform standard police duties in between crisis interventions (Boscerato et al., 2014). Therefore, some police officers may choose to arrest a person with mental illness due to familiarity with the criminal justice system, or to save time, as transportation and assessment at a psychiatric emergency facility can be time consuming (Lamb, Weinberger & DeCuir, 2002).

While limited data is available, some studies suggest that mobile crisis teams can reduce arrest rates down to 2% (Lamb, Shaner, Elliot, Decuir & Foltz, 2001). However, a full understanding of the impact of mobile crisis units is difficult due to the variability in program implementation and models. Either way, one major benefit to collaboration between police departments and community mental health services, particularly those provided by the department of mental health, is access to previous medical records and hospitalizations(Lamb, Weinberger & DeCuir, 2002). This information can help the crisis team approach the situation in an informed manner, and it can also aid in the intake process if a hospitalization is required.

The Role of Police in Responding to Mental Health Emergencies in Texas

texas flag_mapIn 1993, the Texas legislature passed a Health and Safety Code that required at least one designated officer per county be trained as a mental health “peace officer.” This designation requires a minimum of 40 hours of training in the identification and appropriate methods of responding to person with mental illness. Once a peace officer has completed the necessary training, he/she is able to apprehend, or hospitalize, a person with mental illness. It also allows the officer to transport a person with mental illness to a designated hospital for emergency psychiatric services.

Then in 2005, the Texas Senate passed Senate Bill 1473, dubbed the Bob Meadours Act, which requires training in “de-escalation and crisis intervention techniques to facilitate interaction with persons with mental impairments.” Bob Meadours was Texas resident with bipolar disorder that was shot and killed by officers during a response to a 911 call in which the mother called and requested mental health care workers to help her respond to a psychiatric emergency (Khanna, 2004).

Accordingly, Austin provides two options for crisis and emergency services: the Austin Crisis Intervention team (CIT) through the Austin Police Department (APD) and a Mobile Crisis Outreach Team (MCOT) through Austin Travis County Integral Care (ATCIC). The main difference between these crisis services is the level of emergency; immediate emergencies are handled by the CIT team, while less immediate psychiatric crises are handled by the MCOT. However, for Travis County residents that live outside of Austin,  there is also a Travis County Crisis Intervention Team (CIT).

atcic logo

While the creation of CIT teams is a direct response to the 1993 Health and Saftey Code and the 2005 Bob Meadours Act, there are still limitations of the crisis response programs currently in place. Requiring one peace officer per county may not be adequate in terms of the need of each county. In fact, some studies suggest that people with mental illness are at higher risk of being shot by police officers, and make up 58% of police shootings (Torrey, Kennard, Eslinger, Biasotti, & Fuller, 2013; US Department of Justice, 2014). In fact, a Dallas resident with schizophrenia, Jason Harrison, was shot by police officers in June 2014 while responding to a 911 call (WARNING: the attached link includes a video with graphic content). Therefore, it may be beneficial for all police officers to receive training in crisis management and mental health emergencies, not only county peace officers.


Borum, R. (2000). Improving high risk encounters between people with mental illness and police. Journal of the American Academy of Psychiatry and the Law,28.

Boscarato, K., Lee, S., Kroschel, J., Hollander, Y., Brennan, A., & Warren, N. (2014). Consumer experience of formal crisis‐response services and preferred methods of crisis intervention. International journal of mental health nursing,23(4), 287-295.

Khanna, R. (2004). Bob Meadours. Houston Chronicle. Retrieved from

Lamb, H. R., Shaner, R., Elliott, D. M., Decuir, W. J., & Foltz, J. T. (2001). Outcome for psychiatric emergency patients seen by an outreach police–mental health team. New directions for mental health services, 2001(90), 67-76.

Lamb, H. R., Weinberger, L. E., & DeCuir Jr, W. J. (2002). The police and mental health. Psychiatric Services, 53(10), 1266-1271. 

National Public Radio. (2011). Nation’s Jails Struggle with Mentally Ill Prisoners. Retrieved from:

Texas Legislature. (1993). Health and Safety Code, Title 7: Mental Health and Mental Retardation, Subtitle C, Texas Mental Health Code, Chapter 573 Emergency Detention. Retrieved from

Torrey, E. F., Kennard, A. D., Eslinger, D. F., Biasotti, M. C., & Fuller, D. A. (2013). Justifiable Homicides by Law Enforcement Officers What is the Role of Mental Illness? Treatment Advocacy Center. Retrieved from

Shapiro, G. K., Cusi, A., Kirst, M., O’Campo, P., Nakhost, A., & Stergiopoulos, V. (2014). Co-responding Police-Mental Health Programs: A Review.Administration and Policy in Mental Health and Mental Health Services Research, 1-15.

US Department of Justice. (2014). Letter to Albuquerque Police Department. Retrieved from

SB 226, the death penalty for a capital offense committed by a person with an intellectual disability

SB 226 is a new bill being considered by the 84th Texas Legislature regarding the appropriateness of the death penalty for persons with intellectual disability. Before we discuss the details of the proposed bill, we will briefly review the history of the death penalty in the US and how it currently functions in 2015.

Brief History of the Death Penalty

Capital Punishment, also known as the death penalty, dates back to the founding of our country and the first American colonies (Banner, 2002). Historically, executions were public events, believed to deter criminals from engaging in criminal activities. Over time, enforcement of the death penalty has become increasingly private (Banner, 2002). Further, there is no evidence that capital punishment is currently a deterrent for committing crimes or capital murder (Roeder, O., Eisen, L. B., & Bowling, J., 2015).


In 1972, the Supreme Court ruled capital punishment unconstitutional in light of the 8th Amendment, which prohibits ‘cruel and unusual punishment’ (Bill of Rights Institute, 2015). However, in 1976, the US Supreme Court case Gregg vs. Georgia upheld the constitutionality of capital punishment under certain circumstances, and reinstated the death penalty (Death Penalty Information Center, 2015). The Supreme Court created two, broad guidelines for states to follow in terms of capital punishment enforcement and sentencing:

1) objective criteria to determine and limit capital punishment in addition to an an outside review of each person sentenced to capital punishment;

2) adequate context, like the defendant’s character and previous criminal record, need to be provided in order to account for aggravating or mitigating factors

Gregg vs. Georgia also introduced the idea that two trials were required: one to determine whether a defendant was guilty of capital murder, and if found guilty, whether they should be sentenced to death or a lesser sentence (Death Penalty Information Center, 2015).

In 1986, the US Supreme Court case Ford vs. Wainwright upheld the law that people who were “insane” could not be executed (Death Penalty Information Center, 2015). Therefore, all defendants are entitled to a competency evaluation and hearing regarding their mental stability (Death Penalty Information Center, 2015).However, a defendant could be diagnosed with a mental illness and not necessarily deemed ‘insane.’

Finally, in 1994 the Death Penalty Act was passed by President Clinton, which expanded the number of crimes eligible for capital prosecution (Gould & Greenman, 2010).

The Death Penalty in 2015

Today, 32 states continue to enforce the death penalty (Death Penalty Information Center, 2015). There are 5 approved methods of capital punishment: lethal injection, hanging, firing squad, electrocution and a gas chamber (American Civil Liberties Union, 2015). Lethal injection is the most prevalent method of execution, although some jurisdictions allow the prisoner to decide which method to use(American Civil Liberties Union, 2015). There are currently 269 people on death row in the state of Texas, of which 41.6% are African American (Texas Department of Criminal Justice, 2015). According to the Bureau of Justice Statistics (2013), Texas was the #1 enforcer of capital punishment, executing more than twice as many offenders as the #2 enforcer of capital punishment, Florida.

Polunsky, where death row inmates are kept in Livingston, TX.
Polunsky, where death row inmates are kept in Livingston, TX

Death row inmates are kept in a maximum security prison, referred to as the Polunsky Unit, in Livingston TX. Prisoners are housed in single cells, on 22-hour lock down, and are kept separate even during ‘recreation hour’ (Ridgeway & Castella, 2013).

Texas Legislation, SB 226: The applicability of the death penalty for a capital offense committed by a person with an intellectual disability

According to the US Supreme Court, defendants who are found to have an intellectual disability are also exempt from capital punishment (Death Penalty Information Center, 2015). However, the Texas Penal Code does not include this exemption (State of Texas, 2015). Therefore, a current bill is being presented to the Texas State legislation this session regarding the addition of intellectual disability as an exemption from capital punishment (Ellis, 2015). This new policy would require that defendants be entitled to a hearing regarding their intellectual ability. Intellectual disability would be assessed by a qualified institution and an IQ score of 75 or less would be considered intellectually disabled (Ellis, 2015). If the defendant is found to have an intellectual disability, and found guilty of a capital crime, then they will be sentenced to life without parole.


Banner, S. (2002). The Death Penalty: An American History. Cambridge, MA: Harvard University Press.

Bill of Rights Institute. (2015). Gregg. vs Georgia: 1962. Retrieved from

Bureau of Justice Statistics. (2013). Capital Punishment, 2013- Statistical Tables. Retrieved from

Death Penalty Information Center. (2015). Constitutionality of the Death Penalty in America. Retrieved from

Ellis, R. (2015). Texas Legislation, SB 226: The applicability of the death penalty for a capital offense committed by a person with an intellectual disability. Retrieved from

Gould, J. B., & Greenman, L. (2010). Report to the Committee on Defender Services Judicial Conference of the United States Update on the Cost and Quality of Defense Representation in Federal Death Penalty Cases. Retrieved from

Ridgeway, J. & Castella, J. (2013). America’s 10 Worst Prisons: Polunsky. Mother Jones. Retrieved from

Roeder, O., Eisen, L. B., & Bowling, J. (2015). What Caused the Crime Decline? Brennan Center for Justice. Retrieved from

Texas Department of Criminal Justice. (2015). Gender and Racial Statistics of Death Row Offenders. Retrieved from

State of Texas. (2015). Penal Code: Title 2, General Principles of Criminal Responsibilities, Chapter 8, General Defenses to Criminal Responsibility. Retrieved from

Throwback Thursday: Clifford Beers

clifford beers_portrait

Clifford Beers was a Yale graduate who founded the first outpatient, mental health clinic in 1913 called the Clifford Beers Clinic, which is still in existence today (Clifford Beers Clinic, 2015). He was one of the first advocates for improving the treatment of those afflicted by mental illness (The Social Welfare History Project, 2015).

clifford beers

Mr. Beers suffered from mental illness himself, and in 1900, was confined for the first time due to depression and paranoia. In 1908, he published a book A Mind That Found Itself, which chronicled the abuse and maltreatment that he witnessed as an inpatient.

“…I trust that it is not now too late, however, to protest in behalf of the thousands of outraged patients in private and state hospitals whose mute submission to such indignities has never been recorded.” (Beers, 1908)

In 1908, Beers founded the Connecticut Mental Hygiene Society, which expanded to the National Committee for Mental Hygiene in 1909. Today, the organization is known as the Mental Health America, which is a community-based non-profit dedicated to helping all Americans achieve wellness by living mentally healthier lives (Mental Health America, 2015).


Beers, Clifford. (1908). A Mind That Found Itself. Chapter 7. Retrieved from

Clifford Beers Clinic. (2015). The History of the Clifford Beers Clinic. Retrieved from

Mental Health America. (2015). Our History. Retrieved from

The Social Welfare History Project. (2015). Beers, Clifford Whittingham. Retrieved from