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Where mental illness and criminal justice meet

Massachusetts needs a new approach to treating mentally ill prisoners. A promising model could take hold in Middlesex County.

Assistant Medical Director Brian Clark checks vital signs in the Sobering Unit at the Restoration Center in San Antonio, Texas, in 2016.Erich Schlegel/Boston Globe

Law enforcement agencies have historically been ill-prepared to respond effectively to emergency incidents involving behavioral health — that is, when a person suffering from a serious mental illness or substance use disorder behaves in a threatening manner, endangering themselves or the public. That’s starting to change, albeit slowly. As calls for police reform have heightened in recent years, police departments across the country have made it a priority to establish and increase funding for teams of social workers to respond safely to such incidents.

Still, for many people, the possible outcomes after those police encounters are typically constrained to two options: Either the person is sent to an emergency department or gets arrested and sent to jail. If it’s the latter, the person now has a criminal record, which often only compounds the mental-health issues that led to the incident in the first place. And the former is generally a short-term medical solution that doesn’t necessarily guarantee adequate long-term treatment. Emergency rooms in the state are often ill-equipped and overburdened by mental health patients, and beds at mental care facilities too few. Far too often, only these scenarios are available, even when clinicians are embedded in police departments.


But there are alternatives at the nexus of policing and mental illness that Massachusetts hasn’t fully pursued. Jurisdictions all over the country have been moving toward community-based models to disentangle law enforcement from crisis response even more, such as jail diversion facilities where patients can receive urgent crisis stabilization services in less restrictive settings than jails or emergency rooms. It’s time for the Commonwealth to get fully on board with these alternatives.

In 2018, as part of the latest criminal justice reform effort, the Legislature established a task force to explore what such a diversion center would look like: the Middlesex County Restoration Center Commission, chaired by Middlesex Sheriff Peter Koutoujian and Danna Mauch, president and CEO of the Massachusetts Association for Mental Health. But the groundwork began four years ago when Koutoujian traveled to San Antonio to visit the comprehensive work done in Bexar County, widely lauded nationally, to identify and treat people with mental illness before they enter the criminal justice system.


The need has never been greater for this kind of initiative to become successful in Massachusetts.

Pre-pandemic, nearly 50 percent of those in jail or detained in the Middlesex Jail and House of Correction had a mental health condition, and 80 percent had a substance use condition, according to figures provided by the sheriff’s office. Three-quarters of those who are mentally ill have a co-occurring substance use condition. Anecdotally, police chiefs in Middlesex County — the state’s most populous county — reported that up to three-quarters of officer time may be spent on behavioral health calls for service.

Those numbers not only persist now, they are higher due to the increase in releases seen last year as a safety response to the pandemic. Koutoujian said that 69 percent of those currently jailed in Middlesex County have an open mental health case and 49 percent have a confirmed diagnosed mental illness. The co-occurring rate is 87 percent now, he said. “Quite honestly, the acuity level is much higher,” said Koutoujian. “The people we’re [currently] housing also tend to be much more mentally ill.”


Koutoujian spoke of someone who landed in his jail recently. “He has been back and forth with us numerous times over the years just eating anything he could get his hands on — eating his radio, eating pieces of linoleum floor, eating paint chips, eating anything,” he said.

In its fourth year, the commission plans to implement a pilot restoration center in Middlesex County — a facility where law enforcement could send people with substance use or mental health disorders for appropriate treatment. “What happens when they’re in the facility, that’s what this pilot is for,” said Senator Cindy Friedman, who’s part of the commission. “It’s not just getting someone to a place. At the other end there has to be someone who knows what to do and can deal with this person who is ill and not criminal. Right there, it keeps them one step away from the criminal justice system,” she said. The restoration center would also take walk-ins.

As state budget negotiations are underway in conference committee, it is critical that the Legislature funds the center at a minimum of $1 million, which is what the commission expects to get in the budget. Also crucial is for lawmakers to keep a trust fund, included in the Senate budget proposal, that would allow for other sources of revenue to fund the restoration center pilot. “That would be money from foundation grants, federal earmarks, and/or the [American Rescue Plan] act,” said Friedman.


The evidence has not only shown that intercepting those in behavioral health crisis makes a huge difference in their trajectory, but there are also huge cost savings. Estimates show that city and county jails, emergency departments, and courtrooms avoided nearly $97 million in costs during the first years of operation of Bexar County’s restoration center.

The Middlesex County Restoration Center offers Massachusetts the chance to adopt ways that other states have been able to strengthen services for people who suffer from mental illness to see if they can address the crisis here. It would also go a long way to support current diversionary efforts happening among police departments in Middlesex County. The state should do what’s necessary to allow this new model to thrive.

Editorials represent the views of the Boston Globe Editorial Board. Follow us @GlobeOpinion.