Wednesday, January 26, 2005



The PAIR Mental Health Diversion Program of Marion County
[Psychiatric Assertive Identification and Referral Program]

It has now been about ten years since the PAIR Program was started. Some things get hazy with the passage of time, but others become more clear. One of my ideas is to write as much about this local sociological movement to prevent further clouding of the history. I believe it is important and more than an ego boost for any individual. The most prominent issue becoming clearer each day is that persons who actually had little to do with the work of establishing the PAIR Program are purposely, or inadvertently, taking credit for it. [see example 1] There should be a clear accounting of the process as much as possible so others can learn from it. If the emphasis is on promoting one’s self the cause is lost.

And the cause is just and worthy of further work, study, and consideration.

I understand this may be a monumental task and that I am not infallible with my memory. I want to consider it an ongoing work and to get the input from others as much as possible. I plan to keep this journal on my computer as well as my website and to start a blog.

I hope to write this account as accurately as possible with as many names and sources as I can remember. It is my hope that such an account can aid any in doing research of the facts and to establish a body of knowledge that we all can learn from.

"In 1996 Marion County, Indiana, started the Psychiatric Assertive Identification Referral/Response (PAIR) Program in Indianapolis, which many consider to be the nation’s first mental health court. This initiative is a comprehensive pre-trial, post-booking diversion system for mentally ill offenders. In 1997 Broward County (Ft. Lauderdale), Florida launched the first court to be formally called a specialized mental health court." Quoted from here.

The quote above is somewhat in error. It is from a national publication and has been cited many times. While there had been one form or another of informal mental health diversion since the early 1980's, PAIR was not formalized into a concise program with rules and vested stakeholders until 1996. The PAIR Program shares much of its history with the Mental Health Court of Judge Evan Goodman. So in some aspects, the program is much older. [see reference] [See Report from Iowa naming PAIR as a "best practice model"]

Of special note, the literature frequently is wrong about the first mental health court being in Florida in the 1990's. The first mental health court was at Wishard Hospital in Indianapolis in the early 1980's. The presiding Judge was Evan Goodman. The court was set up in the small gym and basketball court we use to use as an exercise area for the inpatients. There are even national stories about this legal court being held on a basketball court. There is even a photo of Judge Goodman with a basketball net. All of this was from the 80's, way before all of the current interest and growth in mental health courts. I was fortunate to be present during that time and joined the forensic mental health team in the mid 80's.

The psychiatrist during the early years of the court was Eugene S. Turrell, MD [deceased] [Read Turrell's Treatment Goals]. I believe there is some published work of his about this historic time.

I came up with the name PAIR [Psychiatric Assertive Identification and Referral] Project in 1995.

The mental health court was at Wishard Hospital from the early 80's until the early 90's. I joined the specialized mental health team which worked with the court in the mid 80's. This team was called the Forensic Team. Its duties were to over see the patients who were on out patient commitment and refused to follow the court's order. Another duty of the team was to work with the criminal courts, the jail, the prisons, the parole department, and the probation departments.

In a consent decree with the jail, ICLU, and the US District Court, I was designated to work with the suicidal inmates once per week at the jail in a group session. The work was with the SP inmates from 1987 to 2000.

I went on a six month leave in 1989 to work with the State of Indiana as a consultant with the CHOICE Program. I acted as a consultant for the placement of the mentally ill in the community rather than placing them in an institution.

While I was on leave, Evan Goodman, the Presiding Judge, of the mental health court, was promoted to the position of head judge over all the administration of the then municipal courts [ about 18 courts in all].

Since many of the staff were promoted and transferred, I was asked to fill the position of Court Liaison for Midtown MHC and the Marion Co. Courts. I continued my work of overseeing the 600+ commitments to Midtown MHC, as well as running the group sessions at the jail for the suicidal inmates.

It was during this period that I developed another important contact. In 1987, I began work with the Midtown MHC's ADAPT program. It was a program on anger management in cooperation with the courts, social agencies, and the Marion Co. Prosecutor's Office. This would lead to me being vice president of the Indianapolis Domestic Violence Network and on a policy committee for Prosecutor Steve Goldsmith in developing policies to handle domestic violence. I believe I contributed a lot to this committee as the problems of mental illness and domestic violence often overlap. {Listen to a radio inteview where I describe this program.]

Later when Goldsmith became mayor, I was to serve on his committee looking into the problem of the dangerous mentally ill in the community and how to develop an effective plan.

We went through several judges at the mental health court. Judge Taylor Baker [See Link 1] was there for a while, but the job did not suit his temperament. Judge Carr Darden stayed for about one year until his promotion. Judge Darden is now on the Court of Appeals.

Judge Steve Eichholtz came last and remained about one year. He often had Commissioner Vicki Yaser also preside over cases. Later, he supervised the closing of the specialized court and the transfer of its unique functions back to the Probate Court.

It is during this time of transition back downtown, I had the opportunity to work with a lot of the courts, the public defenders' agency, the lock up, and the prosecutors' office. I made many acquaintances and friends. I found many advocates for the mentally ill and allies in working to make the system better.

I was contacted by the Johnson County Prosecutor's office and was recruited to do a private domestic violence program for them. I would work as a consultant for about three years with Johnson County.

It was about this time that I was deemed an expert witness and recruited by the Public Defenders' Agency to do private consulting with them and write alternative sentencing reports and recommendations.

Of special note, Judge Eichholtz helped supervise the investigation of several deaths at Central State Hospital, as the deceased patients were on civil commitments out of his court. [On a side note--I personally knew many of these patients having worked at Central State Hospital from 1975 to 1978. Some I even knew from my childhood as my mother was a nurse there.]

It was during this turbulent time that mental health attorney and advocate Jim Frank challenged the state's right to keep the mentally ill hospitalized without giving them the best available medication. At the time, clozapine was seen as a miracle drug for many of the chronically mentally ill with negative symptoms. This were the patients who were frequently in Central State Hospital. Attorney Frank argue if the state was gong to force these people into treatment and to keep them locked up, the state should give them the best available treatment. The problem was that this medication cost anywhere from $10,000 to $20,000 per year, per patient, and one of the possible side effects was death, if not carefully monitored.

Judge Eichholtz heard the case to compel the state to provide clozapine. Doctors gave testimony that there were dozens of patients who would benefit from this treatment. The judge issued an order for state to provide this treatment even though it said it could not afford it.

Some have argued that this was the true reason for the shut down of Central State Hospital: that the state had closed the hospital in an effort to try to pass the ever increasing expense of caring for the mentally ill onto the federal government. Many advocates had claimed that medications and services that were not covered by the federal government while a person was in a state hospital, would be covered if the were "treated" in the community.

It was around this time that Gov. Evan Bayh made his visit to Central State Hospital to make a personal survey. He did not like what he saw. He ordered the hospital to be closed within one year.

A big contributing factor to the start of the PAIR Program was the influence of politicians to keep their private slush funds and make it seem like the monies were being used for the public good. [read A Tale of Money]

Three other big influencing factors would come into the formation of the PAIR Program. One was some Indiana Supreme Court rulings and the other was the formation of a research group to study the closure of Central State Hospital. The final influencing factor was the election of Scott Newman as County Prosecutor.

A few years earlier the Indiana Supreme Court had ruled that Marion County's method of identifying the mentally ill by placing a charge on them as DOC? [disorderly conduct because of mental illness] was unconstitutional. This simply meant that a person accused of a crime faced charges or not, but it often lead to the mentally ill patient being held in the jail for sometimes up to a year and often without treatment.

The other Indiana Supreme Court ruling which affected the history of PAIR was the TT ruling. It basically said that the mental health court had no authority to enforce its orders. The mental health court judge had up to that time, the power to find persons who did not follow his orders, in contempt. He could then order sanctions ranging from incarceration, more intense monitoring, home arrest, etc. After the Supreme Court ruling, the mental health court judge had no power to enforce its orders and no ability to enforce the rules of an out patient commitment. As a result, perhaps hundreds of patients quit treatment without any supervision. For example, Midtown MHC had over six hundred out patient commitments. On any given day, 50% were non-compliant with the court's order to some degree. The only recourse after this court ruling was to hospitalize noncompliant patients. Midtown only has a couple dozen of inpatient beds. The other problem is that patients who stop their treatment may not have their symptoms manifest for months. By the time many of patient's symptoms had worsened, their commitment would have been dropped.

The other big court ruling was the decision that psychiatric medications could only be forced in the treatment of an illness and not for abnormal behavior. A much quoted opinion about the side effects of tardive dykinsia was published. This ruling and opinion had a chilling effect on the psychiatric community. There is no blood test for mental illness. Diagnosis is often made on the basis of behavior. Persons who exhibited psychotic behavior were frequently arrested. It was easier for many mental health providers to wash their hands of the problem and let patients go to jail. It also become fairly common for inpatient facilities to call the police when a psychiatric patient acted up on the ward. These patients would be arrested and transferred to the jail, often in a psychotic state.

Another major influencing factor was the formation of the research program from IU. This did several things to enhance the development of PAIR. Just the fact that they were studying the program and the problem lent some legitimacy. Other factors included the prestige of many of the professional people to be part of the literature and perhaps be named as co-authors. This is important in both the legal and psychiatric field. The final factor was that because of this research, the program might qualify for federal funding. This proved irresistible for many of the stakeholders---the ability to be paid for what they were already doing.

The final major influencing factor which brought about an alignment of forces to permit the development of the PAIR Program was the election of Scott Newman as prosecutor. The National Law Journal called him the "kamikaze prosecutor". I had met him when he first went to work as a young deputy prosecutor when he did some time in the mental health court. He was arrogant, brash, rude, and totally unsympathetic to the problems of the mentally ill. I will always remember him as the worst prosecutor we ever had in the mental health court. [Read more about him in the essay "A Tale of Two Attorneys"] Many professional people could not understand how such a person could be elected, and even Newman himself has been quoted as saying, "even a trained monkey could have won the election that year."

Newman used this slush fund to his advantage while seemingly persecuting the poor and mentally ill because the public defenders' agency was underfunded and understaffed [ see PDA Link]

Newman did four things which were devastating for the plight of mentally ill and the enlargement of the problem of criminalizing the sick. They are:
1. The establishment of "no tolerance zones" or "red zones".
2. The establishment of the no tolerance for plea bargaining and the goal of seeking the maximum sentences even on misdemeanor offenses.
3. The publishing of the "top ten list" of misdemeanor offenders who he publicly stated he wanted to get and put in prison forever. The problem with this list was that at least eight of the top ten were persons with severe mental illness or mentally retarded.
4. The establishment of a policy to rid the downtown of homeless persons, with increase prosecution for trespassing, disorderly conduct, or pan handling.

The Newman factor was the most disturbing to me personally, but has not gotten a lot of press. How could one man persecute and hurt the mentally ill unfettered? I will explore this issue in other essays. [read related article on Scott Newman]

The next stop for many of these patients was the county jail and on to prison. With the passing of "The Kiritsis Law" , the general public showed that it was not symathetic to the mentally ill. The Kiritsis Law was the establishment of the doctrine that a person could be "guilty, but mentally ill." Most of the public, and even today, believe that when a person is found "guilty, but mentally ill", they are kept in a special humane place within the prison system and given treatment while they are contained from society. This is not true and many, if not all, of these individuals are treated worse and more cruelly than if they were just found guilty and given the maximum sentence. Some of these mentally ill inmates would in effect be tortured during their years of incarceration and then be released unsupervised back into the community and often untreated. Many in fact came out without even the supervision of parole as they had often acted up the whole time of their incarceration and thus had served the maximum sentence. There is no provision in Indiana law to add more sentences and parole because of mental illness. What is especially sad here is that frequently, the Department of Corrections, would go to a local mental health hospital and explain that a mentally ill inmate was about to be released. The DOC would ask the center to commit these individuals for treatment. The same individual who had often been mistreated and neglected for years.

Now this is the true setting for the formation of the PAIR Mental Health Program. The state hospital is closing. There is a back log of patients in the community who need hospitalization. Many psychiatric patients are being arrested for acting out with the encouragement of the "kamikaze prosecutor". The mentally ill who have been in prison for years are being released, untreated and abused, back to the community without supervision. The mental health specialty court is shutting down.

****I will continue later*****3/4/05*********

The PAIR Program is cited in the virtual "who's who" of mental health diversion programs listed here.

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