Sunday, July 01, 2012


Presentation of New Ideas for the PAIR Program 2012

Greetings! I am Bob Cardwell.  I am one of the founders of the PAIR Mental Health Diversion Program. Back in the beginning of The Pair Program, I helped facilitate its start by doing the mental health screenings in lock up and leading the group presentations to the PAIR Roundtable.

I am here today to talk today about this program. It is a program dear to my heart. I have worked in the mental health field since 1975.  My involvement though goes back to my visits to my mother who was a nurse at Central State Hospital. In the sixties it was common for employees to bring their kids in to the picnics and festivities. It is becoming rarer as I grow older, but it still , once in a while, I run into a old resident, or hear something about an old Central State Hospital resident I met as a child.

So for good or bad, being involved in the mental health field is a big part of my life. In spite of all the work I have done and goals I have accomplished, there is only one thing I might be remembered for doing, and that is why I am here today. The PAIR Mental Health Diversion Program is my legacy. It is perhaps my sole chance at being recognized or to have my work remembered. I want to see the PAIR Mental Health Program grow and continue to do good work.

Here are my goals for this presentation:  
1. I want to talk about some ideas to grow the program. 
2.  I want to talk about ideas to make the program safer and to increase the quality of care and 
3. I wish to talk about ideas to fund the PAIR Program.

I met with a young lady recently. She was a MSW student making a mid-career switch to social work and was writing a research paper on the PAIR Program. She had already interviewed several past and present members of the PAIR Program.  She updated me on the current state of the PAIR mental health diversion program. The round table meeting still happens every Thursday. It is unclear if any of the players are the same as they were when I and my associates started the PAIR Program. It seems that some of the representatives of the original stakeholders still attend. The representative for the largest mental health service provide is there. An assistant prosecutor is there. A public defender is there as are some support clerical staff from the PD's office. And finally, she said that someone from the MHA--The Marion County Mental Health America association still advocates for the mentally ill as a court monitor.

Sadly, there seems to be missing the attendance of anyone who actively goes out and searches for persons who could actually benefit from the program. In the beginning of PAIR, there were several persons actively advocating for the mentally ill as they entered custody and help coordinate any emergency or long term treatment.

Roughly 60, 000 people are processed through the Arrestee Processing Center. Only 10% or 6000 are held for more than a few days. A conservative estimate would be that 10% of these longer term detainees are the seriously mentally ill, or about 600 are held who need serious psychiatric treatment. That conservative number would easily make the Marion Co. Jail the largest mental health inpatient [or custody] treatment facility in the state. And who is actually treating the largest group of mentally ill persons in custody? A private contractor.  A contractor whose main goal is to make a profit. There is no concern for the long term welfare of the patient or the county. There is no accountability to the patient, the court, or the community. To my knowledge, there is no one at the PAIR round-table to represent this private contractor nor to represent the welfare of the serious mentally ill offender.

 I believe this lack of over-site and accountability for the treatment of the SMIO is wrong and should be corrected. It is possible that I don't have all the facts, but several reports from the PAIR program suggests that there is something wrong. The biggest indicator seems to be the lack of utilization of the PAIR Program by those SMIO [serious mentally ill offender] in jail. I am told that in spite of the program being in existence for 17 years, it is roughly handling the same number of clients, about four dozen, as it did in the beginning of the program. Why is there no growth? What happened to all the in-kind services provided to the PAIR program? What happened to all the significant investments of personnel time and expense? Has the PAIR program evolved into a show boat of good intentions and good will publicity without doing any real work? 

 In the beginning, I believed that we in the PAIR program thought we could really make a difference. It was the naiveté and the belief that caring people could change the world, or at least our county. When I first started working on the PAIR project I tired to pull in people who were not only knowledgeable and powerful, but truly seemed to care about the work and for the ideal of doing something good for the welfare of the community. This group ended up including professors, judges, attorneys, doctors, social workers, nurses, prosecutors, advocates, and the public defenders. Interestingly, many of the early PAIR workers had family members or love ones with mentally illness and had first hand experience with the deficits in the current social network or so called safety net for those with psychiatric problems. All of the early participants in PAIR seemed to understand that the criminal/justice system's treatment of the SMIO is/was a microcosm of how the mentally ill are treated in the real world. Early on we tried to promote the notion that a rationale and humane manner of treating the mentally ill in the criminal/justice system could actually save money. We didn't want money. We wanted to save money and the dignity of the ill. We wanted to save all of us money and be more caring to the mentally ill too. 

We benefited from Prosecutor Scott Newman's crusade to cut costs and his posting of the "top ten frequent arrestees". He asserted that these few persons accounted for over a million dollars in processing costs, which included: man hours, court costs, and the cost of incarceration. Often times when the subject was released by the court to the community, he would then be re-arrested before his release papers were even finished being processed. All of the persons on this list were frequently treated at the local mental health centers. And the final comment on the list was that all of the arrests were for trivial charges like public intoxication, trespass, disturbing the peace, etc; or what are generally known as misdemeanor nuisance charges. Most of the people on this list would be dead before the end of the decade.

Who advocates for a sane system now? Who actually enters into the pit and tries to rescue people? I would like to see the PAIR Program grow and do some good. I would like to shake the program out of it complacency and see it actually do something more than just being happy with the status quo. It seems at present, the program is little more than window dressing, or a dog and pony show. This PAIR program gives elected officials some plausible deniability of the state of the care of the mentally ill in the county facilities. They can say, "We are working on it". "Look what the PAIR Program does." ETC. Meanwhile, sick people are suffering in jail cells and nothing is being done about nudging them toward treatment nor helping them improve their lives.

The PAIR Program is in reality advocating for the same number of people we did 20 years ago and there is no supervision of care on the front lines in the jail. 
 I would like to offer the following suggestions on re-invigorating the PAIR program and improving it:

I would like to see a build up the esprit de corp and an increase of knowledge of the PAIR Roundtable participants. In the beginning of the PAIR program, we went on frequent field trips to treatment facilities and service providers. We went to Carter State Hospital, a Day Reporting program, Richmond State Hospital, Madison State Hospital, and Logansport State Hospital. I did not get the time to do more on the criminal/justice side. I would advocate the PAIR Roundtable start taking tours of the courts, the jail, the arrestee processing center, and community corrections center. The group needs to understand what truly happens on the front lines. These field trips,  educate and informs all who are involved in the work with the mentally ill. 

I believe there needs to be more advocacy in the PAIR program. The Protection and Advocacy service needs to be more involved in the needs of the mentally ill in custody. They have federal and state mandated powers to this. Also, the ACLU needs to get involved and advocate for a rational consent decree to insure that the rights of the SMIO [serious mentally ill offender] are being protected in jail.  Finally, the MHA [Mental Health America] needs to arrange for its staff or volunteers either to respond to the requests of the incarcerated SMIO or to periodically visit to insure the quality of supervision is being maintained. In my day, the local federal court has several supervision projects.

I believe there needs to be a designated staff person from the PAIR program, to screen for the mentally ill in the group of daily new arrestees. That is what I use to do.  I would screen the records of perhaps a hundred new arrestees and interview ten, everyday. Now, this could be a two part screening with the first part being done by trained medical staff and the bail commissioners. If the inmate is grossly psychotic and dangerous, or at risk;  he should be sent for immediate emergency care. The second part of the screening should be done by a representative of  PAIR who has acecss to the county or public mental health records. At any given time, there are dangerous persons entering the jail whom are already under care for mental illness or addiction and  under the supervision of a court order, be it a civil commitment, probation, parole, bail conditions, community corrections, or some other pending criminal case. All of these public and private records need to be available in one database for the use of the PAIR screener. The PAIR screener refers the appropriate case to the respective appropriate entity, while determining those who meet the guidelines for an intervention by the PAIR program.  The PAIR Screener will bring those cases who meet the guidelines to the PAIR roundtable meeting on Thursdays.

I believe that the Prosecutor's screening committee either needs to have a representative of PAIR in attendance or a member of the screening committee needs to attend the weekly PAIR Roundtable. The screening determines the severity and whether charges should even be officially brought against an individual. This process may present the opportunity for the prosecutor to make a informal offer of diversion rather than simply dropping a charge which may be of benefit to the arrestee and the community. The PAIR program could follow up and report whether the agreement was followed or not and if so, the charges could be dismissed. I believe many new cases for the PAIR Mental Health Diversion could be found during this screening process.

I believe here should be periodic public workshops to train and inform the public about the PAIR program. I believe one of the best things we use to do as a group was to participate in public and professional workshops. I traveled all over the state and also gave presentations in Chicago to the National NAMI meeting and to Washington DC, to give a workshop at the National Public Health Convention. The PAIR Program needs to participate more in this process and contribute to the body of knowledge about the incarcerated mentally ill.

I believe that the providers of psychiatric treatment in the Marion Co. Jail System and Community Corrections need to send a representative to the PAIR Roundtable and provide a record of those receiving treatment in custody. This would insure some continuity of care and provide some reasonable oversight. Some of these same inmates may cycle through our different systems many times and the more we know about their history and treatment, the more effective and humane we can be.

 The CIT officer's program seems to be working well.  I believe there should be a CIT officer in attendance at the weekly PAIR roundtable to discuss problems and issues of mutual interest. This could aid in the enforcement of the diversion agreements and increase the effective use of the Immediate Detention law.  This cooperation could aid the ideal of community policing and increase the likelihood that the CIT officer and SMIO have an opportunity to have an informal diversion agreement.

There are multiple types of diversion programs and agreements. There is a domestic violence court, a drug court, a protective order court, and perhaps others who have a diversion agreement. I believe there should be some coordination and database of those on diversion and what the conditions of the agreement are. This sharing of knowledge will cut down on duplication of resources. There should be a public record of a diversion agreement.

I believe there should be a representative of the Marion Co. Probation Department in attendance at the PAIR Roundtable. Many of the mentally ill offenders won't qualify for diversion, but will have their treatment supervised by probation. Another benefit to the probation department is that many of their clients are mentally ill and will need services long after the probation is over. There is a strong possibility that many of them will be re-arrested for nuisance crimes. This cooperation would benefit the community. 

I believe the courts, and specifically the Circuit Court and the Probate Court should be more involved in the PAIR program. Many of those arrested are already on a civil commitment out of the Probate Court which is suppose to supervise the person's mental health treatment. At present, it is possible for a mentally ill person to be on a civil commitment, on several types of diversion, and to be on probation: ALL AT THE SAME TIME! The Circuit Court needs to determine a way to coordinate this better. It would be especially beneficial for the Probate Court to send someone with knowledge of the civil commitments to the PAIR Roundtable as it is the responsibility of this court to supervise committees' treatment. A more long term goal could be that there would be designated court for civil commitments and for minor criminal charges. This court could follow persons on commitment and diversion. This new court could issue new commitments and diversion. It could offer supervision. This new mental health court could also screen and coordinate the petitions for ICST and its mandated provisions. A court with specialized knowledge in ICST would save the system much in time and expense.  

I believe that the PAIR Roundtable needs to be more formalized. There should be formalized roles. There should be an up or down vote on accepting someone for the PAIR program. This would necessitate that there be some formal bylaws and a formal administrative body or advisory board. The advisory board should be appointed by the mayor, the City-County Council, and/or the governor. The PAIR Roundtable would work under the supervision of the PAIR Mental Health Diversion program. The PAIR Advisory board would need a similar body as the community corrections board. There should be a representative of the Mayor, the City-County Council, the IDOC, the Marion Co. Courts, The Marion Co. Sheriff, The Marion Co. Prosecutor, The Community Corrections Director, Mental Health Advocates, Members of the Public, and Mental Health Service Providers. The PAIR Roundtable and interested parties should nominate official members of the roundtable and they shall be affirmed by the advisory board. 

The purpose of the PAIR Roundtable is to hear case presentations and to vote on whether that individual is appropriate for the diversion program and may possibly benefit from its supervision. The cases will be presented by the PAIR screener or other interested parties after being placed on the agenda by the PAIR coordinator. The number of participants to the roundtable should be reasonable to facilitate discussion and to keep information as confidential as possible. Members should include the screener, the coordinator, a public defense attorney, assistant prosecutor, advocate, patient program monitor, and formalized representatives of major public mental health providers. Other interested parties could attend the PAIR roundtable meeting but should have the power to vote.

The court supervision and monitor portion of the diversion program should continue to be in the Mental Health Diversion Court. As usual, there will be a hearing where the court monitor reports on the progress report under supervision of the assistant prosecutor. The client will give testimony under the supervision of the public defender. The judge will ask questions of comments at will. The diversion agreement is either extended, terminated as failure, terminated as a success. If the agreement is a failure, the prosecutor will decide on whether to send this matter back to criminal court for prosecution.

I recommend that the PAIR Program find new ways to fund the program.   I suggest to follow the money. Do a cost benefit analysis. Many of the agencies and government entities which benefit from the PAIR Program have their own revenue streams. Some of these streams are taxes, grants, and fees. Some of these fees are collected from individuals and some from other agencies. Often times this cache of money is not supervised by any oversight and are used at the discretion of a department head or an elected official. Sometimes these individual funds are a repository of millions of dollars collected per year and are sometimes used for the most trivial of projects and to promote the PR of the agency. Two examples are the diversion fund of the prosecutor's office and the sheriff's commissary fund. Most of what the public knows about these funds come from the shadows. There needs to be known more about these funds and how they can be utilized for the public good like funding the PAIR program. If the prosecutor or sheriff has millions of dollars floating around for their discretionary use, the PAIR Program should be advocating for some funding as their services save money for the respective agencies.

Finally, another initiative I have thought about is the Make, Sake, Bake, Take, or Shake Program. PAIR can make money by collecting fees from either the individuals or from the participating agencies. The sake part of the initiative is getting donations because this a good program and people should fund it for goodness' sakes. The bake part is where the members of the PAIR program do different fund raisers to get enough money to fund part of the PAIR program. The take portion is to take funds from agencies which benefit but who may not want to give it to you like the sheriff or prosecutor. The shake idea is to seek funding through taxes or funding through the City-County Council. The PAIR program logically saves money and the time of many agencies. These agencies should contribute funds to help PAIR help them reach their performance goals more efficiently.

These are just a few of my thoughts, here at the beginning of the Summer in 2012.

Are there any questions or comments?


Respectfully Submitted,

Robert Cardwell, LSW, QMHP
Original PAIR Program Founding Member.

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