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. 2021 Aug 16;9(2):7.

Estimating the Size of the Los Angeles County Jail Mental Health Population Appropriate for Release into Community Services

Stephanie Brooks Holliday, Nicholas M Pace, Neil Gowensmith, Ira Packer, Daniel Murrie, Alicia Virani, Bing Han, Sarah B Hunter
PMCID: PMC8383839  PMID: 34484879

Short abstract

Researchers studied the Los Angeles County jail mental health population to identify those who would likely be eligible for diversion based on legal and clinical factors with the aim of providing them with needed care and reducing recidivism.

Keywords: Incarceration, Mental Health Treatment, Recidivism, Prison Reform

Abstract

In 2015, the Office of Diversion and Reentry Division (ODR), an internal department of the Los Angeles County Department of Health Services, was created to redirect individuals with serious mental illness from the criminal justice system. Part of ODR's mission is to identify individuals currently incarcerated in a Los Angeles County jail who are experiencing a serious mental health disorder and, to the extent practical, provide them with appropriate community-based care with the goals of reducing recidivism and improving health outcomes. Such redirection from the traditional criminal justice process is often characterized as diversion. To better build and scale efforts to support this work, in 2018, the Los Angeles County's Board of Supervisors asked for a study of the existing county jail mental health population to identify those who would likely be eligible for diversion based on legal and clinical factors. Researchers found that an estimated 61 percent of the jail mental health population were likely appropriate candidates for diversion; 7 percent were potentially appropriate; and 32 percent were likely not appropriate candidates for diversion. These findings will help the county determine how it would need to scale community-based treatment programs to accommodate these individuals. The authors also provide recommendations for future programming and research. This study will be of interest to state and county governments as well as other organizations serving criminal justice–involved populations with serious mental illness.

Key Findings

  • In June 2019, 5,544 individuals were in the Los Angeles County jail mental health population, which includes individuals in mental health housing units and/or taking psychotropic medications.

  • Researchers developed a set of structured legal and clinical criteria to reflect the factors that contribute to the Office of Diversion and Reentry's (ODR's) decisionmaking when determining whether an individual may be put forward as a candidate for diversion—that is, redirection of eligible individuals with serious mental illness from traditional criminal justice processing into community-based services.

  • Based on a consideration of these legal and clinical factors, an estimated 61 percent of the jail mental health population (about 3,368 individuals) were determined to be appropriate candidates for diversion; 7 percent potentially appropriate (414 individuals); and 32 percent (1,762 individuals) not appropriate candidates for diversion.

  • In conducting our review, we were not bound to existing diversion programs in Los Angeles County (or the current capacity of existing programs). Because of this, these findings will help the county determine the full size of the population that would be appropriate for diversion and how it would need to scale community-based treatment programs to accommodate those individuals.

The largest mental health facilities in the United States are now county jails (Torrey et al., 2010). About 15 percent of men and 31 percent of women incarcerated in jails have a serious and persistent mental disorder (Steadman et al., 2009). Conservative estimates suggest that 900,000 persons with serious mental illness are admitted annually to U.S. jails, usually as pretrial detainees (Steadman et al., 2005). Los Angeles County is no exception to this trend. On average, in 2018, 30 percent of individuals incarcerated in the county jail system on any given day were in mental health housing units and/or prescribed psychotropic medications (5,111 of 17,024 individuals in the average daily inmate population for that year; Los Angeles County Sheriff's Department, 2019). This reflected a substantial increase since 2009, when just 14 percent of those in the county jail were in the jail mental health population. Moreover, between 2010 and 2015, there was a 350-percent increase in the number of incompetent-to-stand-trial cases referred to Department 95, Los Angeles County's mental health court program (Katz, 2019).

This increase in the mental health population in county jails is coupled with an increasing emphasis on establishing programs designed to redirect eligible individuals with mental health disorders from traditional criminal justice processing and provide them with community-based clinical services. Such redirection is often characterized as diversion. Diversion programs have many potential advantages: They connect individuals with needed treatment services, reduce the burden on correctional systems to provide these services, and may save costs without compromising public safety (Heilbrun et al., 2012). Moreover, providing treatment in the least-restrictive environment is a core principle of patient-centered care. The movement toward diversion is taking place on a national level. For example, in 2015, the Stepping Up Initiative was launched by the National Association of Counties, the American Psychiatric Association Foundation, and the Council of State Governments (CSG) Justice Center with the explicit goal of connecting counties with “the tools they need to develop cross-systems, data-driven strategies that can lead to measurable reductions in the number of people with mental illnesses and co-occurring disorders in jails” (National Association of Counties, American Psychiatric Association Foundation, Justice Center/the Council of State Governments, Bureau of Justice Assistance/U.S. Department of Justice, 2018, p. 1).

Recognizing the local need in Los Angeles County for alternative approaches for dealing with mental health challenges in the criminal justice system, the ODR was established within the Los Angeles County Department of Health Services (DHS) in 2015. At the same time, DHS became primarily responsible for provision of care in the county jail (Motion by Supervisors Mark Ridley-Thomas and Sheila Kuehl: Expanding Effective Diversion Efforts in Los Angeles County, 2015). Although several small diversion options were available in Los Angeles County at the time (e.g., specialty courts), most individuals with mental health concerns in county jails received jail-based services (Lacey, 2014). In contrast, ODR aims to support individuals with serious mental illness (SMI) who are involved in the criminal justice system by allowing them to access community-based services (Los Angeles County Department of Health Services, 2018).

ODR currently supports several courtroom interventions along the continuum described in the Sequential Intercept Model (Munetz and Griffin, 2006), which result in release into community services (referred to as diversion for the purposes of this study, but it should be noted that this term is distinct from “the California Department of State Hospitals [DSH] Diversion,” which is a specific program offered by ODR). Current ODR programs that remove individuals with SMI from custody are the following (Los Angeles County Department of Health Services, Office of Diversion and Reentry, undated):1

  • Supportive housing program for individuals experiencing homelessness (i.e., ODR Housing program): Initiated in August 2016, this program is designed to serve individuals with a felony charge who are experiencing SMI and homelessness. Those who enroll in the program plead guilty or no contest and are sentenced to ODR Housing with a term of probation of three to five years. A key condition of probation is to comply with the terms of ODR Housing. Individuals who enroll are then eligible to remain in ODR Housing after probation termination, as it reverts to permanent supportive housing with continued case management services for life.

  • Misdemeanor Incompetent to Stand Trial–Community-Based Restoration program (MIST-CBR): Started in October 2015, this program serves individuals who are charged with misdemeanors and found incompetent to stand trial. For these individuals, ODR submits a conditional release request, and diversion to community-based treatment settings takes place under the supervision of mental health judges.

  • Felony Incompetent to Stand Trial–Community-Based Restoration program (FIST-CBR): Started in July 2018, this program is a collaboration with DSH. DSH provides funding to support community-based restoration for individuals who would otherwise be waiting for state hospital slots. Individuals are committed to housing in the community and receive community-based restoration. Additionally, ODR identifies individuals in jail who have become competent while waiting for DSH placement and typically recommends entry into another ODR program (e.g., ODR Housing) or a jail-based program (a pathway referred to as the “Off-Ramp”).

  • DSH Diversion program (under California Penal Code § 1001.36): This new program (also known as “DSH Diversion”), effective January 1, 2019, was established by California Penal Code §§ 1001.35–1001.36 (“Diversion of Individuals with Mental Disorders”). The new laws allow for diversion of individuals charged with felonies or misdemeanors if a qualified mental health expert can identify a nexus between the offense and a mental health concern. ODR receives funding from DSH to provide services to those who meet the statutory criteria and who have the potential to be deemed incompetent to stand trial. DSH narrowed the eligibility criteria to serve those diagnosed with schizophrenia, schizoaffective disorder, and bipolar I disorder and charged with a felony offense.

As of November 2019, ODR had removed 4,305 individuals from custody and placed them in community-based services through its programs (Health Services, Office of Diversion and Reentry, Los Angeles County, 2019). This included 2,316 through ODR Housing, 1,577 through MIST-CBR, 230 through FIST-CBR/Off-Ramp, and 64 through DSH Diversion.

Current Policy Landscape in Los Angeles

In the last two years, the Los Angeles County Board of Supervisors (BOS) has made significant efforts to encourage the study of alternatives to incarceration, with a particular focus on the population with mental illness. In August 2018, the BOS directed a study of the existing jail mental health population to determine who may be eligible for diversion programs (which resulted in this study) and required the development of a “diversion road map” that would explore how the county could increase the availability of community-based treatment options (Motion by Supervisors Mark Ridley-Thomas and Kathryn Barger: Scaling Up Diversion and Reentry Efforts for People with Serious Clinical Needs, 2018). This includes a focus on the types of programs, staffing, and funding that would be needed to support additional diversion efforts. Furthermore, the BOS acknowledged the lack of both state and local mental health beds in California and directed the Los Angeles County Department of Mental Health (DMH) to “assess current and future need for Mental Health Hospital beds that support the jail population” (Motion by Supervisors Kathryn Barger and Hilda Solis: Addressing the Shortage of Mental Health Hospital Beds, 2019, p. 2). In February 2019, the BOS then established the Alternatives to Incarceration Workgroup, which was tasked with bringing stakeholders together to build a “more effective justice system” (Revised Motion by Supervisors Sheila Kuehl and Mark Ridley-Thomas: Developing the Los Angeles County Roadmap for Expanding Alternatives to Custody and Diversion, 2019, p. 2). In their interim report, the workgroup encouraged the expansion of a system of care that is accessible to individuals experiencing mental illness before they end up involved in the criminal legal system.

In addition to studying the needs of those with mental illnesses and the best practices needed to support them, the county also has taken steps to fund and expand available services. The BOS authorized ODR to expand its current ODR Housing program to eligible individuals in the entire county by the end of 2019; previously, its services were only available to cases heard at the downtown central courthouse (Motion by Supervisors Mark Ridley-Thomas and Sheila Kuehl: Expanding ODR's Housing Program Countywide to Safely Divert More Individuals with Serious Clinical Needs, 2019). Moreover, the passage of Assembly Bill No. 1810, which allows for pretrial diversion of individuals charged with certain crimes who are experiencing mental health issues, expanded ODR's capacity to address the needs of this population as well as the capacity of the courts and public defender's offices to divert individuals more quickly into community-based alternatives (Motion by Supervisors Sheila Kuehl and Mark Ridley-Thomas: Expanding Countywide Diversion for Justice Involved Adults, 2019; Garcia, 2019). Furthermore, as a new measure, the county is investing in a campus-based project designed as an alternative to arresting and incarcerating individuals experiencing mental health issues and homelessness (LAC + USC Restorative Village Concept Paper, undated), which highlights additional efforts to augment existing systems of care.

Another key shift happened in August 2019. The Men's Central Jail, located in downtown Los Angeles, was slated to be replaced with the Consolidated Correctional Treatment Facility, often described as a “mental health jail” that would provide treatment to more than 3,800 incarcerated individuals with mental health concerns in a secure setting. In February 2019, the BOS modified this plan to build at least one mental health facility, which would be run by health providers. On August 5, 2019, DHS, DMH, and the Department of Public Health delivered a report to the County Chief Executive Office outlining the need for services to be developed along a continuum of care, with significant options for unlocked community-based facilities for individuals with mental health issues (County of Los Angeles Chief Executive Office, 2019). On August 13, 2019, the BOS voted to cancel the contract to replace the Men's Central Jail (Motion by Supervisors Hilda L. Solis and Sheila Kuehl: Cancellation of Design-Build Contract with McCarthy Building Companies, Inc., 2019), citing the importance of understanding what percentage of individuals in the jail could be safely diverted to community-based treatment as critical to determining what type (and size) of treatment center would be needed (Motion by Supervisors Hilda L. Solis and Sheila Kuehl: Cancellation of Design-Build Contract with McCarthy Building Companies, Inc., 2019). Together, these recent policy actions highlight the need to understand the current size of the population appropriate for diversion.

About This Research

To ensure that an appropriately sized system of care exists in Los Angeles County, it is critical to know the size of the potentially divertible population. The RAND Corporation was contracted by ODR, in collaboration with Groundswell Services, Inc.; the University of California, Los Angeles, School of Law Criminal Justice Program; and the University of California, Irvine, to estimate the size of the current population of individuals incarcerated in county jails who would likely be legally suitable (i.e., appropriate for diversion from a legal perspective) and clinically eligible (i.e., appropriate for diversion from a clinical perspective) for community-based treatment programs. ODR as an agency is responsible for identifying individuals to put forward as a candidate for diversion. Our goal was to understand the factors that contribute to ODR's decisionmaking when determining whether they will put someone forward as a candidate and then to apply the factors to a representative sample from the jail mental health population. In conducting this research, we were not bound to existing diversion programs (or current capacity within existing programs) in Los Angeles County; rather, we were interested in determining what percentage of individuals incarcerated at the county jail could be diverted assuming that there were no limits on the types of programs or number of treatment slots available in the community. The research was designed to help determine how the county would need to scale community-based treatment programs to accommodate the full divertible population.

Methods

There were two phases to our methods: First, we developed a set of structured clinical and legal review criteria to ensure the reliability and replicability of our decisions regarding appropriateness for diversion. Second, we applied these criteria to a stratified random sample of individuals from the jail mental health population to identify an estimate of divertible individuals.

Phase 1: Developing Legal and Clinical Criteria

We began by developing criteria used to determine legal suitability and clinical eligibility for diversion. We started this phase by holding discussions with ODR clinicians to better understand ODR programs and processes, including the factors they consider when determining if they will put someone forward as a candidate for diversion. We also held discussions with a number of other important stakeholders—including district attorneys, public defenders and alternate public defenders, LASD representatives, and program clinicians—to better understand the context in which the ODR programs operate. Because diversion is a decision that ultimately involves multiple stakeholders—including defense attorneys, prosecutors, and judges—ODR staff work closely with these individuals to determine who may be appropriate candidates for diversion. In practice, ODR staff apply this knowledge when conducting their initial screening of an individual's suitability. Based on our discussions, and dependent on the particular program, it appears that ODR considers whether the case has at least some potential for a successful review when the question of legal suitability is reviewed by a judge. This should be kept in mind in the context of our criteria development work.

Our goal was to develop criteria that reflect ODR's decisionmaking for identifying potential candidates for diversion. These were then formally tested against a sample of cases that ODR reviewed as part of a preliminary study,2 which enabled us to examine the reliability of our criteria before they were applied to a larger sample in the second phase of our study. Our legal criteria were developed to identify current and past charges that might render someone not appropriate for diversion, based on ODR's experience in its interactions with criminal justice stakeholders. Our clinical criteria were developed to identify individuals with SMI, which are the target population for ODR services.3 This was based on diagnosis but also other specific indicators that might capture someone with SMI who did not have a diagnosis in the jail medical records. These indicators included descriptions in the records of observable behaviors that demonstrated SMI as well as prescriptions for antipsychotic medications. Together, the legal and clinical assessment would allow us to classify individuals as appropriate (i.e., no obvious bars to diversion are apparent), potentially appropriate (e.g., some factors may be viewed with disfavor by a judge or district attorney, but no complete bar was identified), or not appropriate for diversion.

Phase 2: Review of Sampled Cases

After establishing the legal and clinical criteria, we conducted a chart review of a stratified random sample of individuals from the jail mental health population to identify an estimate of the number of individuals that are potentially divertible. LASD provided a data set that included all individuals in its jail mental health population on June 6, 2019. This was made up of individuals in LASD custody facilities who were in mental health housing units (including moderate observation housing, high observation housing, or the forensic inpatient unit), taking psychotropic medications, or both. The data sets included all individuals incarcerated at the jail regardless of custody status (pre- versus posttrial) because our focus was determining whether individuals would be suitable given their clinical characteristics and current and previous criminal charges rather than their current stage of processing.4 The jail mental health population at the time the data were pulled was 5,544 people. Based on an initial power analysis, we selected a sample of 500 individuals (details regarding the sampling strategy are provided below).

To conduct the chart review, we began with examining an individual's legal status. At our request, ODR provided select legal-related information for each individual in the sample, including the statutory citation (e.g., California Penal Code § 594[a]) and level (e.g., misdemeanor) for each charge pending against the individual as well as the citation and charge level for each felony conviction within the previous five years. Based on our discussions with ODR, we flagged common California criminal statute citations as to whether they involved alleged or adjudged actions that were likely to result in the individual being viewed as not appropriate or only potentially appropriate for diversion, which were generally based on charge severity. A pending charge of California Penal Code § 261(a)(2) (rape by force or fear of bodily injury) or California Penal Code § 664/187(a) (attempted murder), for example, would characterize the individual as not appropriate for diversion based on our prior research. All cases that were determined to be appropriate or potentially appropriate then underwent the clinical review.

The clinical review was then conducted by a subset of clinicians on the project team. Clinical reviewers did not have access to the individual's legal information when conducting their assessments. Initially, three cases each were reviewed by pairs of clinicians to ensure interrater reliability.5 Then, each individual in the sample was reviewed by one of two team members and was designated as either appropriate or not appropriate for diversion based on the clinical criteria. We randomly selected 20 charts to be independently reviewed by two team members and then assessed interrater reliability by determining whether both team members came to the same determination independently. As the clinicians coded the charts, they flagged any charts that were especially challenging or inconclusive. All flagged charts were reviewed by another clinician to make a final determination.6

After completion of the clinical review, the legal and clinical decisions were synthesized using the rules articulated in the flow chart depicted in Figure 1.

Figure 1.

Figure 1

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Path to Legal and Clinical Decisions to Determine Diversion Appropriateness

Sampling Strategy and Statistical Analysis

We applied the self-weighting stratified sampling method to draw a representative study sample from the jail mental health population (i.e., the sampling frame for this study). Self-weighted stratified sampling aims to produce a representative study sample by using demographic information to create strata (i.e., subgroups of the study population) and minimizing the design effect of survey sampling. The sampling frame contained 5,544 individuals with their sex, age, and race/ethnicity information. Given our target sample size, our sampling rate was roughly 9 percent.7

We performed standard statistical analysis for contingency tables adjusting for survey designs including sampling strata, survey weights, and finite population corrections.8 The survey weights did not introduce a notable impact to the final estimates because of the self-weighting design. The stratification design and finite population correction mostly reduced the standard errors in all analysis slightly. All analyses were performed by the survey package in Stata 14.2.

Results

In Table 1, we describe the demographic characteristics of the jail mental health population at the time our data were drawn. The majority of individuals were men; regarding race/ethnicity, the largest percentage of individuals were non-Latino black (about 41 percent), followed by Latino (about 35 percent).

Table 1.

Demographic Characteristics of the Jail Mental Health Population

Demographic Characteristics Percentage (n)
Sex
 Male 85.10% (4,718)
 Female 14.90% (826)
Age (years old)
 < 28 22.75% (1,261)
 28–34 years old 26.15% (1,450)
 35–44 years old 25.20% (1,397)
 45+ years old 25.90% (1,436)
Race/ethnicity
 Non-Latino white 19.25% (1,067)
 Non-Latino black 40.69% (2,256)
 Latino 35.35% (1,960)
 Other 4.71% (261)
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Based on our analyses, we found that about 60.8 percent of the jail mental health population were appropriate for diversion (about 3,368 individuals, based on the current population); 7.5 percent were potentially appropriate (about 414 individuals); and 31.8 percent were not appropriate (about 1,762) (see Table 2).

Table 2.

Appropriateness for Diversion of the Jail Mental Health Population

Final Decision Percentage 95% Confidence Interval Standard Error Design Effect
Appropriate 60.75% 56.63–64.73% 2.06% 0.981
Potentially appropriate 7.47% 5.55–9.99% 1.12% 0.994
Not appropriate 31.78% 28.07–35.74% 1.95% 0.966
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NOTE: Design effect refers to the ratio in the variance of an estimate between the current sample and a simple random sample without any survey design.

Table 3 reports the decisions regarding appropriateness for diversion by gender. A larger percentage of women were determined to be appropriate candidates for diversion than men.

Table 3.

Appropriateness for Diversion, by Gender

Final Decision Percentage 95% Confidence Interval Standard Error Design Effect
Men
 Appropriate 58.51% 53.97–62.91% 2.28% 0.993
 Potentially appropriate 8.31% 6.12–11.18% 1.28% 0.991
 Not appropriate 33.18% 29.09–37.55% 2.15% 0.970
Women
 Appropriate 73.55% 63.13–81.88% 4.73% 0.962
 Potentially appropriate 2.69% 0.69–9.93% 1.81% 1.053
 Not appropriate 23.76% 15.9–33.93% 4.53% 0.950
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NOTE: Design effect refers to the ratio in the variance of an estimate between the current sample and a simple random sample without any survey design.

Discussion

This study provided an estimate of the percentage of individuals in the jail mental health population who may be appropriate for community-based diversion. Applying our criteria, which were designed to reflect the factors that ODR generally considers when deciding whether to put someone forward as a potential candidate for diversion, we found that an estimated 60.8 percent of the jail mental health population would be appropriate candidates for diversion, and 7.5 percent would be potentially appropriate candidates for diversion. This is similar to estimates found by ODR during its preliminary study, which was conducted with a simple random sample drawn about four months earlier than our sample. Specifically, ODR found that an estimated 56 percent (95 percent CI [confidence interval]: 52–62 percent) of individuals were appropriate for diversion, and 7 percent (95 percent CI: 5–9 percent) were potentially appropriate for diversion (Ochoa et al., 2019). Additionally, we found that more women than men were determined to be appropriate for diversion. Understanding the size and characteristics of the population appropriate for release to community-based treatment is important for the county, as one of the main constraints to serving this population is the existing capacity to serve these individuals. Specifically, knowing how many individuals could be appropriate for diversion is the first step toward understanding the types of programs, staff, and funding that would be needed to treat those individuals in the community, as well as the impact on the overall jail mental health population.

It is important to note that we did not consider specific ODR programs when determining whether an individual was appropriate for diversion. Rather, our approach reflected an “ideal world” scenario in which there was a sufficient number of community-based treatment slots to serve the divertible individuals, regardless of the precise details of any particular program. To build on these results, there are several next steps that would be informative. First, it would be helpful to determine how many of those considered divertible would be eligible for each of the existing diversion programs. That would provide a more nuanced basis for determining the need for expansion of capacity in each of those existing programs. Second, it would be useful to determine the level of care needed by each individual, given their current clinical condition (e.g., acuity of symptoms, level of psychosocial functioning). Our clinical criteria included a mix of historical or static factors (e.g., history of conservatorship) as well as current clinical factors (e.g., presence of observed behaviors consistent with SMI). This means that individuals identified as clinically eligible for diversion could have a variety of current treatment needs. This type of follow-up analysis could provide data regarding the kinds of additional programming that may be needed (e.g., additional community inpatient psychiatric beds), which would allow Los Angeles County to determine what the current community-based capacity is for those levels of care and identify what gaps exist.

In addition, in our review, we did not consider whether individuals were pre-sentence or post-sentence. This is because we operated under the assumption that if an individual was serving a sentence at the time the sample was drawn but had been identified sooner as appropriate for diversion, he or she could have been diverted at some point during pretrial proceedings or at the time the court's judgment was rendered. That said, it is also worthwhile to consider effective community-based treatment options that can be provided along the entire continuum of the Sequential Intercept Model. Although ODR has created interventions across intercepts, most are at intercept 3 (jails/courts). However, early diversion efforts can drastically reduce the demand for competency-related services. Most competency-to-stand-trial evaluations are now conducted pursuant to misdemeanor charges (Cochrane, Grisso, and Frederick, 2001; Gowensmith, 2010; Warren et al., 2006). Many of these evaluations could likely be avoided with the presence of strong, robust diversion and preventive programs. Fortunately, even without an expanded scope, ODR seems to be consistent with (if not advancing) nationwide trends in this regard; however, other examples could be illustrative for the county to consider. Miami-Dade County uses detention, diversion, and holding facilities that prioritize mental health and psychosocial needs over competency services (Qureshi et al., 2015). Bexar County in Texas provides police officers with a dedicated short-term treatment facility for individuals with mental illness who have minor charges; outcomes are promising in that numbers of diversions have increased annually (Cowell et al., 2008). Maricopa County in Arizona fields a similar program with comparable results, offering law enforcement workers a drop-in crisis center for individuals they encounter that prioritizes mental health care over minor criminal prosecution (Gowensmith and Murrie, 2019). Eugene, Oregon, intervenes at the point of arrest, often sending a CAHOOTS (Crisis Assistance Helping Out on the Streets team), which includes a medic and a crisis worker to respond in cases of urgent mental health crises (White Bird Clinic, undated). These services are critical in decreasing the criminalization of persons with mental illness.

Even with increased diversion, however, there will continue to be a large number of individuals with mental health needs who remain in jail—whether because of limited community-based capacity, concerns about legal suitability for diversion, or issues related to public safety. Some of these individuals may be waiting placement in a state hospital (e.g., for restoration to competence to stand trial), and some of these individuals will be serving sentences. In addition, the process of obtaining a judicial determination of whether diversion is an appropriate pathway for an individual—and for finding a suitable facility to accept that person—is neither automatic nor swift. Thus, LASD and DHS will continue to have a major role in housing and supervising individuals with mental illness in the jail system. This is important for two reasons. First, it will be critical to ensure that the mental health needs of individuals who remain incarcerated are met in a timely and effective manner. Second, this creates groups of individuals who will require services following discharge. Although ODR is currently focusing on providing clinical-legal interventions through the court system, there are other efforts underway that provide discharge planning and reentry services. For example, Los Angeles County has piloted certain programs such as the Mentally Ill Offender Crime Reduction grant, although there were challenges to retaining individuals in this program (Hunter et al., 2018). These reentry efforts have been continued through the Whole Person Care initiative, in which evaluation efforts are currently underway (UCLA Clinical and Translational Science Institute, undated). The county might also consider ways to integrate other evidence-based reentry programs or approaches into reentry services, such as forensic assertive community treatment or intensive case management models given the continued need for discharge and reentry service planning (DeMatteo et al., 2013).

Finally, with expansion comes constraints on the courtrooms hearing these cases. In our discussions with legal stakeholders, the issue of overload in cases was raised. Because all cases should receive individualized consideration, the number of cases in any given “mental health” courtroom should be of concern. For example, based on our stakeholder discussions, Department 44 in the Clara Shortridge Foltz Criminal Justice Center of Los Angeles—where cases for ODR Housing are heard—has 400–500 cases on calendar every month. This is not to say that there are 400–500 new cases each month, as the vast majority of these are progress reports that come back to court repeatedly; however, this number is quite large. Expanding the number of individuals being diverted may also require an increase in the number of days per month that diversion cases are heard by the court. If ODR begins working with all clients who are appropriate for diversion, it is clear that an expansion of the number of courtrooms within each courthouse will be required.

Limitations

There are certain limitations to this study that should be considered when interpreting the findings. First, although we were able to use ODR's preliminary study to assess the consistency of our review criteria with ODR's decisionmaking process, we were unable to validate our criteria against true “successful” diversion—that is, whether an individual who was recommended for diversion was actually diverted. In addition, although we conducted informational interviews with several key legal stakeholders in the early stages of this project, we had limited success obtaining input from judges, who are the ultimate legal decisionmakers, given the individualized nature of their decisions and lack of systematic data regarding rates with which diversion is granted. Therefore, our understanding of the legal factors that shape diversion come from our discussion with ODR and its experience. That said, as described above, ODR validated its decisions regarding appropriateness for diversion for a small number of cases in its preliminary review with legal stakeholders, and we used ODR's review as the foundation for our own criteria.

Second, ODR staff are routinely present in the courtrooms of the small number of judges within the Los Angeles Superior Court system who currently consider ODR diversion cases, and our sense is that they are intimately familiar with the dynamics of how prosecutors, defense counsel, and judges in those courts interact at such hearings and how these stakeholders perceive the benefits and drawbacks of diverting individuals. But significant expansion of diversion resources and the associated use of such programs will similarly expand the venues across the county in which cases will be heard far beyond the small number of courtrooms that are currently in play. Legal stakeholders in other courts may have differing views regarding the factors that shape legal suitability and clinical eligibility. If it is assumed that the judges assigned to courtrooms currently handling mental health matters represent a group who are relatively receptive to diversion, then our estimates should be considered as an upper bound of the population that would ultimately be diverted even if treatment resources were available without limitation.

Third, judges do not have unlimited discretion when deciding whether release into community services is an appropriate pathway for the people facing criminal charges in their courtroom. For example, admission to ODR Housing requires that an individual plead guilty or no contest in exchange for probation in which adherence to the rules of that program is a condition of the sentence. California law sets forth a number of situations in which individuals facing criminal charges are statutorily deemed to be ineligible for probation (e.g., California Penal Codes §1203, §667, §667.61), which would presumably apply as well to any diversion program using the ODR Housing admission model. In addition, DSH Diversion includes certain statutory restrictions related to both legal and clinical status (e.g., the program is available to individuals with schizophrenia, schizoaffective disorder, and bipolar I disorder). These factors may affect the specific programs for which a given individual would be eligible.

Fourth, any clinical review of mental health among individuals being held in county jails must grapple with the implications of substance abuse. Individuals with a diagnosis of a substance use disorder alone are not eligible for diversion through ODR's programs. Most individuals in our sample had some substance abuse history, and many even demonstrated the effects of substance intoxication upon admission. Although our review tried to identify only symptoms resulting from SMI, there may be instances in which the jail clinicians (whose notes we reviewed) mistook the effects of substances for symptoms of psychiatric illness. Conversely, there may be instances in which they failed to recognize genuine symptoms that were overshadowed by (or mistakenly attributed to) the effects of substances, especially for individuals who were admitted to jail shortly before our review took place. Because most individuals in our sample remained in jail far longer than most effects of substances persist, we believe this dilemma was mitigated by reviewing clinical information over as much as a yearlong period, although this span varied depending on when individuals were first jailed (and when released, if relevant) during our review period. But we acknowledge that any review of this sort—just like any clinical diagnosis in jail—cannot infallibly distinguish all symptoms of mental illness from all effects of substances.

Fifth, it is important to note that our review focused on the jail mental health population at a single point in time. Individuals with SMI often cycle through the justice system, so it is possible that diverting these individuals could prevent those future cycles through the system and help alleviate the overall jail mental health population in a meaningful way. However, we cannot formally extrapolate what effect diverting 60.8 percent of the jail mental health population at a point in time would have on the jail mental health population in a given year. As a next step, it would be valuable to refine our estimates using additional contextual information, such as the average length of stay of individuals in the jail mental health population, their level of care throughout their jail stay or stays, and the number of repeat admissions in a given period (e.g., one year). This information would be important to gain a more-granular understanding of both the community- and jail-based resources needed to serve this population.

Finally, we were limited in the types of clinical and legal data we could access for this study and were limited only to those individuals with an established mental health concern (i.e., they were part of the jail mental health population). When ODR is determining whether an individual may be appropriate for diversion, it has access to information beyond what was available to the project team. This includes information about the use of publicly funded mental health services and additional detail about the circumstances surrounding current criminal charges. Even with our limited data source, we were able to reliably replicate ODR's decisionmaking on a small number of cases; however, it is possible that access to more complete sources of data would have yielded information relevant to appropriateness for diversion.

Next Steps

As Los Angeles County continues to augment the availability of diversion programs in the community, we offer the following recommendations. First, we recommend considering ways to increase ODR's capacity for ongoing data collection. This could include leveraging existing data-collection efforts in Los Angeles, such as the Chief Information Office's Information Hub, which aims to integrate data from various public agencies, including DHS, DMH, Los Angeles Homeless Services Authority, Probation Department, and LASD. These types of cross-system data sets are also consistent with the recommendations of the Stepping Up Initiative (National Association of Counties, American Psychiatric Association Foundation, Justice Center/the Council of State Governments, Bureau of Justice Assistance/U.S. Department of Justice, 2018). However, criminal justice information is not currently available in the Information Hub, and there are challenges to using the data as a real-time way to track outcomes (Hunter et al., 2017). Therefore, this might also include new data-collection infrastructure or efforts. An increased capacity for ongoing data collection is particularly important because there are numerous systemic changes and evolvement of the systems in place. As there is expansion to other courts, it will be important to track the rates of release to community-based treatment in these different courts, identify differences, and work toward a consistent approach across courts.

Second, it is also critical to closely track the demand, process, and outcomes of diversion. This includes the number of individuals who are at least potential candidates (such as the mental health population in county jails); how many are brought to ODR's attention by attorneys, judges, and jail staff for consideration; how many are selected as candidates for diversion by ODR (and the reasons why others were not); how many of those who are recommended by ODR for diversion are ultimately diverted (and what reasons appear to be controlling for judicial decisions to reject diversion); how many diverted individuals remain stably housed; how many are reincarcerated; and how many are reconvicted. A recent study of ODR Housing is an excellent start to evaluating outcomes (Hunter and Scherling, 2019), but it was limited to one program at one point in time. If ODR were given adequate resources to augment its current data-collection capabilities and policies and maintain them consistently going forward, it would be possible to continuously track progress and identify factors that are associated with successful versus unsuccessful diversion.

In addition, although our findings suggest that a substantial number of individuals could be eligible for ODR's programs, there are some legal procedural issues at play that might prevent ODR from achieving diversion for all who are eligible. For example, as described, ODR Housing requires a guilty or no contest plea, and the program is much more intensive than the plea bargains that are often offered in early disposition courts throughout the county. One of our discussions with a legal stakeholder suggested that public defenders are sometimes less likely to encourage their clients to take advantage of the program for that reason. In contrast, California Penal Code § 1001.36 allows for pre-plea diversion, ultimately resulting in the dismissal of charges at the conclusion of the period of diversion—a key benefit of the program. If ODR shifted more of its programming to be available to individuals pre-plea through this program articulated in the penal code, this could greatly alleviate the issue. Finally, it is important to note that these diversion programs are voluntary, and not every individual who is offered diversion will accept diversion. Therefore, although our estimates reflect those who might be appropriate for diversion, it is likely that some subset would decline to participate in a diversion program.

Finally, although ODR is responsible for developing diversionary programming, there are other local and state agencies that have a stake and a role in providing solutions. Therefore, future work to address the needs of justice-involved individuals with mental illness will continue to require the input and resources of a variety of stakeholders. Similarly, the landscape of diversion is shaped not only by local innovations but also by state-level initiatives and statutes, such as California Penal Code § 1001.36. It will be valuable to understand how to best leverage these opportunities to create additional diversion opportunities in Los Angeles County. Ultimately, policymakers can more effectively address this growing issue without compromising public safety by better understanding who can be successfully diverted, the services that they need, and the opportunities to develop innovative and effective programs.

Notes

This research was prepared for the Los Angeles County Department of Health Services Office of Diversion and Reentry and conducted by the Justice Policy Program within RAND Social and Economic Well-Being.

1

ODR also operates a Maternal Health diversion program, which began in April 2018 and is open to any women who are pregnant during their jail stay. Women who agree to participate plead guilty to their charge and are placed on probation. Women do not necessarily have to have mental illnesses or be experiencing homelessness to participate.

2

ODR's preliminary study was conducted in advance of the current effort to provide the county with initial information to “guide the County's strategy for creating and scaling … program capacity” (Ochoa et al., 2019).

3

ODR also diverts individuals diagnosed with intellectual disability, which was included as a clinically eligible diagnosis. However, because these cases tend to be infrequent, we did not construct criteria to detect undiagnosed cases of intellectual disability in the same way that we did for SMI.

4

This decision reflects our assumption that both pre- and posttrial diversion options could be available, and that if posttrial individuals had been identified as appropriate for diversion earlier, they could have been diverted through a pretrial option. That said, in our data set, posttrial individuals may have had different legal or clinical characteristics than pretrial individuals, which we were unable to quantify. In the jail mental health population at the time the data were pulled, 2,665 people had all open charges, 1,163 had at least one case for which they had been sentenced, and 1,716 had been sentenced on all cases.

5

The legal review did not require multiple raters, as a given charge was either present or not for each individual. However, the clinical data involved review of progress notes in the jail medical record, and certain criteria (i.e., presence of observed behaviors consistent with SMI) involved some clinical judgment. For this reason, we included a formal process for testing interrater reliability.

6

One of the 20 charts included in the interrater reliability sample was flagged as a “challenging case” for review by a third clinician. Cohen's kappa for the remaining 19 charts was 0.86 (considered strong interrater reliability; McHugh, 2012).

7

We defined age categories by the quartiles in the sampling frame: younger than 28 years old, 28 or older, and younger than 35, 35 or older and younger than 45, and 45 or older. We grouped race/ethnicity into four groups: Latinos of all races, non-Latino white, non-Latino black, and others. Sampling strata were defined by age categories, race/ethnicity groups, and sex. There was a total of 32 strata theoretically (four age categories by four race/ethnicity groups by two sex levels). However, this study's sampling frame contained 29 strata because the remaining three strata had no individuals. In each stratum, a simple random sample was drawn where the sample size was proportional to the size of the stratum (i.e., the number of individuals in the stratum). The sample size in all strata was truncated to be no smaller than four so that we could have a minimal number of sampled individuals for any subpopulation. This strategy yielded a roughly self-weighted sample (i.e., the sample weights of all sampled individuals were roughly equal).

8

The finite population correction accounts for the fact that the target population is finite (i.e., 5,544 in this study), and the uncertainty or variance in any sample-based estimate is reduced when the sample size is relatively large compared with the finite population size. Our sampling rate of 9 percent gave a modest amount of reduction by adjusting the finite population correction.

References

  1. California Penal Code, Chapter 1, Rape, Abduction, Carnal Abuse of Children, and Seduction, Section 261(a)(2) September 9, 2013.
  2. California Penal Code, Chapter 2.7, Misdemeanor Diversion, Sections 1001–1001.9. January 1, 2018.
  3. California Penal Code, Chapter 2.8a, Diversion of Individuals with Mental Disorders, Sections 1001.35–1001.36. January 1, 2019.
  4. California Penal Code, Part 1, Of Crimes and Punishments, Title 14, Malicious Mischief, Section 594(a) April 4, 2011.
  5. California Penal Code, Part 1, Of Crimes and Punishments, Title 16, General Provisions, Section 664/187(a) April 4, 2011.
  6. California Penal Code, Part 1, Of Crimes and Punishments, Title 16, General Provisions, Section 667. January 2, 2019.
  7. California Penal Code, Part 1, Of Crimes and Punishments, Title 16, General Provisions, Section 667.61. November 7, 2006.
  8. California Penal Code, Part 2, Of Criminal Procedure, Title 8, Of Judgment and Execution, Section 1203. January 1, 2019.
  9. Cochrane Robert E., Grisso Thomas, and Frederick Richard I. “The Relationship Between Criminal Charges, Diagnoses, and Psycholegal Opinions Among Federal Pretrial Defendants,”. Behavioral Sciences and the Law. July–August 2001;Vol. 19(No. 4):565–582. doi: 10.1002/bsl.454. pp. [DOI] [PubMed] [Google Scholar]
  10. County of Los Angeles Chief Executive Office. Report Back on Developing a Care-First Treatment Model for New Mental Health Treatment Center (Item No. 25, Agenda of February 12, 2019) August 7, 2019. http://file.lacounty.gov/SDSInter/bos/supdocs/139802.pdf As of July 8, 2021:
  11. Cowell Alexander J., Aldridge Arnie, Broner Nahama, and Hinde Jesse M. A Cost Analysis of the Bexar County, Texas, Jail Diversion Program, Report 2, An Analysis of Cost-Shifting Between the Treatment and Criminal Justice Systems. Research Triangle Park, N.C.: RTI International; May 2008. http://www.naco.org/sites/default/files/documents/Cost%20Benefit%20Study.pdf RTI Project Number 0209991.000. As of July 8, 2021: [Google Scholar]
  12. DeMatteo David, LaDuke Casey, Locklair Benjamin R., and Heilbrun Kirk. “Community-Based Alternatives for Justice-Involved Individuals with Severe Mental Illness: Diversion, Problem-Solving Courts, and Reentry,”. Journal of Criminal Justice. March–April 2013;Vol. 41(No. 2):64–71. pp. [Google Scholar]
  13. Garcia, Ricardo. “Request Board Approval Authorizing the Los Angeles County Public Defender's Office (PD) to Execute a Grant Award Agreement Number 18-1806-153381-CJ (Agreement) for Fiscal Years (FY) 2018–20 Phase IV Safety and Justice Challenge Grant Program (Program) from the John D. and Catherine T. MacArthur Foundation (Foundation) in the Amount of $1,200,000, and Approve an Appropriate Adjustment,”. March 12, 2019. http://file.lacounty.gov/SDSInter/bos/supdocs/133610.pdf letter to Los Angeles Board of Supervisors. As of July 8, 2021:
  14. Gowensmith William Neil. Overview of Forensic Evaluations in Hawaii. September 2010. paper presentation at the fifth annual State of Hawaii Forensic Examiner Training, Honolulu, Hawaii.
  15. Gowensmith Neil, and Murrie Daniel. Groundswell Review of CDHS Plan. 2019. report to Judge Nina Wang, Re: Civil Action No. 11-cv-02285-NYW, January 28.
  16. Health Services, Office of Diversion and Reentry, Los Angeles County, PDF with figure. October 2019. http://file.lacounty.gov/SDSInter/dhs/1063956_ClinicalProgramsDashboardOctober2019.pdf As of July 8, 2021:
  17. Heilbrun Kirk, DeMatteo David, Yasuhara Kento, Brooks-Holliday Stephanie, Shah Sanjay, King Christopher, Dicarlo Anne Bingham, Hamilton Danielle, and Laduke Casey. “Community-Based Alternatives for Justice-Involved Individuals with Severe Mental Illness: Review of the Relevant Research,”. Criminal Justice and Behavior. April 2012;Vol. 39(No. 4):351–419. pp. [Google Scholar]
  18. Hunter Sarah B., Buenaventura Maya, and Cefalu Matthew. Local Evaluation Report for Los Angeles County's Mentally Ill Offender Crime Reduction (MIOCR) Program. Santa Monica, Calif.: RAND Corporation; 2018. https://www.rand.org/pubs/research_reports/RR2411.html RR-2411-BRC. As of July 8, 2021: [Google Scholar]
  19. Hunter Sarah B., Davis Lois M., Smart Rosanna, and Turner Susan. Impact of Proposition 47 on Los Angeles County Operations and Budget. Santa Monica, Calif.: RAND Corporation; 2017. https://www.rand.org/pubs/research_reports/RR1754.html RR-1754-LAC. As of July 8, 2021: [Google Scholar]
  20. Hunter Sarah B., and Scherling Adam. Los Angeles County Office of Diversion and Reentry's Supportive Housing Program: A Study of Participants' Housing Stability and New Felony Convictions. Santa Monica, Calif.: RAND Corporation; 2019. https://www.rand.org/pubs/research_reports/RR3232.html RR-3232-BRC. As of July 8, 2021: [Google Scholar]
  21. Katz Mitchell H. Examination of Increase in Mental Competency Cases. Los Angeles, Calif.: Los Angeles County Health Agency, Los Angeles Department of Mental Health, Los Angeles Department of Public Health; September 19, 2019. http://file.lacounty.gov/SDSInter/bos/supdocs/102162.pdf As of July 8, 2021: [Google Scholar]
  22. LAC + USC Restorative Village Concept Paper. 2021. http://file.lacounty.gov/SDSInter/dmh/1031765_LAC_USCRestorativeVillageConceptPaper-DRAFT.pdf undated. As of July 8.
  23. Lacey Jackie. Board Motion—May 6, 2014 Motion by Supervisor Mark Ridley-Thomas Providing Treatment, Promotion Rehabilitation and Reducing Recidivism: A 60-Day Initiative to Develop a Comprehensive Diversion Plan for Los Angeles County. Los Angeles, Calif.: Los Angeles County District Attorney; June 19, 2014. http://file.lacounty.gov/SDSInter/bos/supdocs/85251.pdf As of July 8, 2021: [Google Scholar]
  24. Los Angeles County Department of Health Services, Office of Diversion and Reentry. “Jail and Community Based Diversion,”. webpage, undated.
  25. Los Angeles County Department of Health Services. Request for Evaluation Services for Diversion and Reentry Study for People with Serious Clinical Needs. 2018. Los Angeles, Calif.
  26. Los Angeles County Sheriff's Department. “LASD Mental Health Count 05/14/2019,”. 2019. data provided to authors.
  27. McHugh Mary L. “Interrater Reliability: The Kappa Statistic,”. Biochemia Medica. October 2012;Vol. 22(No. 3):276–282. pp. [PMC free article] [PubMed] [Google Scholar]
  28. Motion by Supervisors Kathryn Barger and Hilda Solis: Addressing the Shortage of Mental Health Hospital Beds. January 22, 2019. http://file.lacounty.gov/SDSInter/bos/supdocs/131546.pdf As of July 8, 2021:
  29. Motion by Supervisors Sheila Kuehl and Mark Ridley-Thomas: Expanding Countywide Diversion for Justice Involved Adults. February 5, 2019. http://file.lacounty.gov/SDSInter/bos/supdocs/132839.pdf#search=%22ab%201810 As of July 8, 2021:
  30. Motion by Supervisors Mark Ridley-Thomas and Kathryn Barger: Scaling Up Diversion and Reentry Efforts for People with Serious Clinical Needs. August 14, 2018. http://file.lacounty.gov/SDSInter/bos/supdocs/124871.pdf As of July 8, 2021:
  31. Motion by Supervisors Mark Ridley-Thomas and Sheila Kuehl: Expanding Effective Diversion Efforts in Los Angeles County. August 11, 2015. http://file.lacounty.gov/SDSInter/bos/supdocs/96594.pdf As of July 8, 2021:
  32. Motion by Supervisors Mark Ridley-Thomas and Sheila Kuehl: Expanding ODR's Housing Program Countywide to Safely Divert More Individuals with Serious Clinical Needs. May 14, 2019. http://file.lacounty.gov/SDSInter/bos/supdocs/135516.pdf As of July 8, 2021:
  33. Motion by Supervisors Hilda L. Solis and Sheila Kuehl: Cancellation of Design-Build Contract with McCarthy Building Companies, Inc. August 13, 2019. http://file.lacounty.gov/SDSInter/bos/supdocs/139739.pdf As of July 8, 2021:
  34. Munetz Mark R., and Griffin Patricia A. “Use of the Sequential Intercept Model as an Approach to Decriminalization of People with Serious Mental Illness,”. Psychiatric Services. April 2006;Vol. 57(No. 4):544–549. doi: 10.1176/ps.2006.57.4.544. pp. [DOI] [PubMed] [Google Scholar]
  35. National Association of Counties, American Psychiatric Association Foundation, Justice Center/the Council of State Governments, Bureau of Justice Assistance/U.S. Department of Justice. The Stepping Up Initiative: A National Initiative to Reduce the Number of People with Mental Illnesses in Jails. 2018. https://stepuptogether.org/wp-content/uploads/Stepping-Up-Overview.pdf As of July 8, 2021:
  36. Ochoa Kristen, Elizabeth Kim, Appel Oona, and Stephens Dustin. “An Estimate of Persons in the Jail Mental Health Population Likely to Be Appropriate for Safe Release into Community Services,”. Los Angeles, Calif.: Los Angeles County Department of Health Services, Office of Diversion and Reentry; April 2019. [Google Scholar]
  37. Qureshi Sana, Leifman Steven, Coffey Tim, and Carney Regina M. Outcomes of the Miami-Dade County Forensic Alternative Center: A Diversion Program for Mentally Ill Offenders. June 2015. https://www.equitasproject.org/wp-content/uploads/2018/07/MDFAC-Outcomes-Poster-RMC.pdf poster presentation at the University of Miami's Miller School of Medicine Annual Research Day, Miami, Fla. As of July 8, 2021:
  38. Revised Motion by Supervisors Sheila Kuehl and Mark Ridley-Thomas: Developing the Los Angeles County Roadmap for Expanding Alternatives to Custody and Diversion. February 12, 2019. http://file.lacounty.gov/SDSInter/bos/supdocs/133125.pdf As of July 8, 2021:
  39. Steadman Henry J., Osher Fred C., Robbins Pamela Clark, Case Brian, and Samuels Steven. “Prevalence of Serious Mental Illness Among Jail Inmates,”. Psychiatric Services. June 2009;Vol. 60(No. 6):761–765. doi: 10.1176/ps.2009.60.6.761. pp. [DOI] [PubMed] [Google Scholar]
  40. Steadman Henry J., Scott Jack E., Osher Fred C., Agnese Tara K., and Robbins Pamela Clark. “Validation of the Brief Jail Mental Health Screen,”. Psychiatric Services. July 2005;Vol. 56(No. 7):816–822. doi: 10.1176/appi.ps.56.7.816. pp. [DOI] [PubMed] [Google Scholar]
  41. Torrey E. Fuller, Kennard Aaron D., Eslinger Don, Lamb Richard, and Pavle James. More Mentally III Persons Are in Jails and Prisons Than Hospitals: A Survey of the States. Alexandria, Va.: National Sheriff Association, Treatment Advocacy Center; May 2010. https://www.treatmentadvocacycenter.org/storage/documents/final_jails_v_hospitals_study.pdf As of July 8, 2021: [Google Scholar]
  42. UCLA Clinical and Translational Science Institute. “Whole Person Care—Los Angeles Research Evaluation,”. https://ctsi.ucla.edu/patients-community/pages/whole-person-care webpage, undated. As of July 8, 2021:
  43. Warren Janet I., Murrie Daniel C., Stejskal William, Colwell Lori H., Morris James, Chauhan Preeti, and Dietz Park. “Opinion Formation in Evaluating the Adjudicative Competence and Restorability of Criminal Defendants: A Review of 8,000 Evaluations,”. Behavioral Sciences and the Law. March 2006;Vol. 24(No. 2):113–132. doi: 10.1002/bsl.699. pp. [DOI] [PubMed] [Google Scholar]
  44. White Bird Clinic. “CAHOOTS: Crisis Assistance Helping Out on the Streets,”. https://whitebirdclinic.org/cahoots/ webpage, undated. As of July 8, 2021:

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