Justice Unshackled | Episode 14 | The Criminalization of Illness: Mental Health, Addiction, and American Jails

Abstract

The American carceral state has undergone a profound, yet largely unacknowledged, structural transformation: it has become the nation’s primary provider of psychiatric and addiction care. This comprehensive analysis examines the mechanisms through which jails and prisons have been converted into de facto mental health institutions, exploring the intersection of untreated illness, addiction, poverty, and law enforcement. By tracing the historical trajectory from the mid-twentieth-century deinstitutionalization movement—spurred by the Community Mental Health Act of 1963—to the contemporary phenomenon of transinstitutionalization, the research exposes how the promise of community-based care devolved into the reality of mass incarceration. A critical driver of this shift is the Medicaid Institutions for Mental Diseases (IMD) exclusion, a legislative artifact that inadvertently created a “patient-to-prisoner pipeline” by denying federal funding for necessary inpatient psychiatric beds, leaving the criminal justice system to absorb the fallout.

Furthermore, this report quantifies the epidemiological reality of confinement, highlighting that a staggering proportion of incarcerated individuals suffer from serious mental psychological distress and substance use disorders. It critically examines the historical and ongoing punishment of addiction, detailing the severe physiological and psychological consequences of denying Medication-Assisted Treatment (MAT) to incarcerated individuals. However, recent enforcement of the Americans with Disabilities Act (ADA) by the Department of Justice signals a paradigm shift toward recognizing the denial of such medical care as a civil rights violation.

The analysis also addresses the fatal collision between mental illness and policing, revealing that individuals in psychiatric crisis represent a disproportionate number of fatal police encounters. In response to these systemic failures, the report evaluates emerging alternative frameworks. It assesses the efficacy of pre- and post-arrest diversion programs like the Miami-Dade Criminal Mental Health Project, the deployment of civilian crisis responders such as the CAHOOTS model in Oregon, and the complexities of California’s evolving CARE Court system. Ultimately, this report argues that the criminalization of illness is not an accidental byproduct of the justice system, but a structural feature that must be fundamentally dismantled through a shift from punitive containment to holistic, community-based public health infrastructure.

Introduction: The Architecture of the New Asylums

The physical landscape of mental healthcare in the United States is no longer defined by the sprawling hospital campuses of the early twentieth century, nor is it characterized by the network of community clinics envisioned by mid-century reformers. Instead, the epicenter of American psychiatric care is composed of concrete, steel bars, and razor wire. Today, the three largest mental health facilities in the United States are not hospitals; they are Rikers Island in New York City, the Twin Towers Correctional Facility in Los Angeles, and the Cook County Jail in Chicago.¹ This reality represents a profound systemic failure, wherein the apparatus of criminal justice has been repurposed to manage the symptoms of severe mental illness, trauma, and chronic addiction.

The conversion of the carceral system into an ad hoc psychiatric ward is the culmination of decades of public policy choices that systematically dismantled the mental health safety net while simultaneously expanding the punitive reach of the state. In the course of a typical year, nearly 12 million people cycle through the nearly 3,000 jail jurisdictions in the United States.⁴ Within this massive churn of human life, individuals experiencing psychiatric crises and substance use disorders are vastly overrepresented. They are arrested for crimes of survival, public nuisance infractions, and behaviors directly manifesting from untreated psychosis or withdrawal. Once ensnared in the system, they remain incarcerated longer than their counterparts without mental illnesses, cost the state exponentially more to house, and face a higher likelihood of returning to a cell shortly after release.⁵

The criminalization of illness functions as a mechanism of social control, effectively hiding the consequences of poverty, a fractured healthcare system, and inadequate social services behind prison walls. The intersection of trauma and addiction is consistently treated as a moral failing or a criminal infraction rather than a complex public health crisis. Previous analyses of the carceral state have demonstrated how wealth-based detention, the privatization of correctional services, and racialized policing sustain mass incarceration. The criminalization of mental illness acts as a central pillar of this machinery, funneling the most vulnerable populations into a system designed for punishment, not healing. To understand how the jail cell replaced the hospital bed, one must trace the historical evolution of mental health policy and the legislative traps that continue to fill America’s cages with its sickest citizens.

The Historical Genesis: Deinstitutionalization and the Illusion of Community Care

The current crisis of mental health incarceration cannot be fully understood without a rigorous examination of the mid-twentieth-century movement known as “deinstitutionalization.” In 1955, the number of individuals housed in state psychiatric hospitals reached its historical apex at approximately 560,000.⁷ Many of these institutions, however, were plagued by severe overcrowding, understaffing, and horrific abuses, often referred to in the public consciousness as “snake pits”.⁹ The exposure of these brutal conditions by conscientious objectors working in hospitals during World War II, combined with the advent of early antipsychotic medications like chlorpromazine in 1954, generated a wave of optimism.¹⁰ The medical community and policymakers alike began to believe that individuals with severe mental illness could be safely and effectively treated within their own communities rather than locked away in remote asylums.¹⁰

This optimism culminated in the passage of the Community Mental Health Act of 1963, signed into law by President John F. Kennedy.¹³ Kennedy’s dedication to this cause was deeply personal, influenced by the tragic experiences of his sister, Rosemary, who suffered from severe mental illness and was subjected to an institutional lobotomy.¹⁴ The 1963 legislation sought to replace the sprawling state hospital system with a network of federally funded community mental health centers, fundamentally altering the geography of psychiatric care.¹³ Legal rulings of the era, such as Lake v. Cameron (1966) and Lessard v. Schmidt (1972), further bolstered this shift by establishing the right of patients to receive care in the least restrictive setting possible.¹⁶

The legislation effectively incentivized the rapid closure of state hospitals, leading to a massive depopulation of psychiatric wards. However, the promise of the 1963 Act was never fully realized. The community-based infrastructure was chronically underfunded, and the network of localized care centers failed to materialize on the scale required to support the hundreds of thousands of patients discharged into the public sphere.¹⁰ Over the subsequent decades, the evaporation of therapeutic spaces left a critical shortage of resources for those requiring intensive, structured environments.¹⁷

As the state hospitals emptied, the total number of psychiatric beds plummeted precipitously. By the first half of 2016, the number of staffed psychiatric beds remaining in state hospitals had dropped to roughly 37,679, representing fewer than 11.7 beds per 100,000 population—the lowest level on record, and a stark decline from the 1955 peak.⁸ While the Treatment Advocacy Center recommends a minimum target of 40 to 60 beds per 100,000 people to adequately serve a community’s acute psychiatric needs, the national average hovers disastrously below that threshold.¹⁹

Year	State Psychiatric Beds	Beds per 100,000 Population	Status
1955	~560,000	~340.0	Peak Institutionalization
2010	~43,000	~14.1	Deinstitutionalization Era
2016	~37,679	~11.7	Historic Low / Bed Crisis
Optimal	N/A	40.0 – 60.0	Recommended Target

Table 1: The Decline of State Psychiatric Bed Capacity in the United States (Data: Treatment Advocacy Center). ⁸

The elimination of over 96 percent of the nation’s last-resort psychiatric beds left a gaping void in the healthcare continuum.¹⁹ For individuals suffering from severe, persistent mental illnesses that required intensive, structured care, the community-based alternatives were simply insufficient. The result was not true deinstitutionalization, but rather “transinstitutionalization”—the shifting of vulnerable populations from one form of state confinement to another.¹⁰ Individuals with severe mental illnesses, left without adequate psychiatric care, housing, or social support, increasingly found themselves living on the streets or in homeless shelters. Consequently, their untreated symptoms inevitably drew the attention of law enforcement, funneling them directly into local jails and state prisons.¹⁰ By failing to provide a therapeutic landing pad, the state effectively ensured that the criminal justice system would become the default repository for the mentally ill, transferring the burden of care from doctors and nurses to police officers and correctional guards.

The Bureaucratic Trap: The Medicaid IMD Exclusion

A critical, yet frequently misunderstood, driver of the patient-to-prisoner pipeline is a specific, highly restrictive provision within federal healthcare law known as the Medicaid Institutions for Mental Diseases (IMD) exclusion. Enacted as part of the original 1965 Medicaid legislation, the IMD exclusion explicitly prohibits the use of federal Medicaid matching funds for the care of patients aged 21 to 64 who are treated in psychiatric hospitals or residential treatment facilities with more than 16 beds.²¹

The original legislative intent behind the IMD exclusion was deeply intertwined with the prevailing philosophy of deinstitutionalization. Lawmakers sought to prevent federal tax dollars from bankrolling the large, abusive state asylums they were actively trying to close, effectively forcing states to shoulder the financial burden of large-scale psychiatric confinement if they chose to maintain it.²³ The policy was engineered to economically incentivize states to develop smaller, community-based care facilities by denying them federal subsidies for institutional warehousing.²³

However, the second-order effects of this policy have proven catastrophic for modern public health and the criminal justice system. Because states cannot access federal Medicaid funds to treat adult patients in large psychiatric facilities, they face an overwhelming financial disincentive to maintain or construct adequate inpatient psychiatric capacity.²² As a result, the IMD exclusion functions as a severe barrier to accessing life-saving, intensive behavioral healthcare for indigent populations. The policy creates an arbitrary and discriminatory access gap: no other Medicaid or Medicare specialty inpatient service places such rigid, systemic restrictions on the size of the facility or the duration of care.²²

The Congressional Budget Office (CBO) has explicitly quantified the financial magnitude of this restriction. The CBO estimates that eliminating the IMD exclusion solely for mental health stays would increase federal Medicaid outlays by $33.5 billion over the 2024–2033 period.²⁵ Eliminating the exclusion for Substance Use Disorder (SUD) stays would increase outlays by an additional $7.7 billion.²⁵

Policy Action (2024–2033 Projection)	Estimated Increase in Federal Outlays	Resulting Behavioral Shift
Eliminate IMD Exclusion for Mental Health	$33.5 Billion	Increased utilization of inpatient/long-term care
Eliminate IMD Exclusion for SUD Stays	$7.7 Billion	Increased utilization of residential addiction care

Table 2: CBO Cost Estimates for Repealing the Medicaid IMD Exclusion. ²

These multibillion-dollar figures represent the exact amount of healthcare spending currently being withheld from the poorest, most severely ill Americans. The ramifications of this withheld funding directly feed mass incarceration. When indigent individuals suffering from acute psychiatric crises cannot access inpatient care due to a federally induced shortage of beds, they deteriorate in public spaces.²³ The resulting “patient-to-prisoner pipeline” is highly predictable.²⁴

Local jails, unlike hospitals, operate under a mandate that prevents them from turning people away at the door. Consequently, the financial burden of managing severe mental illness has simply been shifted from the federal healthcare apparatus to state and county correctional budgets, to the severe detriment of the individuals confined.²⁶ Legal and psychiatric scholars assert that repealing or broadly waiving the IMD exclusion is a necessary structural step toward building a robust continuum of care that could divert thousands of individuals away from the carceral system and into therapeutic environments.⁹

The Epidemiology of Confinement: Data on Mental Illness and Addiction

The scale at which the American justice system warehouses individuals with mental health and substance use disorders is staggering, effectively transforming the epidemiological profile of the incarcerated population. Statistical data provided by the Bureau of Justice Statistics (BJS) highlights the profound and inescapable intersection between illness and imprisonment.

According to BJS data, approximately 43 percent of people in state prisons and 44 percent of individuals in locally run jails have been formally diagnosed with a mental disorder by a mental health professional.²⁷ Furthermore, a significant portion of this population experiences symptoms of serious psychological distress (SPD). An estimated 14 percent of state prisoners and 8 percent of federal prisoners met the clinical threshold for past 30-day SPD.²⁸ The gender disparities within these statistics reveal that incarcerated women carry an even heavier psychiatric burden; females in state and federal prisons were significantly more likely than males to meet the threshold for recent serious psychological distress (19 percent versus 14 percent in state prisons, and 17 percent versus 7 percent in federal prisons).²⁸

The prevalence of specific mental health disorders among incarcerated populations further illustrates the severity of the crisis. An estimated 27 percent of state and 14 percent of federal prisoners reported being told they had a major depressive disorder, making it the most common mental disorder reported.²⁸ Granular state-level data demonstrates extreme concentrations of specific illnesses. For example, in Missouri, 26.8% of incarcerated individuals met criteria for major depression, while in Utah, 25.5% met criteria for ADHD and 25.5% for major depression.²⁹ In Iowa, studies found high rates of Generalized Anxiety Disorder (19.1%), Bipolar Disorder (22.5%), and PTSD (12.5%).²⁹

Demographic / Metric	State Prisons	Federal Prisons	Local Jails
History of a Mental Health Problem	43%	23%	44%
Past 30-Day Serious Psychological Distress (SPD)	14%	8%	N/A
Female SPD Prevalence	19%	17%	N/A
Male SPD Prevalence	14%	7%	N/A
Major Depressive Disorder Diagnosis	27%	14%	N/A
Substance Use Disorder (SUD) Prevalence	58%	N/A	63%

Table 3: Prevalence of Mental Health and Substance Use Disorders in the U.S. Justice System (Data synthesized from BJS and SAMHSA). ⁵

The prevalence of substance use disorders (SUD) is equally pervasive, operating as both a primary driver of incarceration and a highly common co-occurring condition with mental illness. It is estimated that 63 percent of individuals in jail and 58 percent of individuals in prison have a substance use disorder.⁵ Further reports suggest that an overwhelming 85 percent of the prison population has an active substance use disorder or were incarcerated for a crime directly involving drugs or drug use.³¹ BJS data indicates that 65 percent of people in state prisons reported drug use in the 30 days prior to their arrest, and nearly 4 in 10 state prisoners (39%) reported actively using drugs at the exact time of their offense.³⁰

The failure to provide adequate care for these overlapping epidemics within correctional facilities is chronic. Among people in state prisons with a chronic mental illness, roughly 33 percent receive no treatment whatsoever following admission.²⁷ In the federal system, 66 percent of prisoners reported not receiving any mental health care while incarcerated.²⁷ This systemic deprivation of care creates a highly volatile environment. Incarceration is inherently traumatizing; the deprivation of liberty, exposure to violence, severe isolation, and chronic overcrowding actively exacerbate psychiatric symptoms. For individuals with psychotic disorders, the jail environment can precipitate rapid psychological deterioration, turning brief sentences into life-altering psychological injuries.

Furthermore, the data reveal the deep socioeconomic and childhood traumas that precede incarceration. Approximately 18 percent of state prisoners with a mental health problem reported having lived in a foster home, agency, or institution while growing up, compared to just 9 percent of state prisoners without a mental health problem.³³ This indicates that the justice system is heavily criminalizing individuals who have been failed by state welfare, child protective, and social support systems long before they ever committed an offense.

The Criminalization of Addiction: Denying the Standard of Care

The carceral system’s handling of substance use disorders provides one of the clearest and most lethal examples of the criminalization of illness. For decades, the dominant institutional response to addiction has been overwhelmingly punitive. Despite the fact that addiction is widely recognized by the medical community as a chronic, relapsing brain disease requiring clinical intervention, the justice system has historically treated physical dependency as a disciplinary infraction or a moral failing.³⁰

This punitive approach is most visible in the systemic denial of Medication-Assisted Treatment (MAT) for individuals suffering from Opioid Use Disorder (OUD). MAT—which utilizes FDA-approved medications such as methadone, buprenorphine (including brand names Subutex and Suboxone), and naltrexone—is considered the absolute gold standard of medical care for opioid dependency.³⁴ These medications operate by normalizing brain chemistry, blocking the euphoric effects of illicit opioids, and relieving the severe, agonizing physiological symptoms of withdrawal.³⁴

Historically, when individuals suffering from OUD were booked into county jails or state prisons, they were routinely subjected to forced, unmedicated withdrawal—colloquially known as “going cold turkey.” This process is not merely intensely painful; it is physically dangerous and psychologically agonizing. Jails that provide MAT for pregnant women typically discontinue it immediately postpartum, directly violating recommended standards of medical care.³⁵

Furthermore, forced withdrawal severely diminishes an individual’s physiological opioid tolerance. When individuals are eventually released back into the community, this lowered tolerance, combined with the lack of therapeutic treatment during incarceration, places them at an exceptionally high risk for a fatal overdose upon relapse.³¹ In essence, the denial of MAT within the carceral system directly fuels the overdose mortality crisis in the broader community. The justice system, by withholding evidence-based medical treatment, transforms temporary confinement into a potential death sentence.

The Civil Rights Shift: The ADA and Department of Justice Interventions

In recent years, a profound legal and civil rights shift has begun to disrupt this punitive paradigm. Opioid Use Disorder is legally recognized as a disabling condition under the Americans with Disabilities Act (ADA).³⁷ Consequently, the blanket denial of FDA-approved MAT to incarcerated individuals is increasingly being prosecuted as a form of illegal disability discrimination by the federal government.

The United States Department of Justice (DOJ) has taken an aggressive, interventionist stance in enforcing these ADA protections, targeting local jails, state court systems, and departments of correction that prohibit access to life-saving medications. A series of landmark settlements between 2024 and 2026 illustrates this seismic shift in federal enforcement:

Jurisdiction / Facility	Date of Settlement	Key Legal Precedent / Outcome
Pennsylvania Unified Judicial System	Feb 2024	Historic $100,000 settlement prohibiting state courts from denying MOUD to probationers/defendants (e.g., Sonya Mosey). Mandated ADA training for all state judges. 40
Mason County Jail, Washington	Sep 2024	Jail agreed to provide OUD medications upon booking after previously denying a prisoner’s existing prescription. Affirmed jails must provide medical care for OUD. 39
Fayette County Detention Center, KY	Oct 2024	Required the facility to revise policies to provide access to methadone and buprenorphine based on individualized medical determination, rather than blanket bans. 37
Big Sandy Regional Jail, KY	Sep 2024	Jail agreed to medically evaluate all those in custody for OUD and provide FDA-approved medication when requested, with ADA training for personnel. 42

Table 4: Landmark DOJ Enforcement Actions regarding ADA Compliance and Medication-Assisted Treatment in Correctional Facilities. ³⁷

The Pennsylvania case is particularly illuminating. In 2018, a Pennsylvania court ordered an individual named Sonya Mosey to stop taking her prescribed Medication for Opioid Use Disorder (MOUD) or face immediate imprisonment. The Legal Action Center (LAC) filed a complaint with the DOJ on her behalf, triggering a massive investigation into the state’s Unified Judicial System.⁴⁰ The resulting 2024 settlement put all courts nationwide on notice: banning MOUD violates federal civil rights law.⁴⁰

Similarly, statements from federal prosecutors emphasize the mandate. As Assistant Attorney General Kristen Clarke of the Justice Department’s Civil Rights Division articulated during litigation against Delaware County, “People held in our nation’s jails and prisons, including those with substance use disorders, do not surrender their civil rights at the jailhouse door”.⁴³

These enforcement actions establish a critical precedent: individuals do not forfeit their right to evidence-based medical care simply because they are incarcerated. Mandating MAT in correctional settings transforms the facility from a site of punitive withdrawal into an environment where biological stabilization is possible, representing a crucial step in decoupling addiction from pure penal control.

Fatal Encounters: When Policing Collides with Mental Illness

The transformation of the justice system into the primary manager of mental illness extends far beyond the walls of the jail; it begins on the streets, at the exact point of first contact with law enforcement. Because the social safety net has been systematically decimated, police officers have become the default first responders to psychiatric crises, drug overdoses, and incidents related to chronic homelessness.⁵ Armed officers, trained primarily in threat neutralization and the enforcement of the penal code, are routinely dispatched to manage complex medical and psychological emergencies.

The consequences of relying on law enforcement to perform psychiatric triage are frequently lethal. An analysis of the Washington Post’s database on fatal police shootings, alongside extensive epidemiological research, reveals a grim and consistent reality. It is estimated that a substantial portion of all fatal police shootings involve a victim experiencing a mental health crisis.²⁷ In an analysis of data from 2014 and 2015, out of 633 cases classified as “legal intervention homicides” (LIH), 32.1 percent (203 victims) showed definitive signs of a mental health crisis immediately preceding or during the encounter.⁴⁵

Notably, in roughly three out of four of these specific crisis cases, the mental health disturbance manifested directly as suicidal ideation.⁴⁵ Frequently, this ideation was expressed verbally to a family member or intimate partner who subsequently called 911 seeking medical help or a welfare check, only to have the situation end in the deployment of lethal police force.⁴⁵

When a family calls for psychiatric assistance and receives a heavily armed tactical response, the situation routinely escalates. The loud commands, the presence of weapons, and the aggressive posturing inherent to traditional policing can induce severe panic in an individual experiencing psychosis, paranoia, or acute distress. Behaviors that are symptomatic of an illness—such as unpredictable movements, failure to comply with rapid verbal commands due to cognitive overload, or holding an object intended for self-harm—are frequently interpreted by officers as imminent threats to public safety, resulting in the justification of deadly force.

Data from the Washington Post database up through 2025 and 2026 underscores this tragedy. The statistics reveal that up to 67 percent of killings by police in 2025 (amounting to 760 deaths) occurred during traffic stops, police responses to mental health crises (welfare checks), or situations where the person was not reportedly threatening anyone with a firearm.⁴⁶ This underscores a form of structural violence wherein the state’s failure to provide adequate community healthcare leads directly to the state-sanctioned execution of the ill. The intersectionality of race further compounds this violence; systemic biases dictate that Black and Indigenous individuals experiencing mental health crises are even more likely to be perceived as inherently dangerous by law enforcement, increasing the probability of a fatal outcome.

Re-Engineering the Response: Pre-Arrest and Post-Arrest Diversion

Recognizing the catastrophic human and financial costs of criminalizing illness, several jurisdictions have pioneered alternative frameworks designed to intercept individuals before they are deeply embedded in the carceral system. These models focus on diversion, specialized judicial intervention, and removing mental illness from the traditional docket entirely.

One of the most successful and comprehensive diversion models in the nation is the Eleventh Judicial Circuit Criminal Mental Health Project (CMHP) in Miami-Dade County, Florida. Miami-Dade presents a unique demographic challenge, hosting the highest percentage of people with serious mental illness of any urban area in the United States—nearly 9.1 percent, which is three times the national average.⁴⁴ This high prevalence is attributed to several intersecting factors, including the migration of individuals seeking warmer climates and historical events such as the 1980 Mariel boatlift, during which the Castro regime released psychiatric patients from Cuban hospitals and placed them on boats bound for Florida.⁴⁷

The architect of the CMHP, Judge Steve Leifman, realized early in his career that he was functioning as the gatekeeper to the largest psychiatric facility in the state—the county jail.⁴⁸ His motivation was sparked decades earlier; as a 17-year-old legislative intern, Leifman investigated a constituent’s complaint and discovered a boy named Jonathan strapped to a bed in four-point restraints, heavily sedated on Thorazine in a psychiatric hospital.⁶ Leifman discovered that Jonathan was actually autistic, not psychotic, a revelation that exposed the profound dangers of institutional misdiagnosis and neglect.⁶

The Miami-Dade model operates both pre-arrest and post-arrest diversion programs aimed at steering individuals with serious mental illnesses (such as schizophrenia, bipolar disorder, and major depression) away from the jail and into comprehensive community-based treatment.⁴⁴

The pre-arrest component relies heavily on Crisis Intervention Team (CIT) training for law enforcement. CIT equips officers with the specialized skills to de-escalate psychiatric crises and allows them to divert individuals directly to external treatment programs rather than booking them into the county jail.⁶ Following the implementation of this training, the region saw a drastic reduction in fatal police shootings of individuals in mental health crises.⁶

The post-arrest component identifies individuals already booked into the jail and transfers them to community-based treatment systems. For those facing misdemeanor charges, successful completion of the intensive treatment program results in the complete dismissal of their criminal charges, ensuring they do not carry the lifelong, debilitating stigma of a criminal record.⁶

Outcome Metric	Pre-CMHP Implementation	Post-CMHP Implementation
Average Daily Inmate Population	~7,000 Inmates	~4,000 Inmates
Misdemeanor Recidivism Rate (Mental Illness)	75%	20%
Felony Recidivism Rate (Mental Illness)	75%	6%
Incarceration Cost/Duration (Mental Illness vs. Gen Pop)	7x cost, 4 to 8x longer	Significant reduction & diversion
Jail Infrastructure Impact	Severe Overcrowding	One jail facility permanently closed

Table 5: Efficacy of the Miami-Dade Criminal Mental Health Project (CMHP). ⁶

The outcomes of the Miami-Dade model are a testament to the efficacy of prioritizing treatment over punishment. Under the CMHP, the recidivism rate for the misdemeanor population with mental illnesses plummeted from 75 percent to just 20 percent. Even more strikingly, the recidivism rate for the felony population dropped from 75 percent to a mere 6 percent.⁶ By diverting these individuals into care, the project successfully reduced the daily inmate population from roughly 7,000 to 4,000, allowing the county to permanently close a jail facility and save taxpayers hundreds of millions of dollars in operating costs.⁵⁰

Removing Law Enforcement: Civilian Crisis Responders

While CIT training dramatically improves police responses, a more fundamental structural reform involves removing law enforcement entirely from medical and psychiatric emergencies. The pioneering model for this approach is CAHOOTS (Crisis Assistance Helping Out On The Streets), launched in Eugene, Oregon, in 1989.⁵¹

CAHOOTS dispatches a two-person civilian team—typically a medic (nurse or EMT) and an experienced behavioral health crisis worker—to respond to 911 calls involving mental health episodes, public intoxication, psychological crises, and welfare checks.⁵³ Crucially, the responders do not carry weapons and do not possess the legal authority to enforce laws or make arrests.⁵³

The statistical success of the CAHOOTS model proves conclusively that a non-police response to behavioral crises is both exceptionally safe and highly effective. In Eugene, CAHOOTS handles approximately 20 percent of all 911 calls routed through the city’s public safety communications center.⁵² Research indicates they successfully divert 18 to 23 percent of calls that police would otherwise have to handle.⁵⁴ Out of roughly 24,000 calls annually, less than 1 percent (e.g., 311 calls in 2018) require the responders to call for police backup due to an unforeseen safety issue.⁵¹ In its more than three decades of operation, the program has never experienced a casualty, and staff injuries caused by clients are practically non-existent.⁵¹

This model not only prevents the escalation of violence but also generates massive municipal savings. The CAHOOTS program operates on a budget of approximately $2.1 million per year, compared to the roughly $90 million budget for the Eugene police department serving the identical jurisdiction.⁵⁶ By diverting thousands of calls away from expensive police deployments and emergency room visits, the city saves an estimated $1.2 to $2.2 million annually in net officer wages alone.⁵⁷

The unequivocal success of CAHOOTS has inspired the proliferation of similar programs nationwide, demonstrating a viable, scalable alternative to the criminalization of psychiatric distress:

• B-HEARD (New York City): The Behavioral Health Emergency Assistance Response Division responds to behavioral health crises in specific pilot areas. During its first six months, operators successfully routed 22 percent of mental health–related calls to B-HEARD.⁵⁹
• STAR (Denver, CO): The Support Team Assisted Response program resolved its first 2,700 calls without a single injury or arrest, and as of 2022, had never called for police backup due to a safety issue.⁵⁵
• HEART (Durham, NC): Members of the Holistic Empathetic Assistance Response Team reported feeling safe on 99 percent of their calls.⁵⁵

These models highlight a fundamental truth: mental health crises are medical emergencies, not criminal acts. Sending unarmed healthcare professionals rather than armed law enforcement fundamentally changes the trajectory of the encounter from a potential arrest (or fatality) to a therapeutic intervention.

The Complexities of Civil Coercion: California’s CARE Court

In response to the highly visible crisis of untreated severe mental illness and chronic homelessness, California initiated a controversial, statewide approach in 2022 known as the Community Assistance, Recovery, and Empowerment (CARE) Act, commonly referred to as CARE Court (SB 1338).⁶⁰ Designed strictly as a civil court process rather than a criminal one, CARE Court allows family members, first responders (EMTs, police), public guardians, and behavioral health providers to petition a judge to order individuals with severe psychotic disorders into a comprehensive, community-based treatment plan.⁶⁰

The explicit intent behind CARE Court is to intervene proactively—before an individual becomes so impaired that they are arrested, institutionalized in a State Hospital, or placed under a highly restrictive Lanterman-Petris-Short (LPS) Mental Health Conservatorship.⁶⁰ Initially limited exclusively to individuals diagnosed with schizophrenia and other narrow psychotic disorders, the program was legally expanded in January 2026 via a new law (SB 27) to include individuals experiencing psychosis as a result of bipolar disorder.⁶²

However, the implementation and expansion of CARE Court throughout 2025 and early 2026 have revealed significant structural limitations, logistical bottlenecks, and ideological tensions. Despite initial projections by the Newsom administration that between 7,000 and 12,000 Californians would qualify and benefit from the program, actual participation has been staggeringly low. By early 2026, California courts had received just 3,817 petitions statewide. Of those, only 893 treatment agreements were approved, and a mere 32 definitive CARE plans were actively court-ordered.⁶⁵

A primary driver of this low participation is the programmatic tension regarding coercion, consent, and the legal limits of the court. While judges can technically order a participant to follow a mandatory “CARE plan,” they lack the statutory legal authority to physically force a participant to comply with medications or housing mandates if they refuse.⁶⁵ Consequently, individuals suffering from anosognosia—a severe symptom of psychosis that prevents a person from neurologically recognizing that they are ill—frequently refuse voluntary treatment, leading to their cases being dismissed and returning them to the streets.⁶⁵

Furthermore, the bureaucratic complexity of filing a petition presents a barrier. Obtaining medical records and attending repeated court hearings requires a level of bandwidth that overworked first responders and traumatized families often lack. Moreover, as Darrell Steinberg, author of California’s Mental Health Services Act, noted in a 2026 critique, only about a third of CARE Court petitions actually involved people living on the streets, indicating the program is missing the chronically homeless population it was explicitly marketed to save.⁶⁷

Legislative Bill	Implementation Year	Purpose & Impact
SB 1338	2022 / 2023	Established the original CARE Court framework for schizophrenia/psychotic disorders.
SB 27	January 2026	Expanded eligibility to include individuals with psychosis caused by bipolar disorder. 61
SB 989	Proposed 2026	Aims to allow first responders to bypass court filings and refer individuals directly to county behavioral health departments to streamline the petition process. 65
SB 1016	Proposed 2026	Seeks to create a formal bridge allowing judges to order a mental health assessment for involuntary conservatorship if a subject fails voluntary CARE Court treatment. 65

Table 6: The Legislative Evolution of California’s CARE Court. ⁶¹

To address these gaping loopholes, the California legislature introduced subsequent, highly controversial bills in 2026. SB 989 attempts to streamline the referral process for first responders, while SB 1016 aims to create a direct legal bridge from voluntary CARE Court failure to formal involuntary conservatorship.⁶⁵ This proposed expansion toward coercion has drawn fierce opposition from civil rights groups, including Disability Rights California (DRC). They argue that infusing the program with the threat of locked psychiatric facilities erodes civil liberties and ultimately deters vulnerable individuals from trusting the behavioral health system.⁶⁵

The friction surrounding CARE Court illustrates a vital lesson in the landscape of reform: shifting jurisdiction from a criminal court to a civil court does not spontaneously generate the necessary community infrastructure, affordable housing, or therapeutic engagement required to solve the crisis. True reform requires massive investments in housing and voluntary treatment capacity, elements that the state’s $6.4 billion Proposition 1 funding attempts to address but continuously struggles to deploy quickly enough to meet the urgent reality on the ground.⁶⁷

Conclusion: Dismantling the Patient-to-Prisoner Pipeline

The American carceral system is not malfunctioning when it incarcerates the mentally ill and the addicted; rather, it is executing its design perfectly as the ultimate catch-all for the nation’s systemic social and economic failures. By choosing to dismantle the psychiatric hospital system without funding the promised community clinics, and by enacting policies like the Medicaid IMD exclusion that actively defund inpatient care, lawmakers constructed a patient-to-prisoner pipeline that remains fully operational today.

The consequences of this architecture are devastating. Jails have become nightmarish asylums where individuals suffer in solitary confinement, endure the agony of unmedicated opioid withdrawal, and deteriorate rapidly in environments built entirely for punishment. The deployment of armed law enforcement to manage this untreated trauma frequently turns psychological distress into a capital offense, ending in fatal encounters on the streets.

However, as the data from the Miami-Dade Criminal Mental Health Project and the CAHOOTS program in Oregon decisively prove, this reality is not inevitable. When addiction is treated as a medical condition requiring pharmaceutical stabilization rather than penal discipline, and when psychiatric crises are met with unarmed civilian medics rather than armed officers, recidivism plummets, taxpayer money is saved, and, most importantly, human lives are preserved.

Dismantling the criminalization of illness requires a complete paradigm shift. It demands the repeal of the Medicaid IMD exclusion to unlock billions in federal funding for acute psychiatric beds, the universal enforcement of ADA protections ensuring Medication-Assisted Treatment in all correctional settings, and the systematic removal of law enforcement from behavioral health emergency response. Until society stops punishing the manifestations of illness, addiction, and poverty with steel cages, the justice system will continue to be an engine of public harm, bound to the enduring legacy of systemic oppression. Justice can only be truly realized when the care of the mind and body is completely decoupled from the mechanisms of the state’s punitive control.

Works cited

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