TALES FROM THE CLINIC
-Series Editor Nidal Moukaddam, MD, PhD
In this installment of Tales From the Clinic: The Art of Psychiatry, we discuss jail diversion programs. In an era where drug use still often, if not always, leads to legal entanglements, the population that benefits from jail diversion is often underserved, underrecognized, and lacks access to evidence-based treatments. Diversion programs are more present and better funded in environments with more robust societal safety nets and harm reduction-oriented policies, yet their advantages are far-reaching (Figure).
Case Study
“Jim” is a 35-year-old African-American man who was referred to a jail diversion program after being found intoxicated on the streets by police. Over the past 6 months he has been without stable housing and reports a history of alcohol, PCP, heroin, methamphetamines, and cocaine use dating back to his teenage years. He was raised in a household marked by parental substance use and physical abuse, and he never completed high school. In early adulthood, he left his hometown to distance himself from family maltreatment. He held a series of low-wage jobs in fast food and warehouse settings but struggled to maintain any position for more than a few months because of his substance use and anger issues. He was unable to reduce his drinking or substance use, especially after befriending a group who also used. Spending most of his free time with them, his use escalated, leading to financial difficulties and difficulties paying rent. He then moved in with a partner after going out for a few months.
One day, after arriving at work visibly intoxicated, he was terminated. Shortly thereafter his partner ended their relationship following incidents of violence. Left without shelter, he spent the past year being homeless, enduring harsh conditions and multiple episodes of aggression and confrontation. During that time his cellphone was stolen, cutting off all contact with his family. He also lost touch with his former group of friends following a violent altercation with them.
He reports having just been released after a 6-month jail sentence.
He has had multiple emergency department (ED) visits for overdose, violent incidents, and episodes of unspecified psychosis. Following these ED visits, he received diagnoses of posttraumatic stress disorder, bipolar disorder, schizophrenia, anxiety, and depression; however, he experiences hallucinations only when intoxicated and otherwise maintains coherent thought processes. Although he was prescribed psychiatric medications, he cannot recall their names and has been unable to afford refills.
At the diversion center, a psychiatrist conducted a thorough evaluation and concluded that his hallucinations occur only during periods of intoxication, his thought processes are coherent, he exhibits no manic episodes and concludes that the patient must have been misdiagnosed in the past.
Discussion
This case highlights the difficulties that face most patients admitted at jail diversion programs.
Jail diversion programs serve as alternatives to jail by providing treatment and support services rather than incarceration to individuals charged with minor misdemeanors or disorderly conduct. Originally established to serve those with mental health disorders, jail diversion programs have expanded to also address the needs of individuals with substance use disorders (SUDs) and other co-occurring conditions.1 These initiatives seek to lower recidivism, deliver treatment, support services, and strengthen public safety. A 4-year follow-up study found that individuals diverted from mandatory prison sentences to community-based diversion programs had lower rates of rearrest, reconviction, and reincarceration than comparable individuals who did not participate.2
Benefits of Jail Diversion Programs
When effectively implemented, jail diversion programs have shown multiple significant advantages.
Lower rates of reoffending: Individuals enrolled in diversion programs typically exhibit reduced rates of rearrest and recidivism compared to those who undergo traditional incarceration.3 For instance, an analysis in Harris County, Texas reported a 48% reduction in the likelihood of future convictions over a 10-year period among diverted defendants.4Cost efficiency: Diverting individuals from incarceration reduces the substantial direct costs of jail and prison stays, while early intervention helps prevent future criminal justice expenditures. The National Institute of Justice estimates that diverting just 10% of eligible offenders to community-based drug treatment could save approximately $4.8 billion in criminal justice spending nationwide. Community treatment options are considerably more economical; for instance, in Texas, such services cost roughly $12 per adult per day, compared with $137 for a jail bed or $986 for an ED visit. By reducing reliance on costly institutional care, diversion programs ease financial and operational pressures on the justice system, health care facilities, and correctional institutions.3Improved health and social stability: Redirecting individuals into treatment rather than incarceration is associated with improved long-term health outcomes and greater social stability.5 Jail diversion programs targeting individuals with serious mental illness often result in symptom stabilization and improved ability to live independently in the community.6 Participants are more likely to receive consistent medical care, access to psychiatric medications, and supportive services that help manage their conditions. Over time, those who complete diversion programs tend to experience better social integration, with increased opportunities for employment and stable housing, and reduced likelihood of relapse or psychiatric crises compared to those repeatedly incarcerated without treatment.Decreased reliance on emergency services: Treatment of behavioral health conditions through diversion programs helps reduce the burden on EDs. Individuals enrolled in such programs are less likely to require hospital-based crisis care or costly emergency interventions compared to those who remain untreated in the community.7Reduced incarceration costs: Diversion programs help alleviate jail overcrowding and enable the justice system to prioritize resources for higher-risk offenses. Diverting individuals with mental health conditions can also prevent extended incarceration periods often caused by delays in competency evaluations or appropriate placement.7 More broadly, diversion supports the efficient reallocation of public safety resources, reserving incarceration for those who present a substantial threat, while managing others in more appropriate, less costly, and less restrictive community-based settings.Characteristics of Individuals Referred to Diversion Centers
Patients who are referred to diversion centers usually suffer from multiple mental health disorders, legal entanglements, unstable housing, and poorer outcomes. This population require integrated medical, psychosocial, and psychiatric support that extends beyond targeted substance-use interventions because of medical and social determinants related to the onset and escalation of substance use such as unstable housing, poverty, unemployment, and co-occurring psychiatric disorders.8 Most importantly, they encounter numerous barriers to care, including inadequate social support, limited readiness for treatment, extensive substance‐use with physical dependence, co‐occurring psychiatric disorders, prior failed rehabilitation attempts, and the stigma of a criminal record.9 Gender and racial disparities further complicate access and outcomes in diversion programs. African American and Latino participants are overrepresented but have significantly lower completion rates and longer times to program completion compared with non-Latino Whites. These disparities may reflect structural barriers such as financial hardship, prior justice involvement, and discretionary bias in referral decisions. Additionally, women face unique challenges related to trauma, caregiving roles, and limited gender-specific services, all of which can affect engagement and retention in treatment. Addressing these inequities is essential to ensure diversion programs meet the needs of all clients, regardless of race or gender.10
Implications for Diagnosis and Management
Accurately identifying co-occurring mental health and SUDs remains a major challenge on many levels. During shortened visits, clinicians may underrecognize co-occurring conditions or mistakenly attribute intoxication or other substance-related symptoms to a primary mental illness. In the case of individuals with a trauma history, it may mean not having appropriate treatment to address posttraumatic symptoms, which could in turn fuel substance use relapses, anger outbursts and other issues.
These diagnostic errors disproportionately affect racial and ethnic minorities and individuals of low socioeconomic status11; as exemplified by our patient, who was potentially misdiagnosed. Misdiagnosed patients who remain untreated face greater difficulty engaging in care, establishing a therapeutic alliance, and adhering to treatment.11
Misdiagnosis refers to assigning the wrong diagnostic label to a patient’s presentation.12 In mental health care, it can lead to inappropriate or harmful treatment, delays in receiving appropriate care, reinforced stigma, unnecessary costs, and misallocation of limited resources. Misdiagnosis of mental health disorders often occurs during a single encounter such as in the ED when patients lack regular follow-up and do not trust the care team enough to fully disclose their substance use, causing clinicians to misattribute these symptoms, resulting in overdiagnosis of mental health conditions and underdiagnosis of SUD. It results in unnecessary prescription of psychiatric medication, delayed SUD treatment, and reduced engagement with worse clinical outcomes.
These individuals often receive care only during emergencies and lack consistent follow-up, resulting in undertreatment of their psychiatric disorders. Consequently, unmanaged symptoms may precipitate behaviors that lead to incarceration.13 In fact, approximately 75% of incarcerated individuals live with untreated mental health disorders alongside SUDs, a combination that markedly increases their likelihood of reoffending.14 Moreover, data show that individuals with serious mental illness receive substantially longer jail and prison sentences than similarly convicted individuals without mental illness.15
Social Support and Housing Instability
Another significant challenge for patients in jail diversion programs is the lack of a social network. Social isolation can worsen mental health vulnerabilities, undermine resilience, and reduce access to medical, psychiatric, and community support services.16 Family conflict is a leading cause of homelessness; in one study, unhoused individuals overwhelmingly cited substance use and familial discord as the primary reasons they lost stable housing. However, it can be hard to tell whether drug use precipitates homelessness or whether living on the streets drives individuals to use drugs as a means of coping and survival.17 Our patient’s experience reflects this pattern: his escalating alcohol and substance use led to job loss and the loss of his home. Following violent altercations with friends and a partner, combined with preexisting family instability, he was left without any support, became homeless, and was ultimately brought to the jail diversion center.
This underscores the importance of a supportive social network in preventing homelessness; had the patient maintained positive relationships with his family and friends, he might have been supported by them and never have become unhoused. Other triggers that can precipitate homelessness include financial stress, housing instability, relationship breakdown, abuse or violence, mental health disorders, substance use, unemployment, criminal involvement, lack of social support and disengagement from education.18
Beyond immediate social factors, these challenges are often rooted in early-life trauma. Indeed, childhood trauma can impair the neurodevelopment and the functioning of physiological systems such as the brain, nervous system, and endocrine system, weaken social and emotional skills, disrupt behavior and compromise executive functioning,19 thereby increasing vulnerability to substance abuse, relationship breakdowns, and ultimately homelessness. The complicated childhood of this patient could have contributed to his current situation.
Integrative Treatment
For individuals with co-occurring mental illness and SUDs, an integrated treatment approach that addresses both conditions concurrently is best. This approach would combine pharmacotherapy with psychotherapy in a coordinated manner with the addition of social services when indicated. Medication-assisted treatments for SUDs can be successfully combined with psychiatric medications and paired with evidence-based therapies such as CBT and motivational interviewing, delivered by a coordinated multidisciplinary team to address both substance use and mental illness.20,21 This model of integrated care is broadly regarded as the standard of care for co-occurring disorders.20 A study found that comprehensive integrated programs lasting 18 months or longer led to significant reductions in substance use, higher remission rates, fewer psychiatric hospitalizations, and improvements in other outcomes. Likewise, incorporating mental health services into addiction treatment settings enhances client participation and overall treatment success rates.22
Concluding Thoughts
Patients who present at jail diversion centers experience a high burden of polysubstance use, social isolation, mental health disorders, legal problems, and unstable housing. The majority of them are from racial and ethnic minorities. These individuals often carry a history of trauma and repeated misdiagnoses, and they face structural barriers such as poverty, stigma, and limited access to continued care. As a result, they are at increased risk of becoming trapped in a cycle of emergency rooms, jails, and shelters without sustained improvement.
For diversion programs to be effective, comprehensive integrative treatment is essential which includes concurrent management of substance use and psychiatric disorders, housing assistance, and consistent case management. By combining medical treatment with psychosocial supports, diversion centers can break the cycle of incarceration, improve long-term stability, and provide a path toward recovery and reintegration.
Dr Haykal is a postdoctoral research fellow at Baylor College of Medicine in Houston, Texas with an interest in specializing in psychiatry. Dr Moukaddam is a professor of psychiatry at Baylor College of Medicine, Department of Psychiatry, and the director of Outpatient Psychiatry at Harris Health. She also serves on the Psychiatric Times Editorial Board.
References
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