Managing Mentally Ill Offenders in the Community: Milwaukee's Community Support Program.

Series: NIJ Program Focus
Published: Mrch 1994
17 pages
37,282 bytes

Managing Mentally Ill Offenders in 
the Community: Milwaukee's Community 
Support Program

by Douglas C. McDonald, Ph.D., and Michele
Teitelbaum, Ph.D.
------------------------------------
Highlights:

Every day our crowded, overburdened jails and
probation departments face yet another challenge--
dealing with offenders who are mentally ill and
require medication, close monitoring, and other
services. Many of these persons have been in and
out of jails and hospitals. Few have homes or jobs,
and more and more of them are drug-addicted as
well. Their own untreated, often psychotic behavior
may have been the cause of their being arrested in
the first place.

Milwaukee faced up to the problem 15 years ago when
it developed a program to keep these offenders out
of jail, out of the hospital, and under close
community supervision. The Community Support
Program, run by a private nonprofit agency,
provides an alternative to incarceration for this
population through a mix of coercion, incentives,
and housing assistance, money management, and
therapeutic support services.

The program does this for $3,000 a year per
clientless than it would cost for intensive
outpatient treatment in local mental health
systems. This Program Focus describes how the
program works and how it gained community
acceptance. It is an approach that offers a ray of
hope to municipalities seeking a just, humane, and
realistic means of dealing with mentally ill
offenders while protecting the wider community as
well.

National Institute of Justice
---------------------------------------

Persons suffering chronic mental illnesses are
frequently caught up in the criminal justice
system, but justice agencies are usually ill
equipped to respond effectively to the problems
they pose. Jailing them keeps them off the streets,
but this provides only a short-term solution at a
high price. Probation may be warranted in some
cases, but conventional supervision and services
are often insufficient. Many mentally ill persons
need the most elementary of necessities as well as
medication, and they require more intensive
monitoring than most probation departments are able
to devote to them.

The Wisconsin Correctional Service (WCS), a private
not-for-profit organization in Milwaukee, has
established an innovative Community Support Program
(CSP) that adopts a "carrot and stick" approach to
managing mentally ill offenders in the community,
most of whom are schizophrenic. Since many of the
program's clients come to the attention of criminal
justice agencies, formal legal authority is used
initially to get offenders into the program. 

The program is also well suited to serving mentally
ill persons who have not yet come into the criminal
justice system but may be at risk of doing so. Many
WCS clients have run afoul of the law because they
are actively psychotic and not medicated, and with
the court's authority most can be convinced to
accept medications. Once engaged in the program,
many offenders comply willingly with its
requirements because they receive substantial
benefits, various needed social services, and life
supports. Indeed, some choose to stay in the
program for years, well beyond the cessation of
their legal obligations.

The program was developed in 1978, when WCS noticed
the growing numbers of chronically mentally ill
persons coming into Milwaukee's courts and jails.
Since then, the county has copied the basic design
and has funded three other community support
programs, two under contract with private
organizations, and a third operated directly by
county officials. The program model includes the
following five defining elements, all of which can
be adapted quite readily to other jurisdictions.
These include:

Medical and Therapeutic Services. Medication is
prescribed, administered 5 days a week, and closely
monitored by a pharmacy on the premises.
Psychotherapy and group sessions are also
available, and case management services are
provided to all clients to help them obtain primary
health care.

Money Management. The program arranges to be the
legal recipient for the client's social security
and other disability benefits. The client's fixed
expenses (rent, for example) are paid directly by
the program. The remainder is given to the client
in a daily allowance--after the client has taken
his or her prescribed medicine.

Housing and Other Support Services. Intensive
casework is undertaken to provide for the client's
basic needs, either after arrest, or upon release
from jail or a hospital. This includes referral to
other social service agencies, if needed. Housing
in the community is arranged directly by the
program, and daily living is monitored by periodic
home visits.

Day Reporting and Close Monitoring. Most clients
are required to report to the clinic daily, Monday
through Friday, where they can stay either for a
brief period to take their medications and get
their money or for longer periods. The daily
observation and interaction with the clients
enables the staff to monitor behavior and to spot
when changes in medications are needed. Failure to
report is noted, and clients are located.

Participation. Although clients must agree to enter
the treatment program, their choice is constrained
by other less desirable alternatives, including
jail. Because many mentally ill persons are
difficult to manage and resist being medicated, the
combination of supportive services backed by firm
legal authority is effective in bringing them into
treatment. 

Program administrators believe that what keeps them
in the program are the benefits. Prior to coming
into the program, many of the clients are homeless
and without any means of support. By helping them
get shelter, income, and medication, the program
creates a powerful incentive for staying.

Program Operations

The program operates out of a small clinic located
in a predominantly residential neighborhood. The
clinic has a friendly, relaxed feeling about it,
without the trappings of a more institutional
environment. Clients even have a room where they
can socialize with each other or just relax during
the daytime.

Clinic staff are readily available to all clients
and offer a broad range of services. Three
full-time nurses provide clinical support to
clients who, in addition to psychological distress,
often need primary health care evaluation and
referral to medical services. A part-time
psychiatrist diagnoses clients and prescribes them
psychotropic medications as needed. The pharmacy
staff dispense all medications and manage the
required recordkeeping. Four full-time case
managers have a caseload of 60 clients each.
Several financial service staff members help
clients obtain government benefits and manage their
money. Daily allowances are given out by a cashier.
Two staff persons work to obtain housing for those
who need it and to help manage clients' ongoing
relationships with their landlords.
A small management and administrative staff direct
overall operations.

The program has the capacity to serve approximately
250 clients at any one time, a number that has
remained fairly stable over the past several years.
During 1992, a total of 312 clients attended the
program. On any given day, program staff see about
200 clients, most of whom visit briefly to take
their medicine and get their daily allowance. The
others are on schedules that require less than
daily reporting.

The Community Support Program has developed a
combination of coercive elements, incentives, and
support that encourages clients to use services to
help them live in the community without violating
the law. 

Entry Into the Program

Clients come into the CSP through various routes.
Some are identified by workers in other programs
that WCS operates for Milwaukee's municipal courts.
Others are referred by probation and parole
officers or by private attorneys. A small
percentage come into the program on their own. Some
are referred by psychiatric hospitals.

A common entry channel is through the work of the
associated programs run by WCS in the criminal
justice system. Two programs are based at the
courts: the Central Intake Unit and the Municipal
Court Intervention Program. The former is a
pretrial services agency, similar to others
elsewhere in the Nation, although it provides a
more expansive and comprehensive set of services
than many others do. These include a separate
intensive pretrial supervision program and a drug
testing program.

The Municipal Court Intervention Program provides a
structured alternative to incarceration for persons
convicted in municipal courts. It aims principally
to keep in the community persons convicted of
violating municipal ordinances who are in need of
mental health, alcohol, or drug treatment; indigent
persons unable to pay fines imposed by the
municipal court; and those who are due to be
transferred to the local correctional facility.

Staff at the Central Intake Unit's screening center
interview all defendants brought into the courts
for arraignment to obtain information needed by the
court for bail and custody decisions. Each day,
hundreds of such defendants are interviewed. In the
course of these interviews, intake screeners also
identify persons who appear to be candidates for
the programs operated by WCS, including the
Community Support Program. If staff suspect that a
defendant is mentally ill, he or she is interviewed
more intensively and considered for the CSP.

Although such screening may exist in other
jurisdictions, pretrial service agencies generally
lack the capability to provide needed services
directly. Instead, defendants are referred to
services, if they are at liberty, or they must wait
to be transferred elsewhere for services if they
are in custody. For mentally ill persons, such
delays in treatment can exacerbate their mental and
physical conditions. For that reason, the Central
Intake Unit works closely with the courts to place
appropriate offenders and defendants into the
Community Support Program as quickly as possible.

Wisconsin Correctional Service staff also canvass
the populations in the local jails and prison for
possible referral to WCS programs. Again, those
defendants or offenders who show signs of mental
illness are identified and given more intensive
consideration to determine if referral to the
Community Support Program is appropriate.

Once individuals are identified as suitable for the
Community Support Program, the courts are notified.
In some instances, judges may refer defendants to
the program as a condition of pretrial release. If
the potential clients have already been convicted,
the courts may order offenders into the program and
impose treatment obligations as a condition of
probation. Referrals that represent a genuine
alternative to incarceration are given priority.
The close supervision and assistance that the
program provides--and the fact that conditions are
enforced--gives judges and jailers the confidence
to release mentally ill persons to the program. 

Another path into the program is through referral
by probation and parole officers. For those
mentally ill offenders in need of a blend of
services--intensive supervision, day reporting, and
monitored medications--participation in the program
can be imposed as a condition of release. Staffs of
probation, parole agencies, and the program have
developed close working relationships to create a
consistent set of rules and expectations.

After entry into the program, the client's behavior
is closely monitored, and the appropriate
authorities are routinely informed. 

In recent years, about 1,000 arrestees have been
identified annually as being mentally ill. Of
those, approximately 200 to 300 were both eligible
for release and deemed suitable for the program. 
Of the remaining 700 to 800, some were already in
treatment programs and were referred back to them.
Others were hospitalized, and still others had
their charges dropped. Not all those who appeared
to need the program's services and to meet the
admissions criteria could be served immediately
because slots in the program were limited. During
1992, for example, 67 new clients were admitted to
the program. Thirty others were referred to other
county-funded community support programs. Another
40 remained in custody through the end of the year
and therefore were not eligible for admission to
the program. Those who were released but not
admitted to any of the community support programs
were put on a waiting list. Many of those placed on
the waiting lists were released from detention with
the requirement that they report daily to mental
health counselors/case workers in the Central
Intake Unit.

The Clients

The typical CSP client is a male in his
mid-thirties who has never been married, has some
secondary education, and has a diagnosed major
mental illness. The majority had at least two prior
arrests on their record. Clients entering the
program in 1992 averaged 75 days in psychiatric
hospitals during the preceding 2 years. 

Although the number of admitted persons has
remained relatively constant over the past several
years, the clinical conditions of clients have
changed. The Milwaukee area has seen an upsurge in
mentally ill offenders who are drug users
(so-called dually diagnosed clients), paralleling
the reported increase in cocaine use in the area.
Clinic staff say that these dually diagnosed
offenders are more difficult to treat, have more
serious histories of institutionalization, and
demonstrate more frequent relapses and recidivism
than mentally impaired offenders without substance
abuse problems. Program staff report that prior to
the upsurge in cocaine use and dually diagnosed
clients in the area, fewer than 10 percent of the
offenders released from the program were
reinstitutionalized in either jails or psychiatric
hospitals. Staff find that now about one-quarter of
the offenders released from the program are locked
up again, an increase that they attribute to
cocaine abuse. 

The Community Support Program sees many clients who
have histories of noncompliance with outpatient
treatment programs. Indeed, many clients (39
percent in 1992) returned to the Community Support
Program, either voluntarily or through referral,
after a period of not being enrolled. Although the
average length of stay in the program as an active
case (defined as being assigned to a case manager)
is 1-1/2 years, the time clients stay in the
program varies greatly. A small minority of clients
have been in the program for as long as it has
existed (approximately 15 years).

While enrolled in the program, clients generally do
not attend other programs that provide similar
support services or outpatient mental health
assistance. A small proportion of clients are,
however, referred by case managers to other
agencies for such services as substance abuse
treatment and HIV counseling and testing. Such
referrals are not generally made until the clients
have settled into the program and have become
stabilized on their medicines.

Clients leave the program for a variety of reasons.
Some complete their legal obligations to stay in
the program and then drop out. Others are referred
to other mental health or custodial institutions,
while some are sent to jail or prison for
committing new crimes or violating the terms of
their release. In 1992, 84 persons were discharged:

o  Twenty-eight fulfilled their legal obligations
and dropped out. 

o  Five others moved to another State. 

o  Three persons died.

o  One disappeared "off the face of the earth," in
the words of the program's administrator. 

o  Twenty completed their legal obligation and were
referred to other, less structured outpatient
programs. 

o  Six people were found to need closer supervision
and treatment and were placed in inpatient mental
health facilities.

o  Three were referred to hospitals for long-term
treatment for physical illnesses.

o  Three were sent to long-term residential drug
treatment programs. 

o  Fifteen were discharged because they were jailed
either because they committed new offenses or
because they violated the terms of their release. 

The Services

Licensed as a free-standing outpatient mental
health program, the CSP provides three principal
types of services to participants: medical and
therapeutic services, money management, and housing
assistance.

Medical and Therapeutic Services

Each new client entering the program receives a
baseline health interview and physical exam by the
clinical staff. At intake, and every 6 months
there-after, blood tests are given to monitor
clients' health and to evaluate medication levels.
Urine samples are screened for illicit drug use, as
needed, or as mandated by the court. 

The most important element of the program is daily
reporting to the clinic for medication. Most
clients have a history of stopping their
medications, becoming actively psychotic, and, in
some cases, aggressive. To ensure that clients
comply with their medication schedules, the program
has developed an efficient system for dispensing
medicines and monitoring their use. After the
intake exams, a psychiatrist prescribes
medications. On each day, Monday through Friday,
clients come to the clinic, stand in medication
lines at the pharmacy window, and take their
medicines in front of nurses. They then receive a
chit to turn in at the cashier's window, where they
get their daily allowances. 

This process is not rushed, and the nurses have
time to strike up conversations with clients. This
provides them the opportunity to observe clients'
behavior and to spot any need for adjusting the mix
and dosage of drugs. Clients can be either
overmedicated or undermedicated, or they can
develop side effects that can be moderated or
suppressed with other drugs. If a nurse suspects
that an adjustment in the medications is needed or
if there are other problems needing attention, the
client can be referred to the psychiatrist or other
service specialists in the CSP.

The use of a registered nurse, licensed practical
nurses, and pharmacy assistants allows low-cost
maintenance of the medication services. The
pharmacy dispenses medications to some 200 clients
a day. Although most clients starting the program
visit daily, the program reduces this requirement
for some after a period of reliable attendance.
Medication alone would be an insufficient incentive
to keep clients in the program. Caseworkers in the
clinic also provide a number of valuable services
to patients who report faithfully and maintain
their medication schedules. These benefits may be
far more compelling than the court order that
initially motivated most of the clients.

Money Management

Clients receive considerable assistance in managing
their money. Nearly all agree to have the Community
Support Program serve as the payee for Social
Security and other government disability benefits.
The program pays all of the clients' fixed
expenses, such as rent, and the remainder is doled
out to the clients daily--after they have taken
their medications. Failure to comply with a
treatment plan can result in withholding a
scheduled cash allowance. Clients interviewed at
the clinic said that they appreciated this service.
Many realize that they are not able to manage their
money well, and many are afraid of being preyed
upon by thieves and con artists who know when
monthly disability checks are delivered.

The program's full-time financial services advocate
manages clients' entitlement claims. Additionally,
full-time money managers assist clients in
maintaining their accounts, budgeting their funds,
and scheduling payments and billings. A
behind-the-scenes financial services coordinator
oversees all accounts, keeping each client's
funding stable.

Devising the internal money-management procedures
was a challenge. Accounts have to be reconciled
every day because clients make approximately 200
withdrawals of small amounts daily. Accounting
procedures have been computerized, using a program
that was written especially for that purpose.

Upon enrollment, the client (or the program on
behalf of the client) applies for both general
assistance/welfare and Social Security benefits,
either Supplemental Security Income (SSI) or Social
Security Disability Insurance (SSDI). However, some
clients are eligible for both SSI and SSDI, and a
small number are also eligible for veterans'
benefits. The general assistance benefit is usually
approved first, but because the SSI or SSDI benefit
is retroactive from the date of application, these
Federal funds are used to reimburse the general
assistance agency. 

Housing Assistance

Housing assistance is another major component of
the program. Over three-quarters of all clients
lack stable housing when they enter the program,
and the Community Support Program finds rental
housing for them. Over time, and by means of a
variety of strategies (including newspaper
advertisements and word of mouth), CSP officials
have enlisted the help of landlords willing to
house clients. At present, the roster lists
approximately 425 landlords, making about 1,000
apartments available to the CSP. Landlords like the
program because they know that they will receive
rent checks regularly and directly from the
program's administrators. They are also willing to
accept security deposits in several installments.
The housing service has computerized part of its
operations, so that rent checks are written and
mailed out automatically, and an inventory of
housing is maintained and closely monitored. During
1992, WCS found housing for or moved 170 clients.
The program even provides a truck and other
assistance when clients have to move. In addition
to organizing and managing funding for clients'
housing, the program solicits donations of
furniture and household items from the public to
help clients achieve a decent, albeit minimal,
standard of living. Caseworkers visit clients'
households on a periodic basis to assess their
treatment needs and check on their welfare.

As an additional source of assistance for the
housing program, the program received a Housing
Cost Reduction Grant in 1992 from the State
government. This one-time grant was deposited in an
interest-bearing account, and the revenue generated
by this account enables the program to extend loans
to clients for security deposits and first month
rents. Clients can then use their monthly benefit
funds to buy essential furnishings for their
households and to pay the program back over time
for the loans. Obtaining this additional source of
funds, and using it for these purposes have proved
a creative and successful venture by the program.

Success Factors

The program's primary objectives are to keep
persons afflicted with chronic mental illnesses out
of the local jails and hospitals and to help them
live independently. Although the program has not
been formally evaluated, it appears to be achieving
its goals. Indeed, county officials are so
persuaded of the program's usefulness that they
have dedicated scarce State and Federal aid dollars
to fund three other similar programs. By creating a
system for identifying mentally ill persons brought
into court and jail and creating a programmatic
alternative that the courts use, the program is
undoubtedly reducing the number of mentally ill
persons in jail. The program's administrators
report that in recent years the proportion of jail
inmates diagnosed as mentally ill has been small--
about 3 percent, on average--and that the
proportion was much larger prior to the program's
creation.

Further evidence of the program's success in
accomplishing its objective of diverting mentally
ill persons from jail is seen in the tributes
voiced by court officials. The judges, prosecutors,
and defense attorneys interviewed strongly support
the program, as do the court and jail staff.
Relations with other agencies (including mental
health, parole and probation agencies, forensic
services, and State hospitals) are positive,
according to those officials interviewed. One judge
interviewed said that confidence in the program is
"as high as it could be." Another judge said that
the court "cannot do without the program." 

Low Cost 

Central to the program's success has been its
ability to provide this service at a low cost. The
cost per service slot--about $3,000 per year--is
about one-quarter to one-third the cost of
intensive outpatient treatment in the State and
county mental health systems. Costs are low because
the program uses paraprofessionals to deliver
services whenever possible, rather than employing a
large staff of certified specialists with advanced
degrees. (A majority of the program staff have
bachelor's degrees rather than higher, more
specialized degrees.) 

Perhaps the program's greatest accomplishment,
therefore, is that it has devised an important
support service that did not previously exist in a
fiscal environment that has not encouraged public
expenditures for the poor and needy. The program
has increased the level of services in a county
that has high property taxes and great resistance
to increased government spending. According to the
county's budget director, local government would
not provide these services if doing so required the
creation of new county employee positions funded by
county tax revenues. Relying upon a private entity,
the Wisconsin Correctional Service, and a low-cost
model of service delivery made it unnecessary to
create new government positions. 

Financial support is obtained from two principal
sources. The most important and largest is a grant
from the Combined Community Services Board, a State
government entity established to allocate and
administer State and Federal block grant funds for
disabled persons. The second most important source
is the United Way, which has been supporting the
program for years. Additional sources of revenues
include the Community Options Program funds from
the State for long-term chronically mentally ill
clients, as well as medicaid, medicare, and private
insurance payments for psychiatric, psychological,
and pharmaceutical services. 

Creating Similar Programs Elsewhere

The Community Support Program does not depend on
unique conditions in Milwaukee for its existence,
and it could be adapted elsewhere with only slight
modifications. The program did take advantage of
the pretrial screening procedures and organization
already in place. It also benefited from its
private rather than governmental operating
authority. Neither are necessary preconditions,
however.

Pretrial Screening Capacity

In many jurisdictions, there are no specific
services for identifying mentally ill persons in
the criminal justice system and devising placements
for them, although jail administrators may do some
of this on an ad hoc basis to get an unruly
prisoner out of a facility. In many jurisdictions,
judges rely on probation officers to assist them in
fashioning a useful and appropriate response to
mentally ill defendants and offenders. However,
most probation agencies are only brokers: officers
do not provide services directly (other than
supervision), and they must refer their charges to
other service providers.

Jurisdictions that already have pretrial screening
agencies or organizations will be most able to
develop a community support program economically.
Because these agencies assess defend-ants'
likelihood to appear at trial, they also provide a
convenient point for identifying persons who might
be mentally ill. In jurisdictions lacking such
pretrial screening capabilities, procedures would
have to be developed to identify the mentally ill
in jail. While identification and referral in jail
is preferable to no screening at all,
identification at the pretrial stage is better,
because then mentally ill detainees can be diverted
from jail altogether if the charges are not serious
enough to warrant detention.

Private or Public Operation

Since the Community Support Program is privately
operated in Milwaukee, other local governments may
want to follow this model. In considering where to
locate responsibility for development and operation
of a community support program, government
officials should consider how existing standards
and practices in the candidate agency might
constrain its ability to adopt all elements of the
CSP's low-cost design. For example, obligations to
meet more acute care (such as inpatient treatment)
standards in an agency might raise costs
substantially, because such standards require the
use of professional, rather than paraprofessional,
employees. However, governments willing to make the
commitment could create a program similar to CSP
and avoid the issue of relying on local tax
revenues to supply new government services. 

About This Study

This document was written by Douglas McDonald,
Ph.D., and Michele Teitelbaum, Ph.D., senior social
scientists at Abt Associates Inc. Elissa Weitzman,
research analyst, and Stacia Langenbahn, editorial
assistant at Abt, assisted the authors.

Data for this report were obtained from several
sources. Site visits included interviews with
directors and staff of the Wisconsin Correctional
Service and its Community Support Program and
Central Intake Unit; staff of the district
attorney's and public defender's offices, and the
local jail; judges of the State district and
municipal courts and a court commissioner;
representatives of the State's Department of Health
and Social Services and the county's budget office;
and telephone interviews with representatives of
the United Way (a funding source) and the State
mental health hospital. Several useful documents
were also provided by the WSC, including program
descriptions, recent annual reports, and public
presentations of Bowne (Bob) J. Sayner, Assistant
Executive Director of the Wisconsin Correctional
Service. 

Additional information about the Community Support
Program can be obtained from the Wisconsin
Correctional Service, 436 West Wisconsin Avenue,
Milwaukee, WI 53203, (414-271-2512). 

Opinions or points of view expressed in this
document are those of the authors and do not
necessarily reflect the official position or
policies of the U.S. Department of Justice.

The National Institute of Justice is a component of
the Office of Justice Programs, which also includes
the Bureau of Justice Assistance, Bureau of Justice
Statistics, Office of Juvenile Justice and
Delinquency Prevention, and the Office for Victims
of Crime.
--------------------------
------------------
Additional Information:

Avoiding Cash Flow Problems

One of the program's important innovations was to
develop special arrangements with Federal, State,
and county agencies to conduct screening interviews
with clients for benefits. When the program first
began, many clients were not receiving benefits to
which they were legally entitled. 

The program helped manage their enrollment and sent
hundreds of mentally ill people to government
offices for interviews. But for many clients these
interviews were a large stumbling block to getting
registered. Many severely disturbed clients have
neither the social skills nor patience required for
making an appointment, showing up several days or
weeks later, bringing all the required documents,
waiting in line, communicating clearly with social
service caseworkers, and filling out forms. 

It took months to get clients on the rolls with
social security and county welfare agencies.
Because the program was supporting clients in the
interim, substantial cash-flow problems resulted.
When the program lost a client before finally
getting him or her registered, it was unable to
collect the client's past claims and suffered a
financial loss as a consequence. 

The key was to get the various benefit agencies to
let the Community Support Program do all the
necessary paperwork for applications. This occurred
when officials in the welfare department realized
that the information the CSP provided was always
correct and that the difficulties of handling these
clients in their offices could be avoided by having
the CSP conduct the interviews and obtain the
needed data. Once an agreement was reached to
delegate these responsibilities to the CSP, the
program made similar arrangements with other
benefit agencies. This has made registration and
enrollment much more efficient and has reduced the
program's cash-flow problems to a manageable level.
__________________________________________

Gaining Community Acceptance

Locating facilities for mentally ill persons is
difficult in many communities, because residents
and merchants fear that the concentrated presence
of such persons will have a negative effect on
their property values and businesses. Despite this
resistance, the CSP has managed to win the support
of its neighboring community. This has resulted in
part from the program's working to accommodate the
interests of its neighbors. Initially, the program
was located in the heart of the downtown area, in a
government office building. Merchants were
concerned that clients milling about the clinic
might scare customers away. The most effective
solutions to this problem, devised after meeting
with the merchants, were surprisingly simple.
Reporting times were spread throughout the day, so
that an unduly large number of clients would not be
congregating around the clinic at any particular
hour. The building was also opened and staffed
1-1/2 hours in advance of the first scheduled
reporting time so that clients arriving early could
congregate inside, rather than on the street.

When the program moved to its present location, in
a mixed residential and commercial area, citizen
groups were concerned about the effects on their
businesses. To alleviate this anxiety, the
program's directors invited neighbors to an open
house to see the facilities and observe operations.
Local residents were invited to join an ad hoc
advisory committee. Program staff also attend
bimonthly neighborhood coalition meetings and make
themselves available to respond to any complaints
or special concerns. Area businesses are given the
names and telephone numbers of project staff to be
contacted in the event that clients create problems
in the neighborhood. Prompt attention to residents'
requests has helped diffuse tensions as they arise.
Although the program still gets occasional
complaints, it now appears to be operating
inconspicuously in the community.

Although these various outreach efforts have been
important in bringing about good community
relations, the program's administrators believe
that the most effective strategy has been to
address the clients' basic needs (housing, money
management, and medication) early and effectively.
If clients are well served, their anxieties are
generally reduced; acting out is minimized; and the
likelihood of their drawing attention to themselves
in the community is lessened.
-----------------------------------------

Setting Realistic Expectations

Because our knowledge of mental illnesses is
limited, it is unrealistic to expect any program to
cure these illnesses. The best one can
realistically expect is that mentally ill persons
can be helped to achieve some stability in their
living arrangements, to live independently in the
community rather than in a hospital or other
custodial facility, to be protected from persons
who would prey upon them, and to be relieved to the
extent possible of the anxieties, fears, and
delusions that torment them. 

It is clear that the Community Support Program is
accomplishing these goals. If the program did not
exist, a large proportion of the clients would be
homeless, living in a succession of temporary
shelters, or cycling through hospitals. Many would
be actively psychotic, as most would not be
medicated or under psychiatric supervision. By
managing their housing and money, the program
minimizes the opportunities for swindlers and
thieves to victimize clients. It is also likely
that the clients' own criminal behavior--mostly
thefts, assaultive behavior, and drug taking or
selling--is also lessened. 
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U.S. Department of Justice
Office of Justice Programs
National Institute of Justice
Washington, D.C. 20531

NCJ 145330