Tony Mantor: Why Not Me the World

Judge Liefman: Breaking the Cycle of Autism and Mental Illness in Criminal Justice

• Tony Mantor

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Judge Steven Leifman shares his remarkable journey from witnessing horrific conditions in a state psychiatric hospital as a teenager to becoming a leading judicial advocate for mental health reform. 

His work in Miami-Dade County has transformed how the criminal justice system handles people with mental illness, saving millions of dollars while giving thousands a path to recovery.

• Began his advocacy at 17 when investigating abuse at a state psychiatric hospital where he found an autistic young man being improperly treated as psychotic
• Discovered as a judge that our system has transferred responsibility for the mentally ill from inadequate state hospitals to equally inadequate jails
• Found that just 97 people with severe mental illness were arrested 2,200 times over five years, costing Miami taxpayers tens of millions
• Created a comprehensive diversion program that reduced Miami arrests from 118,000 to 53,000 annually and closed one jail, saving $168 million
• Building a first-of-its-kind mental health facility with crisis stabilization, housing, employment support, primary healthcare, and court services
• Working with Chief Justices nationwide to replicate Miami's successful model in communities across America
• Emphasizes that people with mental illness are more likely to be victims than perpetrators of crime
• Advocates for early trauma intervention since 92% of incarcerated women and 75% of men with mental illness have histories of severe trauma

If you know anyone who would like to share their story on our show, please send them to TonyMantor.com/Contact.


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intro/outro music bed written by T. Wild
Why Not Me the World music published by Mantor Music (BMI)

Speaker 1:

Welcome to why Not Me? The World Podcast, hosted by Tony Mantor, broadcasting from Music City, usa, nashville, tennessee. Join us as our guests tell us their stories. Some will make you laugh, some will make you cry. Their stories Some will make you laugh, some will make you cry. Real life people who will inspire and show that you are not alone in this world. Hopefully, you gain more awareness, acceptance and a better understanding for autism around the world. Hi, I'm Tony Mantor. Welcome to why Not Me? The World Humanity Over Handcuffs, the Silent Crisis special event. Joining us today is Judge Stephen Leifman. He was first elected to the 11th Judicial Circuit Court of Florida in 1995. In 2007, he served as a special advisor on criminal justice and mental health for the Supreme Court of Florida. He has received several awards, including one from the Pope. It is truly an honor to have his honor with us today. Thanks for coming on. Sure, thanks for having me. Oh, it's my pleasure. You've been doing this for a very long time. What led you to become an advocate for people with mental health and autism?

Speaker 2:

Yeah, I have two stories and the first one starts when I was 17 years old. I was an intern for a state legislator here in Miami and he had received a letter from the then editor of the Miami Herald about a young man who was in our local state psychiatric hospital. This is 48 years ago. This is the height of institutionalization and it's the height of the abuses that went on at state hospitals. So I guess, being the low guy in the totem pole, I got asked to go to the state hospital to investigate. The editor of the Miami Herald, who wrote the letter to the legislator, raised concerns that there was abuse going on at this facility and that this young man was being abused as well. So I walked through the front doors of a state psychiatric hospital 48 years ago and it was a scene out of. One Flew Over the Cuckoo's Nest. Funny, in a way, I'm a 21-year-old son. I would never allow him to go. I can't believe they sent a 17-year-old kid.

Speaker 2:

Anyway, I found Jonathan, the young man I was looking for. He was in all four-point restraints. He was being injected with probably Thorazine, which was the only antipsychotic at the time. He was screaming and moaning and crying and it was a scene out of a horror movie. So I started to look at his records. This is well before HIPAA. I started to talk to the staff, although, I will candidly tell you, I had no idea what I was looking at. I was 17 and knew nothing. But what I did find that shocked me. And when I spoke to the staff, it turns out that he was not psychotic at all. He was autistic.

Speaker 1:

Wow, that's amazing.

Speaker 2:

Here they were injecting him with antipsychotic medications.

Speaker 1:

What was the next step when this came to your attention?

Speaker 2:

While I was there, there was a group of advocates touring the facility and they found out that there was a representative from a legislator's office, albeit a 17-year-old, who had no knowledge and no power. But they insisted I take a tour of the facility. They brought me downstairs to what looked like a dungeon. It was like a jail cell and I found these seven men lying in their own feces while a guard they were naked and a guard stood there with a hose and washed them down like they were animals and it was pretty traumatizing and pretty horrific. And while I did not have much authority to help them, I was able, with the help of the senator, to get the young man out of the hospital and we got him placed in a really wonderful, amazing adult living facility for other young men with autism and he was very well cared for after that.

Speaker 1:

That's really good that you could help him. How did that affect you?

Speaker 2:

It left a pretty indelible mark on me. About 17 years later I got appointed to the bench and, ironically, that hospital that I had been at 17 years earlier was closed. The jail across the street from me started to become the psychiatric facility for our community. So those same folks, or type of folks that had been in the state hospital, they got released to the streets without services and many of them ended up in the criminal justice system.

Speaker 2:

In 1955, there were about maybe we estimate 5,000 people with serious mental illnesses in state hospitals. There were about excuse me, in jail. There were about 550,000 at that time in state hospitals. Today there's less than 30,000 civil psychiatric beds in this country, and last year we had about 1.5 million people with serious mental illnesses arrested and about 2 million incidents. And so we never deinstitutionalized. What we really did is we transferred responsibility from these really terrible, crappy, horrible state hospitals to these really terrible, crappy jails, and the problem is, in some ways it's worse, because now you end up with a criminal record and it's harder to get housing and it's harder to get employment.

Speaker 1:

Did you have any single case that stands out in your mind? You now look back on it and it was the beginning of your journey of helping those with autism and mental health.

Speaker 2:

When I got assigned to the criminal division, I ended up having a case. This is the second part of my story. I was getting ready to go on the bench one morning and the assistant public defender and the assistant state attorney came to see me and they said that there was a case that was really mind-boggling on my docket. If I wouldn't mind, would I please speak to the defendant's parents, who were in court At the time? I was handling what we call a jail misdemeanor division. These are people on very low-level charges who are still in custody. There's kind of three types of folks in that division. There are those with attached felonies who are not allowed out of custody. There are those that are too poor and they cannot afford to bond out of custody, but mostly it's really people with serious mental illnesses that don't know how to get out of custody.

Speaker 2:

The parents came in and they started telling me this story about how their son was brilliant, how he had gone to Harvard, how he had a late onset of schizophrenia and he became homeless and started cycling through the criminal justice system. And as I started to go back into the courtroom, they were pretty distraught. The mom was crying and the dad was shaking and they literally were begging me to get their son help. Of course, being a new judge, you think you have a lot more wisdom and a lot more power than you do. I made a rookie mistake and I promised them that I would get their son help because I assumed there was a system in place to treat him. Sadly there was not.

Speaker 2:

As I was going back into the courtroom, the mom stopped me and judges. One more thing I need to tell you about my son. She said not only is he brilliant, but he probably knows more about the mental health system than you do. And I was surprised and I looked at her and I think she thought the lawyers had told me the whole story. They had not. And I said, excuse me. And she said my son is the former head of psychiatry at jackson memorial hospital. That was our, or is our, largest public hospital in Florida. And she said he didn't show up to work one day and he was having religious ideations. So he cashed in his life insurance policy, he flew to Israel to be closer to God and within a few weeks he was deported back because he was running around naked in the Orthodox sections of Jerusalem and they were afraid for his safety. So they sent him back to Miami where he became homeless and started cycling through our system.

Speaker 2:

What happened from there? I called this case. We had a great conversation. He ended up having a full-blown psychotic episode in court, screaming at the top of his lungs that his real parents had died in the Holocaust and this couple sitting in the back were from the CIA and they'd come to kill him. And after ordering a battery of evaluations and adjudicating him incompetent to proceed, it turned out in Florida that, because it was only a misdemeanor, I literally had no authority to get him help and I had to release him back to the street. Well, that was the beginning of my journey, and between those two incidents I think I became the Forrest Gump of mental health. I just started going through and trying to fix things the best I could, given the wonderful moral authority I had. To my great pleasant surprise, it has far exceeded all of our expectations. We've been able to do some miracles because I have an amazing staff and an amazing community that has allowed me to make these structural changes that were so necessary.

Speaker 1:

That's great that you have such supportive people around you. Now I understand you are starting a crisis unit or a facility along that line.

Speaker 2:

I'm already working on that. It's not a crisis unit, but I appreciate you asking about it because it's fascinating. It is the first of its kind in the United States, possibly in the world. It is the first of its kind in the United States, possibly in the world. It is a one-stop shop for the most acutely ill that continuously cycle between the most acute systems of care, such as homelessness, jail and hospitalization, both primary and psychiatric. It's the old competency restoration facility. It's 181,000 square feet and it's going to be a mental health diversion facility for that population. Just back up a little bit so your listeners understand the problem.

Speaker 2:

When community mental health was designed in the United States, the most acutely ill were still in psychiatric hospitals.

Speaker 2:

Community mental health was designed for people with moderate mental illnesses, not acute, and so when we shut down the hospitals and we went to the war on crime and the war on drugs and we went to sentencing guidelines and we massively cut housing back in the 80s, this population got thrown into communities, into community mental health systems that were never designed for them, and so of course it didn't work and they didn't behave the way that we wanted them to behave.

Speaker 2:

But instead of looking at how do we build a better system for them? We instead started to incarcerate them and that's what happened. So we are building this facility in fact it's done to account for that population that never got what they needed and understand that there's a smaller subset of this population that are so sick, but they're using up all the resources. We did one study with one of our universities in Florida that looked at who the highest users of criminal justice and mental health services were. We sent them the names of 3,300 people who had come through our system and they had access to all the arrests in Florida and all of the civil commitments in Florida, all the Medicaid and Medicare records.

Speaker 1:

That's very interesting. When you got the numbers back, what did they tell you?

Speaker 2:

They narrowed it down to basically 97 people, primarily men, primarily diagnosed with a severe psychotic disorder, primarily homeless, primarily co-occurring, who over a five-year period these 97 people were arrested 2,200 times. They spent 27,000 days in the Dade County Jail. 13,000 days at a psychiatric facility cost taxpayers tens of millions of dollars and we got nothing for it. And so this building is really for that subpopulation. In fact, we've had this diversion program going on for 24 years and I'll describe it a little bit more in a minute.

Speaker 2:

But we get a list every day from my county of who is eligible to be diverted into the community. Because of the lack of capacity, we can't get to them all. Over the last five years we just looked at the data because we're trying to figure out who's going to go into this building first. Over the last five years we just looked at the data because we're trying to figure out who's going to go into this building first. We identified 16,000 people who over five years they were arrested 32,000 times. They spent 1.2 million days in the Dade County Jail. That's 3,400 years, $414 million in taxpayer dollars wasted and we got nothing for it.

Speaker 1:

Those are just totally amazing numbers. What's this facility going to look like when it's up and going?

Speaker 2:

So it's that type of population that this new facility is for, and so the building will have a receiving facility, a crisis stabilization unit, a short-term residential facility, a deactivity program that'll teach individuals self-sufficiency how to manage their illness, a culinary supportive employment, vocational supportive employment programs like computer labs.

Speaker 2:

It will have a primary health clinic, a dental clinic, an eye clinic and a podiatry clinic. It'll have tattoo removal, because people do silly things when they're psychotic and stunned. It has a courtroom in the facility so we can manage both criminal and civil cases. It has something called the living room model so that for people who are high users, heavy users of these services, but they're not meeting civil commitment, they can stay there voluntarily and we can engage them into services. And it has 208 beds of housing. They're not going to be there permanently, so we'll probably be able to see quite a few thousand a year, and there's a limited number of these people. They're just costing us the most because they go through this deep end the most often. If we can get our arms around them, we can significantly change their trajectory and we can break the cycle of incarceration, homelessness and hospitalization.

Speaker 1:

That's great. My next question actually was this looks like it's a facility where you're helping people. They're getting back on their feet Because of this. It should help the legal system that they don't have to see these people multiple times.

Speaker 2:

Correct and that's the whole idea is to make sure that we're using the criminal system for people that need to be in jail. 70% of people in jail today in the United States either have a serious mental illness, a substance use disorder or both. I always joke that we need specialty courts for the 30% that don't, so that we can make sure we have a therapeutic jurisprudence system for the 70% that do, so we can make sure they get treatment and stop cycling in and out of the system.

Speaker 1:

Now, as a judge, you have certain things that you can do. Of course, you have certain limitations that you have to adhere to. How do we get the empathy from the DA side working with the defense lawyer so they can help these people rather than being focused on the number of convictions that they're able to get?

Speaker 2:

Yeah, and that's a wonderful question and I'm actually quite optimistic because it's changing. And part of the reason it's changing is I've been working very closely over the last several years with something called the Conference of Chief Justices and the Conference of State Court Administrators All the chief justices of all the state Supreme Courts in the United States and all their court administrators and they have made mental illness their primary issue for the last four or five years. They are having summits now. We have tours to Miami quite regularly. They come here, they learn about how to restructure their community. They're going back and starting to put together plans on how to do what we've done, because we've been able to reduce the arrests in Miami as a result of our project from 118,000 a year to 53,000.

Speaker 2:

Our jail audit went from 7,400 to 4,400. We closed one of our three main jails at an actual savings, not cost, shift of about $168 million so far. And one of the things that we hadn't anticipated our police shootings have almost stopped here and while it's possible that race certainly can play a role in a police shooting, it turns out that the reality may be that many of the police shootings have as much to do with PTSD among law enforcement as anything. They overreact because they get scared.

Speaker 1:

I've been talking with several different people. They actually go into precincts, work and train with the police, so I'm hoping that's going to help out a lot as well.

Speaker 2:

The woman that runs my training program for law enforcement. We call it CIT Crisis Intervention Team Policing. She gets between 150 and 250 calls a month from police officers for their own personal mental health issues. It's tragic, but last year more officers died from suicide than in the line of duty. We set up a program to help get them treated when they're having issues and it has helped amazing and they've become incredibly empathetic. And then, as for the prosecutors, our own prosecutor has become a huge advocate because she's learned that if you want to really improve public safety, we have two choices we can release this population without treatment, or we can release them with treatment. You know what happens when we release them without. We might as well do it the right way get people what they need. Recovery is real. Many mental illnesses have better recovery rates than heart disease and diabetes. It's really just about making sure there's access, competent and quality care for this population.

Speaker 1:

This sounds like you have just such a great model to go by. You have the clinical side, you have the prosecutors, the defense, of course, the judges on the bench. How do you get this from being a local to a state, to a nationwide process where it helps everyone across the country?

Speaker 2:

And that's one of the things that we're doing with the Conference of Chief Justices. So they started off by having four or five regional summits around the United States where all the chiefs came and then it worked so well. Most of them are having statewide regional conferences and then it's breaking down specific areas in their states. Last year I probably put 150,000 miles on in the air helping states do it, because I want to focus my time to help them set up similar programs in their own states. And it's exciting and it's a lot of work, but we know that it's doable.

Speaker 1:

I think that you're correct. It certainly is very doable. The hard work you're putting in is just outstanding. It must just give you inner comfort knowing you're working on a project that, when finished, will change so many lives for the better.

Speaker 2:

I just feel very honored and blessed to have the opportunity to do it. My court has been incredibly supportive of me doing this work. My previous chief justice in Florida helped me start this by assigning me to chair a committee for the Supreme Court on this issue and actually for three years, pulling me off the bench and assigning me to the Supreme Court to work on this full-time, and it really gave me an opportunity to learn these issues and figure out a way that we could do it better. But I have to tell you it's not rocket science. A few weeks ago, a month ago, I got back from Italy and I was part of a delegation that was there to study the Trieste mental health system. It was sponsored by the Hilton Foundation and they wanted to see if it was a program that could be replicated or scaled in the US. And the reason they picked Trieste is because the World Health Organization has determined that Trieste has the best mental health system in the world and after visiting it for a week, I can unequivocally tell you it does. They basically had no homeless. They had few, if any, people in jail with mental illnesses, few, if any, people in their state psychiatric system and few, if any in their forensic system. It was really remarkable and they did it not through anything that should shock anybody.

Speaker 2:

They intervened early. If there was a break, the doctor went to the house. Intervened early. If there was a break, the doctor went to the house. They wrap around services, they get you housing. They have a really great day activity program. They don't define you by your illness. They put you on a long-term injectable medication and they make sure that you're incredibly well case managed and you're working during the day. So you have a life and you have goals and hopes. Nothing that we all don't know works. We're so quick to try to incarcerate before we treat that. It's absurd and it's expensive. The United States spent almost a trillion with a T dollars last year on costs related to incarceration. Could you imagine what we could do with that kind of money for mental health and autism?

Speaker 1:

You've had a tremendous amount of success in your area. You're working on the new facility, trying to work with the legal system across the country. What are some of the hurdles that has been presented to you that you see that you've got to either go around or jump over so that you can make a difference, not just in Miami, but across the country as well.

Speaker 2:

It's a couple things. The message is very important, but I'm finding equally important is who delivers the message, and I think one of the great things that's going on in the US right now is the level of judges that have gotten involved. Reality is that we're seen as Switzerland. We don't have an axe to grind. We don't have an interest or a financial interest by having judges become involved in this issue has really opened a lot of doors. It gets the right people to the table. I tell people.

Speaker 2:

The best part of my job is that when I invite people to a meeting, they come, and so we need to use that moral authority, get people to the table and explain to them what we're doing and why it works, and look as cynical as I could be on days, I do believe when you get a chance to meet people one-on-one and you really get to talk about these issues rationally, instead of in the world we live on, where everything is argued, most people get this. They don't want to see people with mental illnesses in jail. They have loved ones, they know people, they want to make sure that this population is cared for, treated, housed, and they know that if you do that, we're going to get better outcomes, and they're pining for it. They really want a system that works, as opposed to trying to navigate one that doesn't.

Speaker 1:

Now let's just take this in a slightly different direction. I see where you got a medal from the Pope. Now that's pretty cool.

Speaker 2:

Yeah, that was pretty amazing. Talk about humbling, and not bad for a Jewish guy. It came as quite a shock, quite a surprise. It was one of the most humbling recognitions I've ever received. The Archbishop, unbeknownst to me, was very familiar with my work and he nominated me and the Pope selected me and I received this beautiful medal. It was pretty stunning.

Speaker 2:

I think what I most appreciated about it was the level of attention it has brought to this cause, and I'm sure that's why they do it, because this isn't one of those sexy issues with cute little kids. People have a lot of stigma about this population. They're afraid of this population. They think they're dangerous. They're not.

Speaker 2:

For him to do that meant a lot, but it also meant a lot for the cause and for the issue and for that I am eternally grateful, and I've ended up developing a wonderful friendship with our local archbishop here in Florida. He actually had me give one of the keynote speeches recently to all the new priests in Florida, which was great, so we could talk to them about mental health and what they can be doing when people approach them, because I used to be on the board of the American Psychiatric Association Foundation and one of the things that we learned is that, by a wide, far margin, more people go to their clergy for mental health than they do a psychiatrist, and you want to make sure that the clergy are well informed and they are well educated and that they don't try to convince people it's the devil or something like that. The Catholic Church is pretty sophisticated, but they really appreciated learning about these issues, so it's been a wonderful experience.

Speaker 1:

With everything that you've done, the medal you received, the facility you've been working on. What's next? What do you see coming in the next three to five years that can add to all your accomplishments? This new journey is just underway. You've got so many things to do with getting the lawyers, the judges, the police, getting everyone on the same page to make a huge difference for all these people that need help. So what's coming in the next three to five years for you?

Speaker 2:

I'm actually optimistic. I'm. I think many of us have been working and toiling in this field for a good 20 years and a lot of groundwork and infrastructure has been laid. And I think the country if we don't kill ourselves politically, I think the country is this may be the last issue everyone seems to agree on is poised to tackle this issue. I think people, whether you're coming from the right because you think it's ridiculous how much we're wasting in taxes, or you come from the left and you think it's horrible how we're treating this population, everybody agrees it's not working and it needs and can be fixed.

Speaker 2:

Through this initiative with the chief justices, through this other initiative I co-chair judges and psychiatrists, through the National Center of State Courts and the Council of State Government and the American Psychiatric Association Foundation, we've all partnered up and we're really working to make the structural changes in each community that are necessary to fix it. It's challenging because every community is different. There's not a switch that you can flip in Minneapolis or San Francisco or Mobile, alabama, right, they're all different. You almost have to go community by community to fix it and our approach, and what I'm going to be doing over the next three to five years with this initiative is to go into the states first, get them to buy in, show them how that they can save a lot of money and save a lot of lives, and then work towards making this structural change. But it's going on.

Speaker 2:

There's examples all over the country right now that didn't exist just five, 10 years ago. I remember when I first started on the lecture circuit for the course, I'd spend the first 45 minutes of my talk trying to convince people there was a problem. Now all they want to know is how do they fix it? And so we've done a really good job, and the media has done a decent job of educating people about the problem. Now we have to show people that it's really fixable and that these are the tools you need. And this is what your system should look like. And while each community is different, we all have the same essential elements that are necessary to be able to get the desired outcomes everybody wants. It's just a matter of figuring out where you are on that and what changes you need to get you to the next level.

Speaker 1:

Yeah, in closing, what do you feel is important that the listeners need to hear so they understand exactly what you're trying to do across the country?

Speaker 2:

Yeah, and thank you for that. One I would say is people with mental illnesses are absolutely no more dangerous than the general population, and on medication they're much less dangerous than the general population. They are much, much more likely, by a wide margin, to be victims of violent crimes than perpetrators, and that recovery rates for this population, for many of these illnesses, are actually much better than heart disease and diabetes. That it's not a lost cause, that people can recover. They can get their lives back. What we need to do is create structures in the community that provide them access, provide them quality of care, provide them an opportunity to recover. We just don't do that In really bad American fashion. We punish them when it's not their fault, and we need to set up a better system of care so that people don't end up in the criminal justice system that was never designed for people with these illnesses. If you do that, you get much better outcomes, you improve your public safety, you save tremendous tax dollars and you give people an opportunity to have a life of hope and recovery, and I think that should be the ultimate goal for every one of us in our society. Why else do what we do? I would tell you, it's been the honor of my life to be a judge for almost 30 years. It afforded me an opportunity to make change that I probably never could have done as a legislator or someone in the executive branch, and it's because in many ways we're first responders, like law enforcement. We're on the front line seeing this population come in every day and we don't have to stand for something that's not working.

Speaker 2:

Our job is to do our best to administer justice, and that doesn't mean just punishing people. It means figuring out why they're in the system and what can we do to keep them from ever coming back, triggering serious mental illness. We know today that we didn't know just 20 years ago that about 92% of the women who are in jail and prisons in the United States with serious mental illnesses have horrific histories of trauma, mostly sexual abuse, and that sexual abuse occurs when they're quite young five, six, seven years old. And about 75% of men who are in jail and prison with serious mental illnesses also have horrific histories with trauma. Sometimes it's sexual abuse. More likely they've been victims of long-term domestic violence or they've been witnesses to violent crimes, like a soldier might see in combat. We know today that trauma is not an emotional response, but physiological.

Speaker 2:

Without getting people treated after they've gone through this kind of trauma, the chances are, by a huge percentage, that they're going to end up with a substance use disorder and or a mental health disorder, and we need to get ahead of that. We need to be using tools to assess kids in elementary school to see if they have histories of trauma and, if they do, make sure we're getting them treated quickly, because if we had done that here even in Miami we weren't aware of trauma when we started we would have kept two, three generations from ever coming into the criminal justice system at all and we got to get smarter about it. We have to do what Trieste is doing and get ahead of this and get people treated just like we want to do with any other illness. We don't want to wait for your skin cancer to metastasize and get you so sick that you have to go to an intensive cancer facility. We want to get it at the beginning because it's going to be easier, cheaper and we're going to get much better outcomes.

Speaker 2:

Mental illness is no different. I would leave your listeners with that. We need to get ahead of this and if we do, we'll get much better outcomes. We'll save a lot of money and we will improve our public safety, and people won't have to live a life cycling in and out of acute systems like homelessness, jail, prison and hospitalization.

Speaker 1:

Absolutely. I totally agree. This has been a great conversation, great information. It's been a pleasure having you on. I really appreciate you taking the time.

Speaker 2:

I appreciate you having me. You have such a nice voice for your podcast. It's great, and your tone and your questions are just perfect. I'm honored to be here today and thank you for inviting me.

Speaker 1:

The pleasure is all mine. Thanks again. Thanks for taking the time out of your busy schedule to listen to our show today. We hope that you enjoyed it as much as we enjoyed bringing it to you. If you know anyone that would like to tell us their story, send them to TonyMantorcom Contact then they can give us their information so one day they may be a guest on our show. One more thing we ask tell everyone everywhere about why Not Me, the world, the conversations we're having and the inspiration our guests give to everyone everywhere that you are not alone in this world.