Mark Heyrman spent more than four decades teaching about the mental health system as a University of Chicago Law School professor. He says the biggest problem he sees is this: No single entity in Illinois coordinates care.

The Chicago Sun-Times, as part of an investigation into the circumstances behind random attacks downtown involving suspects with histories of severe mental illness, asked Heyrman why these people seem to have fallen through Illinois’ safety net of treatment.

FAILURE TO TREAT, FAILURE TO PROTECT

“If you failed in the previous discharge plan, we should say, ‘Why did you fail?’ And usually it’s not ‘you failed,’ but ‘we failed you, we didn’t give you enough services,’ ” says Heyrman, a public policy committee member with the organization Mental Health America who’s retired from the U. of C.

There’s no single entity overseeing the mental health care system in Chicago. That means, for instance, that homeless patients discharged from private hospitals might be given a bottle of medication and told to follow up at a clinic without what experts say should be a “warm handoff” to a treatment provider.

Heyrman and other experts say the holes in the safety net for mentally ill people need to be addressed by federal, state and local officials.

With only about 1,200 state psychiatric beds in Illinois, he says more funding for community mental health would allow people who don’t need 24/7 hospitalization to leave state mental hospitals — meaning hospital spots could go to people in even greater need.

“When you only have 1,200, every bed must be used for the persons who most need them,” Heyrman says. “And that means people who, if you let them out the door today, are almost apt to come to harm or harm someone else.”

But replacing long stays at state mental hospitals like the one in Elgin with comprehensive outpatient treatment would require a radical shift in thinking — away from retribution and toward treatment aimed at reducing suffering.

It also would require supporting mechanisms that largely don’t exist, like providing housing for homeless people who have severe mental illness so they can be reached by medical and social service providers.

Recognizing that some people don’t care about problems with Illinois’ mental health system, Heyrman says they should consider the costs of a failed system.

“If the person who doesn’t get decent services commits a crime, now we have a crime victim, and that’s a cost,” he says. “And we have the cost of prosecuting her or him, and that’s a cost. And who’s paying for that?”

The answer is taxpayers.

Illinois spent an average of $49,271 on each person in prison in 2024, far more expensive than the cost of so-called wraparound services to keep people in treatment. The two biggest Chicago social service providers pegged these intensive services at $15,000 to $35,000 per client per year, depending on the person’s needs — which is as much as 70% less expensive than incarceration.

For these stories, Sun-Times reporters investigated a series of downtown attacks since 2021 to try to understand how a small number of violent people with severe mental illness has cycled through the criminal justice and mental health systems in Chicago without getting lasting help.

Joseph Kromelis (left) in 2011, and a burn mark on a garage door where he was set on fire.

Mentally ill, in jail

Cook County Sheriff Tom Dart has pushed for more to be done to address the mental illness of detainees. People in the throes of mental illness often end up temporarily held in the Cook County Jail. It happens so frequently that Dart says the jail is a de facto psychiatric hospital. About 35% of the detainees his agency oversees while held there have some mental illness, he says.

“On an average day, I have 3,000 people with an undiagnosed mental illness in my custody,” Dart says. “I was forever saying the mentally ill are not supposed to be incarcerated in a thoughtful society.”

Dart’s staff screens new detainees for mental illness. But with bail reforms that have limited judges’ ability to detain people charged with crimes, many of them are quickly back on the street, he says.

“In the old days, when a person came into my custody on a minor offense, we could work with them,” Dart says. “We discharged them with a plan. Now, they’re coming into custody for an hour or two, and right away they go. So there’s no plan. Where do they go? They’re still sleeping on buses and trains. They’re still on Michigan Avenue.

“We plead with them, but they don’t have to talk to us,” he says. “We have no control. It’s really depressing.”

For years, Dart also has grappled with the state over people who are deemed unfit to stand trial. He says many are languishing in jail instead of getting placed in Illinois’ psychiatric hospitals, as judges ordered.

Those detainees are supposed to get state-provided treatment until they’re deemed able to stand trial.

In response to a public records request, the Sun-Times obtained a list that showed 23 people, including three women, who were found unfit for trial and being held in the Cook County Jail on Feb. 24. There were twice as many at the end of November.

Most of those people had been in the jail for at least 50 days after a judge ordered them sent to a state hospital. Four were in jail for more than 100 days after such a court order.

During their waits to be sent to a state hospital, most of the jail’s mentally unfit detainees have required the highest level of psychiatric treatment available on at least one occasion, records show. That means they were housed in the jail’s Cermak Hospital, which doesn’t offer the same level of care as found at the state’s mental hospitals.

The Cook County Jail at 26th Street and California Avenue.

Jail officials have recorded dozens of “incidents” involving most of the 23 mentally ill detainees who were awaiting transfers. Those include disciplinary problems and other issues. Dart says the disciplinary flareups pose safety issues for correctional officers and other detainees.

In 2016, when WTTW-Channel 11 reported on the same problem, state authorities said they were planning to expand the number of beds in mental hospitals. Nine years later, the shortages remain. And the state is still making the same promises.

Legislation proposed in Springfield would funnel certain legally “unfit” low-level offenders into a diversion program where they’d be provided with mental health services.

‘This is a punitive system’

A Cook County court case offers a look at how these problems play out. On Nov. 14, the Cook County public defender’s office asked a judge to find the Illinois Department of Human Services in contempt of court for failing to put murder defendant Alberto Ibarra in a state mental hospital and submit a treatment plan.

Last July, Ibarra had been judged not guilty of murder by reason of insanity. According to the public defender’s office, the state agency agreed in September that the state psychiatric hospital in Elgin was the best place for Ibarra.

But the human services department told the judge the following month there wasn’t room for Ibarra because 225 other detainees already were waiting for placement in the state’s five mental health facilities, and they were all at “full capacity.”

Records show Ibarra has since been moved to IDHS custody, where he was on Jan. 30, according to a court filing that day.

Asked about the shortage of hospital beds, the agency says it has boosted the number of its “forensic beds” by 17% since 2019 and plans to add more. Forensic beds for people in the criminal justice system account for a portion of the total number of hospital beds, which also include those for civilly committed patients.

The problem, according to IDHS, is that court referrals to state mental hospitals have roughly doubled — from an average of about 50 to 60 detainees a month in 2019 to about 100 a month last year.

As a result, the average wait has gone way up despite the additional beds. The state agency says it’s looking for “unprecedented solutions to this challenge.”

Those who represent people with severe mental illness in the criminal justice system say more emphasis is needed on treatment so people don’t spiral into their second, third or even 10th arrest.

“It’s not fair to the system actors, to law enforcement and to the guards at the jail and so on,” says Rory McHale, director of legislative and external affairs for the public defender’s office. “This is not what they are trained for. This is not what they signed up for.

“I mean, it’s a criminal justice system. This is a punitive system that has specific goals that are not having to do with satisfying the mental health needs of Cook County residents,” McHale says.

The public defender’s office has five mental health clinicians to screen defendants whose cases are ongoing, according to Brittany Wells, the agency’s associate director of client services. The clinicians try to involve the defendants’ families for support and aim for those much-needed “warm hand-offs” to community mental health providers.

“Increasing services like that bridges the gap, so people don’t get lost in the system,” Wells says.

Amanda Antholt, a senior attorney with Equip for Equality, an Illinois nonprofit that has fought for defendants waiting for court-ordered treatment, agrees that a better approach is to address the underlying illness. Medicating someone to restore their fitness for trial isn’t the same as treatment, she says.

“There’s this misperception, and we even hear it from criminal defense attorneys, that, well, they’re going to get connected with the help they need to be stable when they go home,” Antholt says. “And that is not true. That is not what the [unfit to stand trial] system is designed for, and it’s not how it functions.”

Ideally, Antholt says, when mentally ill people are arrested, they’d get help before their release with housing, employment, disability services and mental health treatment, which currently exist in “very siloed” systems.

“Where is this person going to go?” she says. “Where are they going to sleep? If you’re giving them a prescription, where do they go to get that prescription filled? Setting up appointments for them with mental health providers.”

Nonprofit providers say they’re doing their best to keep people healthy and out of the criminal legal system.

Some, including the largest in Chicago, Thresholds, run “Assertive Community Treatment,” or ACT, teams, providing intensive wraparound services to people with severe mental illness. The teams meet people as they’re being discharged from hospitals and take them home, get their prescriptions filled, make sure they have food, connect them with psychiatrists and work out immediate transportation needs.

“You’re actually in somebody’s life where they’re living and helping them negotiate everything that could be a potential barrier for them,” says Debbie Pavick, who retired as Thresholds’ chief clinical officer in February after 43 years with the organization.

Thresholds runs eight ACT teams in Chicago and one each in Lake, McHenry and Kankakee counties.

The ACT teams require psychiatrists and nurses as well as social workers.

“We need a lot more [teams], but it’s really hard work, and it’s really hard to find staff who are committed to doing this work,” Pavick says.

These teams also need to get buy-in from the mentally ill people, who sometimes are leery of the process, says Susan Doig, president and chief executive officer of Trilogy Inc., an agency that runs six ACT teams.

Thresholds’ CEO Mark Ishaug says more than half of the 4,000 people his organization serves each year with its teams have had interactions with police and the justice system.

The goal, he says, is to tackle mental illness and stop the conveyor belt to jail.

“We know that the cost of even a couple nights in jail and a couple years in prison is exorbitant,” Ishaug says. “Plus, that doesn’t lead to the recovery that we are focused on.”

He says the “magic bullet” for solving the problem is a “very good use of resources up front instead of very expensive institutionalization” because “the cost of prison and jails and hospitals and ERs is very expensive, and we can’t afford this in the long run.”

State officials say they’re trying to expand community treatment, including ACT teams. According to the state Department of Human Services, Illinois’ annual spending on ACT treatment rose from $23.8 million in fiscal year 2019 to $29.3 million in fiscal year 2024. The state reimburses agencies for those services through Medicaid.

But Gov. JB Pritzker has been warning of potential Medicaid cuts by the Trump administration and the Republican-controlled Congress that could affect 1 in 4 Illinoisans who rely on Medicaid.

Nonprofit providers got more bad news in late March, when the Trump administration rescinded $153 million in federal grant money for Illinois, including $28 million for behavioral health services. Illinois and 22 other states are fighting back in court, and a federal judge on April 3 temporarily blocked the grant cancellations.

In a March 26 email to nonprofit mental health providers, David Albert, director of the IDHS Division of Mental Health, said the state was trying to mitigate the cuts but warned, “Due to the uncertainty of the future availability of these federal grant funds, we are alerting you that federal funding and related service reductions are likely.”

Pritzker says the public health cuts “will cause immeasurable harm and disruption” to health and safety.

Illinois also is exploring greater use of “outpatient civil commitment,” which is allowed under state law but rarely used. It’s a legal process in which a court orders someone with severe mental illness who is deemed a danger to themselves or others to be placed in supervised treatment in the community, rather than in a hospital. It’s meant for seriously ill people who are unable to stick to their treatment plans.

Illinois recently got a federal grant to educate stakeholders about the civil commitment process and find ways to streamline it, says Scott Block, behavioral health administrator for the Illinois court system. The grant will be used to match courts with providers so that, during a court order for up to 180 days, people would get case management, care and peer support.

Block says he hopes the program will handle about 50 cases a year in Cook County.

“We know that these are individuals that are winding up cycling through institutions like jails and/or prisons,” he says. “And we’re seeing these costs. We’re seeing not just monetary costs but costs to families, costs to public systems, costs to individual lives.

“I think the courts really shifted in taking a look at moving past just processing cases to: How do we improve what we’re doing here to produce the greatest potential outcome for all parties in these specific cases?”

Similar problems elsewhere

Chicago isn’t the only place wrestling with such questions as the pendulum swings toward mandating treatment. In New York, a string of violent attacks in the subways by people with mental health issues has unnerved commuters and led to calls to change state law to make it easier to commit people involuntarily. California voters recently passed a law that will do the same thing.

Illinois ranks 15th among states in the quality of its mental health care when taking into account prevalence of illness and access to treatment, according to a 2024 report by Mental Health America, a Virginia nonprofit organization that promotes mental wellness.

Illinois was found to do well with youth mental illness, for which the state was ranked fourth. On dealing with adult mental illness, though, Illinois ranked 29th, which put it behind Wisconsin (14th), Michigan (15th) and Indiana (16th).

IDHS officials point to Illinois’ mental health division budget, which has risen from $608 million in fiscal year 2019 to $930 million in fiscal year 2025. Since 2018, when Pritzker took office, the state has expanded the number of state behavioral health centers from one to 19, IDHS says.

City Hall also has expanded the number of its clinics. In January, Chicago opened a mental health clinic in Roseland, the city’s seventh. When Mayor Brandon Johnson took office in 2023, there were five of them. Chicago once had 19.

Under Johnson, the city also created “Crisis Assistance Response & Engagement,” or CARE, teams in seven police districts, which allow mental health clinicians and emergency medical technicians to respond to calls of people in psychiatric distress.

Dr. Miao Hua, the city of Chicago’s interim deputy commissioner of behavioral health.

Still, Dr. Miao “Jenny” Hua, the city’s interim deputy commissioner of behavioral health, says those CARE teams shouldn’t be considered a primary way to help mentally ill people who pose a threat to themselves and others.

“Ultimately, I think [with] the group of people you’re talking about, CARE is not going to be able to implement the full spectrum of services needed,” Hua says.

What’s urgently needed, many experts say, is housing to provide the stability people need so they can address their illnesses.

Betty Bogg, CEO of Connections for the Homeless in Evanston, says emergency shelters can help but aren’t a substitute for permanent housing and a meaningful mental health safety net.

“We don’t have the capacity to serve someone the way they need to be served” if they have an untreated, severe mental illness, Bogg says. “We’re like putting Band-Aids on them and sending them back out.”

Dr. Stephen Dinwiddie, chief of forensic psychiatry at Northwestern University’s medical school and a former medical director at Elgin Mental Health Center, says mental illness “by no means is going to be predictive of dangerous and violent behavior.”

But he also says it doesn’t mean society can’t prevent those who are mentally ill who might become violent from doing so, especially when they’ve had numerous encounters with law enforcement and clearly need medical treatment.

“Had there been the ability to early on adequately treat the mental illness, which was the driver of the other acts, then [the] tragedy would not arise,” Dinwiddie says. “Nobody would be thinking about it because the interventions worked.”