Upstream: The Intersection of Behavioral Health, Public Health, and Pretrial Services
I’d like to talk with you about the intersection of public health and the criminal legal system—specifically, behavioral health and pretrial services.
People detained pretrial make up a significant portion of the population in our nation’s local jails. We also know that behavioral health needs are highly prevalent among people who come into contact with the criminal legal system, including substance use disorders and mental health conditions. Often, these needs occur together. For purposes of this discussion, I will refer to them as co-occurring disorders.
Those statistics matter, but the people behind them matter even more.
Looking Beyond the Charge
Many people entering the pretrial system face charges that do not necessarily indicate a high likelihood of new criminal activity or failure to appear. When validated pretrial assessment tools are appropriately used, they can help practitioners and courts identify individuals who have a high likelihood of remaining arrest-free and returning to court while their cases are pending.
Put positively—as we are increasingly learning to do—many of the people we encounter have a high likelihood of succeeding in the community while awaiting trial.
Yet many people remain detained.
Courts may believe that setting what appears to be a relatively low monetary bond—$100, $250, or $500—provides a reasonable path to release. Those of us working directly with pretrial populations know that even a seemingly small amount can represent an insurmountable barrier for someone experiencing poverty.
For a person choosing between rent, food, transportation, medication, or other basic necessities, there may simply be no money available for bond.
Poverty does not exist independently from health.
When people experience poverty, they are more likely to face unmet social determinants of health—the conditions in which people are born, live, learn, work, and age that influence their health and well-being.
Those needs may include:
- Access to safe and stable housing
- Reliable access to food and clean water
- Transportation
- Employment and economic stability
- Access to physical and behavioral healthcare
- Personal and community safety
- Social connection and support
Now picture yourself on one of the hardest days you have ever experienced.
Maybe it was a final exam in college. Maybe it was going through a divorce. Maybe it was moving your family from one home to another or losing someone you loved.
Now imagine navigating that same experience without stable housing, reliable transportation, employment, education, financial resources, or a strong support system.
Then imagine doing it while also experiencing a serious mental health condition, substance use disorder, or both.
How much harder would that hardest day become?
A Public Health Issue Within the Criminal Legal System
I believe it is incumbent upon us as a field to look closely at the prevalence of behavioral health needs among people entering our jails and pretrial systems.
When we see the same challenges repeatedly—untreated mental health conditions, substance use disorders, housing instability, poverty, food insecurity, and limited access to healthcare—we should ask whether we are responding to an individual criminal legal problem or seeing the consequences of much larger public health and community challenges.
That distinction matters.
If we understand these challenges partly through a public health lens, our response begins to change.
Instead of asking only, “What condition should we impose?” we can also ask:
“What does this person need to succeed?”
And then:
“Does that need require a court condition, or is it something we can offer voluntarily through supportive services?”
Those are very different questions.
Treatment Should Not Require Incarceration
For far too long in the United States, jails and other parts of the carceral system have become de facto points of access to behavioral healthcare for people who were unable to obtain adequate services in their communities.
We have all heard some version of the same statement:
“What is the largest provider of mental health services in our community?”
Too often, the answer is the local jail.
In Maine, where I work, that conversation frequently points to facilities such as the Cumberland County Jail.
But consider what that really means.
Think about the people in your own life who have never been involved in the criminal legal system.
How many take medication for depression or anxiety? How many receive counseling? How many need medication or other support to focus, function, sleep, work, or manage daily life?
Probably more than we realize.
Now think about people you know who live with serious and persistent mental health conditions and have never been arrested.
We understand that they need healthcare.
Why should our understanding of behavioral health fundamentally change when the person needing care has also come into contact with the criminal legal system?
Jail should not have to become the gateway to treatment.
Support Without Turning Support Into a Condition
Our country is moving—far too slowly, in my estimation—toward a model that better recognizes the value of supportive services for people involved in the pretrial system.
The idea is relatively simple: we can help people access what they need without automatically turning every service into a condition of release.
I strongly support that approach.
At Maine Pretrial Services, we have been doing versions of this work for 40 years. We may not always have had a particular name for it.
If pushed to describe it, I might simply call it humanity.
If you met someone who had very little and you had access to resources that could help, what would you do?
You would ask:
“What do you need?”
You might follow that with:
“What can you do, and what can I do to help?”
Sometimes people need treatment. Sometimes they need housing. Sometimes they need transportation, identification, food, medication, or help understanding where they are supposed to be next.
Sometimes they simply need someone who knows the system to point them in the right direction.
That is support.
It does not always have to become supervision.
Navigators—and a Larger Purpose
That brings us to the growing role of navigators.
Navigators can be tremendously valuable, particularly when systems are complicated and resources are fragmented. But I believe we should challenge ourselves to think beyond helping one person navigate a broken or disconnected system.
What if navigation also helped us identify where the system itself needs to change?
If we repeatedly encounter people who cannot find behavioral healthcare, that tells us something.
If we repeatedly encounter people without stable housing, that tells us something.
If transportation consistently prevents people from reaching treatment, employment, or court, that tells us something.
If people routinely enter jail because community services were unavailable long before their arrest, that tells us something too.
Instead of addressing each issue only after an individual has been arrested and detained, we should also be asking:
What does this community need to better support the people who live here?
That is the larger purpose.
If communities are supported, funded, connected, and trained to respond effectively to behavioral health and social needs, they can become the center of service rather than relying on the criminal legal system to fill gaps it was never designed to fill.
Moving Upstream
I believe we need to move upstream.
We should not wait until someone's needs have gone unmet for so long that crisis becomes the point of intervention.
We should not wait until housing instability becomes homelessness.
We should not wait until an untreated behavioral health condition becomes an emergency.
And we should not wait until someone enters the criminal legal system before they can finally access help.
The consequences of unmet needs do not necessarily stop with one person. Persistent poverty, instability, trauma, and lack of access to care can affect families and communities across generations.
I was fortunate.
My parents grew up during the Depression, but they had enough. And because they had enough, we could keep our eyes open and our bodies moving forward. We could go to school. We could work. We could contribute.
When you do not have enough—enough food, enough safety, enough stability, enough healthcare, enough opportunity—it becomes extraordinarily difficult to do those things.
We can change that.
The Role of Pretrial Services
None of this means pretrial services should become the behavioral health system, housing system, public health department, or social services agency.
It should not be up to pretrial services to fix every unmet community need.
But pretrial professionals occupy a unique position.
Every day, we see where systems connect—and where they do not.
We see the person who could succeed in the community if transportation were available.
We see the individual whose behavioral health needs existed long before an arrest.
We see the person whose housing instability makes nearly every other part of life more difficult.
We see what happens when community resources are available.
And we see what happens when they are not.
That perspective gives our field both an opportunity and a responsibility to contribute to the conversation.
We can build partnerships with public health agencies, behavioral health providers, housing organizations, peers, community-based organizations, and other local resources.
We can offer voluntary connections to services without unnecessarily transforming every need into a court mandate.
We can collect and share data about the barriers we repeatedly see.
We can ask whether our practices support successful pretrial outcomes while preserving the presumption of innocence and using the least restrictive interventions necessary.
Most importantly, we can use our proximity to the issue to advocate within our own systems for a different way of thinking.
Start upstream.
Build communities in which people can access help before crisis becomes criminal legal system involvement.
Make treatment available because someone needs treatment—not because someone has been arrested.
Create systems where support is truly support.
It should not have to be the responsibility of pretrial services to solve these problems.
But, as always, pretrial services aims to assist.
And because we have such a close perspective on these issues, I call upon us to be among those who help change them.
About the Author:

Elizabeth Simoni is the Executive Director of Maine Pretrial Services, Inc., a private non-profit dedicated to assisting primarily indigent individuals in Maine’s civil and criminal court systems. Ms. Simoni is active in Maine and nationally. In 2024, she received the National Association of Pretrial Services (NAPSA) Lifetime Achievement Award for assistance with national pretrial publications, national standards board service, and three decades of pretrial service development in Maine. She is an active member of the National Institute of Corrections’ (NIC) Pretrial Executive Network and is the criminal justice representative on the Co-Occurring Collaborative Serving Maine’s board of directors. Her agency portfolio includes pretrial and reentry services, treatment court case management, behavioral health contracting for specialty courts, and holistic defense case management. She graduated from the University of Maine School of Law (1992), and Michigan State University (1989).









