Report of the Study Commission on Violence

Study Commission on Violence
Camelia M. Valdes
Passaic County Prosecutor
Co-Chair
Salaam Ismial
National Director of Youth Council, Inc.
Co-Chair
Sheetal Ranjan, PhD
Grant Director, Campus Violence Program, William Paterson University
Secretary
Mary Jo Buchanan, LSCW, MPA
CEO, Ocean Partnership for Children, Inc.
Joseph C. Fanaroff, Assistant Attorney General
New Jersey Department of Law and Public Safety
Steven M. Fishbein, MS, CRC, LRC
Manager, Justice Involved & Veterans Services
Division of Mental Health Services
Juli Harpell-Elam, M.A.Ed., LPC
Abuse Prevention Coordinator, Jersey Battered Women’s Services, Inc.
Bretta Jacquemin, MPH
New Jersey Department of Health
Debra Jenkins
Assistant Director of Municipal Court Services (Ret.)
Administrative Office of the Courts

Staff – Deputy Attorneys General
Emily Anderson
Nancy Andre
Gerard Hughes
TaraBeth LeFurge
Jennifer Lochel
Michelle Perry-Thompson
Jane Schuster

TABLE OF CONTENTS
EXECUTIVE SUMMARY ............................................................................................... 1
INTRODUCTION ............................................................................................................ 3
A. The Creation of the Study Commission on Violence .......................................... 3
1.
2.
3.
4.

Legislation in Response to Violence ............................................................... 3
About the Commission ................................................................................... 3
The Commission’s Mandate ........................................................................... 4
The Commission’s Activities ........................................................................... 4

B. The Study Commission on Violence and the Public Health Approach................ 5
CHAPTER 1. STUDYING SOURCE, TRENDS, AND IMPACT OF VIOLENCE ........... 9
A.
B.
C.
D.

Introduction – What Is Violence? ......................................................................... 9
Data And Resources ......................................................................................... 10
General Risk And Protective Factors ................................................................. 12
Specific Risk and Protective Factors ................................................................ 14
1.
2.
3.
4.
5.
6.
7.
8.

Youth Violence ...................................................................................... 14
Child Abuse And Neglect By Parents And Other Caregivers ................ 17
Intimate Partner Violence ...................................................................... 18
Women’s Use of Force .......................................................................... 22
Elder Abuse ......................................................................................... 23
Sexual Violence .................................................................................. 23
Suicide Or Self-Directed Violence ........................................................... 25
Collective Violence ............................................................................... 29

E. Statistics on Violence ....................................................................................... 29
1. National Statistics .................................................................................. 29
2. New Jersey Statistics ............................................................................ 30
a.
b.
c.
d.

Homicide and Interpersonal Violence ...............................
New Jersey Gang and Gun Statistics ..............................
2014 Statistics ..................................................................
Suicide and Self-Directed Violence ..................................

30
33
34
35

F. Recommendations ............................................................................................ 41
CHAPTER 2. FUNDING AND GRANTS .................................................................... 48
A. Overview ......................................................................................................... 48
B. Recommendations .......................................................................................... 50

CHAPTER 3. MENTAL HEALTH AND ACCESS TO TREATMENT
IN NEW JERSEY ........................................................................................................ 52
A. Introduction ....................................................................................................... 52
B. Mental Illness and Violence .............................................................................. 52
C. Recommendations ............................................................................................ 53
CHAPTER 4. MENTAL HEALTH DIVERSION WITHIN
THE CRIMINAL JUSTICE SYSTEM .......................................................................... 55
A. Overview ......................................................................................................... 55
B. Current Mental Health Diversion Programs ...................................................... 55
C. Recommendations ............................................................................................ 56
CHAPTER 5. OUTPATIENT COMMITMENT ........................................................... 58
A. Introduction and Background on Outpatient Commitment ................................ 58
B. Outpatient Commitment in New Jersey .......................................................... 60
C. Recommendations ............................................................................................ 63
GLOSSARY OF TERMS ............................................................................................ 64
ACKNOWLEDGEMENTS .......................................................................................... 65
APPENDIX A. VIOLENCE REDUCTION AND PREVENTION PROGRAMS
AND MENTAL HEALTH SERVICES .......................................................................... 67

EXECUTIVE SUMMARY
The Study Commission on Violence discharged its duty to examine trends and sources
of violence, the impact of violence on the community, identified funding opportunities
that address violence, and the mental health system through the receipt of subject
matter expert briefings, public hearings, and its own independent research. This report
summarizes the Study Commission’s findings and its recommendations to the
Legislature and the Governor.
Violence in our communities is a concern we heard expressed time and again in our
public hearings and in examining data related to the frequency of violence in New
Jersey. There is no one source of violence or a single impact on the communities where
it occurs. Rather, violence is brought on by a host of socio-economic factors and
individual decisions made by people who choose to perpetrate violent acts against
others or themselves. While ―violence‖ is an all-encompassing term, it can also be
imprecise. Deaths due to violence are at a generational low; yet, violence remains
stubbornly high in certain areas - in New Jersey, roughly 80 percent of all violent crime
occurs in just 21 cities. It is not coincidental that these cities also have lower rates of
high school graduation, higher rates of unemployment, lower rates of household
income, and higher rates of school truancy. Violence does not occur in a vacuum;
rather, it thrives in poor and disadvantaged communities where educational and
economic opportunities are limited and residents have become accustomed to a certain
level of lawlessness. In recent years, the challenges facing these communities have
been compounded by economic turmoil that has resulted in reductions in law
enforcement. Violence, however, is not confined to urban settings and occurs in
suburban and rural communities as well. The issue of violence should be a concern to
all New Jersey residents, to one degree or another.
And while violent ―street‖ crime is found disproportionately in a small number of places
in New Jersey, certain crimes like domestic violence are more widespread. Still others,
like elder abuse, are emerging as concerns in the community. At the same time, a
consensus has begun to form around the manner in which those who are drug addicted,
particularly those suffering from heroin addiction, are treated when they are arrested.
Whereas public policy once focused exclusively on incarcerating individuals, even for
low-level offenses, for significant periods of time, current policy has shifted toward
diverting non-violent offenders away from incarceration and into treatment. Moreover,
this trend has extended into how law enforcement treats juvenile delinquents. Through
diversion programs that offer community-based oversight, some county youth detention
facilities have closed because too few juveniles are being remanded to custody and the
number of juveniles in Juvenile Justice Commission facilities has dropped by roughly
half.
Of course, violence is not limited to acts by one person against another. Self-directed
violence in the form of suicide and attempted suicide is also prevalent in our country.
Indeed, the number of suicides that occur nationally each year is more than twice the
number of homicides that occur in our nation. The Study Commission took seriously its
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charge to examine the trends, sources, and impact of violence in the community, the
availability of grant funding to combat violence, the implementation of expanded
involuntary outpatient commitments, and whether and how defendants with identified
mental health disabilities but who are charged with crimes, can be offered an alternative
to incarceration in the form of a structured, case managed program of treatment and
counseling.
The Commission learned that there are a wide range of programs and services
available to those with a diagnosed mental health disability or illness. Indeed, coverage
for mental health treatment is now available to more individuals through the expansion
of Medicaid under the Affordable Care Act. That said, issues still remain regarding
access to that treatment due to limited resources and reimbursement for practitioners
who treat these patients. With respect to at least one specific charge of the Commission
– examining the involuntary outpatient commitment program and whether it should be
extended statewide – the Commission determined that this has been mooted by
legislation passed by the Legislature and signed by the Governor.
It is the Commission’s hope that the submission of this report is the beginning of a
robust conversation among policy makers in our state regarding the ways in which
violence can and should be addressed and how people with mental illness, and
particularly those who come into contact with the criminal justice system, are treated.
The Commission met many people of good faith who are working each day to make
their communities safer. We also learned about a number of programs being led in cities
throughout our state that are attempting to address some of the root causes of violence
and address it at both ends of the spectrum – through crime prevention initiatives that
try to reduce the incidences of violence occurring in the first place and through reentry
initiatives that work with ex-offenders to decrease the likelihood that they will commit
crimes in the future. We also found a heightened awareness of, and interest in,
programs that offer diversion out of the criminal justice system for clinically appropriate
defendants whose conduct is driven by their mental illness or drug addiction and,
through treatment, have a lesser chance of recidivism.
At bottom, there is no single program or initiative that will address all of the issues the
Study Commission was charged with examining. Rather, our investigation confirmed
that a multi-disciplinary approach that incorporates as many stakeholders addressing
the suite of challenges offers the greatest likelihood of success.

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INTRODUCTION
A. The Creation of the Study Commission on Violence
1. Legislation in Response to Violence
On August 8, 2013, and in response to recent incidents of mass violence in America,
Governor Christie signed a bill passed by the New Jersey Legislature establishing the
Study Commission on Violence.1 Statistics from the U.S. Department of Health and
Human Services, Centers for Disease Control and Prevention (―CDC‖), give one
indication of how heavy the burden of violence is on society - there were over 16,600
homicides and 41,000 suicides in the United States in 2013 alone.2 Nationally, homicide
is in the top five leading causes of death for everyone up to age 45, and suicide is in the
top five leading causes of death from ages 15 through 54.3 In New Jersey, homicide is
the second leading cause of death among 15 to 24-year-olds and 25 to 34-year-olds,
and suicide is in the top five for every age group from ages 15 through 54.4 Beyond
fatalities, there are economic and societal costs. In 2013, data from the New Jersey
Department of Health, Center for Health Statistics and Informatics (―CHSI‖) show that
the cost of treatment for the 27,000 hospitalizations and emergency department visits
for non-fatal assaults and 4,800 non-fatal self-inflicted injuries in New Jersey hospitals
was more than $530 million, with substantial impacts to healthcare resource use,
families, and communities.5
2. About the Commission
The New Jersey Legislature found that it is ―in the public interest for the State to
establish a commission to study violence in order to raise awareness about one of this
country’s most significant public health crises.‖6 The Study Commission on Violence
(―The Commission‖) is comprised of nine members: one member representing the
Attorney General, the Department of Health, the Administrative Office of the Courts, and
the Department of Human Services, the President of the County Prosecutor’s
Association, and four public members, two of whom were selected by the Governor and
one each by the President of the State Senate and Speaker of the State Assembly.
Support staff is provided by the Department of Law and Public Safety.

1

N.J.S.A. 52:17B-239 et seq.
CDC, Centers for Injury Control and Prevention, National Center for Injury Prevention and Control. Webbased Injury Statistics Query and Reporting System (WISQARS). Available at:
http://www.cdc.gov/injury/wisqars/
3
Ibid.
4
Ibid.
5
Center for Health Statistics and Informatics, The New Jersey Violent Death Reporting System:
Surveillance Updates and Trends, 2003-2013 (Trenton: New Jersey Department of Health, 2015 (in
publication)
6
N.J.S.A. 52:17B-239(1)(q).
2

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As outlined in the legislation, the Commission enlisted field experts from academia,
various violence prevention agencies, organizations, and community groups to assist
with the Commission’s directives, and held public hearings where testimony from
interested groups, local officials, and the general public was heard and recorded.
3. The Commission’s Mandate
Under the enacting Legislation, the Commission has the following duties:7
a) To study the trends of violence, the source of violence, and the impact of violence
on the community, to develop a method to address the epidemic of violence at the
federal and State levels, and to make recommendations for State and
Congressional action;
b) To seek out funding and grants for the implementation of programs to reduce
violence from sources including, but not limited to, the Centers for Disease Control
and Prevention and any other funding sources;
c) To study the issue of insufficient access to mental health treatment and violence;
d) To study and make recommendations regarding whether the Special Offenders
Unit created by the Union County Prosecutor’s office to address the increase in
criminal prosecutions against individuals with mental illness should be expanded to
other counties; and
e) To study and recommend whether the community-based mental health treatment
system, through which there are involuntary outpatient commitments under a court
order supervised by a case manager, should be expanded to all counties in this
State and how to adequately fund the program in all counties.
4. Commission Activities
The Commission was briefed by various experts on those factors they believe contribute
to violence in New Jersey, as well as their thoughts on solutions. With their assistance,
the Commission studied the impact of various factors such as family structure,
poverty/economic class, education, behavioral and mental health, substance abuse,
recreational activities, gender, social and community norms, prison culture and
recidivism.
The Commission held eight public hearings across the state where members of the
public provided oral testimony. The Commission also received written statements and
email from the public expressing their views on the topics we were charged with
examining. This information was reviewed and considered in conjunction with the expert
briefings, independent research, and statistical analysis conducted by the Commission.

7

N.J.S.A. 52:17B-241.

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B. The Public Health Approach To Violence Prevention
As directed by the State Legislature, the Commission used the public health approach
to guide its examination of violence in New Jersey. As initially described by the World
Health Organization (―WHO‖) and implemented at the federal level in the United States
primarily by the CDC, the public health approach for violence prevention starts with the
underlying assumption that violence is preventable, like infectious diseases, and with
multiple possible points of intervention. It is an interdisciplinary approach that
emphasizes ―collective action from members of diverse fields such as health, education,
social services, criminal justice, and policy, and encourages the development of
additional public/private partnerships with the ultimate aim of providing the maximum
benefit for the largest number of people.‖8
An evolution in thinking about the very nature of the intersection of violence and health
started in the United States in the late 1970s. According to the CDC’s historical
timeline,9 in 1979 the U.S. Surgeon General’s Report, Healthy People, first identified
stress and violent behavior as a key priority area for public health. During the 1980’s,
the CDC began collaborating with local agencies and law enforcement to investigate
incidents such as the Atlanta child murders and a disturbing pattern of suicides in
Texas; this work demonstrated the effectiveness of using field epidemiology methods to
investigate violent deaths. In 1993, the CDC established the Division of Violence
Prevention, thereby solidifying violence as a public health issue of importance with
possible prevention strategies. The following year, the World Health Organization
declared that ―violence is a leading worldwide public health problem.‖ In 2002, WHO
published its World Report on Violence and Health, the first worldwide comprehensive
summary of violence, with an emphasis on challenging long-held assumptions on what
violence actually is, who it affects, and who can prevent it.10
The complex nature of violence, which involves individuals, relationships, environments,
and cultural factors, makes trying to identify a single strategy to understand and prevent
violence impossible. The ―public health approach‖ is rooted in the scientific method, and
involves a four-step process that can be applied to violence as well as many other
health problems that affect populations. The approach, as outlined by WHO, involves:
1) Uncovering as much basic knowledge as possible about all the aspects of violence
– through systematically collecting data on the magnitude, scope, characteristics
and consequences of violence at various levels;

8

Krug, E., et al., eds. World Report on Violence and Health at 3-4 (Geneva, World Health Organization,
2002). http://apps.who.int/iris/bitstream/10665/42495/1/9241545615_eng.pdf
9
CDC, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control,
Division of Violence Prevention. ―A Timeline of Violence as a Public Health Issue‖ (2014)
http://www.cdc.gov/violenceprevention/overview/timeline.html.
10
Krug, supra fn. 8 at 5.

5|Page

contexts or interactions, and suggests that to prevent violence it is necessary to act
across different levels at the same time and throughout the lifespan.14
While the first two steps of the public health approach are focused on describing the
problem with appropriate definitions, data, and research on the risk and protective
factors for populations at risk, the practical application of the public health approach is in
developing targeted programs, putting prevention into action, and evaluating results.
There are three distinct phases of injury and violence that prevention can address.
Primary prevention is aimed at preventing violence before it occurs; secondary
prevention seeks to lessen the immediate damage of violence through strategies that
may employ limitations on the availability of deadlier weapons, adequate emergency
response, and health care treatment; and tertiary prevention, which focuses on longterm needs after violence occurs, including rehabilitation and disability care.15
The strategic development of most public health injury and violence prevention
programs starts with diagramming the problem using the Haddon Matrix. William
Haddon, Jr., was the Director of the National Highway Traffic Safety Administration and
the Insurance Institute for Highway Safety in the 1960s and 1970s. Dr. Haddon is
considered a visionary in the field of injury epidemiology. His work posited that motor
vehicle crash injuries were foreseeable events, and could be described in a similar
epidemiologic framework as a disease, with a host, vector/agent, and environment that
could be analyzed for risk factors and intervention and prevention opportunities.
The Haddon Matrix can also be applied to violence prevention. Table 1 shows an
example of using the Haddon Matrix to describe the various event phases of domestic
violence; a prevention program may focus on identifying and altering pre-event or event
phase factor(s) that may make a victim more susceptible to domestic violence. The
victim (host) could have strengths such as good existing health or limitations such as
smaller size or co-dependence. The perpetrator (agent) could have larger size to deliver
more energy to the victim, thereby doing more damage, or fear of losing control over
their partner. They both may have common pre-existing risk factors such as being
witness to violence in the past, and both may be intoxicated or have issues with
substance abuse. The environment could be a slippery surface or an isolated area
which may increase injury severity, and the criminal justice system could be the social
environment within which the incident takes place.16

14

Id. at 15.
Ibid.
16
Hamberger, L.K. & Phelan, M.B., Domestic Violence Screening and Intervention in Medical and Mental
Healthcare Settings, 272-275 (New York: Springer Publishing Company, Inc., 2004).
15

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Table 1. The Haddon Matrix: Domestic Violence (Hamberger and Phelan, 2004.)

HOST
VICTIM)
Pre-event

Event

Post-event

ENVIRONMENT
(aka AGENT
(aka
PERPETRATOR)
SCENE

 Witness to or victim of
physical or sexual abuse
as a child.
 Dependent
on
perpetrator financially,
emotionally,
coparenting.
 Young age (18-24).
 Experience
of
prior
verbal abuse within
relationship.
 Isolation from family and
friends.
 Intoxication.
 Pushing,
punching,
kicking, grabbing, striking
with blunt object.
 Use of weapon (gun,
knife).
 Sexual assault.
 Tissue damage secondary
to
crush
injury,
laceration.
 Fractures, head injury,
intra-abdominal injuries.
 Sexually
transmitted
disease
exposure,
including HIV.
 If medical attention
sought for injuries, may
be entry point for legal
aid,
education,
counseling services.

CULTURAL,
SOCIOECONOMIC

 Witness to violence in
family setting as a child.
 May have been a victim
of physical or sexual
abuse as a child.
 Perpetrator uses power
and control within the
context of an adult
relationship.
 May include verbal,
emotional, sexual abuse.
 May do so incrementally.
 Intoxication.

 Car, home, workplace,
public areas.
 Lack
of
pre-existing
security (i.e., workplace
plan).
 Lack of safety plan.

 Legislation
(i.e.,
mandatory arrest).
 Victim’s
access
to
alternate housing.
 Occurs in all cultures, and
across
socioeconomic
classes.
 Immigrant status may
further increase isolation.

 Perpetrates the violence
described on the host
during the event phase.

 Home without a phone
or perpetrator blocks
access to phone or
escape.
 Workplace not secure.

 Cultural, religious, or
familial expectations.
 Economic dependence.

 May be victim of
retaliatory violence with
injuries similar to above.
 Negative
behavior
reinforced
if
no
consistent
negative
consequences,
or if
achieves desired effects
(i.e.,
control
over
partner).
 If medical attention
sought for injuries, may
be entry point for legal
aid,
education,
counseling services.

 Methods of response:
911, security guards.
 Scene
secure
for
EMS/police access.

 Reporting
may
be
minimized because of
language barriers, or
concerns of deportation.
 Culturally
sensitive
outreach and resource
availability in appropriate
language may improve
access.

Each of these elements and phases presents opportunities for prevention or mitigation,
and completing the matrix guides prevention specialists toward systematically
examining a problem to determine pursuit of the best strategy.

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CHAPTER 1: THE SOURCES, TRENDS AND IMPACT OF VIOLENCE
A. Introduction – What Is Violence?
The first duty assigned to the Commission was:
―To study the trends of violence, the source of violence, and the impact of
violence on the community, to develop a method to address the epidemic of
violence at the federal and State levels, and to make recommendations for
State and Congressional action.‖17
To do so, the Commission first had to determine how broadly to define the word
―violence.‖ The WHO defines ―violence‖ as:
The intentional use of physical force or power, threatened or actual, against
oneself, another person, or against a group or community, that either results
in or has a high likelihood of resulting in injury, death, psychological harm,
maldevelopment, or deprivation.18
The intention to use force or power is the key aspect in defining ―violence‖ irrespective
of the outcome; the use of violence can be reactive, proactive, or criminal in nature,
done in the public versus private spheres and simply be contemplated, not actualized.
As the WHO’s World Report notes:
This definition covers a broad range of outcomes - including psychological
harm, deprivation, and maldevelopment. This reflects a growing recognition
among researchers and practitioners of the need to include violence that does
not necessarily result in injury or death, but that nonetheless poses a
substantial burden on individuals, families, communities, and health care
systems worldwide. Many forms of violence against women, children, and the
elderly, for instance, can result in physical, psychological, and social
problems that do not necessarily lead to injury, disability, or death. These
consequences can be immediate, as well as latent, and can last for years
after the initial abuse. Defining outcomes solely in terms of injury or death
thus limits the understanding of the full impact of violence in individuals,
communities, and society at large.19
The CDC follows this definition. Since 2006, the CDC’s Division of Violence Prevention
has developed strategic plans around certain topics in violence reflective of the WHO’s
typology. The plans are organized around the many areas of public health research and
practice in the United States that also link back to the overall field of violence prevention

17

N.J.S.A. 52:17B-241.
Krug, supra fn. 8 at 5.
19
Ibid.
18

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



provided the information about police involvement is noted on the certificate.23,24
Otherwise, it would be coded as ―homicide.‖
Medical examiners do not use the ICD-10 when coding death cases. Guidance
from the National Association of Medical Examiners (―NAME‖) defines homicide
as when death results from ―an injury or poisoning or from a volitional act
committed by another person to cause fear, harm, or death.‖ The intent to cause
death is a common element but not required for classification as homicide. 25 This
same death will be reported simply as a ―homicide‖ in their data set as there is no
separate category for legal intervention deaths.
This death would not be included at all in the UCR because officer-involved
shootings are excluded from that report.

Data for non-fatal injuries resulting from violence are primarily obtained from hospital
discharge data from health departments. In New Jersey, these data are maintained by
the Office of Health Care Quality Assessment within the state Department of Health.
However, because of limitations in coding and lack of mandatory reporting systems for
conducting surveillance for most injuries, non-fatal violent injuries are believed to be
substantially under-reported. Table 2 outlines the minimum recommended data sets that
should be available to a state health department for conducting violence surveillance.26
Table 2. Core injuries, injury risk factors, and data sets for state injury surveillance (adapted)

Vital
Records

Hospital
BRFSS
Discharge
YRBSS
Data

ED data

Medical Child
Examiner Death
data
Review

Firearm injuries

X

X

(X)

(X)

(X)

Homicides

X

X

(X)

(X)

(X)

Suicides

X

X

(X)

(X)

(X)

Suicide Attempts

X

Both

(X)

Other*
(UCR)
(EMS)
(NVDRS)
(UCR)
(NVDRS)
(NVDRS)
(EMS)

BRFSS = Behavioral Risk Factor Surveillance System; YRBSS = Youth Risk Behavior Surveillance System; ED = Emergency
Department; UCR = Uniform Crime Reporting System; EMS = Emergency Medical Services; NVDRS = National Violent Death
Reporting System. () Parentheses indicate data sets that are considered supplementary, all others are considered essential.
*NVDRS does not appear in the original listing but is available in New Jersey.
23

WHO, International Statistical Classification of Diseases and Related Health Problems 10th Revision
(ICD-10)(2015) available at http://apps.who.int/classifications/icd10/browse/2015/en#/y35-y36.
24
Ibid.
25
Centers for Disease Control and Prevention, National Center for Health Statistics, Medical Examiners’
and Coroners’ Handbook on Death Registration and Fetal Death Reporting, 2003 Revision (Hyattsville:
Department of Health and Human Services Publication Number 2003-1110)(April 2013) available at
www.cdc.gov/nchs/data/misc/hb_me.pdf.
26
State and Territorial Injury Prevention Directors Association, Injury Surveillance Workgroup 5,
Consensus Recommendations for Injury Surveillance in State Health Departments (Atlanta: State and
Territorial Injury Prevention Directors Association, 2007).

11 | P a g e

C. General Risk and Protective Factors
As part of its charge, the Commission studied the various root causes and contributing
factors of violence, as well as the various protective factors that mitigate the effects of
violence and lessen their impact on people and communities. In addition to hearing
expert testimony on various types of violence, which in many cases discussed root
causes and contributing factors, the Commission reviewed existing research and
reports compiled by WHO, CDC, state agencies, and academic peer-reviewed journals.
A joint publication by the CDC and Prevention Institute, Connecting the Dots: An
Overview of the Links Among Multiple Forms of Violence (2014), quotes Deborah
Prothrow-Stith, M.D., an adjunct professor at Harvard School of Public Health, as
saying, ―Gang violence is connected to bullying is connected to school violence is
connected to intimate partner violence is connected to child abuse is connected to elder
abuse is connected. It’s all connected.‖27 This comprehensive publication is intended to
assist practitioners in developing strategically designed prevention programs and
employing coordinated, integrated responses to violence.
In Connecting the Dots, risk factors for violence were broken down into societal risk
factors, community risk factors, and relationship risk factors. Under this approach,
societal risk factors include:






cultural norms that support aggression toward others;
media violence;
societal income inequity;
weak health, educational, economic, and social policies and laws; and
harmful norms around the concepts of masculinity and femininity.

Community risk factors include:






neighborhood poverty;
high alcohol outlet density;
community violence;
diminished economic opportunities/ high unemployment rates, and
poor neighborhood support and cohesion.

Relationship risk factors include:




social isolation and lack of social support;
poor parent-child relationships;
family conflict;

27

Wilkins, N., et al., (quoting Deborah Prothrow -Stith, M.D.), National Center for Injury Prevention and
Control, Centers for Disease Control and Prevention and Prevention Institute, Connecting the Dots: An
Overview of the Links Among Multiple Forms of Violence, (Atlanta: Centers for Disease Control and
Prevention and Oakland: Prevention Institute, 2014).

12 | P a g e












economic stress;
associating with delinquent peers;
gang involvement;
low educational achievement;
lack of non-violent problem-solving skills;
poor behavioral control and impulsiveness;
history of violent victimization;
witnessing violence;
psychological and mental health problems; and
substance abuse.28

CDC also considered and evaluated the protective factors that make it less likely that
people will experience violence and/or increase their resilience against risk factors for
violence. Protective factors can include community protective factors, relationship
protective factors, and individual protective factors. Community protective factors can
include:




coordination of resources and services among community agencies;
access to mental health and substance abuse services; and
community support and connectedness.

Relationship protective factors include:





family support and connectedness;
connection to a caring adult;
association with pro-social peers; and
connection and commitment to school.

A protective factor for individuals is having non-violent problem-solving skills.29
The authors then compared studies from peer-reviewed journals and considered
surveys and statistics that show the association between the above-referenced risk and
protective factors and eight different types of violence perpetration: child maltreatment;
teen dating violence; intimate partner violence; sexual violence; youth violence; bullying;
suicide; and elder maltreatment. The results are staggering. Substance abuse is a risk
factor for every category of violence, as are a history of violent victimization and a lack
of non-violent social problem-solving skills. Similarly, witnessing violence is a risk factor
for all but one type of violence perpetration, and family conflict and harmful norms
around masculinity and femininity were contributing factors to all but two types of
violence perpetration. The two protective factors with the most far reaching implications
across the most types of violence are community support and connectedness, as well
as connection and commitment to school.30
28

Ibid.
Ibid.
30
Id. at 8-9.
29

13 | P a g e

Research specifically focused on recurring themes of violence in New Jersey yielded
similar findings. Prior exposure to violence, particularly domestic violence, was found to
be a significant factor in becoming a victim of future violence. The New Jersey Child
Fatality and Near Fatality Review Board reported that of the 158 deaths from 2011 that
were reviewed, 50 percent of child suicide victims had been involved in or exposed to
domestic violence, and 38 percent of the child homicides involved perpetrators who also
had domestic violence in their history.31 Substance abuse was found to be a powerful
predictor of violence.32 Work by authors at The Violence Institute of New Jersey
(formerly UMDNJ, now Rutgers University), found that violence is more likely to occur in
areas that are socially disorganized and suffer from economic deprivation,33 and
research from the Michigan State University School of Criminal Justice comparing
intimate partner homicide in Newark, New Jersey with Indianapolis, Indiana, found that
gender roles and cultural norms were found to be significant risk factors for intimate
partner violence and that particular risk factors may vary widely by location.34
D. Specific Risk and Protective Factors
The 2002 WHO World Report makes the case that violence is preventable and that
public health has a crucial role to play in addressing its causes and consequences. In
doing so, the WHO report compiled extensive research and identified and described
several key risk factors for different types of violence and further categorized each risk
factor as an individual, relationship, community, or societal factor.
1. Youth Violence
WHO’s World Report chapter on youth violence reported that at the individual level
there are a number of major personality and behavioral factors that may predict
violence: hyperactivity, impulsiveness, poor behavioral control, and attention
problems.35 Low intelligence levels and low levels of achievement in school have also
been consistently found to be associated with youth violence.36 Relationship factors for
youth violence include family and peer influences, with peer influences gaining
increased significance in adolescence.37
Regarding family influences, ―[p]arental behavior and the family environment are central
factors in the development of violent behavior in young people.‖38 Specifically, ―[p]oor
31

New Jersey Child Fatality and Near Fatality Review Board, 2013 Child Fatality & Near Fatality Review
Board Annual Report, (Trenton: Department of Children and Families, 2014).
32
Zarza, M. & Adler, R., Latina Immigrant Victims of Interpersonal Violence in NJ: A Needs Assessment
Study, J. Of Aggression, Maltreatment and Trauma, Vol. 16 (2008).
33
Boyle, D. & Hassett-Walker, C., Individual-Level and Socio-Structural Characteristics of Violence: An
Emergency Department Study, J. Interpersonal Violence, Vol. 23, No. 8, 1011-1026 (2008).
34
Dejong, C., et al., Can Situational and Structural Factors Differentiate Between Intimate Partner and
"Other" Homicide, J. Fam. Violence (2011).
35
Krug, supra fn. 8 at 32.
36
Krug, supra fn. 8 at 33.
37
Krug, supra fn. 8 at 33.
38
Ibid.

14 | P a g e

monitoring and supervision of children by parents and the use of harsh, physical
punishment to discipline children are strong predictors of violence during adolescence
and adulthood.‖39 Moreover, ―[v]iolence in adolescence and adulthood has been
strongly linked to parental conflict in early childhood . . . and poor attachment between
parents and children.‖40 With respect to peer influence, having delinquent friends is
associated with violence in young people, but it is not clear whether having delinquent
friends came before or after a young person violently offends.41
The communities in which young people live are powerful influences. Studies have
shown that boys in urban areas, and particularly in high-crime areas, are more likely to
be involved in violence. The ―presence of gangs, guns and drugs in a locality is a potent
mixture, increasing the likelihood of violence.‖42 The degree of cohesion or solidarity
within a community — or ―social capital‖ — of young people in those communities is
also correlated with violence. Violence increases when young people feel less
connected, and develop an increased mistrust of other community members due to
destruction of infrastructure, amenities, and opportunities.43 Societal factors such as
income inequality, political structures, and cultural influences projecting a norm around
violence are also associated with increased violence in young people.44
The CDC has made similar findings in its work. In 2011, more than 700,000 young
people ages 10 to 24 were treated in emergency rooms nationwide for non-fatal injuries
sustained from assaults.45 On average, 16 people between the ages of 10 and 24 die by
homicide each day in the United States.46 Youth violence jeopardizes the future strength
and growth of all communities and it harms the physical, mental, and economic health
of all residents.47 Youth violence has been described as ―harmful behaviors that can
start early and continue into young adulthood. The young person can be a victim, an
offender, or a witness to violence.‖48 Youth violence includes acts such as bullying,
slapping, hitting which can cause more emotional harm than physical harm, and other
acts such as robbery and assault which can lead to serious injury or even death.49
There are a number of risk factors that can contribute to a youth becoming violent,
including individual, family, peer/social and community risk factors. However, there are
a number of protective factors that can ―buffer‖ young people from the risks of becoming
39

Ibid.
Ibid.
41
Id. at 34.
42
Id. at 34-35.
43
Id. at 36.
44
Id. at 36-37.
45
CDC, Youth Violence National and State Statistics at a Glance, p. 1 (2013) available at
www.cdc.gov/violenceprevention//pub/yv_datasheet.html.
46
CDC, Youth Violence: Consequences, p. 1 (2013) available at
www.cdc.gov/violenceprevention/youthviolence/consequences.html.
47
CDC, Taking Action to Prevent Youth Violence, p. 2-4, available at
ww.cdc.gov/violenceprevention/youthviolence/pdf/opportunities-for-action-companion-guide.pdf.(June
2014).
48
CDC Injury Prevention & Control: Division of Violence Prevention, Youth Violence, 1 (March 8, 2015).
available at www.cdc.gov/violenceprevention/youthviolence/index.html.
49
Ibid.
40

15 | P a g e

violent.50 The goal is to stop youth violence and find prevention efforts that are aimed at
reducing factors that place youth at risk for perpetrating violence and promote factors
that protect youth at risk for violence.51
There are many ways to prevent youth violence but concerted individual efforts are
essential. Young people can be taught the skills to help cope with violent situations and
develop the self-esteem needed to solve differences without violence. They can be
taught about the situations or actions that are likely to result in violence such as
associating with violent peers, alcohol and drug use, possessing firearms and weapons.
They can be provided with mentors and role models, and provided training, support and
recreation.52 Many resources are needed to have a successful community violence
prevention program, but the greatest resource of all is the collaborative effort of the
community.53
During our public hearings, we heard from many organizations across the state, some
at a ―micro-local‖ level, who expressed interest in developing the types of programs that
incorporate CDC principles. The overwhelming concern expressed was a lack of
available funding for such programs and the limitation on the number and type of
participants who can be served. Consistency and follow-up with program participants is
essential, as it may be the only stable thing in a child or adolescent’s life at that time.
Community members have ideas that they are excited about, but identified certain
obstacles, including:







A lack of appropriate spaces to meet (recreation centers, after school spaces,
community centers, churches);
A lack of minimal funds for resources such as extra hours of security staff or
utilities, food for the children who were in attendance, or gas money to help with
pick-up and drop-off;
Youth with minor records that would benefit from a program are often excluded
from larger funded programs because of restrictions on participant eligibility;
Adults with records who wish to re-join the community through mentoring are
often excluded from larger funded programs because of restrictions on mentor
eligibility;
Loss of program identity - a potentially good community idea gets absorbed by a
larger program, and leaves the originators behind;
While overall strategies may be employed across county and municipal lines, the
details of programs and efforts are local and need to cross jurisdictions when
appropriate; and

50

CDC, Youth Violence: Risk and Protective Factors, p. 1-4, available at: www.cdc.gov/violence
prevention/youthviolence/riskprotectivefactors.html
51
CDC, Youth Violence, Prevention Strategies, p. 1, available at:
www.cdc.gov/violencepreventiion/youthviolence/prevention.html
52
CDC, The Prevention of Youth Violence: A Framework for Community Action, p. 3, available at:
http://wonder.cdc.gov/wonder/prevguid/p0000026/p0000026.asp
53
Id. at 10.

16 | P a g e



A lack of resources for developing a program, no central directory of programs,
and that organizers do not know where to go to get started.

The overwhelming message from the public hearings and expert briefings was that
communities want to do this for themselves, to be in control of their neighborhoods, but
they need assistance, recommendations on best practices, and resources to help them
evaluate, improve, and potentially expand their programs.
2. Child Abuse and Neglect by Parents and Other Caregivers
Based on limited international research in this area, the WHO reported there are a
number of factors believed to increase a child’s vulnerability or risk of abuse, including
those that relate to both the child and caregiver.54 Age is one such factor, and the risk of
the type of abuse changes as children get older. While young children are at increased
risk for becoming victims of physical abuse, children are more likely to become victims
of sexual abuse after the onset of puberty and with the approach of adolescence.
Physically abusive parents and caregivers ―are more likely to be young, single, poor and
unemployed and to have less education than their non-abusing counterparts.‖55
Abusers are more likely to have been similarly maltreated by their own parents and/or to
be in a violent relationship with an intimate partner, thereby continuing the cycle of
abuse.56 Stress and social isolation of the parent or caregiver is also associated with
child abuse and neglect, as is substance abuse.57
On a community level, there is a strong association between child abuse and neglect
and poverty. Children living in areas with less ―social capital‖ appear to be at greater risk
of abuse and have more psychological and behavioral problems.58 Societal factors such
as cultural norms surrounding gender roles, child and family policies, and the strength of
the social welfare system are believed to be associated with violence but studies of the
impact of these factors are lacking.59
In New Jersey, the Child Fatality and Near Fatality Review Board (―NJCFNFRB‖) was
established by passage of the New Jersey Comprehensive Child Abuse Prevention and
Treatment Act.60 The principal objective of the Board is to ―provide an impartial review of
individual case circumstances and to develop recommendations for broad-based
systemic, policy, and legislative revisions for the purpose of preventing future
tragedies‖.61 Their selective reviews are not limited to homicides or undetermined
causes of death - the Board review includes suicides among children and young adults
up to age 21, deaths where substance abuse may have been a contributing factor, and
54

Krug, supra fn. 8 at 59-81.
Krug, supra fn. 8 at 67.
56
Id. at 67-68.
57
Id. at 68.
58
Id. at 68.
59
Id. at 68-69.
60
N.J.S.A. 9:6-8.88.
61
NJCFNFRB, 2013 Annual Report (issued 2014) available at
www.state.nj.us/dcf/documents/abouut/commissions/fatality/CFNFRB.report2013.pdf.
55

17 | P a g e

unintentional injury deaths such as drowning and certain motor vehicle crash situations.
The Board’s activities include:






Reviewing child fatalities and near fatalities in New Jersey in order to identify the
cause of the incident, the relationship of the incident to governmental support
systems, as determined relevant by the Board, and methods of prevention;
Describing trends and patterns of child fatalities and near fatalities in New Jersey
based upon its case reviews and findings;
Evaluating the response of government support systems to the children and
families who are reviewed and to offer recommendations for systemic
improvements, especially those that are related to future prevention strategies;
Identifying groups at high risk for child abuse and neglect or child fatality, in
terms that support the development of responsive public policy; and
Improving data collection sources by developing protocols for autopsies, death
investigations, and the complete recording of the cause of death on the death
certificate, and make recommendations for system-wide improvements in data
collection for the purpose of improved evaluation, potential research, and general
accuracy of the archive. 62

3. Intimate Partner Violence
Through the Commission’s work, it has found violence and abuse in the family is
connected to all other manifestations of violence, including intimate partner violence
(―IPV‖), child abuse, sexual violence, youth violence and bullying.
IPV (also referred to as domestic abuse or domestic violence) is prevalent in our
communities. 1 in 3 women and 1 in 4 men have experienced some form of physical
violence by an intimate partner within their lifetime. 1 in 5 women and 1 in 7 men have
experienced severe physical violence by an intimate partner.63
For the purposes of this document, IPV is defined as: the willful intimidation, physical
assault, sexual assault, and/or other abusive behavior as part of a systematic pattern of
power and control perpetrated by one intimate partner against another. It includes
physical violence, sexual violence, threats, and emotional abuse. The frequency and
severity of domestic violence can vary dramatically.64
The risk for women in a relationship with an abusive partner is significant. According to
a 2012 report by the Violence Policy Center, 72 percent of all murder/suicides involved
an intimate partner and 94 percent of those victims were female.65 Intimate partner
62

Ibid.
Black, M.C., Basile, K.C., Breiding, M.J., Smith, S.G., Walters, M.L., Merrick, M.T., Chen, J., & Stevens,
M., The National Intimate Partner and Sexual Violence Survey: 2010 Summary Report. National Center
for Injury Prevention and Control, Centers for Disease Control and Prevention (2011) available at
http://www.cdc.gov/violenceprevention/pdf/nisvs_report2010-a.pdf.
64
http://www.ncadv.org/images/National_Domestic_Violence_Statistics.pdf.
65
Violence Policy Center, American Roulette: Murder-Suicide in the United States (2012) available at
www.vpc.org/studies/amroul2012.pdf.
63

18 | P a g e

homicides also affect the community at large. A study of intimate partner homicides
found that 20 percent of victims were not the intimate partners themselves, but family
members, friends, neighbors, persons who intervened, law enforcement responders, or
bystanders.66 It is also worth noting that there appears to be a connection between
mass shooting incidents and domestic violence. Of 43 instances of ―mass shootings‖
(defined as incidents where at least 4 people are shot) between 2009 and 2013, in at
least 17 cases (40%), the shooter killed a current or former spouse or intimate partner,
and at least 6 of those shooters (20%) had a prior domestic violence charge.67
The CDC recognizes that IPV is ―a serious, preventable public health problem that
affects millions of Americans,‖ and in 2002 published a set of uniform data elements
and definitions for states to use in developing their own surveillance systems for IPV.68
While women are the most frequent victims of IPV, men can be victims of intimate
partner violence and more are starting to come forward; CDC does not exclude men as
victims from its prevention efforts.
There are four main types of IPV according to the surveillance definitions: (1) physical
violence, such as ―hitting, choking, shoving, pushing, or punching with the potential for
causing death disability, injury or harm;‖ (2) sexual violence, including the use of force
to compel someone to engage in a sexual act against their will, attempting or
completing a sexual act against someone unable to consent due to illness,
incapacitation, disability, intimidation or pressure, and abusive sexual contact; (3)
threats of physical or sexual violence through words, gestures, or the brandishing of
weapons to communicate the intent to cause death, disability, injury or harm; and (4)
psychological/emotional violence where IPV victims experience trauma due to acts,
threats of acts, or coercive conduct meant to minimize, humiliate, embarrass or diminish
them.
In addition, stalking is often included among the types of IPV. Stalking generally refers
to ―harassing or threatening behavior that an individual engages in repeatedly, such as
following a person, appearing at a person’s home or place of business, making
harassing phone calls, leaving written messages or objects, or vandalizing a person’s
property.‖
According to the WHO report, among the individual demographic factors associated
with intimate partner violence are young age and low income. Both ―were consistently
66

Smith, S., Fowler, K., & Niolon, P., Intimate Partner Homicide and Corollary Victims in 16 States:
National Violent Death Reporting System, 2003-2009. American Journal of Public Health, 104(3), 461466 (March 2014).
67
Mayor’s Against Illegal Guns, Mass Shootings since January 20, 2009, available at
http://www.washingtonpost.com/blogs/wonkblog/files/2013/02/mass_shootings_2009-13__jan_29_12pm1.pdf.
68
Saltzman LE, Fanslow JL, McMahon PM, Shelley GA, Centers for Disease Control and Prevention,
National Center for Injury Prevention and Control, Division of Violence Prevention, Intimate partner
violence surveillance: uniform definitions and recommended data elements, version 1.0. (Atlanta: Centers
for Disease Control and Prevention, 2002) available at
www.cdc.gov/violenceprevention/pdf/ipv/intimatepartnerviolence.pdf.

19 | P a g e

found to be factors linked to the likelihood of a man committing violence against a
partner.‖69 A history of violence in the family — both being abused as a child and
witnessing parental abuse by a father — has been found to be a ―powerful risk factor for
partner aggression by men.‖70
Studies have also shown that men who assault their partner are more likely to be
emotionally dependent, to be insecure and have low self-esteem, to have difficulty
controlling impulses, and exhibit greater anger and hostility than non-violent peers.71
Some common traits of men who perpetrate domestic violence include: (1) holding
traditional beliefs about gender roles (men are ―breadwinners,‖ women should stay
home); (2) a personal history of, or exposure to, abuse, particularly as a child; (3)
previous history of violence against a woman (those who have a history of physical
violence against their partners are 13 times more likely to commit future acts of physical
aggression compared to persons who have never committed this form of physical
abuse.72); (4) childhood bullying (men who reported bullying their childhood peers in
school were found to be significantly more likely to physically or sexually abuse their
female partners as adults); and (5) substance abuse, particularly alcohol, correlates to
IPV; however, while drugs and alcohol impair judgment, IPV is a matter of choice often
conducted in a ―safe‖ setting for the batterer that minimizes their risk of detection,
occurs at a time of their choosing and against a predetermined victim.
According to the Prevention Institute, there are social norms that promote violence
against women (such as IPV, sexual assault and stalking):73


Traditional gender roles of men in society, including those that promote
domination, control and dangerous risk-taking behavior;



Traditional gender roles of women in society, including those that promote
objectification and oppression of women and girls;



Power, where value is placed on claiming and maintaining control over others;



Violence, where aggression is tolerated and blame is attributed to victims; and



Privacy, individual and family privacy are considered sacrosanct - secrecy and
silence is fostered and those who witness violence are discouraged from
intervening.

69

Id. at 97.
Id. at 98.
71
Id. at 99.
72
Lisak, D., Hopper, J., & Sung, P., Factors in the cycle of violence: Gender rigidity and emotional
construction, Journal of Traumatic Stress, 9(4), 721-743 (1996).
73
Cohen, L. et al., Poised for Prevention: Advancing Promising Approaches to Primary Prevention of
Intimate Partner Violence, Prevention Institute (2007) available at
http://www.preventioninstitute.org/component/jlibrary/article/id-32/127.html.
70

20 | P a g e

Similar to the New Jersey Child Fatality and Near Fatality Review Board, the New
Jersey Domestic Violence Fatality and Near Fatality Review Board (―Domestic Violence
Review Board‖) was created in 2000 by Executive Order No. 110 and codified by
legislation in 2004.74 The Domestic Violence Review Board’s most recent report to the
Legislature examined intimate partner violence among women in New Jersey’s African
American community and found it to be triple that of white women.75,76
Children are also affected by IPV – 15.5 million children in the United States live in
families where intimate partner violence occurs at least once a year and seven million
children live in families where severe partner abuse has occurred.77 Thirty-one percent
of children who witnessed intimate partner violence reported being physically abused
themselves.78 Of those children who did not witness intimate partner violence, only 4.8
percent reported physical abuse. The findings for psychological abuse were similar.79
While IPV can be perpetrated by men and women, research shows that 78% of
incidents involve male perpetrators, most commonly fathers, and that most children who
report seeing IPV have only witnessed male-perpetrated violence.80 Overall, studies
indicate that children who witness domestic violence can have increased experiences of
negative emotions, such as anxiety and depression, and can suffer from post-traumatic
stress disorder (PTSD).81
The longer-term impact on children who are exposed to IPV is also troubling. A study of
young adolescents in the Cleveland area found that ―recent exposure to violence at
home…was one of the most significant predictors of a teen’s use of subsequent

74

N.J.S.A. 52:27D-43.17b.
New Jersey Domestic Violence Fatality and Near Fatality Review Board, Findings and
Recommendations of the 2013 Domestic Violence Fatality & Near Fatality Review Board: Intimate
partner violence in New Jersey’s African American Community: Findings and recommendations of the
2013 Domestic Violence fatality & Near Fatality Review Board, p. 1 (Trenton: Department of Children and
Families, 2013) available at
http://www.nj.gov/dcf/news/reportsnewsletters/taskforce/DVFNFRB%20Report.pdf.
76
Center for Health Statistics, New Jersey Department of Health, Deaths Associated with Intimate Partner
Violence (New Jersey Violent Death Reporting System), (Trenton: New Jersey Department of Health and
Senior Services, 2009).
77
Whitfield, C., Anda, R., Dube, S., Felittle, V., Violent Childhood Experiences and the Risk of Intimate
Partner Violence in Adults: Assessment in a Large Health Maintenance Organization. Journal of
Interpersonal Violence. 18(2): p. 166-185.(2003).
78
Rosewater, A., Promoting Prevention, Targeting Teens: An Emerging Agenda to Prevent Domestic
Violence, Family Violence Prevention Fund, 11 (2003).
79
Hamby, S, Finkelhor, D., Turner, H., & Ormrod, R. The Overlap of Witnessing Partner Violence with
Child Maltreatment and Other Victimizations in a Nationally Representative Survey of Youth, 34 Child
Abuse and Neglect, p. 734, 737 (2010).
80
Ibid.
81
Summers, A., Children’s Exposure to Intimate Partner Violence and Other Family Violence, Juvenile
Justice Bulletin (Office of Juvenile Justice and Delinquency Prevention), October 2011 at p. 7 available at
https://www.ncjrs.gov/pdffiles1/ojjdp/232272.pdf.
75

21 | P a g e

violence at school or in the community.‖82 Of the roughly 457,000 14 to 24 year-olds that
leave the juvenile justice system, federal and state prisons or local jails annually, a ―high
percentage‖ have experienced or witnessed violence at home.83
Intimate partner violence also affects adolescents. One in three adolescent girls in the
United States is a victim of physical, emotional or verbal abuse from a dating partner, a
figure that far exceeds victimization rates for other types of violence affecting youth. 84
Boys are more likely to inflict injuries as a result of perpetrating dating violence than
girls. This trend – where girls slap and push and boys hit and punch – continues into
adulthood.85 Teen victims of physical dating violence are also more likely than their nonabused peers to smoke, use drugs, engage in unhealthy diet behaviors (taking diet pills
or laxatives and vomiting to lose weight), engage in risky sexual behaviors, and attempt
or consider suicide.86
4. Women’s Use of Force
Following changes in law enforcement policies that encourage or mandate the arrest of
domestic violence offenders, a concomitant increase in women arrested and mandated
to batterer treatment programs has occurred. Most research shows that heterosexual
intimate partner violence is gendered – that is, men engage in IPV as a means to wield
power and control, whereas women engage in IPV for self-defense or for nonaggressive reasons.87
That said, there are instances when women use force to gain power and control over
their partner; however, research suggests this more commonly occurs as a means of
retaliation or resistance against abuse and is done to stop or escape from violence.88
While women can be the instigators of IPV, it is far less common and rarely is the use of
violence the first or only tactic to stop their partner’s ongoing abuse. Often, violence
occurs after other tactics such as negotiation, appeasement, seeking help from others

82

Singer, M.I., Miller, D.B., Guo, S. et. al., Children’s Exposure to Domestic Violence: A Guide to
Research and resources, 21-23(National Council of Juvenile and family Court Judges et. Al., 2006)
available at http://www.ncjfcj.org/sites/default/files/Childrenss%20Exposure%20to%20Violence.pdf (last
accessed August 10, 2015).
83
Rosewater, A., Promoting Prevention, Targeting Teens: An Emerging Agenda to Prevent Domestic
Violence, Family Violence Prevention Fund, p. 11 (2003).
84
Id. at 11.
85
The National Council on Crime and Delinquency, Interpersonal and Physical Dating Violence Among
Teens, 1 (Sept. 2008) available at http://www.nccdglobal.org/sites/default/files/publication_pdf/focusdating-violence.pdf.
86
Silverman, J, Raj A, et al. 2001. Dating Violence Against Adolescent Girls and Associated Substance
Use, Unhealthy Weight Control, Sexual Risk Behavior, Pregnancy, and Suicidality. JAMA. 286:572-579.
Available at http://jama.ama-assn.org/cgi/reprint/286/5/572.
87
Silverman, J, Raj A, et al., Dating Violence Against Adolescent Girls and Associated Substance Use,
Unhealthy Weight Control, Sexual Risk Behavior, Pregnancy, and Suicidality, 286(5) Journal of American
Medical Association, p. 572-578 (2001).
88
Susan L. Miller, S.L. & Michelle L. Meloy, Women’s Use of Force: Voices of Women Arrested for
Domestic Violence, 12(1) Violence Against Women 89-115 (2006).

22 | P a g e

(e.g., family, friends, law enforcement), and/or threatening to leave or withdraw from the
relationship have failed.89
5. Elder Abuse
The WHO defines elder abuse as ―a single, or repeated act, or lack of appropriate
action, occurring within any relationship where there is an expectation of trust which
causes harm or distress to an older person.‖ It can include ―physical, psychological or
emotional, sexual and financial abuse.‖ It includes intentional and unintentional
neglect.90
Research on individual risk factors of elder abuse reported by the WHO indicates that
abusers who are physically aggressive are more likely to have substance abuse
problems and mental health issues than non-violent family members and caregivers.91
Financial difficulties on the part of abusers also appear to be an individual risk factor.92
Relationship risk factors include the level of stress of the caregiver as a contributing
factor in cases of abuse, but a dependent victim and overstressed caregiver does not in
itself predict elder abuse.93 Older people are more at risk of abuse when living with the
caregiver. In terms of community and societal risk factors, ―social isolation emerges as
a significant one in elder mistreatment.‖94 ―Cultural norms and traditions — such as
ageism, sexism and a culture of violence — are also now recognized as playing an
important underlying role‖ in elder abuse.95
6. Sexual Violence
The WHO defines sexual violence as ―any sexual act, attempt to obtain a sexual act,
unwanted sexual comments or advances, or acts to traffic, or otherwise directed,
against a person’s sexuality using coercion, by any person regardless of their
relationship to the victim, in any setting, including but not limited to home and work.‖96
Coercion can include physical force, psychological intimidation, blackmail, or threats,
and encompasses situations where the victim is unable to give consent.97 It includes
rape, attempted rape and gang rape:


Rape – physically forced or otherwise coerced penetration of the vulva or anus,
using a penis, other body parts or an object.

89

Larance, L., Serving Women Who Use Force In Their Intimate Heterosexual Relationships: An
Extended View. Violence Against Women, 12(7) p. 622-640 (2006).
90
Ibid.
91
World Health Organization, Elder Abuse, available at:
http://www.who.int/ageing/projects/elder_abuse/en/
92
Ibid.
93
Ibid.
94
Krug, supra fn. 8 at 130.
95
Id. at 131.
96
Ibid.
97
Ibid.

23 | P a g e



Gang rape – the rape of a person by two or more perpetrators.98

Forms and contexts of sexual violence include:












rape within marriage or dating relationships;
rape by strangers;
systematic rape during armed conflict;
unwanted sexual advances or sexual harassment, including demanding sex in
return for favors;
sexual abuse of mentally or physically disabled people;
sexual abuse of children;
forced marriage or cohabitation, including the marriage of children;
denial of the right to use contraception or to adopt other measures to protect
against sexually transmitted diseases;
forced abortion;
violent acts against the sexual integrity of women, including female genital
mutilation and obligatory inspections for virginity; and
forced prostitution and trafficking of people for the purpose of sexual
exploitation.99

Although there is not a single definition, trafficking for the purpose of sexual exploitation
includes ―the organized movement of people, usually women, between countries and
within countries for sex work‖ and ―coercing a migrant into a sexual act as a condition of
allowing or arranging the migration.‖100
According to the WHO report, factors increasing a woman’s vulnerability to sexual
violence include being young, consuming alcohol or drugs, having been previously
raped or sexually abused, having many sexual partners, being involved in sex work,
poverty, and, in situations where sexual violence is perpetrated by an intimate partner,
becoming more educated or economically empowered.101 Factors increasing a man’s
risk of committing rape include, alcohol and drug consumption (particularly cocaine) and
various psychological factors. Men who commit rape are more likely to consider the
victims responsible for the rape, are less knowledgeable about the impact of rape on the
victims, misread cues by women in social situations, have problems with aggression
and impulse control, have coercive sexual fantasies and are generally encouraged by
access to pornography.102
Among the reported peer and family risk factors for sexual violence are childhood
environments that are physically violent, emotionally unsupportive, and patriarchal (as
opposed to egalitarian) family structures.103 There is also evidence to suggest that
98

Ibid.
Id. at 149.
100
Ibid.
101
Ibid.
102
Krug supra fn. 8 at 149-150.
103
Id. at 160.
99

24 | P a g e

sexual violence is learned behavior in some men, particularly with child sexual abuse.104
Poverty is a community risk factor for sexual violence and it is linked both to the
perpetration of sexual violence and the risk of becoming a victim.105 Another community
risk factor is the tolerance of a community and the strength of sanctions for the sexually
violent conduct.106 Societal factors include laws and policies about sexual violence,
global trends and economic factors (that may increase the likelihood of sex trafficking),
and societal norms such as ideologies of male sexual entitlement and the use of
violence as a means to achieve objectives.107
As with tracking the problem of intimate partner violence in the United States, the CDC
has developed a set of uniform definitions and data elements for states to use in their
sexual violence surveillance efforts.108 Passage of the Violence Against Women Act in
1994 established the Rape Prevention and Education program at CDC (―RPE‖), with the
goal of strengthening sexual violence prevention efforts at the state, local, and national
level. All 50 states, the District of Columbia, Puerto Rico, and four United States
territories participate in the program. An inter-departmental collaboration occurs in New
Jersey, as the Department of Health is the grantee for funds and the Department of
Children and Families implements the programs.
7. Suicide or Self-Directed Violence
In the course of defining its scope of work, the Commission felt it was important to gain
an in-depth understanding of suicide and self-directed injury in addition to interpersonal
violence. While suicide and self-directed injury have traditionally not been regarded as
―violence‖ the way child abuse or homicide have been (unless it is a murder-suicide),
suicide and attempted suicide are unquestionably violent acts that result in harm and
death, with many of the same characteristics as homicide. Again, from the World Health
Organization:
Suicide (self-directed violence) is a focus because suicidal behavior is often
the end result of many of the same underlying social, psychological, and
environmental factors as other types of violence.109
From the hearings and briefings, it became apparent that prevention programs for
suicide face many of the same hurdles that homicide prevention programs face: lack of
funding for programs and limitations on the number and type of participants able to be
served. This can include inconsistent mental and behavioral healthcare follow-up with
those at risk for suicide and suicidal behavior, regardless of a patient’s insurance status;
104

Id. at 161.
Ibid.
106
Ibid.
107
Id. at 162.
108
Basile K., Smith S., Breiding M., Black M., Mahendra R., Centers for Disease Control and Prevention,
National Center for Injury Prevention and Control, Division of Violence Prevention, Sexual Violence
Surveillance: Uniform Definitions and Recommended Data Elements, Version 2.0. (Atlanta: Centers for
Disease Control and Prevention, 2014).
109
Krug, supra fn. 8 at p. 5.
105

25 | P a g e

being known to law enforcement for disruptive or unusual behavior without the
recognition of suicidality; and stigma attached to seeking help, particularly among the
groups most at risk for completing suicide (middle-aged men, veterans, police and
correctional officers). In addition to deaths and injuries, the Commission also recognizes
the important but difficult-to-measure experience of suicidal ideation, which is defined as
thinking about, considering, or planning for suicide.110
According to the CDC, suicide was the 11th leading cause of death overall in the United
States every year from 1999 through 2007; from 2008 through 2013 (when the most
recent data are available), suicide became the 10th leading cause of death in our
country. In 2013, more than 41,000 people died by suicide nationally, two and half times
the number that died from homicide and legal intervention combined.111
In alignment with the WHO definition of ―violence,‖112 the CDC further describes suicidal
violence as, ―behavior that is self-directed and deliberately results in injury or the
potential for injury to oneself.‖ The CDC gives further clarification of what the behavior is
not: ―this does not include behaviors such as parachuting, gambling, substance abuse,
tobacco use or other risk taking activities, such as excessive speeding in motor
vehicles.‖113 The distinction being that, while the behaviors may be life-threatening,
there is no intent on the part of the risk-taker to injure themselves or die.
According to the WHO report, self-directed violence, or suicidal behavior ―ranges in
degree from merely thinking about ending one’s life, through developing a plan to
commit suicide and obtaining the means to do so, attempting to kill oneself, to finally
carrying out the act.‖114 As with other types of violence, research indicates that suicidal
behavior has a large number of complex factors that interact with one another, and
many of them are repeated across violence types. The risk factors include demographic
factors, as well as psychiatric, biological, social, environmental factors, and factor
related to an individual’s life history, including:











family history of suicide;
family history of child maltreatment;
previous suicide attempt(s);
history of mental disorders, particularly clinical depression;
history of alcohol and substance abuse;
feelings of hopelessness;
impulsive or aggressive tendencies;
cultural and religious beliefs (e.g., belief that suicide is noble resolution of a
personal dilemma);
local epidemics of suicide;
isolation, a feeling of being cut off from other people;

110

http://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf (2012).
CDC, WISQARS, supra fn. 2.
112
Krug, supra fn. 8 at 5.
113
CDC, supra fn. 2.
114
Krug, supra fn. 8 at 185.
111

26 | P a g e







barriers to accessing mental health treatment;
loss (relational, social, work, or financial);
physical illness;
easy access to lethal methods; and
unwillingness to seek help because of the stigma attached to mental health and
substance abuse disorders or to suicidal thoughts115

Some of the principal psychiatric and psychological factors associated with suicide are:







major depression;
other mood affective disorders;
schizophrenia;
anxiety, personality, and conduct disorders;
impulsivity; and
a sense of hopelessness.116

There are also biological and medical markers for suicide, such as:



having a family history of suicide; and
altered levels of serotonin metabolites in the cerebrospinal fluids.117

Physical illness is also an important contributory factor to suicidal ideation and
completion, particularly when accompanied with psychiatric symptoms.118 Life events
that may serve as precipitating factors for suicide include:





personal loss;
interpersonal conflict;
a broken or disturbed relationship; and
legal or work-related problems.

These difficult life events can lead to feelings of hopelessness and depression.119 Other
types of life events, such as being a victim of physical or sexual abuse in childhood, are
also risk factors for suicide, as they may result in feelings of humiliation and shame and
negatively impact the victim’s ability to maintain positive interpersonal relationships.120
In adolescents and young adults, sexual orientation may be related to an increased risk
of suicide due to discrimination, stress in interpersonal relationship, and limited sources
of support, among other reasons.121
Social and environmental risk factors for suicide include:
115

Krug, supra fn. 8 at 191-192.
Id. at 192.
117
Id. at 194.
118
Id. at 194.
119
Krug, supra fn. 8 at 193.
120
Id. at 193-94.
121
Id. at 195.
116

27 | P a g e






the availability of the means of suicide;
a person’s place of residence, employment, or immigration status;
religious affiliation; and
economic conditions such as periods of recession and high unemployment.122

There is a great deal of national attention paid to the availability of firearms and the risk
of suicide. The Firearm Injury Center at the University of Pennsylvania published a data
report that looked at firearm use in suicide, and found that firearms were the most
commonly used weapon to complete suicide nationally, a result confirmed by CDC.123
In New Jersey, the most utilized method of suicide is hanging/strangulation/suffocation,
with firearms ranked second and drug overdoses ranked third.124
More recently, New Jersey has seen a trend toward more extreme methods of suicide,
including suicides involving pedestrians jumping in front of moving trains or motor
vehicles on highways.125 With the online publication of an update to the suicide how-to
book ―Final Exit‖ in 2009, New Jersey experienced an increase in suicide methods
directly referenced in the book, indicating an increasing use of the internet for
researching suicide methods among people with the intent to complete suicide.126,127
Although they have not been studied as extensively as risk factors, understanding
protective factors for suicide is equally as important as understanding risk factors, and
they are consistent with protective factors for other types of violence. According to the
U.S. Public Health Service,128 these protective factors may include:







effective clinical care for mental, physical, and substance abuse disorders;
easy access to a variety of clinical interventions and support for help seeking;
family and community support (connectedness);
support from ongoing medical and mental health care relationships;
skills in problem solving, conflict resolution, and nonviolent ways of handling
disputes; and
cultural and religious beliefs that discourage suicide and support instincts for selfpreservation.

122

Id. at 196-98.
Firearm and Inquiry Center at Penn (FICAP), Firearm Injury in the United States (2011), available at:
http://citeseerx.ist.psu.edu/viewdoc/download;jsessionid=7E26A51558378A7472DDD0CF83D7AADB?doi
=10.1.1.394.3321&rep=rep1&type=pdf
124
Center for Health Statistics, NJVDRS Update (2015). http://www.nj.gov/health/chs/oisp/njvdrs.shtml
125
Ibid.
126
Jacquemin, B., Increased Use of Helium and Plastic Bag Suicide Technique in New Jersey, 20032009, Portland, OR, 2010 CSTE Annual Conference (2010).
127
CHSI, NJVDRS Update, 2015 supra fn. 124.
128
CDC, Injury Prevention and Control: Division of Violence Prevention, Suicide: Risk and Protective
Factors, available at http://www.cdc.gov/violenceprevention/suicide/riskprotectivefactors.html.
123

28 | P a g e

8. Collective Violence
The final category of violence and its risk factors as addressed by the WHO is collective
violence, which includes, among other things, war, terrorism and other violent political
conflict, as well as organized violent crime such as banditry and gang warfare.129 Risk
factors for collective violence include political factors, such as unequal access to power;
economic factors, such as unequal access to or unequal distribution of resources and
control over drug production and trading; societal and community factors, such as the
fueling of group fanaticism along ethnic, national or religious lines, and the ready
availability of small arms and other weapons, and rapid demographic change.130
As discussed later in this report, a gang presence can be found throughout the state of
New Jersey. While the World Report does not go into detail on gang violence in the
United States or in New Jersey, this is a significant segment of interpersonal violence,
especially in urban areas. Many times this is the primary manifestation that comes to
mind when the word ―violence‖ is heard. This discussion is included in the ―Collective
Violence‖ category because while the suspect-victim interaction is primarily a subset of
interpersonal violence, whole neighborhoods and communities are traumatized by gang
violence. Additionally, significant resources are diverted to this problem to the detriment
of other community priorities.
E. Statistics On Violence
1. National Statistics
Violence continues to be a significant problem in the United States and affects people in
all stages of life. In 2013, more than 41,000 people died by suicide, and homicide
claimed nearly 17,000 lives.131 Since 1965, homicide and suicide have consistently
been among the top 15 leading causes of death in the United States.132
The Federal Bureau of Investigation (―FBI‖) reports on violent crime in the United States
each year through the publication of its annual Uniform Crime Report (―UCR‖). The UCR
defines ―violent crime‖ as: murder and non-negligent manslaughter, rape, robbery, and
aggravated assault, and involve force or the threat of force (similar to the WHO’s
definition).133 In 2013, an estimated 1,163,146 violent crimes occurred in the United
States, a decrease of 4.4 percent from the 2012 estimate. Aggravated assaults
accounted for 62.3 percent of violent crimes reported, robbery offenses 29.7 percent;

129

Krug, supra fn. 8 at 215.
Krug, supra fn. 8 at 220-22.
131
CDC, WISQARS, supra fn. 2.
132
National Center for Health Statistics, National Vital Statistics System. Leading Causes of Death 19001998, available at: http://www.cdc.gov/nchs/data/dvs/lead1900_98.pdf.
133
Uniform Crime Reporting Program, U.S. Department of Justice, Federal Bureau of Investigation,
Crime in the United States 2013 available at: http://www.fbi.gov/about-us/cjis/ucr/crime-in-theu.s/2013/crime-in-the-u.s.-2013/violent-crime/violent-crime-topic-page/violentcrimemain_final.
130

29 | P a g e

rape 6.9 percent, and murder 1.2 percent. Firearms were used in 69 percent of the
nation’s murders, 40 percent of robberies and 21.6 percent of aggravated assaults.134
A second report, the National Crime Victimization Survey (―NCVS‖), that surveys victims
of crime, also found there to be a decrease in violent crime in 2013; however, it found
no statistically significant change in the rate of ―serious violence,‖ which NCVS defines
as rape or sexual assault, robbery or aggravated assault.135 Additionally, the NCVS
found there was no significant change from 2012 to 2013 in the rates of firearm
violence, violence resulting in injury to a victim, domestic violence or intimate partner
violence.136
While national violent crime statistics, which enumerate interpersonal violence, show a
small decrease from 2012 to 2013, national suicide statistics show that a rise in suicide
rates that began in 2004 has continued through 2013.137 Citing a 2013 SAMHSA study,
the latest report from the American Association for Suicidology indicates there is a 25:1
ratio, meaning that for the 41,000 Americans who died by suicide in 2013, there were
nearly 1,030,000 suicide attempts.138 However, the ratio of attempts to suicides varies
greatly depending on age range. For example, the ratio is 100-200:1 for young people
but 4:1 for the elderly. It is estimated that each suicide intimately affects 6 other people,
which makes 1 out of every 64 Americans a ―suicide survivor‖ - a close family friend or
loved one left behind when someone takes their own life.139
2. New Jersey Statistics
New Jersey is home to a broad multi-cultural population living in small towns and
villages older than the nation itself, sprawling suburban developments, and city centers
within commuting distance to our nearest major metropolitan influences, New York City
and Philadelphia. The state is organized into 21 counties, 566 municipalities, and with a
population of nearly 9 million people, New Jersey is the most densely populated state in
the nation.140 The locally-oriented nature of the state can present certain challenges
when attempting to define a problem statewide and implement generalized solutions.
a. Homicide and Interpersonal Violence
Interpersonal crime in New Jersey is reported at the state, county, and municipal level,
and is included in the state’s contribution to the FBI’s UCR. The six largest communities
have been identified as ―Major Urban‖ in the UCR - these are Camden, Jersey City,
Paterson, Elizabeth, Newark and Trenton. The 15 urban communities with populations
134

Ibid.
National Crime Victimization Survey 2013 available at:
http://www.bjs.gov/index.cfm?ty=pbdetail&iid=5111
136
Ibid.
137
Drapeau, C., & McIntosh, J., U.S.A. Suicide 2013: Official Final Data, American Association of
Suicidology, available at http://www.suicidology.org.
138
Ibid.
139
Ibid.
140
https://www.census.gov/compendia/statab/2012/tables/12s0014.pdf.
135

30 | P a g e

As Figure 3 indicates, although homicide rates overall and among non-Hispanic whites
and the Hispanic population have remained relatively stable over the past 10 years,
homicide rates among the black, non-Hispanic population and among the black male,
non-Hispanic population began trending upward around 2009. This initial uptick
occurred in places like Newark, Camden, and Trenton that experienced reductions in
law enforcement. In response, federal, state, and local law enforcement agencies
throughout the state have emphasized the need for greater collaboration and
cooperation to address violent crime. In places like Camden and Trenton, more recent
reductions in murders have been attributed to integrated, multi-agency law enforcement
collaboratives that utilize concepts like intelligence-led policing, community outreach,
and improved technological capability.144 Statewide, homicides were down 5% in 2014
as compared to 2010 and the total number of violent crimes was down 15% compared
to 2010.145
The need for collaborative law enforcement is best illustrated in Northern New Jersey,
with its densely populated cities and proximity to mass transportation. As Figure 4
indicates, homicides occur in concentrations that cross municipal boundaries, as
highlighted in the example of the neighboring municipalities of Newark, East Orange,
and Irvington. The Commission notes that a cross-jurisdictional effort, Corridor-Status
(―Corr-Stat‖), launched nearly three years ago among agencies in North Jersey, now
includes more than 30 local law enforcement agencies, five county prosecutor’s offices,
and federal and state partners who meet regularly to discuss crime trends and patterns
and share information on the criminal environment in their cities. Corr-Stat is now
supported by the Real Time Crime Center, which opened in Newark in December 2014.
The RTCC pushes out intelligence as it is generated and will help investigators in the
field by getting them information more quickly.

144

http://www.nj.com/news/index.ssf/2015/01/declines_in_newark_camden_drive_nj_homicides_down_15_p
ercent_in_2014.html,
http://www.nj.com/opinion/index.ssf/2015/02/editorial_trenton_police_meeting_with_community_fo.html,
http://nj.gov/oag/newsreleases14/pr20140514c.html
145
http://www.njsp.org/info/ucr2010/pdf/2010_uniform_crime_report.pdf (2010 statistics),
http://www.njsp.org/info/pdf/ucr/current/20150904_ucr_2014stats.pdf (2014 statistics).

32 | P a g e



Grape Street Crips – reported presence in 51 towns.148

Nine out of 21 counties reported a presence of 90 or more gangs:










Essex – 106 gangs
Monmouth – 132 gangs
Middlesex – 126 gangs
Ocean – 114 gangs
Bergen – 108 gangs
Camden – 107 gangs
Burlington – 101 gangs
Atlantic – 97 gangs
Union – 95 gangs149
c. 2014 Statistics

The following is a comparison of the 10 cities with the highest reported gang population
and the 10 cities with the highest number of shooting hits (data as of 11/12/14 provided
by the New Jersey State Police). As Table 5 shows, six of the cities with the highest
reported gang population are also in the top 10 of reported shooting hits.
Table 5: Cities with the highest number of shooting hits cross-referenced with cities with the highest number of
known gang members

Municipality
Newark
Paterson
Camden
Trenton
Jersey City
Elizabeth
Plainfield
Irvington
Orange
Bridgeton
East Orange
Union City
Atlantic City
New Brunswick

Number of Gang Members
2,664
1,940
Not in top 10
1,330
Not in top 10
Not in top 10
1,030
885
685
600
584
522
488
Not in top 10

Number of Shooting Hits
296
112
117
140
77
51
24
37
Not in top 10
Not in top 10
15
Not in top 10
52
18

While New Jersey has some of the strictest gun control and safety laws in the
country,150 many of the guns used in crimes here are trafficked into New Jersey from

148
149

Id. at 1.
Ibid.

34 | P a g e

other states. As Table 6 notes, out of 3,834 guns recovered in New Jersey in 2013,
approximately 87 percent were purchased in another state and transported into New
Jersey. The cities where the most guns were recovered are also the cities with the
highest number of shooting murders, including Newark, Camden, Trenton, Paterson,
Atlantic City, East Orange, and Irvington. In sum, while guns play a significant role in
incidents of violent crime in New Jersey, most of the guns used in the commission of
crime appear to be purchased from out-of-state and brought into New Jersey.
Table 6: More crime guns originate from out-of-state than New Jersey (USDOJ, ATF, 2013 Report #143900)

State of Origin

Number
of
Guns Recovered

New Jersey
Pennsylvania
Virginia
North Carolina
Georgia
South Carolina
Florida
Ohio
New York
Texas
Alabama
West Virginia
Tennessee
California
Louisiana
Indiana

496
363
189
176
158
137
135
78
66
48
45
31
20
17
17
17

d. Suicide and Self-Directed Violence
While homicide is what traditionally comes to mind when discussing ―violence‖, it is only
part of the picture - one of several possible outcomes for people who face, in many
ways, similar challenges in their lives and communities. For every homicide in New
Jersey since 2005, there have been on average 1.7 suicides, and recent trends indicate
that suicide is increasing in New Jersey (Figure 5).151

150

The Law Center to Prevent Gun Violence and the Brady Campaign to Prevent Gun Violence, 2013
State Scorecard: Why Gun Laws Matter, 4 (2013) available at:
www.bradycampaign.org/sites/default/files/2013-scorecard.pdf.
151
CHSI, NJVDRS Update, 2015, supra fn. 124.

35 | P a g e

Figure 8. Method of Suicide Based on Gender

Suicide weapons by gender, New Jersey residents, 2011-2013
50%
45%

Percent suicides

40%
35%
30%

Males

25%

Females

20%

Total

15%
10%
5%
0%
HANG,
STRANG,
SUFF

FIREARM

POISONING

SHARP
FALL/JUMP
INSTRUMENT

DROWNING OTHER TRANS OTHER &
(TRAIN)
UNKNOWN

Weapons and mechanisms
Source: Center for Health Statistics and Informatics, Suicide Weapons By Gender (CHSI, NJVDRS Update 2015)

F. Recommendations


Individual Interventions: An individual approach to violence prevention and
reduction focuses on healthy attitudes and behaviors in children and young
people and addresses negative attitudes and behaviors among those who may
be at-risk of, or have already shown a propensity towards violence. Such
interventions should include:
o Educational programs that provide incentives for students to
complete secondary schooling, vocational training for economically
disadvantaged youths and young adults, and programs focused on
drug abuse prevention;
o Social development programs designed to help children and
adolescents develop social skills, manage anger, resolve conflicts,
and develop an appropriate moral perspective to reduce the
chances they will engage in bullying;
o Therapeutic programs to provide counseling for victims of violence
and those exposed to violence and support services for those with
depression or other disorders associated with an increased risk of
suicide; and
o Treatment programs in a group format that address gender issues
and teach skills such as anger management, personal

41 | P a g e

responsibility, and medical treatment for people at risk of harming
themselves or suffering from psychiatric disorders.166


Relationship Interventions: A relationship approach focuses mainly on influencing
the types of relationships that victims and perpetrators have with people they
interact with on a regular basis. Such interventions should include:
o Training for parents/caregivers that focuses on improving the
emotional bonds between parents/caregivers and children and
encourages consistent child-rearing methods;
o Mentoring programs that pair youth at-risk of developing anti-social
behavior with a caring adult from outside the family to provide a
positive role model;
o Family therapy programs that improve communication between
parents and children and teaches problem-solving skills to assist
them;
o Home visitation programs that include regular visits from a nurse,
mental health or other health care professional to the residences of
families in need of special support or are at risk of child
maltreatment; and
o Groups that learn skills to develop healthier relationships with their
partners (with intimate partner violence assessed prior to the
group’s formation.)167



Community-Based Interventions: A community-based approach is geared toward
raising public awareness about violence, stimulating community action, and
providing for the care and support of victims. Such interventions should include:
o Public education campaigns using the media to address community
violence;
o A focus on environmental improvements such as repairing and
bolstering street lighting, creating safe routes for children and youth
to school, addressing public works concerns in a timely fashion
such as abandoned buildings, vacant lots, pothole repair, and
nuisance complaints;
o Extracurricular activities for young people such as sports, drama,
art, and music;
o Training for police, health and education professionals, and
employers to help them identify and respond to different types of
violence;
o Community policing that places a greater emphasis on ―walking the
beat‖ and having officers interact with and get to know the residents
they serve; and
o Coordinating community interventions by having local agencies
partner in service and program delivery.168

166

Krug, supra fn. 8 at 25.
Id. at 26.
168
Id. at 27.
167

42 | P a g e



Societal Interventions: Societal approaches focus on the cultural, social, and
economic factors related to violence and emphasize changes in legislation and
public policy.

Collaboration and Coordination of Services: During our public hearings, the Study
Commission heard from many organizations and individuals who have attempted to
curtail violence in their communities by utilizing one or more of the intervention
strategies discussed above. The Study Commission also determined that resources are
sometimes not well-coordinated or are scattered among agencies that do not work
together. Accordingly, the Study Commission recommends that:


Each county should establish a ―Division on Violence Prevention and
Intervention‖ that brings together all county and local resources to share
experiences and strategies for addressing violence prevention and reduction. It is
further recommended that cities and those municipalities interested in sharing
services also be encouraged to form a Division on Violence Prevention and
Intervention if they deem it appropriate. The Division on Violence Prevention and
Intervention should:
o Create a directory of existing violence prevention services and activities in
the County;
o Develop or recommend services to be funded by local governing bodies
encompassing both interpersonal violence and suicide prevention
programs;
o Identify vacant properties or existing community spaces that could be
transformed for use by local organizations that lead violence prevention
activities or provide supportive services to at-risk youth and their families;
o Develop a network of volunteers and mentors within the community who
can address issues such as youth violence, suicide prevention, and go
into schools to speak with young people about engaging in prosocial
behavior;
o Emphasize collaboration among all agencies that work with at-risk
populations, identify cross-cutting risk factors and prevention strategies
and establish working groups to address core issues such as homicide
and suicide prevention, youth violence, and drug abuse;
o Encourage locally-led groups to seek out grant funding to scale their
initiatives and reach a critical mass of individuals. Provide technical
assistance and support so that applications have the greatest likelihood of
success;
o Partner with a local university to develop an evaluation tool for violence
prevention and reduction strategies and partner on grant applications to
implement prevention and reduction plans; and
o Focus on providing assistance to ex-offenders with an expressed interest
in transitioning back into the community through employment assistance,
treatment and counseling, and housing. Utilize ex-offenders who have
rehabilitated themselves as mentors or role models for at-risk youth who
43 | P a g e

have engaged in criminal activity or are at-risk of engaging in criminal
behavior.169


The Commission recognizes that there are a number of ways to address intimate
partner violence. A best practice in this field is the Family Justice Center (FJC)
model. FJC co-locates a multi-disciplinary team of police officers, prosecutors,
civil legal service providers, and community-based advocates in one location to
provide coordinated services to victims of family violence. Accordingly, the Study
Commission recommends:
o Each county establish a Family Justice Center and provide adequate funding
and space for its implementation;
o That the Legislature consider legislation that would authorize any city, county,
of community-based non-profit organization to establish a multi-agency, multidisciplinary family justice center to assist victims of domestic violence, sexual
assault, elder or dependent abuse, and/or human trafficking; and
o That county-level liaisons communicate with the Center for Hope International
(formerly the National Family Justice Center Alliance) for input and
recommendations on obtaining FJC funding and sustainability strategies.

Intimate Partner Violence: Currently, if perpetrators of intimate partner violence are
required to receive treatment and counseling, many are referred to services that do not
fully address the perpetrator’s violence, such as anger management. However, anger
management is often not an appropriate form of counseling for someone who
perpetrates IPV. An alternative to anger management is a Batterer’s Intervention
Program (BIP), that focuses more on the root causes of IPV, batterer accountability, and
coordinated community response.170 Accordingly, the Study Commission recommends
the following:




That the Legislature and Governor consider the implementation of BIPs that
include the following components: psycho-education groups for men who
perpetrate abuse, assistance to victims for safety, and ongoing communication
collaboration, and training with judicial and child welfare systems to hold
perpetrators accountable and keep victims safe. Among the topics that should be
included are: IPV as abusive behavior tied to power and control, focus on
accountability for one’s behavior, examining and changing thoughts and beliefs
that contribute to abusive behavior, impact on gender norms, respectful coparenting with partners, and the impact IPV has on children;
That the Legislature and Governor consider additional funding for current and
future research into the effectiveness of BIP program outcomes that includes an

169

Id. at 28.
A best practice in this area is the ―Duluth Model‖ developed by the Domestic Abuse Intervention
Programs in Minnesota available at http://www.theduluthmodel.org.
170

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




examination of re-offense and recidivism rates, but also measures whether the
safety of victims and their children increased;171
If charged, women who use force should attend a program that addresses their
violent behavior and teaches alternatives to force and the impact using force has
on their victims, themselves, and other family members;
Training should be provided to judicial staff about the differences that commonly
occur when IPV is perpetrated by women against men as opposed to the other
way around;
Women who use force should not be ordered to a BIP for males; and
Professionals who respond to incidents of IPV should be trained to assess and
differentiate between using violent behavior for retaliation/resistance/self-defense
versus coercive control;

Primary Violence Prevention: The Commission agrees with the CDC that primary
prevention should start at an early age. Accordingly, the Study Commission
recommends the following:







As mandated by law, ensure that all school districts have implemented dating
abuse education into their health curriculum172 and have either adopted the state
Department of Education policy regarding dating abuse or adopted one of their
own.173 Encourage schools to collaborate with local domestic violence agencies
for information and assistance in fulfilling this mandate;
Develop a statewide primary violence prevention awareness campaign in
consultation with violence prevention experts that addresses a range of
strategies to address violence, including, gun violence and intimate partner
violence;
Consider appropriating additional funds for primary prevention programs; and
Encourage the Department of Children and Families and the Department of
Education to consult with national and state domestic violence/dating abuse
experts to identify curricula, programs, and training that can be shared with
interested community organizations, youth sports teams, and other groups to
educate parents and children about intimate partner violence and dating abuse.

Sexual Violence: The Study Commission believes there are several ways the state and
universities and colleges can be responsive to the issue of sexual violence and
therefore recommend the following:


Creation of a Coordinated Community Response Team comprised of
representatives from the college or university (e.g., student affairs, faculty,
residence life, athletics, campus security/police, survivors of abuse), local law
enforcement, the county prosecutor’s office, and victim’s advocates to discuss

171

Kelly, L. and Westmarland, N., Domestic Violence Perpetrator Programs: Steps Toward Change.
Project Mirabel final report. (London and Durham: London Metropolitan University and Durham University,
2015).
172
N.J.S.A. 18A:35-4.23a.
173
N.J.S.A. 18A:37-35(3)b.

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





and develop policies and programs to address sexual violence, dating violence,
domestic violence and stalking on campus;
That County Prosecutors should develop protocols, consistent with Attorney
General guidelines, for investigating campus sexual assaults. The Study
Commission recommends that the County Prosecutors work with campus
police/security, local law enforcement, victim’s advocates, campus judicial affairs,
and campus Title IX coordinators in developing these protocols;
That New Jersey become a ―Start by Believing‖ state and encourage towns,
municipalities, and cities to build ―Start by Believing‖ public awareness
campaigns that focus on changing the way we respond to rape and sexual
assault in our communities;174 and
That appropriate law enforcement, health, and victim’s advocates be made
aware of the availability of End Violence Against Women International’s free
online training curriculum and encourage those who investigate sexual assault
cases or interact with sexual assault victims, access training as needed.

Expand Mentoring Programs: The Study Commission supports the concept of
mentoring for people of all age groups, and in particular, for young people in
economically distressed and/or high crime areas. Accordingly, the Study Commission
recommends:




Creating a website that identifies all existing mentoring programs in New Jersey;
That the Legislature and Governor consider making funding available on a
competitive basis for non-profit and other community groups who lead mentoring
programs that will allow for greater participation by at-risk youth and adults; and
Convening a forum that highlights successful mentoring programs in
communities throughout the state.

Establish an Injury Surveillance and Statistics Program: The Study Commission
recommends the creation of an Injury Surveillance and Statistics program within the
state Department of Health to serve as a resource for injury and violence epidemiology
and statistics and serve as a clearinghouse for resources on injury and violence
prevention.
Review Quality and Timeliness of Administrative Data Reported to the State
Department of Health: The Study Commission recommends that the state Department
of Health should engage injury and violence prevention stakeholders to conduct an
evaluation of hospital encounter data (e.g., emergency department and inpatient data)
for timeliness and case identification suitability.
Appoint an Additional Study Commission Member: As the legislation forming the Study
Commission requires it to report on a yearly basis, we recommend appointing an
additional member drawn from a university or college with a background in violence
prevention using a public health model.
174

http://www.startbybelieving.org/BuildYourCampaign.aspx.

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Study Group on Police/Community Relations: The Study Commission recommends the
formation of a working group comprised of members of law enforcement, community
and faith leaders, and academic experts in the field of community policing to survey
current efforts in New Jersey focused on building trust between police and the
communities they serve, consider the feasibility of creating citizens police review
boards, to review the President’s Task Force on 21st Century Policing, and issue a
report containing recommendations regarding ways to strengthen the relationship
between police departments and the people they serve.

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CHAPTER 2 – FUNDING AND GRANTS
A. Overview
As part of its charge, the Study Commission was directed to ―seek out funding and
grants for the implementation of programs to reduce violence from sources including,
but not limited to, the Centers for Disease Control and Prevention and any other funding
sources.‖175
In 1992, the CDC established the National Center for Injury Prevention and Control
(―NCIPC‖) to focus on the question of violence prevention. Within NCIPC, the Division of
Violence Prevention (―DVP‖) has as its mission the prevention of injuries and deaths
caused by violence.176 The DVP focuses on monitoring violence-related injuries,
conducting research into the risk and protective factors attendant to being a perpetrator
or victim of violence, creating and evaluating violence prevention programs, and
providing technical assistance to other levels of government in implementing violence
prevention programs.177 Through this effort, the DVP works to reduce many things
including intimate partner violence, sexual violence, youth violence, and suicidal
behavior.
The DVP also collects information and reports on studies being conducted throughout
the country regarding violence prevention. A recent DVP report highlighted a wide range
of topics, including, protecting against teen dating and intimate partner sexual violence,
recent findings on risks and protective influences on violence, the economic impact of
violence, preventing suicide through ―connectedness,‖ and other topics.178 Part of the
strategy at the DVP is fostering collaborative efforts between academia, government,
and local organizations. One such initiative is the National Centers of Excellence in
Youth Violence Prevention. These centers are currently funded with the expectation that
they engage in collaborations among researchers, local organizations, and a high-risk
community with a common goal of reducing youth violence.179
In addition to the CDC, there are a variety of other federal agencies that have
committed resources to a panoply of violence and violence-reduction strategies that the
Commission studied. While it is impractical to provide a complete accounting of every
program at the federal level that addresses in some way the issues the Study
Commission is charged with examining, a few bear noting:

175

N.J.S.A. 52:17B-241(b).
Center for Injury Prevention & Control: Division of Violence Prevention available at
http://www.cdc.gov/violenceprevention/overview/index.html.
177
Ibid.
178
National Center for Injury Prevention and Control, Division of Violence Prevention, Understanding and
Preventing Violence: Summary of Research Activities: Summer 2013, available at
http://www.cdc.gov/violenceprevention/pdf/dvp-research-summary-a.pdf.
179
Center for Injury Prevention & Control: Division of Violence Prevention, National Centers of Excellence
in Youth Violence Prevention available at: http://www.cdc.gov/violenceprevention/ace/index.html.
176

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







The White House: My Brother’s Keeper mentoring program that works
specifically with African-American youth, of which, Newark, New Jersey is a
member;
The White House: The National Forum on Youth Violence, of which, Camden,
New Jersey is a member;
The U.S. Department of Justice: Second Chance Act grant funding for programs
targeted at supporting ex-offenders;
The U.S. Department of Justice: Project Safe Neighborhoods grant funding that
seeks to reduce gang and street violence, of which, Jersey City, New Jersey is a
grant recipient;
The U.S. Department of Education: Promise Neighborhood programs have
launched throughout the country that are focused on ensuring children have
access to good schools and strong support networks with the ultimate goal of
having those children matriculate to college; and
Substance Abuse and Mental Health Services Administration (SAMHSA):
Provides grant funding for a number of different projects in New Jersey, including
suicide prevention, youth substance abuse prevention, and trauma care for youth
who have been exposed to violence.180

Similarly, state and local governments are the recipients of, and provide for, programs
that address violence reduction and violence prevention. An extensive list of those
programs is appended to this report as Appendix A, however, the Study Commission
takes note of several promising initiatives:

180



Jersey City Employment and Training Program: Hailed as a national model for
prisoner re-entry, the Jersey City Employment and Training Program focuses on
providing sober living, employment, and housing for ex-offenders while
integrating social services to improve their likelihood of a successful transition
back into the community. The Jersey City model is being rolled out in five other
cities statewide – Atlantic City, Newark, Paterson, Toms River, and Trenton;



Trenton Violence Reduction Strategy: TVRS works with ex-offenders and at-risk
adults by providing wrap-around services to program participants and their family
members to include employment, treatment and counseling, and life skills
training. Modeled as a hybrid of the Boston and Chicago CeaseFire programs,
TVRS also includes a law enforcement component that communicates to those
who opt against participating in the program that future criminal activity will be
dealt with swiftly and seriously;



Justice-Involved Services: Through funding provided by the Department of
Human Services, JIS is operational in 15 county jails and assists in transitioning
individuals with mental illness from county jails back to the community as well as
working with probation and the courts;

http://www.samhsa.gov/grants-awards-by-state/details/New%20Jersey.

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

Probation Mental Health Supervision: The Division of Probation within the
Administrative Office of the Courts designates caseloads to officers with specific
training in working with individuals with mental illness. Probation officers are able
to provide a greater level of management and supervision while assisting
probationers in overcoming barriers that might otherwise hinder their chances of
successfully completing their term of supervision;181 and



Crisis Intervention Team Training: CIT is an innovative national model that
provides an intensive, 40-hour training curriculum to police officers, mental health
professionals, and advocates on how to appropriately respond to people
experiencing a behavioral crisis who pose a risk to themselves or others.
Because law enforcement officials are often the first on the scene when a person
experiences a mental health crisis, this specialized training gives the officers the
capabilities to respond to these unique and sensitive situations in a professional
and humane manner. In New Jersey, more than 2,000 police officers from more
than 70 police departments have completed CIT.

B. Recommendations
Although the Commission was directed to ―seek out funding and grants for the
implementation of programs to reduce violence,‖ as a practical matter, the Study
Commission is not the appropriate vehicle through which grant applications should be
submitted. Typically, funding is limited to government agencies or non-profit
organizations and also requires dedicated resources to manage, supervise, and lead
any effort. Moreover, the Study Commission determined that there are numerous
programs funded through either the federal or state government that, in one way or
another, address violence prevention and reduction.
That said, public information and awareness of the vast array of initiatives aimed at
reducing violence could be strengthened and many municipalities that may be
interested in applying for grant funding but are not well-versed in the mechanics of
doing so, could benefit from receiving technical assistance. Finally, certain promising
programs merit consideration by the Legislature and the Governor for replication and
expansion. Accordingly, the Study Commission recommends:


181

Creation of a Grants Website: Public awareness would be increased if there was
a single website that listed all violence prevention and reduction grant programs
in New Jersey. Such a website should not only include the name and description
of all such programs, but the source of funds, the amount of funds received, the
duration of the program, and a point of contact for those interested in receiving
additional information. The website should also provide links to grant
opportunities that may be of interest to governmental and non-profit agencies.

http://www.judiciary.state.nj.us/atlantic/mentalhealth.htm.

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

Statewide Forum: The Study Commission recommends that a statewide forum
be held for the purposes of information sharing among grant officers regarding
funding opportunities. The forum would provide individuals who apply for,
manage, and/or implement grant programs the chance to learn more about other
initiatives that may be of interest to them and to discuss grant application
strategies.



Technical Assistance: The Study Commission recommends that technical
assistance be offered by state agencies with expertise in applying for grants to
local and municipal governmental agencies interested in applying for grant
funding but in need of assistance in the application process.



Replication Project – Trenton Violence Reduction Strategy: The Study
Commission recommends that the Legislature and Governor consider
appropriating funding that would allow for the replication of the Trenton Violence
Reduction Strategy in at least one other city in New Jersey and that hews to best
practices for violence reduction and prevention based on programs such as
CeaseFire (now known as Cure Violence) and Project Safe Neighborhoods.



Replication Project – Promise Neighborhoods: The Study Commission
recommends that the Legislature and Governor consider appropriating funding
for at least three local programs modeled on the Promise Neighborhood initiative
led by the U.S. Department of Education or the Harlem Children’s Zone model
upon which Promise Neighborhoods is itself modeled.



Justice-Involved Services Expansion: The Study Commission concurs with the
New Jersey SAFE Task Force that the Legislature and Governor consider
making funds available to expand JIS into the six counties without such a
program. Additionally, the Study Commission recommends that the Legislature
and Governor consider making funds available to counties interested in
expanding existing JIS programs.

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CHAPTER 3 – MENTAL HEALTH AND ACCESS TO TREATMENT IN
NEW JERSEY
A. Introduction - Defining Mental Illness
The CDC defines mental illness as ―disorders generally characterized by dysregulation
of mood, thought, and/or behavior, as recognized by the Diagnostic and Statistical
Manual, 5th edition, of the American Psychiatric Association (DSM-V).‖182 The National
Institute of Mental Health (―NIMH‖) defines serious mental illness as a mental,
behavioral or emotional disorder which is diagnosable currently or within the past year,
of sufficient duration to meet diagnostic criteria in the DSM-V, and results in serious
functional impairment which substantially interferes with or limits one or more major life
activities.183
Mental illness is much more prevalent than many believe. SAMHSA and the NIMH
recently released a report providing detailed information on the prevalence of many
specific types of mental disorders among adults (age 18 and older). The report, ―Center
for Behavioral Health Statistics and Quality (CBHSQ) Data Review: Past Year Mental
Disorders Among Adults in the United States,‖ includes information on the prevalence of
mood disorders, anxiety disorders, eating disorders, substance use disorders,
adjustment disorders, and psychotic symptoms, shows that an estimated 22.5 percent
of American adults (51.2 million people) had at least one mental disorder in the past
year. Seventeen million adults (7.4 percent of the adult population) suffered mood
disorders, including major depressive disorders and bipolar disorders.184
The data shows that 5.7 percent of adults (12.9 million people) suffered some form of
anxiety disorder in the past year such as social phobia, panic disorder and agoraphobia.
The report also indicates that 7.8 percent of adults (17.9 million people) experienced
some form of substance use disorder in the past year.185
An estimated 6.9 percent of adults (16 million people) experienced a past year
adjustments disorder -- a variety of functionally impairing emotional or behavioral
symptoms that result from an identifiable stressor. The study shows that 0.6 percent of
adults (1.3 million people) had psychotic symptoms in the past year.186
B. Mental Illness and Violence
Mental illness is often associated with violence in the public’s mind. The Institute of
Medicine concluded that ―although findings of many studies suggest a link between
mental illnesses and violence, the contribution of people with mental illnesses to overall
182

http://www.cdc.gov/mentalhealth/basics/mental-illness.htm.
http://www.nimh.nih.gov/about/director/2013/getting-serious-about-mental-illnesses.shtml.
184
http://www.samhsa.gov/data/sites/default/files/NSDUH-DR-N2MentalDis-2014-1/Web/NSDUH-DRN2MentalDis-2014.htm.
185
Ibid.
186
Ibid.
183

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rates of violence is small.‖ Further, ―the magnitude of the relationship is greatly
exaggerated in the minds of the general population.‖187 For people with mental
illnesses, violent behavior appears to be more common when there is also the presence
of other risk factors. These include substance abuse or dependence; a history of
violence, juvenile detention, or physical abuse; and recent stressors such as being a
crime victim, getting divorced, or losing a job.188 That said, those individuals who have a
mental illness and seek treatment should get access to it, and in particular, right after or
as soon after a traumatic event as possible.
The enacting legislation creating the Study Commission on Violence directed us to
―study the issue of insufficient access to mental health treatment and violence.‖189 The
question of whether and to what degree a nexus between mental illness and violence
exists was examined at some length by the New Jersey SAFE Task Force.190 Like the
Institute of Medicine, the SAFE Task Force’s findings tended to confirm that individuals
with a mental health disability are more likely to be victims of violent crime as opposed
to perpetrators of violent crime. Indeed, the SAFE Task Force noted that one study
found that criteria such as unemployment, divorce within the past 12 months, and a
history of physical abuse were greater indicators of a person’s propensity for violence in
the next three years than whether that person suffered from mental illness.191
On the other hand, violence is correlated with substance abuse. One survey of
individuals receiving addiction treatment indicated that 75 percent had a past incident of
violent behavior. In fact, it is when substance abuse co-occurs with mental illness that
we see a connection to criminal activity. For example, a SAMSHA study found that
among prisoners with a mental health disorder, 72 percent also had a substance abuse
problem.192 The same study found that two-thirds of all juveniles who are exposed to the
criminal justice system have co-occurring mental health and substance use disorders.193
C. Recommendations
The Study Commission takes notice of the recommendations of the New Jersey SAFE
Task Force and concurs with the following recommendations provided by that group:

187

Institute of Medicine, Improving the Quality of Health Care for Mental and Substance-Use Conditions
(2006) available at http://www.ncbi.nlm.govbooks/nbk19831/#a2000e8elddd00058.
188

Elbogen and Johnson, The Intricate Link Between Violence and Mental Disorder, Archives of General
Psychiatry, 66(2):152-161(February 2009) available at
http://archpsyc.jamanetwork.com/article.aspx?articleid=210191.
189
N.J.S.A. 52:17B-241.
190
http://nj.gov/oag/newsreleases13/NJSAFE-REPORT-04.10.13-WEB.pdf. See generally, p. 39-44.
191
Elbogen and Johnson, supra fn. 188.
192
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services
Administration, Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse
Disorders and Mental Disorders (2002) at p. 13 available at
http://www.nasmhpd.org/docs/Policy/Behavioral%20Health%20Primary_CoOccurringRTC.pdf.
193
Ibid.

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

Mental Health Parity: Establishing mental health parity for State health insurance
plans provided such action would not have a meaningful, negative impact on
access to care or insurance rates.



Early Intervention & Crisis Screening: The Study Commission recommends that
the Legislature and Governor consider providing appropriations to adequately
fund early response and intervention support services as well as mobile crisis
screening to a significantly broader group of individuals whose emotional
difficulties have not risen to the level of emergency room care or law enforcement
intervention and for those who have suffered a trauma because of one or more
forms of violence.



Access to Outpatient Treatment: The Study Commission recommends that the
Legislature and Governor consider providing appropriations to adequately fund
and expand access to outpatient licensed clinical treatment services for children
and adults so that emergency services are better utilized for those in crisis and
those who need more routine counseling and treatment are not taxing those
scarce resources. Such an expansion would directly address those who have
suffered trauma as a result of violence, a concern raised on numerous occasions
during the Commission’s hearings. These services and any trauma outreach
should be coordinated with the Prosecutor Victim Assistance Program as a
trauma response.



Screening Centers: The Study Commission recommends that the Legislature and
Governor consider additional appropriations to (1) create a pilot to expand the
capacity of screening centers and other community-based points of entry for
those with substance abuse or substance abuse and co-occurring mental illness
so that triaging and treatment options can be provided and (2) for the substance
abuse treatment system generally so that patients can access services
recommended at the screening centers or community-based points of entry.



Public Awareness: Launching a media and public awareness campaign that
destigmatizes mental illness and encourages those suffering from mental illness
to seek treatment.

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CHAPTER 4 – MENTAL HEALTH DIVERSION WITHIN THE CRIMINAL
JUSTICE SYSTEM
A. Overview
As state prison populations increased in the late 1990s and early 2000s, greater
attention was paid to utilizing alternatives to incarceration, and in particular, for those
charged with low-level or non-violent criminal offenses and who have a substance
abuse problem, mental health disability, or co-occurring substance use and mental
health disorder.
In New Jersey, Drug Courts have been utilized for more than a decade to offer
defendants the opportunity to avoid incarceration in exchange for rigorous, monitored
supervision of a drug treatment program. Since 2002, when the Drug Court program
was expanded statewide, more than 17,500 participants have enrolled and there are
more than 5,800 active participants.194 For those defendants who graduate from Drug
Court, their outcomes are very promising – less than 19 percent are re-arrested for a
new, indictable crime within three years of graduation, only 7 percent are re-convicted of
a new indictable crime, and under 3 percent serve a new sentence in state prison.195
Indeed, the Drug Court model has proven so successful that its reach was recently
expanded so that judges now have the authority to mandate that a defendant participate
in the program.196
Like Drug Court, providing alternatives to incarceration for defendants with mental
health disabilities is borne out of the idea that offering treatment is both a more fiscally
responsible option and one that will decrease the chances that a defendant will
recidivate.197 The enacting legislation creating the Study Commission on Violence
directed it to examine the mental health diversion program in Union County and to
provide a recommendation as to whether that model should be expanded to other
counties.198
B. Current Mental Health Diversion Programs
The Union County Prosecutor’s Office established its Special Offenders Unit (―SOU‖) in
2004 to deal exclusively with mentally ill criminal defendants. The goal of the SOU was
to incorporate a treatment plan into the disposition of these cases so that mentally ill
194

New Jersey Adult Drug Court Program, New Jersey Statistical Highlights (May 4, 2015) available at
https://www.judiciary.state.nj.us/drugcourt/njstats.pdf.
195
Ibid.
196
Prior to the passage of N.J.S.A. 2C:35-14.1 participation in Drug Court was voluntary.
197
McNeil, D., and Binder, R., Effectiveness of a Mental Health Court in Reducing Criminal Recidivism
and Violence, American Journal of Psychiatry (September 2007).(A study of the Mental Health Court
program in San Francisco estimated a more than $22,000 per defendant cost savings over three years for
individuals in their Mental Health Court program) available at
http://www.sfsuperiorcourt.org/sites/default/files/pdfs/2417%20Examine%20Program%20Costs%20and%
20Outcomes.pdf.
198
N.J.S.A. 52:17B-241(d).

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defendants could receive immediate medical treatment. In 2006, and with funding
provided through the Department of Human Services, the Union County Prosecutor’s
Office launched a formal partnership with Bridgeway Rehabilitation Services and
Trinitas Hospital that diverts and case manages criminal defendants – primarily those
charged with third and fourth degree offenses, but with some second degree charges
considered on a case-by-case basis – out of prison and into supervised counseling and
treatment.
In 2011, Dr. Kenneth Gill of the University of Medicine and Dentistry of New Jersey
conducted an evaluation of the Union County program. Among Dr. Gill’s findings were
the fact that the program resulted in ―decreased jail and prison time, fewer and later
arrests, and increased global level functioning‖ among the program participants. Like
Drug Court, Dr. Gill found the benefits of the program most pronounced among
individuals who completed the program. For those individuals, in the 12 months after
enrollment compared to the 12 months before enrollment, the number of days they
spent in jail dropped by nearly 80 percent (25 days vs. 4 days). Only 14 percent were
re-incarcerated at all in the first year of the program and after five years, only 33 percent
had been re-incarcerated.199
In 2014, the New Jersey Department of Law & Public Safety made funding available on
a competitive basis for County Prosecutors interested in implementing a mental health
diversion program. Awards were issued to Ocean County and Essex County, with the
former standing up a new program and the latter utilizing funding to expand an existing
program.200 Although both programs will be evaluated, neither has been operational for
a sufficiently long period of time to engage in a meaningful academic study.
Lastly, the Warren County Prosecutor’s Office has created a Mental Health Unit to work
with defendants with serious mental health illnesses. The Prosecutor's Office works with
defense attorneys and mental health providers to develop a plan of treatment, with the
intent of a rehabilitative sentence focused on avoiding further or future court
involvement. This program provides opportunities for diversion to probation with
treatment oriented conditions for legally involved individuals with serious mental illness
while ensuring the safety of the community and the individual. Currently, the program
relies entirely on collaborative relationships and flexibility in the utilization of existing
resources.
C. Recommendations
Studies have shown that a well-tailored mental health diversion program can decrease
recidivism among defendants who complete the program, reduce costs by lowering the
number of days spent in prison and the attendant treatment expenses, and provide
more robust treatment and counseling for those who commit low-level and non-violent
offenses. The current range of prosecutor-led programs shows that the diversion
199

Gill, K. and Murphy A., Report on Union County Jail Diversion Program 2006-11 (May 24, 2011).
The Department of Law and Public Safety has issued a Notice of Available Funding for the expansion
of this program into up-to two additional counties. See, 47 N.J.R. 2008(a)(August 3, 2015).
200

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process can be accomplished with or without dedicated funding, however, the
comprehensiveness of the program and the options available are necessarily limited
when dedicated funding is not provided and/or adequate mental health services are
unavailable.


Create a Toolkit for County Prosecutors: The Study Commission recommends
that those prosecutors with mental health diversion programs work with mental
health providers on a toolkit from which other prosecutors could understand how
a diversion program would be implemented. Among the information that the
toolkit should include would be an identification of the agencies and
organizations necessary for the partnership, how (and by who) defendants are
screened for clinical appropriateness, options for which criminal charges are or
are not permitted for consideration into the program, and what training assistant
prosecutors and investigators should receive to be assigned to the program.



Expand the Availability of Crisis Intervention Training: The Study Commission
recommends that the Department of Law and Public Safety consider providing
funds that would expand the availability of CIT training, and in particular, for the
expansion of the CIT Center for Excellence so that CIT training can be made
available throughout the state. The Study Commission further recommends that
the Department of Law and Public Safety and the Department of Human
Services consider forming a task force that would work with County Prosecutors
and municipal police departments interested in formalizing CIT and other
police/community-based diversion interventions as part of their law enforcement
strategy.



Develop a Plan for Law Enforcement and Mental Health Cross Training: The
Study Commission recommends that the Department of Law and Public Safety,
Department of Human Services, State Parole Board, and Administrative Office of
the Courts consider developing a plan for coordinated cross-training of law
enforcement officers, first responders, mental health providers, and families and
consumers of mental health services. Such a plan would identify education and
training from awareness of mental illness and the criminal justice process
through advanced techniques for CIT-certified officers.



Expand Mental Health Diversion: The Study Commission recommends that the
Legislature and Governor consider funding be appropriated to the Department of
Law and Public Safety for the development, in conjunction with the Department
of Human Services, of a Request for Proposals (RFP) that would be submitted by
County Prosecutors interested in developing a new, or expanding an existing,
mental health diversion program. Such appropriations should include funding to
support both prosecutorial and concomitant case management and mental health
services.

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CHAPTER 5 – OUTPATIENT COMMITMENT
A. Introduction and Background on Outpatient Commitment
The Commission has been tasked with studying involuntary outpatient commitment in
the State and recommending whether it should be expanded to all counties and how to
adequately fund the program.201 In carrying out this task, members of the Commission
reviewed the outpatient commitment law, met with staff from DMHAS, reviewed funding
for the program, attended a meeting of an outpatient commitment workgroup created by
DMHAS, reviewed data regarding implementation of the program, and interviewed
representatives from outpatient commitment programs in Essex and Warren Counties.
Outpatient commitment refers to the process by which a court orders an individual with
mental illness to comply with a community treatment plan.202 Failure to abide by a
treatment plan may but does not always result in hospitalization. The vast majority of
states utilize some form of involuntary outpatient commitment as part of an existing
framework for providing mental health services in the community. Patients utilize
services that are offered to all public mental health care recipients, and no additional
funding is provided for services for individuals on outpatient commitment status. In a
minority of states, such as New York, outpatient commitment programs involve a
separately funded and distinct infrastructure of services.203 As more fully explained
below, New Jersey funds its outpatient commitment program at a level which allows
community agencies to provide primarily case management services and to link
consumers with existing services funded separately.
Researchers have classified three types of outpatient commitment: first, conditional
release from a hospital where a patient is discharged on the condition that he or she
continues to receive treatment in the community; second, an alternative to inpatient
hospitalization for individuals who otherwise meet the criteria for hospitalization but are
instead ordered to receive outpatient treatment when such treatment is deemed
sufficient to render them non-dangerous; and third, mandatory treatment for individuals
who do not currently meet the legal criteria for inpatient hospitalization, but who are at
risk of decompensation to the point that they may qualify for hospitalization if left
untreated.204 However, it appears that, regardless of whether outpatient commitment
applies to individuals who are currently dangerous or at risk of decompensation, states
often use it as a discharge planning tool for patients who are hospitalized. For example,
in New York, where outpatient commitment is allowed to prevent deterioration before

201

N.J.S.A. 52:17B-241(e).
Monahan et al., Mandated Community Treatment: Beyond Outpatient Commitment, 2 (2014) available
at: http://www.macarthur.virginia.edu/article.pdf.
203
Esposito, et al., A Guide for Implementing Assisted Outpatient Treatment, 7 (2012) available at:
www.treatmentadvocacycenter.org/storage/documents/aot-implementation-guide.pdf.
204
Monahan, supra fn. 202.
202

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hospitalization is necessary, nearly three-quarters of individuals were committed upon
discharge from a hospital.205
A growing body of research has found that outpatient commitment, when paired with
sufficient community services, is effective in treating serious mental illness, preventing
and shortening lengths of hospitalization, and reducing arrests and violence. The most
extensive study to date concerned New York’s outpatient commitment law, called
―Kendra’s Law.‖206 According to the researchers, New York’s program ―features more
comprehensive implementation, infrastructure and oversight‖ than any other
comparable program in the country, largely because the enactment of Kendra’s Law
was accompanied by a substantial amount of funding for new services.207 The Kendra’s
Law study revealed that individuals on outpatient commitment status were hospitalized
at less than half the rate than prior to commitment.208 Moreover, individuals who
received intensive case management services on a voluntary basis were more likely to
be hospitalized (58%) than individuals who received these same services involuntarily
on an outpatient commitment order (36%). The researchers also found evidence that
individuals on outpatient commitment status were less likely to be arrested than other
individuals with serious mental illness, as the monthly rate of arrest for individuals
dropped from 3.7 percent to 1.9 percent.
Outcomes for individuals after they were discharged from outpatient commitment varied
depending on their length of commitment status. For individuals who were committed for
fewer than six months their chances of hospitalization decreased post-discharge only if
they continued to receive intensive case management services. However, the rate of
hospitalization of individuals who were committed longer than six months decreased
regardless of whether they continued to receive case management.
Similarly, a 1999 study of North Carolina’s outpatient commitment program found that
outpatient services when paired with outpatient commitment of greater than six months
reduced hospitalization 57 percent when compared to individuals receiving the services
alone.209
Several other studies have concluded that outpatient commitment reduces arrests and
incidents of violence among individuals with serious mental illness. A 2010 study of
Kendra’s Law found that the odds of arrest for individuals receiving outpatient
commitment services were nearly two-thirds lower than for individuals who had not yet

205

Swartz and Swanson, New York State Assisted Outpatient Treatment Program Evaluation (2009)
available at https://www.omh.ny.gov/omhweb/resources/publications/aot_program_evaluation/
206
Ibid.
207
New York allocated an annual total of $32 million for direct support of outpatient commitment
programs. Additionally, the state allocated $125 million yearly for enhanced community supports, which
benefitted all recipients of community services, not only individuals on outpatient commitment.
208
Ibid.
209
Swartz & Swanson, et al, Can Involuntary Outpatient Commitment Reduce Hospital Recidivism?
156(12) American Journal of Psychiatry 1968-75 (1999).

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initiated involuntary commitment or only signed a voluntary service agreement.210
Likewise, a 2008 study of Florida’s outpatient commitment program found that
outpatient commitment reduced days spent in jail among participants from 16.1 to 4.5, a
72 percent reduction.211 The 1999 study of North Carolina’s program found that, for
individuals who had a history of multiple hospital admissions combined with arrest or
incidents of violence in the prior year, long-term outpatient commitment reduced the risk
of arrest by nearly 75%.212 Similarly, another study of Kendra’s Law revealed that
outpatient commitment recipients were four times less likely to commit acts of serious
violence after undergoing treatment, despite having histories of violence.213
B. Outpatient Commitment in New Jersey
New Jersey’s outpatient commitment law, which was enacted in 2009, utilizes outpatient
commitment as an alternative to inpatient hospitalization, rather than expanding
commitment criteria to individuals who may deteriorate if untreated.214 It allows
outpatient commitment for individuals who are already dangerous and otherwise would
have been hospitalized, but whose dangerousness is not imminent and can be
alleviated with outpatient treatment.
Specifically, an individual with mental illness is in need of involuntary commitment to
treatment (inpatient or outpatient) when his mental illness causes him to be dangerous
to self, others or property and he is unwilling to accept appropriate treatment
voluntarily.215 An individual may be committed to outpatient treatment, rather than
inpatient hospitalization, when such treatment ―is deemed sufficient to render the person
unlikely to be dangerous to self, others or property in the reasonably foreseeable
future.‖216 Conversely, an individual should be committed to inpatient treatment when
―he is immediately or imminently dangerous or if outpatient treatment is deemed
inadequate to render the person unlikely to be dangerous to self, others or property
within the reasonably foreseeable future.‖217 A screening service shall consider an
individual’s prior history of hospitalization and treatment and the person’s current mental
health condition in rendering this determination.218
When committed to outpatient treatment, an individual is required to comply with a plan
of outpatient treatment, which is ―a plan for recovery from mental illness approved by
the court … that is to be carried out in an outpatient setting and is prepared by an
outpatient treatment provider for a patient who has a history of responding to
210

Gilbert & Moser, et al., Reductions in Arrest Under Assisted Outpatient Treatment in New York,
619(10) Psychiatric Serv., 996-999 (October 2010).
211
New Jersey Adult Drug Court Program, supra fn. 194 at 14.
212
Ibid.
213
Phelan, et al., Effectiveness of Outcomes of Assisted Outpatient Treatment in New York State
Psychiatric Services, Columbia University, Vol. 61 No. 2 (2010).
214
N.J.S.A. 30:4-27.1 et seq.
215
N.J.S.A. 30:4-27.2.
216
N.J.S.A. 30:4-27.5.
217
Ibid.
218
Ibid.

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treatment.‖219 If a patient fails to materially comply with the outpatient treatment plan, or
if the outpatient treatment provider determines that the plan is inadequate to meet the
patient’s mental health needs, then the provider shall notify the court and the screening
service and the patient shall be considered for inpatient hospitalization.220
Initially, the outpatient commitment law required the Commissioner of DHS to phase in
implementation of the program over a three-year period, implementing outpatient
commitment in seven counties in the first year, seven more counties in the second year,
and the remaining seven counties in the third year.221 Ultimately, DHS was appropriated
approximately $2 million for outpatient commitment in 2012, which allowed the agency
to implement the program in six counties – Burlington, Essex, Hudson, Ocean, Warren
and Union. In 2014, DHS was appropriated an additional $4.5 million to expand the
program statewide. DMHAS issued a Request for Proposals for outpatient treatment
providers in the remaining fifteen counties on March 17, 2014. As a result of this RFP,
DMHAS awarded contracts to outpatient providers in eleven additional counties –
Atlantic, Bergen, Camden, Cape May, Cumberland, Gloucester, Hunterdon, Mercer,
Passaic, Salem and Somerset. DHS did not receive satisfactory bids for Middlesex,
Monmouth, Morris and Sussex Counties. Outpatient commitment is now operational in
fourteen counties.222 DMHAS will continue to seek providers in the outstanding four
counties.
Each county outpatient treatment provider receives approximately $300,000 per year in
State funding. Providers may also seek reimbursement for certain services through
Medicaid and insurance to the extent individuals served are eligible for these programs.
This funding gives providers the capacity to serve approximately 30 to 40 individuals at
any one time. Outpatient treatment providers generally consist of a full-time program
director, two full-time case managers, and a psychiatrist who is available approximately
15 hours a week to provide evaluations, clinical certificates and court testimony.
Providers mainly offer intensive case management support, linking patients with
already-existing community services, resolving legal issues and ensuring that patients
attend court hearings and other appointments. Providers also monitor treatment
compliance and report to the commitment court. Outpatient commitment programs do
not provide residential services, so individuals must already have housing to be eligible
to participate in the program. The programs sometimes provide therapy session on-site
or at patients, but generally cannot provide more robust services due to limited funding.
Instead, they primarily link patients with community services already funded by DMHAS
through other programs.
The outpatient commitment law requires DHS to monitor and evaluate the program and
to report to the Governor and Legislature on its implementation.223 Factors to be
219

Ibid.
N.J.S.A. 30:4-27.8a.
221
P.L. 2009, Ch. 112.
222
While DMHAS has awarded a contract to a community agency to operate outpatient commitment
programs in Cumberland, Gloucester and Salem Counties, that agency was still searching for psychiatrist
services and the programs had not begun at the time this report was written.
223
See, fn. 221, supra.
220

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evaluated include the effect of outpatient commitment on individuals, the extent to which
outpatient commitment affects the rate of institutionalization and incarceration, whether
sufficient services are available to individuals who have been committed to outpatient
treatment, and the effect of outpatient commitment on the availability of services to
voluntary consumers with mental illness. As authorized by statute, DHS contracted with
the Rutgers University School of Social Work to assist the agency with conducting this
evaluation. The first Rutgers’ report is expected in June 2015.
DMHAS provided data from fiscal year 2014 for the six outpatient programs that were
operational at that time. These programs served 374 individuals during the fiscal year.
103 of these individuals were hospitalized while on outpatient commitment status,
although DMHAS noted that some of these individuals may have been hospitalized for
non-psychiatric, medical reasons. Even disregarding this qualification, the
hospitalization numbers appear favorable when considering that absent outpatient
commitment, these individuals may have all been hospitalized. DMAHS does not yet
have data regarding arrests of individuals on outpatient commitment, but it is anticipated
that the Rutgers’ report will include this data.
The Commission interviewed representatives from the outpatient commitment programs
in Essex and Warren Counties in an effort to learn more about how outpatient
commitment works in practice. The Essex County program receives $294,000 per year
from the State. Additionally, it is able to bill Medicaid for approximately $150,000 per
year for case management services. The Essex County provider agency initially
anticipated that it could serve up to 65 individuals in its outpatient commitment program
with this funding. But it has since realized that it may effectively serve up to 45
individuals, which still appears to more than other counties with outpatient commitment
programs. The Essex County program typically serves individuals who have been
hospitalized on multiple occasions over the past year. Indeed, the vast majority of
individuals served in Essex County have been converted to outpatient commitment from
inpatient hospitalization at a county hospital or short term care facility.
The Essex County program consists of a Director, three to four case managers, a part
time secretary, and a part-time psychiatrist who is available about 20 hours per week.
During the first two to four weeks of an individual’s outpatient commitment, the
outpatient team provides intensive case management services, seeing the client up to
seven days per week at his home or at on-site at the program. They continue to provide
case management throughout the duration of the commitment. The team links patients
with various other mental health services, in addition to providing therapy. The team is
in court approximately once every two weeks for outpatient commitment purposes. If
successfully discharged, a patient remains linked to other programs and may continue
to receive case management through other programs.
Outcomes for individuals who have been involuntarily committed to Essex County’s
outpatient commitment program have been generally positive. On average, 6 percent of
patients are involuntarily hospitalized per month and 7 percent are voluntarily
hospitalized. Arrests of individuals on outpatient commitment have been rare. The
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Essex County representative advised that voluntary hospitalization is preferable
because the patient does not lose his outpatient commitment status and can return to
the program upon discharge. In contrast, involuntarily hospitalized patients lose their
outpatient commitment status and must be re-committed or converted to outpatient
commitment upon discharge from a hospital, assuming the outpatient program is aware
of the discharge.
The Warren County program also receives $294,000 per year in State funding, although
it is not able to bill Medicaid for its case management services to the degree that Essex
County can. The Warren County program originally intended to serve 30 people at a
time, but has since learned that 20 individuals is a more reasonable amount. When
fully-staffed, the program consists of a supervisor/director who also serves in a clinical
role, two case managers, and a part-time psychiatrist who is available 12 hours per
week. However, at the time of the interview the director had resigned and they were
struggling to find a replacement due to the salary limitations. Unlike Essex County’s
Program, where patients usually are converted to outpatient commitment from inpatient
hospitalization, Warren County’s patients are typically committed to outpatient
commitment directly from a screening center.
The Warren County program provides intensive case management services and links
patient with other services. Like the Essex County program, the Warren County
program also attends court approximately once every two weeks. Court appearances
for patients as well as travel to service providers are often difficult due to a lack of
transportation options. The program’s representative estimated that about 30 percent of
its patients have been discharged successfully to date. Others have been involuntarily
hospitalized or are still under outpatient commitment.
The Warren County representative felt that the outpatient program helps individuals to
live in the community more safely and to access need services. She advised that the
program could serve more individuals with more funding and staffing.
C. Recommendations
The issue of whether outpatient commitment should be expanded to all counties in the
State is largely moot. DHS has already begun efforts to expand the program statewide
and has been appropriated funding to do so. The Commission agrees with this decision.
Outpatient commitment has proven to be a valuable tool in treating mental illness in the
community and reducing inpatient hospitalization. Individuals who can benefit from this
program should have access to it regardless of their county of residence. That said, the
Study Commission recommends:


Outpatient Commitment Analysis: The Commission also recommends that a
county-by-county analysis be made to determine the average wait times for those
with serious mental illness that are coming out of state and county psychiatric
hospitals and those at risk of hospitalization. Based on the findings of this survey,
the Commission recommends appropriations be provided where necessary to
reduce wait times and ensure speedy access to treatment.
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GLOSSARY OF TERMS
BIP – Batterer’s Intervention Program
CDC – U.S. Department of Health and Human Services, Centers for Disease Control &
Prevention
CHSI – New Jersey Department of Health, Center for Health Statistics and Informatics
CIT – Crisis Intervention Training
Corr-Stat – Corridor-Status
DHS – New Jersey Department of Human Services
DMHAS – New Jersey Department of Human Services, Division of Mental Health and
Addiction Services
DSM-V – Diagnostic and Statistical Manual, 5th Edition
DVP – Division of Violence Prevention
EVAWI – End Violence Against Women International
FJC – Family Justice Center
IPV – Intimate Partner Violence
JIS – Justice-Involved Services
NAME – National Association of Medical Examiners
NIMH – National Institute of Mental Health
NCIPC – National Center for Injury Prevention and Control
NJCFNFRB – New Jersey Child Fatality and Near Fatality Review Board
NJDVFNFRB – New Jersey Domestic Violence Fatality and Near Fatality Review Board
National Crime Victimization Survey
NJVDRS – New Jersey Violent Death Reporting System
NVDRS – National Violent Death Reporting System
SAMHSA – Substance Abuse and Mental Health Services Administration
SOU – Special Offenders Unit
TVRS – Trenton Violence Reduction Strategy
UCR – Uniform Crime Report
WHO – World Health Organization

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ACKNOWLEDGEMENTS
The Study Commission gratefully acknowledges the following individuals, organizations,
and institutions for their assistance:
Acting Union County Prosecutor Grace Park
Assistant Union County Prosecutor Doreen Yanik
Dr. Doug Boyle, Rutgers University – Violence Institute of New Jersey
Nicole Morello, New Jersey Battered Women’s Shelter
Anthony Ambrose, Chief of Detectives, Essex County Prosecutor’s Office
The Newark Anti-Violence Coalition
Captain Thomas Ulrich, Vineland Police Department
Rev. Gary Holden, Police Chaplain Program
Ocean County Prosecutor Joseph D. Coronato
Cumberland County Prosecutor Jennifer Webb-McRae
Warren County Prosecutor Richard T. Burke
Atlantic County Prosecutor James P. McClain
Tracy Swan, Rutgers University – Walter Rand Institute for Public Affairs
Mayor Dana L. Redd, City of Camden
Dr. Louis Tuthill – Rutgers University
Bernadette Shanahan, Camden County Boys and Girls Club
Richard Stagliano, Center for Family Services
Dr. Bernadette Hohl, Rutgers University – School of Public Health
Elizabeth Manley, New Jersey Department of Children and Families
Roger Canaff, End Violence Against Women International
Lieutenant Greg Demeter, New Jersey State Police
Kurt Baker, Attitudes in Reverse
Trish Baker, Attitudes in Reverse
Shavar Jeffries, Esq., Lowenstein Sandler, LLC
Governor James E. McGreevey, Jersey City Employment and Training
John Koufos, Jersey City Employment and Training
Lisa Ciaston, New Jersey Department of Human Services
Jane Shivey, New Jersey Coalition for Battered Women
Dr. Roger Mitchell, Medical Examiner, District of Columbia
Detective Alexis Durlacher, Trenton Police Department
Abdul Muhammad, Co-Ordinator, Trenton Violence Reduction Strategy
Dr. Sandy Gibson, The College of New Jersey
The U.S. Attorney’s Office for the District of New Jersey
William Paterson University
Rutgers University – Camden Campus
Shiloh Baptist Church (Trenton)
St. James AME Church (Newark)
Cumberland County Community College
Barnabas Health
Newark Beth Israel Hospital
65 | P a g e

Greater Newark Healthcare Coalition
Paterson CeaseFire
Mary Houtsma, CSW, DVS, Essex County Family Justice Center
NJ CIT Center of Excellence
Dr. Maria Kirchner, New Jersey Department of Human Services

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APPENDIX A – VIOLENCE REDUCTION AND PREVENTION
PROGRAMS AND MENTAL HEALTH SERVICES
The Study Commission on Violence provides this summary of programs our respective
agencies are involved with and programs that were brought to our attention during the
course of our survey of anti-violence, crime prevention, and mental health initiatives in
New Jersey.
Department of Human Services









NJ HOPELINE (1-855-654-6735): NJ HOPELINE is a 24-hour-a-day, 7-day-aweek peer support and suicide prevention hotline operated by Rutgers
University’s Behavioral Health Care unit through a contract with the New Jersey
Department of Human Services Division of Mental Health and Addiction Services
(DHS-DMHAS). Calls are handled by trained volunteers and paid staff. A clinical
supervisor is assigned to each shift and works with the volunteers and staff to
transfer calls to emergency service providers as needed.
NJ HOPELINE Advertising: New Jersey Transit (―NJT‖), in conjunction with DHSDMHAS, has placed NJ HOPELINE posters at every NJT station in New Jersey.
Adult Suicide Prevention Plan. DHS-DMHAS developed an adult suicide
prevention plan.224 The plan is designed to address the rate of suicide in New
Jersey and contains strategies and an action plan for crisis response and
practical application in the field. While New Jersey does not lead the nation in
suicide numbers, 60% of all violent deaths are suicides and suicides outnumber
homicides nearly two to one in New Jersey.225
Mental Health First Aid: Mental Health is an 8-hour adult public education
program that introduces participants to risk factors, warning signs, and symptoms
for a range of mental health problems, including comorbidity with substance use
disorders; builds participants’ understanding of the impact and prevalence of
mental health problems; and provides an overview of common support and
treatment resources for those with a mental health problem. In New Jersey,
Mental Health First Aid training is already being utilized by Administrative Office
of the Courts - Probation Services and the New Jersey State Human Services
Police, among others. In December 2013, 30 individuals from the Department of
Human Services attended the five-day train-the-trainer program and are now
certified to train others throughout the State in Mental Health First Aid.
Peer Respite Centers: 226 The DHS-DMHAS funds a Peer Respite Center in each
region of New Jersey. These facilities provide beds, temporary lodging, and
treatment alternatives for individuals who may be experiencing a psychiatric

224

New Jersey Department of Human Services, Division of Mental Health and Addiction Services, Adult
Suicide Prevention Plan (2014-2017) available at
www.sprc.org/sites/sprc.org/files/adult%20suicide%20pevent%20plan%20final%202014-17.pdf.
225
Center for Health Statistics, New Jersey Department of Health, New Jersey Violent Death Reporting
System (2013).
226
NJDHS-DMHAAS, supra fn. 217 at 7.

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














227
228

crisis situation but do not warrant an inpatient level of care. Patients stay on
average between 7 and 16 days and are then linked to community self-help
centers and other supportive services in the community.227
Peer Recovery WarmLine: Operated by the Mental Health Association of New
Jersey, the Peer Recovery WarmLine is a statewide toll-free line operating year
round to assist individuals with mental health concerns or in times of need.228
Short Term Care Facility: These facilities are locked units to which individuals are
involuntarily committed for a limited duration. The facilities are operated by 24
different agencies in all 21 counties.
Designated Screening Service Programs: These programs provide screening,
assessment, crisis intervention, referral, linkage to other programs, and crisis
stabilization in every part of the State 24-hours-a-day, 365-days-a-year.
Screening Service programs manage individuals who are in acute psychiatric
crisis, and determine whether involuntary commitment is necessary.
Early Intervention Support Service: These programs provide rapid access to
short term, non-hospital based crisis intervention and stabilization services. They
are designed to divert the undue use of emergency rooms and inpatient
programs.
Intensive Outpatient Treatment Support Services: These programs operate in 19
counties to alleviate strain on the acute mental health system.
Involuntary Outpatient Commitment: Individuals are committed to outpatient
treatment when they are dangerous because of mental illness, but whose
dangerousness is not imminent and can be alleviated on an outpatient basis
without the need for hospitalization. Such individuals are court ordered to comply
with an outpatient treatment plan which is created and overseen by outpatient
treatment providers.
Outpatient services are provided in a community setting to individuals with a
psychiatric diagnosis including clients who are seriously and persistently mentally
ill, but excluding substance abuse and developmental disability unless
accompanied by treatable symptoms of mental illness. Periodic therapy,
counseling, and supportive services are generally provided for relatively brief
individual, group or family sessions. Services may also include medication
monitoring under the supervision of a licensed physician, certified nurse
practitioner or clinical nurse specialist.
Partial Care & Partial Hospitalization are comprehensive, structured, nonresidential health services provided to seriously mentally ill adult clients in a day
program setting to maximize client's independence and community living skills.
Partial Care programs provide or arrange services necessary to meet the
comprehensive needs of the individual clients.
Programs in Assertive Community Treatment: A multi-disciplinary mobile
treatment team provides a comprehensive array of mental health services to
individuals with serious mental illness. The program is designed to meet the
needs of individuals, who are at high risk for hospitalization, are high service

Ibid.
http://www.mhanj.org/peer-recovery-warmline-prw/

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
















users and who have not benefitted from other mental health services. Although
an EBP, PACT is considered to be part of the acute care system.
Integrated Treatment for Co-occurring Disorders: This program provides
combined mental health and substance abuse disorder treatment for adults. It
aims to reduce hospitalization and homelessness, and to increase independent
living and employment. The program is incorporated in existing services including
Integrated Case Management Services, Partial Care and Supported Housing,
and is not a stand-alone service.
Supported Employment: The SE program provides employment assessment, job
placement and ongoing support for individuals with mental illness. Supported
employment assists mental health consumers in forming an attachment to the
workforce through employment and education and is critical to their community
integration and economic independence.
Supported Education: Supported education programs serve individuals with
severe mental illness and/or co-occurring disorders who participate or desire to
participate in post-secondary education. Services include accommodation
education, managing disclosure issues, and exploring/securing funding options.
Illness Management Recovery: Illness Management Recovery is a psychiatric
rehabilitation practice which seeks to empower consumers with severe mental
illness to manage their illness and develop their own goals for recovery.
Components include psychoeducational, behavioral tailoring for medication
relapse prevention training, and coping skills training.
Veterans’ Services: DMAHS provides mental health and related support services
to members of the armed forces and veterans as part of its regular behavioral
health service delivery system.
Projects for Assistance in Transition from Homelessness: These programs
conduct outreach to locations known to be frequented by homeless individuals in
an effort to assess and identify individuals with serious mental illness who may
benefit from linkage to mental health and housing programs.
Supportive Housing: DMHAS contracts with supportive housing providers and
supervised residential providers in all 21 countries. Services range from
consumer-leased housing to supervised settings with 24/7 staffing. Supportive
housing promotes community inclusion, housing stability, wellness, recovery and
resiliency.
Intensive Family Support Programs: These programs provide families with
greater knowledge about mental illness, treatment options, the mental health
system, and skills useful in managing and reducing symptomatic behaviors of the
member with a serious mental illness. Services include psycho-education groups,
family support groups, single family consultation, respite activities and
referral/linkage.
Consumer Operated Services: At the state level, the DMAHS involves individuals
with mental illness in upper level management decision-making, program
development, proposal reviews, community site reviews, state hospital
monitoring, and participation in key committees and workgroups. DMHAS
provides funding and support for peer providers working in the system. There
are also peers working in designated screening centers/psychiatric emergency
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







rooms, and plans are underway to develop peer-operated alternatives to crisis
and screening. DMHAS currently funds and supports 33 consumer operated
self-help centers statewide, including a self-help center on the grounds of three
State hospitals.
Managed Behavioral Health Organization: In January 2015, the Governor
announced that the Division is developing an interim managing entity (IME) for
addiction services as the first phase in the overall reform of behavioral health
services for adults in NJ. University Behavioral Health Care (UBHC) will be the
IME with an implementation date of July 1, 2015. The IME will serve as a single
point of entry for those seeking treatment for substance use disorders. The IME
will ensure that individuals are receiving the right level of care for the right
duration at the right intensity. This will allow the state to manage its resources
across payors and across the continuum of care.
Justice Involved Services: JIS identifies and intervenes with individuals in the
criminal justice system whose mental illness and behavior directly results in
violence or increases the risk of violence through criminal actions. DMHAS funds
15 JIS programs which serve about 1,500 consumers each year. The services
are as follows:
o Re-entry services: JIS provides referrals for inmates being released from
county correctional facilities; programs have between 1 to 2 case
managers who interview and enroll potential candidate while in jail,
provide pre-release planning and then successful linkage and coordination
to mental health and other social/community services. No psychiatric or
treatment services are directly provided by the program; rather, they link
existing mental health services. Counties include: Atlantic, Bergen,
Burlington, Camden, Cumberland, Essex, Gloucester, Hudson,
Monmouth, Morris, Middlesex, Mercer, Passaic, Ocean, and Union.
o Pre-booking Jail diversion: This option typically involves a police-based
intervention to avoid arrest for non-criminal, non- violent offenses. Police
are trained to identify and de-escalate situations involving individuals with
mental health disabilities and to divert them to mental health crisis or precrisis services.
o Post-booking diversion: This option typically involves intervening so that
consumers are released from detention earlier than they otherwise would
be. Individuals are released on their own recognizance or released from
jail with mental health intervention and treatment conditions.
Veterans Mental Health Diversion Program: The Atlantic County Prosecutor’s
Office leads a diversion program that offers military veterans and active duty
personnel accused of committing certain crimes the opportunity to avoid
incarceration if they are deemed clinically appropriate for treatment and with the
approval of the prosecutor’s office. Program participants are case managed by a
non-profit service provider and receive counseling and treatment consistent with
their needs.
Hudson County Municipal Court Program: DMHAS funding has been used in
Jersey City to assign a case manager/municipal court liaison directly in the
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Jersey City Municipal Courts. The liaison provides individual consultations to the
judges and attorneys, upon request regarding defendants with mental illness and
recommended options for care and treatment in lieu of incarceration.
PROMISE Parole program: A joint effort among DMHAS, the State Parole Board
and & Parole Collaboration is a collaborative program of the State Parole Board,
DMHAS and the Housing and Mortgage Finance Agency to assist parolees with
serious mental illness to transition and integrate into their community and provide
mental health and other wrap around services including employment and housing
to reduce the number of violations of probation. DMHAS funds a case manager
who provides linkages and coordination of services.
Inmate Screening: DMHAS meets regularly with representatives from the
Department of Corrections, Ann Klein Forensic Center to review prisoners with
serious mental illness who are nearing their ―max out‖ release date to determine
whether the prisoners may need continued commitment at AKFC or at a
community mental health service facility.
Veterans Assistance Initiative (VAI): This program provides services to
veterans/service members who get arrested and need linkage and coordination
with services through the local Veterans Service Offices of the Department of
Military and Veterans Affairs. DMHAS-licensed providers provide case
management & treatment services as needed in an effort to avoid or reduce the
incidence and length of incarceration.

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2NDFLOOR: Youth Helpline of New Jersey is a DCF funded confidential and
anonymous statewide helpline for New Jersey's youth and young adults. Youth
can call 2NDFLOOR at (888) 222-2228 and receive support to find solutions to
any problems they are having with school, family, peers, etc. The helpline is
available 24 hours per day every day of the year.229
New Jersey Youth Suicide Prevention Project: Through funding from the U.S.
Department of Health and Human Services, Substance Abuse Mental Health
Services Administration (SAMHSA), 860 mental health professionals have been
trained in evidence-based and best practice suicide prevention strategies.
Trainings have been conducted in Passaic, Camden, Monmouth, and Bergen
Counties.
New Jersey’s Children’s System of Care (CSOC): A Division of the Department
of Children and Families (DCF), the Children’s System of Care provides
behavioral health treatment services, developmental and intellectual disability
services, and substance use treatment services to the children and youth of New
Jersey. Services may be accessed by calling Performcare at 1-877-652-7624.230
Family Support Organizations (FSOs): FSOs provide direct peer support and
assistance to children and families by family members of children currently
involved in the Children’s System of Care. Among the services offered by FSOs

http:www.2ndfloor.org.
http://www.performcarenj.org/index.aspx.

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are peer mentorship, education and advocacy, information, referral, and the
hosting of parent and peer support groups. FSOs are operational in all 21
counties within New Jersey.
Transitions for Youth (TFY): TFY is a multi-faceted statewide initiative that
utilizes a positive youth development framework to address the complex needs of
youth transitioning to adulthood, particularly those who are aging out of foster
care or who were involved with the juvenile justice or behavioral health systems.
TFY’s goal is to ensure that youth develop essential skills and competencies in
education, employment, daily living, decision-making, and interpersonal
communications.231
Mobile Response and Stabilization Services (MRSS): MRSS provides face-toface intervention for children who are experiencing escalating emotional and/or
behavioral issues. MRSS initially focuses on de-escalation, assessment and
crisis management and can, as needed, provide longer-term care and
stabilization services. MRSS is available 24 hours a day, 7 days a week and
attempts to deploy staff within one hour of receiving a request for assistance.
MRSS can be accessed 24 hours per day every day of the year by calling 1-877652-7624.
Outreach to At-Risk Youth (OTARY): OTARY is a DCF initiative designed to
prevent crime and deter gang involvement by providing enhanced recreational,
vocational, educational, outreach and supportive services to youth aged 13 to 18.
OTARY programs are primarily located in communities with high crime rates and
high levels of gang violence.232
School-Based Youth Services Program (SBYSP): SBYSP is a program led by
DCF’s Office of School-Linked Services and is operated by non-profit
organizations or the school district itself in communities throughout New Jersey.
SBYSP programs offer services before, during, and after school and throughout
the summer to youth aged 10 to 19 in areas including, mental health and family
services, health services, substance abuse counseling, employment services,
pregnancy prevention programs, learning support services, and referrals to
community-based services.233
DCF Inventory of Statewide Resources: The Department of Children and
Families provides an online resource guide for programs and services available
by county for youth in need of support services.234

Department of Law & Public Safety (Office of the Attorney General)
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Trenton Violence Reduction Strategy: A three year, $1.1 million initiative in
Trenton geared toward providing ex-offenders and those at-risk of engaging in
criminal activity the opportunity to receive supportive assistance and wrap around
services if they are willing to take responsibility for their past mistakes and
ownership of their future. The program is led by the Trenton Police Department,

http://www.socialwork.rutgers.edu/instituteforfamilies/officeofchildwelfareinititives/TFY.aspx.
http://www.nj.gov/dcf/adolescent/oasresourceguide.pdf.
http://www.state.nj.us/dcf/families/school.
http://www.state.nj.us/dcf/families/dfcp/DFCPDirectory.pdf.

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The College of New Jersey, and Isles, a non-profit in Trenton, who are now
working with more than 40 individuals and assisting them in securing
employment, receiving counseling and treatment, providing educational
opportunities, and other needed support.
Positive Youth Development Grants: In 2014, the OAG awarded grants to six
non-profits throughout the state to provide supportive services to vulnerable
youth under the age of 21 who are experiencing adverse circumstances because
they live in economically disadvantaged or high crime areas. The key objective is
deterring delinquency and criminal conduct while encouraging prosocial
behavior.
Municipal Planning Boards: The OAG convenes a diverse group of stakeholders
from government, community and faith-based organizations and law enforcement
who focus on a core mission of juvenile crime prevention and coordination of
services for at-risk youth. There are six MPBs operational in nine cities (Atlantic
City/Pleasantville, Asbury Park, Camden, Cumberland County (Bridgeton,
Millville, Vineland), Newark, and Trenton). OAG is in discussion with leaders from
three other areas – Paterson, Jersey City, and Burlington County to create MPBs
in those areas as well.
Faith-Based Outreach: The Attorney General convenes two separate working
groups of faith leaders – the Muslim Outreach Committee and the Interfaith
Advisory Council to discuss issues of importance to these religious leaders and
their congregants.
Corridor-Status Initiative (―Corr-Stat‖): Launched nearly three years ago among
agencies in North Jersey, Corr-Stat now includes more than 30 local law
enforcement agencies, five county prosecutor’s offices, and federal and state
partners who meet regularly to discuss crime trends and patterns and share
information on the criminal environment in their cities. Corr-Stat is now supported
by the Real Time Crime Center, which opened in Newark in December 2014. The
RTCC pushes out intelligence as it is generated and will help investigators in the
field by getting them information more quickly.
SJ Stat: Building off the success of Corr-Stat, the Attorney General’s Office stood
up a similar regional collaborative in South Jersey to cover Cumberland, Salem,
and Atlantic Counties and bring together law enforcement agencies from those
areas to address the criminal element in their communities.
Prosecutor-Led Mental Health Diversion Programs: OAG funds prosecutor-led
mental health diversion programs in Ocean and Essex Counties. These
programs offer diversion from incarceration for clinically appropriate defendants
who are approved for the program by the County Prosecutor.

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Crisis Intervention Team Training (CIT): CIT is an an innovative national model
that provides an intensive, 40-hour training curriculum to police officers, mental
health professionals, and advocates on how to appropriately respond to people
experiencing a behavioral crisis who pose a risk to themselves or others. The
curriculum focuses on educating law enforcement officers about mental illnesses
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such as schizophrenia, bi-polar disorder, post-traumatic stress and others and
strategies to de-escalate situations when a person with a mental illness is in
severe crisis. When utilized effectively, individuals who might have otherwise
been incarcerated receive treatment, the safety of officers and the general public
is heightened during these encounters, and police/community relations are
strengthened because family members see that their loved ones are not treated
as criminals, but rather, as sick people in need of help. In New Jersey, more than
2,100 officers and State Troopers across 9 counties and more than 70
jurisdictions have completed the 40-hour curriculum.
National Forum on Youth Violence Prevention:235 The National Forum on Youth
Violence Prevention is focused on building federal-local collaboration to increase
awareness, drive action, and build local capacity to more effectively address
youth violence. Camden, New Jersey is one of ten cities that participate in this
effort.236
Juvenile Detention Alternatives Initiative (JDAI): In 2004, New Jersey was
selected by the Annie E. Casey Foundation to participate in the national JDAI
initiative. The primary goal of JDAI is to offer alternatives to detention for youth
engaged in low-level delinquent activity. Eighteen counties in New Jersey
participate in JDAI, which has resulted in a roughly 60% reduction in the number
of juveniles in detention on any given day. JDAI has been so successful that the
Casey Foundation designated New Jersey as a model site and representatives
from fifteen other states have traveled to New Jersey to learn more about our
program.
Project Safe Neighborhoods (Jersey City):237 In September 2014, Jersey City
was awarded $500,000 from the U.S. Department of Justice to implement a
Project Safe Neighborhood program. Funding will support ongoing efforts to
reduce gun and gang violence through collaborative law enforcement strategies.
Promise Neighborhoods (Camden): The Center for Family Services received a
grant from the U.S. Department of Education to implement a Promise
Neighborhood program in the Cooper Lanning neighborhood of Camden. The
primary objective of the grant is to develop and implement a ―cradle-to-career‖
service plan designed to improve academic achievement (including college
matriculation) and healthy development of children in the Cooper Plaza and
Lanning Square area.
Jersey City Employment Training: Hailed as a national model for prisoner reentry, the Jersey City Employment and Training Program focuses on providing
sober living, employment, and housing for ex-offenders while integrating social
services to improve their likelihood of a successful transition back into the
community. The Jersey City model is being rolled out in five other cities statewide
– Atlantic City, Newark, Paterson, Toms River, and Trenton

235

http://youth.gov/youth-topics/preventing-youth-violence.
http://www.ci.camden.nj.us/wp-content/flyers/camdencityforumplan2013.pdf.
237
http://www.justice.gov/usao-nj/pr/us-department-justice-awards-500000-crime-fighting-grant-newjersey.
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Non-Governmental Programs
Boys and Girls Club of New Jersey: The Boys and Girls Clubs effectively serve youth
nationwide and in New Jersey. In 2013, Boys and Girls Clubs nationwide worked with
nearly 3.8 million youth ages 6-18. In New Jersey, there are 23 active Boys and Girls
Clubs who work with young people throughout the state to help them achieve academic
success, good character and citizenship, and maintain healthy lifestyles.
Mentoring Moms:238 Mentoring Moms is a program led by the Volunteer Center of
Bergen County. Since 1995, Mentoring Moms has provided education and support
services to parents and care-givers to address the issue of child maltreatment and
prevent future interaction with violence either as victim or perpetrator. Mentoring Moms
has trained approximately 500 mentors and provided mentoring services to over 500
mothers/guardians. Mentoring Moms recruit, train and supervise adult volunteer
mentors who serve as a caring, supportive network to overwhelmed mothers or
guardians in need of parenting and life skills. Mentors commit to spending a minimum of
2-3 hours per week in shared activities, for one year, in a peer-to-peer relationship with
a mother.

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http://www.bergenvolunteers.org/info.aspx?c=4bd3e1131e1985a8&n=502&p=Mentoring%20Mom.

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