The Mental Health and Criminal Justice Systems: the Burden of Forcing One System’s Responsibilities onto Another

By Kacey Heekin (2015)

Introduction

Mental illness is a serious and prevalent condition in today’s society. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), approximately 18.5% of adults in the United States currently experience any mental illness (AMI) and 4.2% experience serious mental illness (SMI) (SAMHSA, 2014). Mental illness is associated with many severe consequences, including: negative impacts on quality of life and physical health; significant contributions to disability in the U.S.; strains on familial and other interpersonal relationships; and serious societal costs.

Advances in pharmacological, psychosocial, and preventative interventions have helped to improve the treatment of mental illness. However, the mental health system has been fraught by significant underfunding and a deficit of quality mental health services. Thus, the condition of this system has continued to deteriorate over the past 50 years, leaving many individuals without mental health care and placing tremendous burden on the criminal justice system.

A Brief History of the Mental Health System

The U.S. mental health system has changed considerably throughout the past 50 years. Prior to the deinstitutionalization movement, individuals with mental illness were largely confined to psychiatric hospitals. Due to improvements in psychiatric medications that allowed for better management of mental disorders and increased social and political concern for the treatment of individuals with mental illness, the transition of mental health services from institutions to community-based facilities was initiated in the 1950s. Research has supported this transition, and empirical evidence shows that community-based mental health services (e.g., supported housing and employment programs, primary care medical services, community mental health centers, and Assertive Community Treatment [ACT]) are effective in managing mental illness and are generally preferred to institutionalization. However, a lack of funding and support throughout the process of deinstitutionalization, along with the criminalization of drug offenses and the evolution of civil commitment laws, has left many individuals with mental illness without adequate care and often times in jail or prison.

A Lack of Access to Care

A substantial proportion of individuals with mental illness in the U.S. do not receive the mental health services they need. According to SAMHSA, only around 44.7% of adults with AMI and 68.5% of the adults with SMI received mental health services in the past year (SAMHSA, 2014). These services are very expensive, especially for individuals without insurance, often inaccessible to those in need (e.g., individuals with low incomes in rural areas), and not adequately assessed for quality.

The Effect of an Insufficient Mental Health System on the Criminal Justice System

The condition of the mental health system has placed tremendous burden on the criminal justice system. The prevalence of individuals with mental illness who are involved with the criminal justice system is significant, with research indicating that over half of all jail and prison inmates have a mental health problem (James and Glaze, 2006). The number of inmates with mental illness and the severity of these illnesses are on the rise (Torrey et al., 2010). The number of inmates with SMI in jails and prisons is shockingly 10 times greater than the number of individuals with SMI residing in state psychiatric hospitals (Torrey et al., 2014). Yet, most individuals in the criminal justice system with mental health issues do not receive treatment.

Issues Surrounding the Criminal Justice System and Mental Health

There are several complications surrounding the way the criminal justice system handles mental health issues, including: inadequate screenings and data management systems for inmate mental health; medication discontinuity for inmates with mental illness who were treated prior to incarceration; a shortage of trained mental health staff and treatment options in correctional facilities; stressful conditions in correctional facilities (e.g., the presence of violent, dangerous offenders and tight and overcrowded quarters); the utilization of solitary confinement; increased risk of violence, brutality, and sexual abuse for inmates with mental health issues; increased lengths of stay for inmates with mental illness; and lack of follow-up treatment once inmates are released from jail or prison, which contributes to repeated incarceration. Other complications include substantial societal cost; fragmentation of mental health service delivery and stigmatization of individuals with mental illness (e.g., increased arrests of individuals with mental illness perpetuates the harmful perception that those with mental illness are more prone to being dangerous; although untreated serious mental illness is associated with a higher rate of violence, mental illness more generally is not associated with a significantly greater risk of violence).

Rikers: Where Mental Illness Meets Brutality in Jail

Inmates are housed on cellblocks supervised by uniformed men and women who are often poorly trained to deal with mental illness, and rely on pepper spray, take-down holds and fists to subdue them.

The prolonged isolation, extremes of hot and cold temperatures, interminable stretches of monotony punctuated by flashes of explosive violence can throw even the most mentally sound off balance and quickly overcome those whose mental grip is already tenuous.

– New York Times

Recent Changes in Relevant Services in the Criminal Justice System

There have been several recent changes in the services that are related to the criminal justice system and mental health. One of these changes includes modified and increased mental health training for law enforcement personnel. Another of these changes is the continuous advancement of screening services upon intake into jails, prisons, or other correctional facilities. There has also been considerable growth in community-based services to prevent individuals from interacting frequently and intensively with the criminal justice system.

Diversion services, which have become more popular throughout the past decade, are services that are designed to reduce the arrest and incarceration of individuals with mental illness and to divert individuals engaging in problematic behavior or committing minor crimes into the appropriate treatment. Examples of diversion services include crisis intervention teams (CITs), problem-solving courts/mental health courts, re-entry services, and intensive case management. In order for these community-based alternatives to be effective, the criminal justice system will have to be able to rely on and collaborate with a strong mental health system with adequate services.

Wrestling with a Texas County’sMentalHealth System

The San Antonio Restoration Center is an efficient jail diversion program that has resulted in major cost savings and is a model for similar improvements across the country. The Restoration center is an integrated complex with 48-hour inpatient psychiatric care, sobering and detox centers, outpatient primary care and psychiatric services, a 90-day recovery program, housing for people with mental illnesses, job training, and a program to help individuals transition to supported housing.

More than 18,000 people pass through the Restoration Center each year and officials say the coordinated approach is saving the city more than $10 million each year.”

–Keiser Health News

The Future of the Mental Health and Criminal Justice Systems – Recommendations for Improvement

The U.S. criminal justice system in relation to mental health is burdened by an array of serious challenges; urgent practice and policy reform is essential to ensure an ethical, safe, and efficient system. In order to improve this system, change within the public mental health system is also necessary.

The U.S. mental health system is still critically underfunded. Recommendations for the improvement of both the mental health and criminal justice systems include expanding funding for state mental health services, increasing the availability of community-based mental health services, inpatient mental health hospital beds and forensic mental health treatment facility beds (for individuals with greater needs), and quality mental health services in jails and prisons, conducting more research on the effectiveness of diversion services/programs and implementing successful ones (e.g., CITs and mental health courts), raising the training requirements for law enforcement personnel and correctional officers (especially in regard to de-escalating confrontations with individuals with mental illness and minimizing the use of force), updating screening procedures and data management systems within jails and prisons, minimizing the crowding within jails and prisons, eliminating the utilization of solitary confinement for inmates with mental illness, implementing suicide, brutality, and sexual abuse preventative strategies within jails and prisons, increasing the availability of re-entry services and follow-up treatments that emphasize a rehabilitative approach, encouraging collaboration and coordination between state criminal justice and mental health departments, modifying civil commitment laws, and supporting promising bills that promote relevant reform.