Criminalization of Mentally Ill People: How Can We Stop It?

My presidential initiative has been to take a hard look at the criminalization of people with mental illness. Statistics show that as access to mental health services in the community have decreased, there has been an incremental increase in the number of people with mental illness in the criminal justice system. With this awareness in mind, it was an exciting moment when a group of dedicated experts on the subject joined together last month at APA’s central office to brainstorm strategies and future directions for reform (see page 1).

The conference, organized by the APA Corresponding Committee on Jails and Prisons and co-chaired by Dr. Steve Sharfstein and me, focused on these points:

• What do we know?

• What are we doing?

• How can we forge new efforts and plan for the future?

Who was there? Katherine Power, the director of the Center for Mental Health Services (CMHS), and three top center officials; and representatives of the GAINS Center for People With Co-Occurring Disorders in the Justice System, Council of State Governments, Community Services Division of the National Association of Counties, Research Triangle Institute International, Human Services Research Institute, National Association of State Mental Health Program Directors, National Alliance for the Mentally Ill, Bazelon Center for Mental Health Law, and National Mental Health Association. Also participating were the executive director of a state Appropriations Committee and a representative from the Center for Behavioral Health, Justice, and Public Policy.

APA participants included the members of APA’s Corresponding Committee on Jails and Prisons; Dr. Howard Goldman, a professor of psychiatry at the University of Maryland School of Medicine who is known for his work on the organization and financing of health care; Dr. Jim Nininger, APA speaker-elect; and Sam Muszynski, director of APA’s Office of Healthcare Systems and Financing.

This group was large, the members knowledgeable, and the dialogue throughout the day was lively and informed.

What do we know? We know that large numbers of imprisoned people have current symptoms of serious mental illness. Studies have shown that jail-diversion programs result in positive outcomes for individuals, systems, and communities. The multisite programs studied to determine cost offset varied in their findings. In general, jail diversion results in lower criminal-justice costs and greater treatment costs. The treatment program used in most diversion studies, for both diverted and comparison subjects, usually consists of medication and “counseling.” This program—“treatment light”—is less than what is needed for a population that is often struggling with severe mental illness and co-occurring substance abuse. Assertive Community Treatment (ACT) with psychotropic medications and integrated programs for co-occurring substance use disorders is recognized as yielding the best results. Still, even “treatment-light” diversion produced fewer jail days, no increase in arrests, and fewer arrests than the subjects had experienced previously.

David Hughes of the Human Services Research Institute presented a simulation model to predict the cost impact of jail-diversion programs. Designed to make use of evidence-based treatment, good services push people into a better functioning system and in the long run can save money.

You may ask, “Why this focus on the fiscal dimensions when people with mental illness are in the criminal justice system?” Everyone around the table had a strong and abiding interest in making quality treatment available to mentally ill people. However, if we want to improve our chances of receiving the necessary funding in an era of budget shortfalls, evidence that there is a substantial cost offset will result in new programs.

We were fortunate that Katherine Power joined us for most of the day. In her role as director of CMHS, she leads the efforts to implement the report of the President’s New Freedom Commission on Mental Health, which was released last year. Among other issues, the report singles out the increased criminalization of mentally ill people as an issue that must be actively addressed. She spoke of the need for state leadership to declare this issue a priority, which must be negotiated with state Medicaid and the justice systems.

Many practical issues were discussed. When people with mental illness are incarcerated, they lose their SSI and Medicaid eligibility. This development increases treatment costs for the states and the counties. People with mental illness are shown to have much longer incarcerations than other inmates. Mothers are separated from children, with a devastating impact on the integrity of family life. Frequently, incarceration occurs at considerable distances from the homes of inmates, incurring expensive and fatiguing travel by family members, who are usually living below the poverty line. The facilities and environment in most jails and prisons aggravate the very illness that has led to bizarre and antisocial behavior. Once people with mental illness have spent time in jail, they are stigmatized in their efforts to receive treatment upon leaving the correctional facility.

We need long-term research programs that include well-designed diversion programs. We must incorporate evidence-based practices, as well as adequate housing and substance abuse programs, in the treatment-planning period. Now there must also be major advocacy efforts at the state and national levels.

Tom Hamilton, a member of APA’s Corresponding Committee on Jails and Prisons and a past president of Texas NAMI, is an example of the fact that advocacy works. With strong lobbying, he convinced the Texas legislature to divert $35 million over a two-year period from the criminal justice system to provide mental health treatment at the back door of the prison system (Psychiatric News, October 3).

In the near term, the dual prejudices against criminals and mentally ill people conflate, making APA’s undertaking these related projects a steep hill to climb. But the urgent needs of families, the community, and our society make these efforts critically necessary. ▪