To better understand this problem, a literature review was conducted. Two of the primary questions addressed were whether large numbers of persons with severe mental illness who commit legal transgressions are being taken to jails and sent to prisons instead of to hospitals or other psychiatric treatment facilities, and whether the number has increased since deinstitutionalization.
The review also examined other aspects of this issue, including the characteristics of mentally ill offenders, factors cited as causes of mentally ill persons' being placed in the criminal justice system, the relationship between mental illness and violence, access to treatment for this population, the role of the police, and society's attitudes toward mentally ill offenders. Finally, recommendations are made about how inappropriate placement of this population in the criminal justice system can be prevented and how to treat mentally ill offenders both in the system and after they are released into the community.
Conclusions and recommendations
Much has been learned about what needs to be done to prevent mentally ill persons from being inappropriately placed in the criminal justice system and about how to treat them once they are there and after they are released into the community. What has been lacking is widespread and comprehensive implementation of interventions shown to be effective (
29). Several of these strategies are summarized below.
Steps should be taken to prevent inappropriate arrest of mentally ill persons (
94). The police are often the first to respond to emergencies involving people with severe psychiatric disturbances (
75). However, the police may not always recognize a need for, or have access to, emergency psychiatric resources. Clearly, mental health expertise is needed at this point to prevent criminalization. There is a pressing need for formal training of police officers to help them better understand mental illness and to improve their attitudes toward individuals with mental disorders (
81,
95).
Mental health consultation provided to the police in the field can result in a response that combines the specialized knowledge and expertise of law enforcement and mental health professionals. Such an approach can greatly increase the number of mentally ill persons given appropriate access to the mental health system rather than inappropriately diverted to the criminal justice system. For example, an evaluation of psychiatric emergency teams consisting of police officers and mental health professionals found that the teams were able to deal with psychiatric emergencies in the field, even with a population characterized by acute and chronic severe mental illness, a high potential for violence, a high prevalence of serious substance abuse, and long histories with both the criminal justice and the mental health systems (
77). These teams took or sent almost all of the persons in crisis to the mental health system and not to jail.
For individuals who are arrested and placed in jail, it is generally recommended that the facility routinely screen all incoming detainees for severe mental disorder and that jail administrators negotiate programmatic relationships with mental health agencies to provide multidisciplinary psychiatric teams (
24,
78). These teams should be established inside jails to provide short-term crisis evaluation, treatment, and referral to a psychiatric hospital if necessary. The teams should include psychiatrists so that psychoactive medications can be prescribed.
Mentally ill detainees who have committed minor crimes, such as trespassing and disorderly conduct, should be diverted to the mental health system entirely, or at minimum for treatment. For instance, mental health teams should be readily available for consultation to the arraignment courts and especially to the municipal courts, where many acutely psychotic patients appear with very minimal criminal charges. Steadman and associates (
96) found that only a small number of U.S. jails have diversion programs for mentally ill detainees. They also observed that objective data on the effectiveness of these programs are lacking. On the other hand, it has been found that court-mandated and -monitored treatment in lieu of jail was effective in obtaining a good outcome for chronically and severely mentally ill persons who committed misdemeanors (
97).
Belcher (
59) wrote that a system that relies solely on voluntary compliance may not provide adequate structure for mentally ill offenders. He and others (4,94,98-101) recommended such mechanisms as outpatient commitment, court-monitored treatment, treatment as a condition of probation or parole, and psychiatric conservatorship or supervision by agencies such as Oregon's Psychiatric Security Review Board (
102). Freeman and Roesch (
103) acknowledged that the court or parole board has a right to set conditions for release to the community that include mandatory treatment. Nevertheless, mental health professionals have an ethical and legal obligation to fully inform patients about the nature of the treatment and obtain their consent for it.
It is important to recognize that persons with mental disorders who are discharged from psychiatric or correctional institutions experience multiple problems that cannot be adequately treated in traditional community-based facilities (
104,
105). Thus placement in the community often results in rehospitalization or reincarceration (
106). To reduce this cycle, assertive case management programs are recommended.
The great majority of mentally ill offenders need the basic elements of case management, which starts with the premise that each person has a designated professional with overall responsibility for his or her care (
20,
107). The case manager formulates an individualized treatment and rehabilitation plan with the participation of the mentally ill person and often the supervision of the court. As care progresses, the case manager monitors the mentally ill person to determine if he or she is receiving and complying with treatment, has an appropriate living situation, has adequate funds, and has access to vocational rehabilitation.
The case manager not only provides outreach services, but also serves as an advocate for the individual and makes sure that the mentally ill person is not drifting away from the supportive elements of such a network. An assertive case management program deals with clients on a frequent and long-term basis, using a hands-on approach that may necessitate meeting with clients “on their own turf” or even seeing clients daily (
106). This form of contact and familiarity with clients helps the case manager and client anticipate and prevent significant decompensation.
Important advances have been made in recent years in the management of the violent behavior of severely mentally ill persons (
108,
109). Behavior therapy and pharmacotherapy—in particular, the use of the new atypical antipsychotic medications—are but a few examples. It is crucial that these modalities be widely implemented.
Mental health agencies in the community must be able to provide the degree of structure and limit setting needed by mentally ill offenders, as well as ensure the safety of staff. When highly structured 24-hour care is required, it should be provided.
The role of family members is an important aspect in the care of mentally ill offenders. Often overlooked are family members' needs for guidance and support. Families should be instructed in ways to help stabilize their relative (
107). They should also be involved in support programs to help them during crises and in self-help programs so they can benefit from the experience of other families in similar situations (
110).
We believe that a significant increase in mental health services for severely mentally ill persons, from outpatient treatment and case management to highly structured 24-hour care, would result in far fewer mentally ill persons' committing criminal offenses. Thus one of our most important recommendations is for increased mental health services. The criminal justice system should not be viewed as an appropriate substitute for the mental health system. Moreover, it has been our experience that an enormous stigma is attached to people who have been categorized as both mentally ill and an offender, and it is thus extremely difficult to place them in community treatment and housing. The difficulty is even greater when they have been in a forensic hospital.
Clearly, many mentally ill persons who commit criminal offenses present formidable challenges to treatment because of their treatment resistance, poor compliance with antipsychotic medications, potential dangerousness, high rate of substance abuse, and need for structure. To a large extent, the public mental health system has given up on them and allowed them to become the responsibility of the criminal justice system. We believe these recommendations would contribute to successful treatment of this population.
Implementing these recommendations would mean tailoring mental health services to meet the needs of mentally ill offenders and not treating them as if they were compliant, cooperative, and in need of a minimum of controls. The lives of a large proportion are characterized by chaos, dysphoria, and deprivation as they try to survive in a world for which they are ill prepared. They cry out for treatment and for structure, and we believe it is the obligation of the mental health system to provide it. If effective and appropriate interventions are provided, these individuals may not only improve psychiatrically but may also engage in considerably less criminal behavior.