Commentary

by Jennifer J. Parish

In the last twenty years, the number of people with psychiatric disabilities in the criminal justice system has risen dramatically. The incidence of mental illness in the jail and prison population is about three to four times that of the general U.S. population.

The Bureau of Justice Statistics (BJS) Special Report, "Mental Health Problems of Prison and Jail Inmates," released in September 2006, suggests more than half of all people incarcerated in jails and prisons have a mental health problem. Prisons have become de facto warehouses for people with problems that society does not wish to confront. In fact, Rikers Island in New York City and the Los Angeles County Jail are the two largest psychiatric institutions in the U.S. The phenomenon of criminalizing mental illness has been the subject of much attention by both policymakers and the media.

The criminal justice system is not the appropriate institution to address this public health crisis. Its orientation toward the accused is first and foremost punitive.

In most courtrooms across the country, the outcome of a criminal case involves the interplay of a few factors - the crime charged, the strength of the evidence, the defendant's criminal record, and the standard plea offer. Little attention is paid to the individual before the court. The severity of the person's psychiatric disability and whether and what kind of treatment could be effective are generally not considered. Rehabilitation is rarely part of the equation.

Unfortunately most of the concrete attempts to address this crisis do not take a broad view of the problem and how policy choices have lead to this result. Increasing arrests for "quality of life" crimes, such as panhandling, loitering, and drinking in public, is but one example of how decisions in the realm of public policy create an immediate, if unwise, influx of people with psychiatric disabilities coming into the criminal justice system.

Also, the war on drugs has contributed to this phenomenon. According to The Sentencing Project, in 2002 one in four people in jail was incarcerated for a drug offense, compared to one in ten in 1983. With seventy-two percent of people with psychiatric disabilities in the criminal justice system having a co-occurring substance abuse disorder, it is not surprising that the emphasis on drug enforcement and harsher sentencing laws for drug crimes has contributed to this crisis.

Reform measures have come primarily from the criminal justice system and are confined by the parameters of that system. For instance, the development of mental health courts is one approach to addressing this issue that has become quite popular. Since the first mental health courts were developed in the late 1990s, the number has grown to more than 120 nationwide. Although there are no national standards for mental health court policies, and the manner in which they operate varies widely across the country, their main selling point is that they recalculate the factors to include consideration of the needs of the accused and to offer treatment and services as part of the resolution of the charges.

These courts can link individuals to treatment, pressure someone who may not have sought treatment to accept it, and keep some people out of prison. However, there is a large gap left un-addressed by these courts. Namely, they do not increase or enhance the resources available in the community - they simply funnel people into existing services.

Without the creation of additional services and housing options, individuals whose cases are adjudicated by the mental health court may end up waiting in jail for months before being placed in a treatment program. In addition, those who are unsuccessful in treatment can wind up back in jail serving more time than if they had not bargained for diversion in the first place.

To address this problem comprehensively, the mental health community must take the lead -- and not just state agencies and service providers but consumers, family members, and advocates. We need to look at the current system and see what is lacking, such as housing for people with psychiatric disabilities; what could be expanded, such as Assertive Community Treatment teams, which offer personalized services delivered to the individual in the community by a team of practitioners who are available 24 hours a day; and what should be developed, such as more engaging treatment models. We need to examine the efficacy of social service programs in the community to determine if they are truly responsive to the needs of mental health consumers.

The mental health system has to expand not only to meet the needs of individuals with psychiatric disabilities who are in the court system, but also to address the needs of mental health consumers to prevent them from becoming involved in the criminal justice system in the first place. It might start byaddressing the needs of young people, especially those involved in the foster care and juvenile justice systems. Fifty to seventy-five percent of incarcerated youth have a diagnosable mental health problem. Increasing the availability of affordable and supportive housing is essential for addressing homelessness among people with psychiatric disabilities.

The President's New Freedom Commission on Mental Health recognized that the "shortage of affordable housing and accompanying support services causes people with serious mental illnesses to cycle among jails, institutions, shelters, and the streets." By improving our mental health options, we can keep people out of the criminal justice system and have more capacity to divert those who do wind up there despite prevention efforts.

Fortunately, there are programs that could become national models for engaging this population. For instance, the Nathaniel Project in New York City has proven to be effective at serving people with serious and persistent mental illness who have been indicted on a felony offense and are facing a lengthy prison sentence.

The Project serves people charged with violent crimes, demonstrating that these individuals can be safely treated in the community. The staff of master's-level social service professionals are available 24 hours a day, seven days a week, and they deliver services wherever the client is. The staff's high expectations for their clients and commitment to helping them succeed have made the program remarkably successful. For instance, 92 percent of Project participants were homeless at intake, but after only one year, 79 percent had permanent housing. Likewise, the recidivism rate for project participants decreased dramatically -- from 101 arrests (35 misdemeanor and 66 felony) in the year prior to their acceptance into the Project to 7 (5 misdemeanor and 2 felony) in the year since intake.

In addition, the "Housing First" model developed by Pathways to Housing in New York City has also been remarkably successful at keeping people who had been chronically homeless and diagnosed with severe mental illness housed. Pathways' approach differs significantly from traditional programs. Rather than having to move along a continuum of care, from living in congregate supervised settings to graduating to independent, supported housing after proving they can follow rules and comply with treatment, Pathways clients are offered immediate access to an apartment of their own. They are not removed from housing for violating rule, being charged with a criminal offense, or refusing to take medication. Eighty percent of the people who were first provided with an apartment of their own through Pathways to Housing remained in stable housing twelve months later compared to only 24 percent who were served by programs using the more common treatment first method.

Finally, it is critical to involve family members and consumer when developing new models. They have firsthand knowledge of why the current system is failing, as well as insight into what has worked for them.

We must reclaim those people with psychiatric disabilities who are cycling through the criminal justice system as mental health consumers, not inmates, and develop the policies and services to take them out of the punitive criminal justice system and into recovery.


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