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REDUCING CRIMINALIZATION OF PERSONS WITH SERIOUS MENTAL ILLNESS

REDUCING CRIMINALIZATION OF PERSONS WITH SERIOUS MENTAL ILLNESS. H. Richard Lamb, M.D. August 18, 2012. A HETEROGENEOUS GROUP.

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REDUCING CRIMINALIZATION OF PERSONS WITH SERIOUS MENTAL ILLNESS

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  1. REDUCING CRIMINALIZATION OF PERSONS WITH SERIOUS MENTAL ILLNESS H. Richard Lamb, M.D. August 18, 2012

  2. A HETEROGENEOUS GROUP • Persons with SMI (which is defined here as schizophrenic disorder, schizoaffective disorder, bipolar disorder, and major depressive disorder with psychotic features) are a heterogeneous group.

  3. THE FIRST GROUP • A very large percentage of persons with SMI recognize they are mentally ill and participate willingly in treatment. • In most cases, they are able to live in the community, are often productive in terms of work, do not have a serious problem with substance abuse, are not violent, and show potential for recovery.

  4. THE FIRST GROUP • As a result of the very visible success this group has had, much of the discussion in treating persons with SMI has focused on such individuals.

  5. A SECOND GROUP • On the other hand, there is a small but significant minority of persons with SMI who do not believe they are mentally ill. • The result is resistance to psychiatric treatment (including medications). • Anosognosia, a biologically determined inability to recognize that one is mentally ill. • Linked to frontal lobe dysfunction.

  6. A SECOND GROUP • This minority of persons may have overt psychotic symptoms, problems with substance abuse, great difficulty interacting appropriately with others, antisocial tendencies and a tendency to become violent when stressed. • As a result, involvement with the criminal justice system is likely.

  7. THE TWO GROUPS • Attention to the two groups varies significantly. • The literature and practice tend to focus on the first group and not the second group. • Second group is not usually thought of when developing the community treatment of SMI. • This group is overlooked because so many, (perhaps 350,000+/-) are out of sight in jails and prisons.

  8. BROWN v PLATA • However this may change • Brown v Plata – U.S. Supreme Court found in 2011 that the California Department of Corrections and Rehabilitation must reduce their overcrowded prison populationto 137.5% of the institutions’ combined design capacity (a reduction of 46,000 inmates statewide) by June 2013.

  9. BROWN v PLATA • When there is pressure, judicial and or financial, to reduce overcrowding, incarcerated persons who are believed to be among those least likely to recidivate and pose the least amount of danger to the community are those typically chosen for release. • Persons with SMI have been identified as falling into that category in this instance.

  10. LIMITS ON CRIMINALIZATION • Persons with SMI will no doubt be released • This can only lead to limiting the number of persons with SMI in our prison system. • Until now, jail and prison officials have not welcomed responsibility for SMI, but have been powerless to prevent it. • In the foreseeable future, the criminal justice system may not remain the “system that can’t say no”.

  11. LIMITS ON CRIMINALIZATION • The release of SMI from jails and prisons as well as the reluctance to incarcerate them at the outset sends a clear message to the mental health community; namely, that we must accept responsibility for their care and treatment. • Is that not our mission-- to offer recovery oriented treatment to those persons with mental illness who are most in need.

  12. LIMITS ON CRIMINALIZATION • This may pressure the community mental health system to become more involved with these persons. • Many correctional facilities in the United States are experiencing serious overcrowding and budget constraints. • What happens in California as a result of Brown v Plata is being closely watched.

  13. STRUCTURE • Some persons with SMI need little if any structure. • Others, lack sufficient inner controls to cope even in supervised open settings, such as living with family or in a halfway house. • Without sufficient structure, they may decompensate, become homeless, hospitalized, or incarcerated.

  14. STRUCTURE • Sufficient support and structure have often been the missing ingredients for successful community treatment. • Shortage of intensive and effective community services, such as ACT, supervised housing, AOT, acute hospitalization, etc. • Thus, when persons with SMI commit a legal transgression, they are likely to be arrested.

  15. SMI & JAILS/PRISONS • Because of criminalization, it has often been left to the criminal justice system to provide the needed support and structure, as well as mental health treatment. • Despite the beliefs of many correctional officials’ that these persons should not be their responsibility, correctional institutions have no choice but to provide treatment.

  16. STATE HOSPITAL BEDS • In California in 2005, there were only 500 state hospital beds for non-forensic patients (1.5 beds per 100,000 population). • Before deinstitutionalization 339 per 100,000 • A recent study from the Treatment Advocacy Center indicates that the need is 50 long-term hospital beds per 100,000 population. • SMI in California jails and prisons is currently approx. 100 per 100,000 population.

  17. BARIERS TO TREATING SMI • Problems of access is a primary problem • For those who do not recognize they are mentally ill and also need more structure, barriers to treatment include • Shortage of mental health resources and funding generally • Not enough structured community housing • High cost of treatment modalities such as ACT

  18. BARIERS TO TREATING SMI • Belief by many that hospital admission and involuntary treatment are seldom necessary • Preference on the part of most treatment staff to work with persons who are treatment adherent and who do not tend to be violent

  19. STUDY IN AN URBAN COUNTY JAIL • Retrospective study of a random sample of 104 male inmates who were identified as mentally ill and placed in a 1,500 jail bed unit set aside for this population. • We ascertained: • Their demographics, diagnoses, and psychiatric and legal histories. • Psychiatric services they used while incarcerated.

  20. SOURCES OF DATA • The subjects’ current charge, circumstances of the arrest, treatment in jail and the court’s disposition were obtained from the jail psychiatric records. • Past mental health treatment was obtained from the Los Angeles County Department of Mental Health, Management Information System. • Arrests and convictions were obtained from the Consolidated Criminal History Reporting System provided by the State.

  21. FINDINGS • 80% of the sample had a diagnosis of serious mental illness (schizophrenic disorder, schizoaffective disorder, bipolar disorder, major depressive disorder with psychotic features). Of this 80%: • 76% of those with a serious mental illness required acute psychiatric inpatient treatment, given in the jail, for part of their time in jail.

  22. ACUTE PSYCHIATRIC INPATIENT TREATMENT • Clearly, a large number of people with severe mental illness are receiving their acute psychiatric inpatienttreatment in the criminal justice system rather than the mental health system. • In most cases, this should be the responsibility of the mental health system. • Acute inpatient beds must be a high priority, and lengths of stay should not be unreasonably short.

  23. ACUTE PSYCHIATRIC INPATIENT TREATMENT • If there were enough acute inpatient beds • Many acutely psychotic persons might not come to the attention of law enforcement. • Or if they did, could be transported and admitted to acute psychiatric facilities rather than arrested. • Jail generally not a therapeutic milieu • Acute psychiatric inpatient treatment should be the responsibility of the mental health system.

  24. DIVERSION • Prebooking Diversion - Crisis Intervention Teams (CIT) - mobile crisis teams of specially trained police officers in conjunction with families and consumers • Postbooking Diversion • Mental Health Courts - for mentally ill defendants • nonadversarial team of professionals • linked to mental health system for treatment • may involve sanctions by the court for nonadherence

  25. WHAT IS NEEDED? • Persons with SMI who need but are resistant to treatment may require high degrees of structure. • Thus they need: • assertive community treatment (ACT) • intensive case management • Increased access to appropriately structured housing

  26. WHAT IS NEEDED? • Professionals who have the ability to work with and support family members • Cognitive Behavioral Therapy • co-occurring SMI and substance abuse treatment • for some, assisted outpatient treatment combined with ACT • adequate number of community crisis and acute inpatient psychiatric beds.

  27. WHAT IS NEEDED? • The Mental Health System needs to give high priority in both funding and effort to persons who are at risk of becoming criminalized.

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