In 1975 the Supreme Court dealt a final blow to a broken state hospital system by severely restricting the ability of government to confine citizens involuntarily simply for being mentally ill.
Four decades later, there are few mental health experts who would argue that the deinstitutionalization movement was wrong in principle. But most now acknowledge that the shortsighted reforms of the 1960s and 1970s – and the corresponding lack of community support and investment – was a recipe for disaster that funneled tens of thousands of Americans who lived in deplorable conditions in state psychiatric facilities to even more deplorable conditions in the nation’s jails and prisons.
“If you set out to design the absolute most expensive and worst way to address mental illness you would do it in a jail setting,” said John Snook, executive director of the Treatment Advocacy Center (TAC).
Snook spoke during a panel discussion yesterday at the National Criminal Justice Association conference in Philadelphia that focused on innovative strategies for addressing what by all accounts is a runaway public health crisis.
“This a problem that is rapidly increasing and we are only just getting a handle on it,” he said. ”and if we don’t solve it we are going to look back in 20 years and wonder how things got so bad.”
It’s estimated that roughly 1.5 million people with severe psychiatric conditions are arrested every year, and that more than 350,000 of them are currently languishing in the nation’s jails and prisons.
State prisons and county jails house ten times more mentally ill Americans than state psychiatric hospitals, according to a report released last month by TAC, and the total number of inmates suffering from mental illness continues to grow.
Many were arrested for minor offenses, and are housed in conditions that are medically unsound while placing a severe financial burden on the municipalities tasked with caring for them.
With the support of the Bureau of Justice Assistance, researchers and policy makers are beginning to identify early intervention strategies that can identify at-risk individuals before they are arrested and provide a continuum of care.
“You get the biggest bang for your buck if you intervene early,” said Dr. Mark Munetz, a professor of psychiatry at Northeast Ohio Medical University and a pioneer of crisis intervention research.
Munetz has spent more than a decade promoting his “Sequential Intercept Model” – a tiered-based system that qualifies different stages of potential intervention for diverting mentally ill individuals away from the criminal justice system.
“Ideally the primary intercept is the mental health system, which unfortunately in most communities isn’t adequate,” said Munetz.
Instead, it frequently falls on law enforcement to pick up where social service fails.
According to Munetz, police officers estimate that from five-ten percent of the calls they respond to involve a person or persons with mental illness. He developed the first Crisis Intervention Team training program in Ohio to give cops the tools they need to identify at-risk offenders.
In May 2015, the Council of State Governments and the American Psychiatric Association launched the Stepping Up Initiative encouraging local authorities to intervene before the situation reaches a crisis level. To date, 293 counties have joined the program.
A bill sponsored by Sen. Al Franken (D-MN) would further codify this model. The Comprehensive Justice and Mental Health Act would require mental health and criminal justice stakeholders to develop “a shared understanding of the flow of individuals with mental illnesses through the criminal justice system, and identify opportunities for improved responses, including emergency and crisis services, specialized police-based responses.”
Research suggests that this could be accomplished by focusing on a relatively small number of “high utilizers” who cycle in and out of the criminal justice system at rates as high as 10 times other inmates.
A study of inmates at Rikers Island released in 2013 identified 800 so called “hot spotters” who accounted for nearly 19,000 total admissions to the jail over the prior five years. These inmates exhibited higher rates of mental illness, homelessness and substance abuse issues, and cost the city of New York $129 million in custody and health care costs – three times more than the general population.
“If we just hire a doctor for each of these people it would be cheaper,” said Lynn Overmann – a member of the Obama administration who advises on the role of technology in criminal justice – who joined Snook on the panel.
Thanks to outdated technology and a lack of uniformity in reporting, however, researchers still struggle to get a handle on the full scope of the crisis. Part of the problem is a lack of information sharing among multiple networks – hospitals, jails, social service and law enforcement agencies – that together are tasked with providing a safety net for vulnerable populations.
“How many people with serious mental illness are in jail or prison right now? Most jails and prisons can’t tell us,” said Overmann.
“It’s not because they don’t have the data, they just don’t know how to translate it. If we are really going to be effective linking people with service we need to get better at documenting and we need metrics.”
Christopher Moraff is a freelance writer based in Philadelphia. He welcomes readers comments.