In a recent article, researchers from the University of South Florida correlated arrest rates with recent histories of involuntary commitment. They found that people who underwent an involuntary psychiatric evaluation were 12 percent more likely to be arrested in the three months after that evaluation than people who had not been involuntarily evaluated.
Significantly, they also noted that those who had been involuntarily evaluated were 20 percent more likely to be arrested for a felony offense than those who were not involuntarily evaluated.
What does this mean?
Those of us who urge treatment for people with mental illness as opposed to incarceration for criminal acts based in their mental illness should read this carefully.
First, because this was a retrospective study that used administrative data only, it should not be used to conclude that involuntary evaluations or treatment somehow cause later arrests. Rather, the strongest conclusion that can be drawn is that there is a correlation between involuntary evaluations and arrests for alleged criminal behaviors.
Secondly, the very nature of involuntary evaluations varies widely from place to place.
In Maryland, where I work, a person can be forced to undergo an emergency psychiatric evaluation if they present a danger to the life and safety of him or herself or others. This can be ordered by a court after taking testimony from people who know the individual, or it can be executed without court involvement by a clinician or a peace officer who have observed the dangerous behavior or threats.
In other states, the standards may differ (e.g. by the use of the word “imminent” or in other ways) and the mechanism by which an evaluation may be mandated may require more or less due process. Where I work, the balance struck is to get the person to a place of safety (an emergency room) first, and to impose due process requirements later. (The patient if admitted has the right to an administrative hearing within 10 days of admission.)
Third, and the main point: in the mental health world, we are tasked with a difficult balance between doing right by our patient (the fiduciary duty) and protecting the public (in a police-power sense). This is a difficult balance for many of us, who, after all, trained in psychiatry, psychology, nursing or social work to help people needing help.
And yet, sometimes, those people do not want our help, and in a few cases, risk harming themselves or others due to untreated or inadequately treated illness.
If the use of police power is designed to keep the patient and the public safe, what does this recent study tell us?
Seems to me that something is not working, if the use of that police power correlates with an increased risk of arrest rather than a decreased risk of arrest.
Sure, there are many contaminating factors:
What sort of treatment did the individuals get after the evaluation? Were they admitted to a hospital? For how long? What outpatient follow up did they have?
Could that outpatient follow up be mandated (a la outpatient commitment)?
But, in Florida at least, it appears to me that the public safety mission of public mental health is not working.
The authors suggest that because involuntary hospitalization no longer serves as a gateway to long-term care – and especially to long-term inpatient care – perhaps there is no longer a role for this intervention.
Further, they suggest that “it may be inadequate to think of diversion from only the criminal justice system; it may become necessary to think about diverting people from interventions historically thought to be therapeutic as well.”
This is a curious suggestion, going quite against the current grain whereby advocates argue strongly, and at times persuasively, for an increasing use and scope of involuntary interventions. Certainly, neither I nor, I suspect, the authors of this important study, would suggest that we simply do away with involuntary evaluations.
While the data is correlative only, it seems clear to me that there must have been some factor in the individuals who were subject to involuntary evaluation that led both to the involuntary evaluation and to the later arrest. In other words: a “selection bias”.
I present this article and analysis because I want to make those who read this aware of how complex these issues are.
There are people who suggest that “if only we had X, the problem would be solved.” But as my fellow Baltimorean H.L. Mencken is quoted as saying: “For every complex problem, there is a solution that is simple, neat, and wrong.”
The needs of people with serious mental illness are nothing if not a complex problem, for which any simple solution will be inadequate.
Erik Roskes, a regular blogger for The Crime Report, is a forensic psychiatrist and currently the Director of Forensic Services at the Springfield Hospital Center in Maryland. He welcomes readers comments. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes' employers or consultees, including the Maryland Department of Health and Mental Hygiene. He can be found at http://mysite.verizon.net/eroskes