The 'Revolving Door' for the Justice-Involved Mentally Ill


Recent developments in Minnesota's mental health and criminal justice policy are worth watching. They've brought law enforcement authorities, mental health advocates and state legislators to the same table to address the increasing number of individuals with mental illness who are involved in the criminal justice system.

State Sen. Barb Goodwin has received broad support for her proposal last month to build three 16-bed diversion facilities, at a cost of $5.5 million, that will offer short-term stays for individuals with mental illness. The facilities are intended to provide evaluation services and “immediate treatment” for persons taken into police custody.

The proposal addresses a chronic problem. The scarcity of psychiatric crisis beds has frequently forced officers to transport individuals hundreds of miles away for evaluation—often after the individual has already spent many hours waiting in a hospital emergency department for an assessment by a mental health professional and then locating a hospital bed somewhere in the system.

Now local law enforcement will have options other than “jail, the ER, or nothing,” Hennepin County Judge Dan Quam, a supporter of the proposal, told the local press.

The problem extends well beyond Minnesota. Frequently, individuals with mental illness who become involved with the justice system are ensnared in a “revolving door.” They are shunted between ER assessments, arrests and short- term stays in psychiatric units and jails. The result: inconsistent access and engagement with the mental health system.

The Minnesota pre-jail diversion concept provides an alternative by offering officers a different route to ensure access to mental health treatment for those who need it.

Sue Abderholden, the executive director of the Minnesota branch of the National Alliance on Mental Illness (NAMI) has made the case that state funds are best targeted to increasing crisis beds in psychiatric facilities and establishing more mobile mental health crisis teams that can respond, in collaboration with local law enforcement, to psychiatric crises.

Building on the existing treatment infrastructure, NAMI and other supporters of the Minnesota proposal argue, is the most viable strategy—rather than creating another component of the revolving-door system.

Minnesota's proposal indicates that changes in existing infrastructure which incorporate evidence-based practices has the potential to produce results, particularly when those changes are developed in collaboration with all the system stakeholders, including law enforcement, mental health providers, advocacy groups, and legislators.

But reform should not stop there. As a former mental health professional with clinical experience with justice-involved consumers in institutional and community settings, I would also like to highlight some other issues that need to be addressed at the same time.

First, these policy discussions assume that the majority of individuals with severe mental illness are present in the criminal justice system because of an inadequately funded mental health system, and because law enforcement officers have no other options but to take individuals to jail when displaying symptoms in the community.

This “criminalization of mental illness” model of explaining the prevalence of psychiatric disorders in incarcerated populations has generally dominated public discourse over the last several years. It's the position taken by the Minnesota NAMI. Undoubtedly, many experiences of individuals with severe mental illness and criminal justice involvement fit within this model.

However, my own research suggests that this population of “mentally ill offenders” is a heterogeneous group and clinically complex. That is, they display a number of factors that contribute to their incarceration, such as co-occurring substance abuse disorders as well as criminogenic risk factors, including anti-social behaviors.

Other recent research recommends re-examining the universal application of the “criminalization of mental illness” model. Substance abuse disorders and risk factors must be concurrently addressed to decrease the involvement of individuals with mental illness in the criminal justice system. According to a 2008 paper entitled “Disengagement from Mental Health Services,” these individual-level clinical factors, in conjunction with environmental factors such as homelessness, also increase the risks of disengagement from community treatment.

Clearly, decreasing the number of individuals with mental illness in the criminal justice system will not be resolved by a single magic-bullet solution such as increasing crisis beds or jail diversion centers. This complex issue is compounded by the intersection of a population that is clinically challenging to treat within two large public sector systems with overlapping—but often contradictory—goals.

A critical component of implementing evidence-based treatments is tailoring the treatment to the intended population's treatment needs.

If substance abuse treatment needs and criminogenic risk factors are not concurrently addressed in community treatment systems, increased crisis beds, mobile crisis teams, or diversion centers will not impact the numbers of individuals with mental illness in the criminal justice system.

If evidence-based treatment engagement strategies are not utilized by local mental health systems for hard-to-reach, vulnerable populations, then there may be high rates of treatment disengagement and discontinuity. If substance abuse treatment is not integrated within community mental health services, then individuals' treatment needs are only being partly addressed. If criminogenic risk factors are not assessed and treated, then these factors may continue to drive incarceration rates.

The emerging conversation among criminal justice practitioners, mental health advocates and state legislators in Minnesota points the way forward. It's reasonable to assume that the proposed diversion centers will decrease the numbers of individuals with mental illness taken to jail when no other options are in sight for local officers. And increasing services such as mobile crisis units may further strengthen the established treatment infrastructure.

However, these conversations also need to focus on individual clinical outcomes, such as increasing rates of treatment engagement and increasing quality of life. The tools are out there, but we need to implement these clinical treatments at the same time as we implement system-wide changes.

Without a concurrent focus on this population's complex needs, the consequences of the lack of effective treatment get lost within these policy debates.

Joseph Galanek, PhD, MPH, is a Research Associate at the Begun Center for Violence Prevention Research & Education at Case Western Reserve University's Jack, Joseph, and Morton Mandel School of Applied Social Sciences. Dr. Galanek's research and evaluation activities have been funded by the National Science Foundation, the National Institute of Mental Health, and the Ohio Department of Mental Health. He welcomes your comments.

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