Mental Illness and the Criminal Justice System: History, Effects of Incarceration, and the Criminal Justice Response
The traditional criminal justice model seems to be an ineffective method of preventing recidivism amongst individuals suffering from mental disorder; in fact, incarceration can be particularly injurious to these individuals. Correctional facilities are ill-suited to treat severely disordered individuals, but are being forced to do so, which causes strain on the criminal justice system. Crisis intervention teams, mental health courts, and community-based treatment are alternative criminal justice response methods that could potentially serve to divert mentally ill individuals from entering and/or reentering the criminal justice system. This is important as criminalization of individuals with mental illness can exacerbate preexisting mental health issues. Further research is needed to assess and improve the effectiveness of these strategies. However, a shift from punishment to treatment is necessary in order to alleviate strain on the criminal justice system and help individuals in need of mental health treatment.
On June 14th, 2014, two officers fatally shot Jason Harrison in his driveway in Dallas, Texas. The Dallas police officers were responding to a call from Harrison’s mother asking for help with her son who suffered from schizophrenia. The police arrived at the mother’s home and after a brief exchange, the officers shot and killed Harrison who was holding nothing but a screwdriver (McLaughlin, 2015). Unfortunately, it is not a rare occurrence that a police encounter with a mentally disturbed individual turns violent, or even deadly. In fact, according to a recent Washington Post investigation, 124 of the 462 people who were fatally shot by police this year suffered from some type of mental illness (Lowry et al., 2015).
When an interaction between police and an individual with mental illness does not result in the deadly use of force, it often leads to incarceration and criminalization. According to Vogel and his colleagues (2014), an estimated 20 percent of prison inmates and 21 percent of jail inmates suffer from mental illness. These numbers have increased since the creation of the Community Mental Health Act in 1963, which marked the beginning of deinstitutionalization. While community-based treatment may in some cases be a better alternative to institutionalization, the new focus led to decreased funding toward state mental health hospitals, and left many without proper treatment. Consequently, these individuals often became homeless, and eventually ended up in emergency rooms or jails (Vogel, Stephens, & Siebels, 2014).
Today, the number of people with mental illness who come into contact with the criminal justice system is at an all-time high, which is problematic for several reasons. The increased presence of mental illness in correctional institutions produces a financial strain on the system. Moreover, prisons are often not equipped to treat people with mental illness, or provide necessary services. Of even greater concern are the negative effects of incarceration: the jail or prison environment can add to or aggravate mental health issues. Because of these concerns, and their increased relevancy, it is important to consider alternative strategies to effectively handle mental illness in the criminal justice system. Some potential alternatives that focus on intervention and treatment include implementation of crisis intervention teams to train police and connect individuals to resources and services; mental health courts, which refer individuals to appropriate programs; and, specialized treatment and reentry programs that help keep individuals from reentering the system (Heilbrun et al., 2012).
This paper will examine the intersection of mental illness and the criminal justice system. First, historical development of the treatment of individuals with mental illness within the United States, with special focus on deinstitutionalization, will be presented. Next, the effects of criminalization and incarceration on individuals who suffer from mental illness will be considered. The traditional criminal justice responses to individuals with mental illness, and potential alternatives to these methods, such as the use of crisis intervention programs within police departments, will subsequently be analyzed. Finally, policy implications and suggestions for future research will be discussed.
Historical Development of the Criminal Justice Response to Mental Illness
Historically, individuals suffering from mental illness have been subjected to less than humane treatment by society. Before the 18th century, mental disorder was considered a demonic or supernatural infliction, and was treated as such. During the 18th century, in the best-case scenario, those with mental illness were viewed as defective or deficient, placed in madhouses, workhouses, or jails, and subjected to harsh treatment and torture. Severely inflicted individuals were often killed or exiled (Vogel et al., 2014).
In response to these heinous methods, reformists proposed more “humane” treatment of the mentally ill which led to the establishment of insane asylums. Asylums began to sprout up around the United States and by the early 1900’s, approximately 140,000 people were receiving treatment in asylum facilities. However, humane intentions quickly turned sour: as the number of individuals requiring care grew, facilities struggled to meet rising treatment needs. At the same time, the birth of psychiatry and mounting popularity of eugenics (i.e. the science of selective breeding to advance the human population) led to experimentation with psychiatric surgery. As a result, the mentally ill were among the first to be subjected to forced sterilization and lobotomization (Vogel et al., 2014).
Throughout the 20th century, other disturbing procedures were used to treat mental illness. For example, the insulin-coma involved using large doses of insulin to put the individual into a comatose state, which often resulted in permanent brain damage. The transorbital lobotomy was also introduced, which was a less complicated method of lobotomy that could be performed without anesthesia. This procedure often led to brain damage, which caused changes in personality and other disorders including seizures, incontinence, and catatonia, or abnormal movements and behaviors. These procedures were often performed within asylums, which were becoming increasingly overcrowded (Vogel et al., 2014).
Deinstitutionalization and Criminalization of Mental Illness
About midway into the 20th century, treatment of mental illness was transformed by the invention of psychotropic drugs, beginning with Thorazine, which was used to treat psychosis. Those living with mental illness could now be prescribed antipsychotic drugs to alleviate psychotic symptoms and continue to function in society. The creation of drugs to treat mental illness combined with overcrowded and despondent conditions of mental health facilities led to the creation of the Community Mental Health Act in 1963. Government funding was diverted from mental health facilities, and funneled into community-based treatments, leading to the closure of many facilities, a process referred to as deinstitutionalization. While community-based treatment and prescription drugs were beneficial alternatives for some individuals, those with severe mental illness and a need for hospitalization were often left without appropriate treatment options. Without necessary care, these individuals often ended up homeless, and eventually found themselves in emergency rooms or jails (Vogel et al., 2014).
Thus, deinstitutionalization led to increased contact between the criminal justice system and individuals with mental illness. Without the proper facilities, training, or resources, correctional facilities became increasingly responsible for managing inmates with mental illness. Because these individuals were not receiving adequate treatment, recidivism was very common. Consequently, a cycle was created, and criminalization of mental illness emerged (Shelden et al., 2016, p. 243).
Consequences of Criminalization and Incarceration
Criminalization and increased incarceration of individuals with mental illness has many consequences for both the individual and the criminal justice system. Mentally ill inmates are especially vulnerable to violent and sexual victimization in jails and prisons. Without proper treatment and medication, those with mental illness are more likely to violate jail and prison rules, which could lead to longer sentences and less possibility of early release or parole. Furthermore, once released, individuals with mental illness have higher rates of recidivism, and are therefore more likely to return to jail or prison (Gur, 2010).
The correctional environment can often contribute to and aggravate mental illness: inmates are removed from any outside social support networks, and placed in conditions of overcrowding and disease. Furthermore, mentally ill inmates are often placed in solitary confinement, and are more likely to be subjected to harsh management techniques, such as physical restraint. Additionally, mentally ill inmates are at greater risk of becoming victims of physical or sexual violence (Vogel et al., 2014).
One study by Blitz, Wolff, and Shi (2008) attempts to shed light on the issue of physical victimization in prisons by comparing rates of victimization for those with a mental disorder to those without a mental disorder. The researchers drew a sample of 7785 inmates (7221 men and 564 women) from 14 U.S. prisons. The participants completed a self-report computer-administered survey about their experiences with victimization while incarcerated. The participants were asked about victimization by other inmates as well as prison staff, and whether the participant had previously been treated for a mental disorder. The study revealed higher rates of victimization for both male and female inmates with mental disorders. More specifically, males were 1.6 times (inmate-on-inmate) and 1.2 times (staff-on-inmate) more likely to be victimized than male inmates without mental illness, and females were 1.7 times more likely to be victimized by other inmates than female inmates without mental illness. Based on these findings, the authors suggest that mental illness is a significant factor for prison victimization.
Mentally ill inmates also cause a strain on the criminal justice system and correctional institutions. In fact, according to a recent report by the Treatment Advocacy Center (2014), the cost of incarcerating mentally ill inmates can be considerably higher than that of inmates without mental illness. For example, Florida’s Broward County Jail reports $130 versus $80 (a difference of $70) a day to detain mentally ill inmates compared to inmates without mental illness. One Washington State prison that contains a special psychiatric unit of 500 inmates, reports an annual cost of $101,653 compared to just $30,000 for other inmates (Torrey et al., 2014).
Prisons and jails have become responsible for mental health treatment; a responsibility that many correctional facilities are ill equipped to address. Jail and prison staff members lack the education, training, and resources needed to properly fulfill the needs of an individual suffering from mental illness. Based on this, it is critical to investigate the benefits of alternative programs for mentally ill individuals that would not only be better suited to address the treatment needs of these individuals, but also alleviate financial strain on the criminal justice system and correctional institutions (Gur, 2010).
The Criminal Justice Response
Individuals with mental illness suffer serious consequences as a result of criminalization. Therefore, it is important to consider the criminal justice response that takes place when these individuals come into contact with the law. According to DeMatteo, et al. (2013), it has become increasingly clear that the standard criminal justice response is not an appropriate or effective approach to addressing the special needs of individuals with mental illness. Based on findings related to the negative effects of incarceration and criminalization on mentally ill individuals, it is important to consider alternative responses that specifically aim to address the unique needs of individuals with mental illness. Several alternatives that could potentially serve to address these special needs, including crisis intervention teams, mental health courts, and community-based treatment, are discussed below (Vogel et al., 2014).
Crisis Intervention Teams
Law enforcement officers are typically the first point of contact when an individual becomes involved with the criminal justice system. This is the first stage of the process where an individual with mental illness could potentially be diverted from entering the criminal justice system. At this stage, diversion can occur through the utilization of crisis intervention teams (CITs). CIT programs involve training dispatchers and police officers to recognize and respond appropriately to situations involving individuals with mental illness. For example, dispatchers with CIT training might send officers who are also CIT trained to a call involving a possibly mentally ill individual. That officer could then respond to the situation by connecting them to treatment services instead of making an arrest. CIT training ultimately aims to reduce response times to crisis situations involving individuals suffering from mental illness, provide better treatment and care of individuals with special needs, and increase safety of officers and offenders (DeMatteo et al., 2012).
One study by Tyuse (2012) examines the effectiveness of using CIT’s to deescalate encounters between police officers and individuals with mental illness, and divert these individuals to treatment rather than detention. To do this, Tyuse examined 5,623 CIT reports completed by CIT officers between 2005 and 2009 that involved (1) individuals currently experiencing or having a history of severe mental illness, and (2) a suicidal attempt or threat. Through this study, Tyuse found that officers with CIT training were significantly likely to divert individuals with mental illness to treatment rather than make an arrest, especially when suicidal threat was present.
Tyuse suggests that the findings of this study can be attributed to several factors related to crisis intervention training including, CIT officers’ increased knowledge of issues related to mental illness and local mental health resources; and, improved communication between CIT trained officers, CIT trained dispatchers, and hospital employees. While further research is warranted to understand the most effective methods related to CIT programs, these findings suggest that CIT training is critical to providing first responders with the necessary skills and knowledge required to effectively deescalate and minimize risk during an encounter with an individual in a mental health crisis. Furthermore, officers trained in crisis intervention are more likely to connect these individuals with resources and treatment instead of resorting to arrest.
Mental Health Courts
Mental health courts (MHCs) are becoming increasingly popular in various jurisdictions across the United States as a method to handle cases that involve mentally ill offenders. The purpose of these specialty courts is to divert offenders from correctional facilities, and direct them to community-based treatments. Community-based programs often involve various services including, “…housing, substance abuse treatment, traditional medical services, and psychological counseling” (Shelden et al., 2016, p. 195).
Several studies have been conducted to assess the effectiveness of MHCs in reducing recidivism rates among mentally ill offenders. One such study by Sarteschi, Vaughn, and Kim (2011) involves a meta-analytic review of 18 MHC studies in July, 2009. The results of this research yielded a significant mean effect size for recidivism of -0.54. This finding suggests that MHCs may be moderately effective in reducing recidivism. However, the researchers note: an important limitation to MHC research that warrants further investigation is the potential presence of gender and race bias. Previous research suggests that white males and females are more likely to be diverted to MHCs than minority offenders with mental illness. This pattern was revealed in their analysis, with most studies consisting of over 50% white MHC participants. Despite this and other limitations, Sarteschi and colleagues argue that MHCs are likely an effective intervention. This may largely be attributed to MHCs’ focus on rehabilitation rather than incarceration, which has been shown to be especially detrimental for individuals suffering from mental illness.
A subsequent study by Anestis and Carbonell (2014) attempts to address issues of sampling bias by comparing the outcome of individuals assigned to MHC and matched counterparts that had been assigned to traditional criminal court. Control variables included the offense, mental illness diagnosis, homelessness, and demographic information. The sample was taken from a court database and included 396 participants (198 assigned to MHC and 198 assigned to traditional court) who were followed for 12 months in order to observe reoffending outcomes. The study revealed superior recidivism results amongst those individuals who had been assigned to MHCs compared to those assigned to traditional criminal courts. The researchers argue that this finding suggests MHCs may be effective based simply on their role in keeping mentally ill offenders out of correctional institutions. Overall, this study supports the effectiveness of MHCs in reducing recidivism amongst offenders suffering from mental illness.
Community-based treatment is another specialized criminal justice response to managing mentally ill offenders more appropriately and effectively. Community-based programs are often recommended by mental health courts in order to deflect mentally ill offenders from incarceration. Post-arrest diversion could involve community treatment programs, residential programs, and inpatient or outpatient programs. An example of a post-arrest diversion program is assertive community treatment (ACT), which involves behavioral health services provided by a team of psychiatric and substance abuse professionals. Another example is intensive case management, which also provides behavioral health treatment but is generally less intensive than ACT programs (DeMatteo et al., 2012).
Criminal Justice diversion programs seek to identify and evaluate mentally ill individuals, and divert these individuals to community-based programs rather than incarceration. Research on the effectiveness of community-based treatment programs, such as ACT, to reduce recidivism amongst mentally ill offenders have yielded mixed results. Rotter and Carr (2011) argue that this can be attributed to the programs’ focus on meeting clinical needs of offenders, and the assumption that offending behavior is rooted in inadequate psychological treatment. In fact, Rotter and Carr posit that while mental health treatment is an important element in treating mentally ill offenders, it is critical to address the unique needs of mentally ill individuals engaging in criminal behavior. Thus, Rotter and Carr suggest that it is essential to structure clinical interventions to specifically target the, “…thoughts, feelings, and behaviors associated with criminal justice contact” (Rotter & Carr, 2011, p. 723). More specifically, treatment programs for mentally ill offenders should seek to treat substance abuse issues, facilitate educational and vocational opportunities, improve family support, and dissuade homelessness. Methods to address these special needs include integrated treatment, employment and education services, family therapy, and housing support.
In addition to providing targeted clinical services, Rotter and Carr discuss the potential for a modified form of cognitive-behavioral therapy (CBT) to be an effective method of reducing recidivism among mentally ill offenders. Traditional CBT aims to alleviate psychological symptoms by correcting dysfunctional thoughts that lead to problematic behavior. Thus, the ultimate goal is to address intra-personal issues to allow for improved feelings and functioning. Rotter and Carr argue that offending behavior and recidivism is primarily interpersonal in nature as opposed to intra-personal; therefore, traditional forms of CBT are ineffective in reducing recidivism amongst mentally ill offenders. Recidivism focused CBT that concentrates on improving interpersonal skills such as problem solving and moral reasoning, is likely to be a more effective method of reducing recidivism amongst offenders suffering from mental illness, and future research should seek to address this hypothesis.
The traditional criminal justice response to criminal behavior, which relies most heavily on incapacitation and deterrence, seems to be an ineffective method of addressing offending and preventing recidivism amongst individuals suffering from mental disorder; in fact, incarceration can be particularly injurious to these individuals. Mentally ill inmates experience higher rates of victimization by other inmates and correctional staff. They are also often subjected to harsher treatment and solitary confinement, which can aggravate mental illness. Correctional facilities are ill-suited to treat severely disordered individuals, but are being forced to do so, which causes strain on the criminal justice system
There are several alternatives to the traditional criminal justice response to individuals with mental illness who come into contact with the law that aim to address the specific needs of mentally ill offenders. Crisis intervention teams, mental health courts, and community-based treatment are three such alternatives that could potentially serve to divert mentally ill individuals from entering and/or reentering the criminal justice system. It is important to investigate these options as criminalization and incarceration of individuals with mental illness can exacerbate preexisting mental health issues. Further research is needed to assess and improve the effectiveness of these strategies; however, a shift from punishment to treatment is necessary in order to alleviate strain on the criminal justice system and help individuals in need of mental health treatment.
* Olivia Tuttle is a graduate student in the Department of Criminal Justice, University of Nevada- Las Vegas. This is a revision of a paper prepared for a course called "Seminar on the Administration of Justice."
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