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Making the case for treatment

July 13, 2009
by Kate K.V. Lawson, MPA; Michael R. Berren, PhD; and Neal Cash, MS
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Details on the interface between a local care system and the criminal justice system

The situation is not uncommon: A family member of an individual with a mental illness calls local law enforcement as a “last resort.” A situation has escalated to the point of being a crisis and, for everyone involved, it appears as though all other options have been exhausted. While the call is generally a last-ditch effort to ensure safety for the individual and/or others, law enforcement’s presence often results in the individual with a mental illness being arrested or detained.

In addition to this scenario, it is not unusual for individuals with a mental illness to become involved in the criminal justice system for crimes that often are a consequence of their illness and/or social situation (such as vagrancy because the individual often has nowhere else to go). They then must manage the difficult task of negotiating a complicated criminal justice system while attempting to reengage in treatment.

The criminalization of mental illness is hardly a new topic. It has been written about for decades, with an article by Abramson (1972) being one of the earliest.1 Following Abramson’s article have been hundreds of others addressing the issue of jails and prisons becoming primary housing facilities for individuals with mental illness. Not only is it a topic of concern for professional publications, the criminalization of people with mental illness regularly is addressed in the popular press. For example, a March 3 blog post on the Dallas Morning News Web site talked about a bill that would prevent local authorities from using “time and convenience” as reasons for incarcerating mental health patients.2

There are a myriad of reasons, however, why using the criminal justice system as a de facto mental health system is inappropriate, including the following.

• Jails and prisons are ill-equipped to serve as mental health facilities. Where statistics are available, inmates with mental illness have higher than average disciplinary rates. A study in Washington State found that while inmates with mental illness constituted nearly 19% of the state's prison population, they accounted for 41% of infractions.3 This leads to the additional issue of inmates with mental illness who have problems with controlling their behavior being disproportionately placed in solitary confinement. Furthermore, solitary confinement is particularly difficult for inmates with mental illness because of limited medical care and the psychologically harmful consequences of isolation and idleness.
• While in detention medications may be discontinued or changed, and the variety of case management, skill building, and clinical services will be limited or eliminated completely.
• Incarceration is an expensive alternative to treatment. While prison can cost quite a bit more, even incarceration at the Pima County (Arizona) jail can cost nearly $100 per day.
• Once an individual’s treatment has been interrupted by incarceration it can be difficult to reengage him/her in services, thereby adding to the long-term costs.
• In addition to the costs to taxpayers and adverse impact on the individual, it is unethical to use incarceration and prison as an alternative to treatment.

Our response
Given all of the reasons for not wanting to inappropriately incarcerate individuals with mental illness, the Community Partnership of Southern Arizona (CPSA) collaborated with its provider network and the criminal justice system to form the Behavioral Health/Criminal Justice System Workgroup. The workgroup’s first task was to identify systemic issues that led to inappropriate incarceration and/or inappropriate length of stay. Following the identification of issues the workgroup began to focus on the strategies and interventions that could be implemented to reduce the time that an individual with a mental illness is inappropriately incarcerated. That is not to say that incarceration is always inappropriate. There are a variety of circumstances in which incarceration might be appropriate to protect an individual from being a danger to him/herself or others, or serve as an intervention before more serious destabilization occurs. Furthermore, incarceration may become a “wake-up call” for the individual as to the consequences of not properly managing his/her illness.

One of the workgroup’s primary outcomes was creating the CPSA Criminal Justice Team, established to be a resource and link between the justice and treatment systems. The team works with behavioral healthcare provider agencies (each of which was mandated to employ a criminal justice specialist) and other stakeholders, such as courts, probation officers, pre-trial services, the jail, police departments, and attorneys, to facilitate resolutions of both system-wide and member-specific issues.

To have a positive impact on inappropriate incarceration, the collaborative relationship between the various behavioral healthcare and justice entities must allow for information to pass quickly and efficiently, while at the same time observing applicable HIPAA rules and regulations. Contrary to popular belief, HIPAA rules do not necessarily have to be a barrier for communication between criminal justice and behavioral healthcare agencies. Rather, it can provide tools to aid in cross-system information sharing.

For example, when an individual is detained in the jail, time is of the essence in transmitting critical behavioral healthcare information from the treatment provider in the community to the treatment provider in the jail. Failure to do so can result in further destabilization and crisis for the individual, thereby increasing risk of injury to the individual (including suicide), other inmates, and jail staff.