Transcript SOCIAL CLASS AND MENTAL ILLNESS

REDUCING CRIMINALIZATION OF
PERSONS WITH SERIOUS
MENTAL ILLNESS
H. Richard Lamb, M.D.
August 18, 2012
A HETEROGENEOUS GROUP
• Persons with SMI (which is defined here as
schizophrenic disorder, schizoaffective disorder,
bipolar disorder, and major depressive disorder
with psychotic features) are a heterogeneous
group.
THE FIRST GROUP
• A very large percentage of persons with
SMI recognize they are mentally ill and
participate willingly in treatment.
• In most cases, they are able to live in the
community, are often productive in terms of
work, do not have a serious problem with
substance abuse, are not violent, and show
potential for recovery.
THE FIRST GROUP
• As a result of the very visible success this
group has had, much of the discussion in
treating persons with SMI has focused on
such individuals.
A SECOND GROUP
• On the other hand, there is a small but
significant minority of persons with SMI who
do not believe they are mentally ill.
• The result is resistance to psychiatric treatment
(including medications).
• Anosognosia, a biologically determined
inability to recognize that one is mentally ill.
• Linked to frontal lobe dysfunction.
A SECOND GROUP
• This minority of persons may have overt
psychotic symptoms, problems with
substance abuse, great difficulty interacting
appropriately with others, antisocial
tendencies and a tendency to become violent
when stressed.
• As a result, involvement with the criminal
justice system is likely.
THE TWO GROUPS
• Attention to the two groups varies significantly.
• The literature and practice tend to focus on the
first group and not the second group.
• Second group is not usually thought of when
developing the community treatment of SMI.
• This group is overlooked because so many,
(perhaps 350,000+/-) are out of sight in jails
and prisons.
BROWN v PLATA
• However this may change
• Brown v Plata – U.S. Supreme Court found
in 2011 that the California Department of
Corrections and Rehabilitation must reduce
their overcrowded prison population to
137.5% of the institutions’ combined design
capacity (a reduction of 46,000 inmates
statewide) by June 2013.
BROWN v PLATA
• When there is pressure, judicial and or
financial, to reduce overcrowding,
incarcerated persons who are believed to be
among those least likely to recidivate and pose
the least amount of danger to the community
are those typically chosen for release.
• Persons with SMI have been identified as
falling into that category in this instance.
LIMITS ON CRIMINALIZATION
• Persons with SMI will no doubt be released
• This can only lead to limiting the number of persons
with SMI in our prison system.
• Until now, jail and prison officials have not
welcomed responsibility for SMI, but have been
powerless to prevent it.
• In the foreseeable future, the criminal justice system
may not remain the “system that can’t say no”.
LIMITS ON CRIMINALIZATION
• The release of SMI from jails and prisons as
well as the reluctance to incarcerate them at
the outset sends a clear message to the
mental health community; namely, that we
must accept responsibility for their care and
treatment.
• Is that not our mission-- to offer recovery
oriented treatment to those persons with
mental illness who are most in need.
LIMITS ON CRIMINALIZATION
• This may pressure the community mental
health system to become more involved
with these persons.
• Many correctional facilities in the United
States are experiencing serious
overcrowding and budget constraints.
• What happens in California as a result of
Brown v Plata is being closely watched.
STRUCTURE
• Some persons with SMI need little if any
structure.
• Others, lack sufficient inner controls to cope
even in supervised open settings, such as living
with family or in a halfway house.
• Without sufficient structure, they may
decompensate, become homeless, hospitalized,
or incarcerated.
STRUCTURE
• Sufficient support and structure have often
been the missing ingredients for successful
community treatment.
• Shortage of intensive and effective community
services, such as ACT, supervised housing,
AOT, acute hospitalization, etc.
• Thus, when persons with SMI commit a legal
transgression, they are likely to be arrested.
SMI & JAILS/PRISONS
• Because of criminalization, it has often been
left to the criminal justice system to provide
the needed support and structure, as well as
mental health treatment.
• Despite the beliefs of many correctional
officials’ that these persons should not be
their responsibility, correctional institutions
have no choice but to provide treatment.
STATE HOSPITAL BEDS
• In California in 2005, there were only 500
state hospital beds for non-forensic patients
(1.5 beds per 100,000 population).
• Before deinstitutionalization 339 per 100,000
• A recent study from the Treatment Advocacy
Center indicates that the need is 50 long-term
hospital beds per 100,000 population.
• SMI in California jails and prisons is currently
approx. 100 per 100,000 population.
BARIERS TO TREATING SMI
• Problems of access is a primary problem
• For those who do not recognize they are mentally
ill and also need more structure, barriers to
treatment include
– Shortage of mental health resources and
funding generally
– Not enough structured community housing
– High cost of treatment modalities such as ACT
BARIERS TO TREATING SMI
– Belief by many that hospital admission
and involuntary treatment are seldom
necessary
– Preference on the part of most treatment
staff to work with persons who are
treatment adherent and who do not tend
to be violent
STUDY IN AN URBAN COUNTY JAIL
• Retrospective study of a random sample of
104 male inmates who were identified as
mentally ill and placed in a 1,500 jail bed
unit set aside for this population.
• We ascertained:
– Their demographics, diagnoses, and psychiatric
and legal histories.
– Psychiatric services they used while
incarcerated.
SOURCES OF DATA
• The subjects’ current charge, circumstances of the
arrest, treatment in jail and the court’s disposition
were obtained from the jail psychiatric records.
• Past mental health treatment was obtained from
the Los Angeles County Department of Mental
Health, Management Information System.
• Arrests and convictions were obtained from the
Consolidated Criminal History Reporting System
provided by the State.
FINDINGS
• 80% of the sample had a diagnosis of serious
mental illness (schizophrenic disorder,
schizoaffective disorder, bipolar disorder,
major depressive disorder with psychotic
features). Of this 80%:
• 76% of those with a serious mental illness
required acute psychiatric inpatient treatment,
given in the jail, for part of their time in jail.
ACUTE PSYCHIATRIC INPATIENT
TREATMENT
• Clearly, a large number of people with severe mental
illness are receiving their acute psychiatric inpatient
treatment in the criminal justice system rather than
the mental health system.
• In most cases, this should be the responsibility of the
mental health system.
– Acute inpatient beds must be a high priority, and
lengths of stay should not be unreasonably short.
ACUTE PSYCHIATRIC INPATIENT
TREATMENT
• If there were enough acute inpatient beds
– Many acutely psychotic persons might not come to
the attention of law enforcement.
– Or if they did, could be transported and admitted to
acute psychiatric facilities rather than arrested.
– Jail generally not a therapeutic milieu
– Acute psychiatric inpatient treatment should be the
responsibility of the mental health system.
DIVERSION
• Prebooking Diversion
- Crisis Intervention Teams (CIT) - mobile crisis teams
of specially trained police officers in conjunction with
families and consumers
• Postbooking Diversion
-
Mental Health Courts - for mentally ill defendants
nonadversarial team of professionals
linked to mental health system for treatment
may involve sanctions by the court for nonadherence
WHAT IS NEEDED?
• Persons with SMI who need but are resistant to
treatment may require high degrees of
structure.
• Thus they need:
– assertive community treatment (ACT)
– intensive case management
– Increased access to appropriately structured
housing
WHAT IS NEEDED?
– Professionals who have the ability to work with and
support family members
– Cognitive Behavioral Therapy
– co-occurring SMI and substance abuse treatment
– for some, assisted outpatient treatment combined
with ACT
– adequate number of community crisis and acute
inpatient psychiatric beds.
WHAT IS NEEDED?
• The Mental Health System needs to give
high priority in both funding and effort to
persons who are at risk of becoming
criminalized.