Implications in the Criminalization of the Mentally Ill
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Transcript Implications in the Criminalization of the Mentally Ill
Policy, Practice and Perception:
Implications in the Criminalization
of the Mentally Ill
SAKS INSTITUTE FOR MENTAL HEALTH LAW
SPRING SYMPOSIUM: CRIMINALIZATION OF
THE MENTALLY ILL
STEPHEN MAYBERG, PhD
APRIL 11, 2013
Criminalization of the Mentally Ill
New trends or long term problem
Contributory factors
Perceptions/Public Policy
Promising alternatives
Policy Issues
Realignment CA Mental Health 1991
Funding/Responsibility shift
State to county responsibility/authority
State Hospital Population
Civil Commitments/LPS
Forensic
Commitments
1991
3300
600
2012
550
6000
Policy Impact: Realignment
Financial Incentives
County choice/flexibility
State pays for forensic care
State hospital beds
County pays LPS
State pays – NGI, IST, MDO, SVP
IST Costs
Counties – Misdemeanors
State - Felony
Resource Issues
County mental health allocation insufficient for all
services
Limited long term care available
Declining state hospital beds
24 hour acute care
Short term – Crisis use
Average stay less than 7 days
Follow up capabilities inconsistent
Responsibility and resources
National Policy Trends
Community Care vs. Institutional Care
Declining state hospital beds
State hospitals/ IMD’s – no 3rd party payment
Court decisions stressing communities instead and
community programs
Policy Decisions - Funding
MediCal (Medi-Caid) not available for single adults
(forensic population)
State hospitals, IMDs, jails, prisons mental health
services not reimbursable
Loss of MediCal eligibility in jail and juvenile hall
100% county (or state) cost for forensic services
No federal participation
Program Development Practice/Policy
Incentive to develop programs is in areas where
monies can be leveraged
Law enforcement more likely to be funded at local
level with county dollars
Public Safety
Politically more acceptable
Liability/Public Perception
Local mental health programs concerns about
responsibility for forensic patients
ADVERSE EVENTS
Media coverage – “Blame”
Torts/liability
Local political pressures
Accountability/responsibility
Liability Perception Impact
Conditional Release from Parole for Mentally Ill
Inmates (CONREP)
Extensive Service/Treatment Array – 100% state
funded
Counties have right at first refusal
Very few counties participate
Consequence: lack of coordination with local
programs
Conflict About Responsibility for Care
Parole outpatient versus county mental health
Screening, evaluation, and recommendations
Probation vs. County Mental Health
Who should provide/pay for service
Conflict
Voluntary vs. Involuntary treatment
LPS Law variably implemented
“Fungible” definition of WI 5150
Police vs. First Responders
Jail vs. hospitals
Can reflect lack of clarity
Impact training, resources, responsibilities
Laura’s Law – Outpatient commitment
Only 1 county has implemented
Accountability
Who is accountable/responsible
Lack of clarity
“fall between cracks”
Conflicting laws/standards
Welfare and institution code vs. penal code
Court Decisions Impact
Sell – U.S. Supreme court rules IST’s cannot be
involuntarily medicated without criteria/hearing
Jameson vs. Farabee – California Courts – inmates
cannot be forcibly medicated without hearing
Consequence – decompensation
Barriers complicate ability to treat
IST Process
Incentives for state hospital treatment vs. jail
Reduces jail census, jail treatment cost, court time
Incentive – Defense attorneys/inmates: hospital
better than jail environment
Credit time served – hospital in lieu of jail
Medication in jail usually cannot be involuntary
Consequence: Disconnected system
Revolving door
Impact
Inadequate or insufficient treatment resources
available in 24 hour institutions
Mentally ill in jail/prison opt to not get treatment
Recidivism common
Mentally ill parolees most likely to be revoked/reoffend
Other Contributory Factors
Substance Abuse
70% SI Adults have substance abuse issues
90% forensic mentally ill have co occurring diagnosis
Drug Use/Possession
Illegal – Criminal Justice Contact
Substance Abuse Behavior
Impulsive, lower frustration tolerance, aggression
Consequence: Untreated Substance Abuse
More likely to become part of system
Contributory Factors
Vacaville Mental Health Study
Evaluations on consecutive admissions over two time periods
Findings
Average IQ - low to low average
Education – 8th grade
Social Economic Status (SES) -low
Brain Injuries – 65%
Fighting, Falls, Drug Use
Vacaville Continued
Employment marginal
Family History– more apt to be single, disengaged
from family
History of violence
Consequence: Complex factors must be addressed to
prevent criminal behavior
Policy Implications for Treatment
Cognitive/Outpatient treatment may not be effective
Structured environment may be required
Coordination of substance abuse/mental health
treatment essential
Educational/Vocational programs integral part of
approach
Contributory Factors: Homelessness
Substance use/Mental illness
Hostile living environment
Crimes of opportunity/Quality of life crimes
High visibility
Lack of coordinated resources or responsibility
Contributory Factors: Stigma
Failure to access treatment because of stigma
Perception of nexus of violence and mental illness
Media sensationalism
Blame
NRA - Monsters
Contributory Factors: Public Perception
Perception: community safer with individuals locked
up rather than treated in outpatient or in the
community
NIMBY issues for community program placement
Elected officials tend to fund programs that lock up
or promise “public safety” before funding community
programs
Public Perception Continued
Tolerance/Expectations
Parolee “Acting out” vs. Mentally Ill
Differential response from press, media, community
Funding for Control Agencies (Law Enforcement) rather than
treatment programs
Prison realignment experience -AB 109
Summary of Issues - Responsibility
State vs. Local
Law Enforcement vs. Mental Health
Mental health vs. Substance Abuse
“No One”
Summary of Issues - Finance
Insufficient funds for mental health/substance abuse
treatment
No Federal dollars (MediCal) available for treatment
of most forensic populations
Incentive in construction of laws/regulations for
state to pay rather than counties for forensic
populations
Paradox: Counties responsible and funded for rest of
MH system a disconnect
Priority funding for Law Enforcement vs. Mental
Health when monies are available
Summary of Issues – Stigma
Perception: individual concerns inhibits treatment
seeking behavior
Perception: public concerns of stereotypes of
mentally ill
Mental illness and violence
Perception: community concerns, 24 hour care is
“safer” than community treatment
Fear of Violence/unpredictability consistent and
reinforced by media
Summary – Lack of Resources
Limited long term or structured care
Lack of specialty trained professionals
Lack of specific programs addressing unique needs
of this population
Lack of 3rd party participation
CONSEQUENCE
Jails/Prisons have become our defacto mental health
treatment programs
Summary – Legal System
Involuntary medication difficult
Involuntary commitments difficult
Legal system may encourage accepting charges
rather than treatment
Criminal Justice system not always well informed
about mental illness and options
Administrative Office of Court Findings
Promising Practices/Opportunities
Policies that work
Programs that work
Potential opportunities
Programs that Work
AB 34/2034 Steinberg
Homeless Mental Health Services
Significant reduction in hospital days
Significant reduction in jail days, arrests
Cost effective – 50% reduction in costs
Defined responsibility, broad based approach
Promising Programs (Con’t)
Law Enforcement Training/Partnership
CIT (Crisis Intervention Training) for Law Enforcement
Smart/PET teams
Mobile Crisis
Promising Program (con’t)
Court/Criminal Justice Involvement
Mental health/behavioral health court
Drug courts
Diversion
MIOCR programs
Policy that Works
24/7 Mental Health availability in crisis
Point of contact responsibility
Crisis training/consultation
Co-Occurring programs
Violence programs
Bullying
Domestic violence
Anger management
Trauma based approaches
Policy that Works (Con’t)
Mental Health Services in Jails/Prisons
Connected with community programs
Screening/case management
Dedicated trained staff
Policy that Works (Con’t)
Stigma Reduction
Media education
Court/Law enforcement education
Public education/awareness
Advocacy Involvement
NAMI
Strong advocacy for recognition/treatment alternatives
Client Groups
Peer Support/Self help
Promoting less stigmatizing alternatives
Best Practices/Opportunities
Proposition 63/Mental Health Service Act
Target At-Risk Populations
Los Angeles County Mental Health examples
Cultural Competence Outreach
Urgent Care
24/7 Full Service Partnership (FSP)
Homeless programs
Los Angeles Mental Health
Community Partnerships
Early Intervention programs/Prevention
Stigma reduction programs
Jail programs
Best Practice/Opportunities
Co-Occurring Programs
Specific programs designed for mentally ill/substance abuse
forensic patients
PROTOTYPES as example
Target population
Broad array services
CONREP
Recidivism less than 10%
Opportunies
Health Care Reform
Parity for Mental Health/Substance Abuse now required
Reduces Stigma
Expands access
Expanded eligibility
3rd party payment for uninsured population
Incentives for treatment
Opportunities (Con’t)
Prison Realignment AB 109
New dollars for criminal justice system approaches
Local decision making
Role of prevention, diversion, and treatment
Opportunities (Con’t)
Utilization of Research finding
Program success rates
Cost Reduction Data
Return on Investment (ROI)