The Criminalization of the Mentally Ill: How Public Health is Failing to Protect the Vulnerable – Regina Ram
In the 1960s in the U.S., a movement began to remove the mentally ill from institutions and integrate them back into the community. The movement, termed deinstitutionalization, was fueled by reports of poor conditions in mental health hospitals, the availability of effective medicinal therapies for patients, and a more accepting societal view of the mentally ill. While deinstitutionalization was launched with the promise of community-based health services to provide care, the efflux of patients overwhelmed many of these existing supports and new centers never materialized due to lack of funding. Instead, in the relocation from hospitals to the community, many mentally ill were left homeless and without resources (1).
Since the 1960s, jails and prisons have been replacing mental health hospitals as the primary providers of psychiatric services for individuals with serious mental illness in the U.S.. The rate of mental illness among those incarcerated is three times higher than what is seen in the general population, and between 15% and 24% of U.S. inmates have a severe mental illness (2-3). About a third of American jails report incarcerating mentally ill people with no criminal charges. In many cases, these individuals are being held while awaiting psychiatric evaluation, the availability of a hospital bed, or transportation to a psychiatric hospital (4).
From a Social Sciences perspective, there are three major reasons why this approach to mental illness in the U.S. increases health and safety risks associated with psychiatric disorders. First, the mentally ill in jails and prisons are highly subject to physical, verbal, sexual and psychological abuse. Secondly, the mentally ill who are criminalized face a double stigma of being mentally ill and convicts, and have a harder time finding help when released into the community. Finally, those with mental illness face more repeat incarcerations and often are released from jails and prisons only to return again.
Once the mentally ill enter into the criminal justice system, they face abuse, victimization and stigma from other inmates (5). Non-ill inmates react violently towards the mentally ill, who behave abnormally due to illogical thinking, delusions, auditory hallucinations, and severe mood swings. In a 1992 survey of U.S. jails, 40% of jail officials reported that mentally ill inmates are abused by other inmates (6). While all inmates are at risk for attempted or actual rape, confused mentally ill inmates are more vulnerable and less able to defend themselves (2).
The mentally ill in jails and prisons are also subject to abuse from guards and other institutional authorities. Corrections officers in 84% of jails receive either no training or less than three hours training regarding people with severe mental illness (4). Attendants in correctional facilities do not know how to deal with mentally ill patients, and the mentally ill often cannot understand rules or follow orders (6). In many cases, guards view the mentally ill as disciplinary problems and use physical force to make them fall in line with the other inmates. In addition, claims of abuse by the mentally ill are not taken seriously and are largely ignored.
Poor mental health is exacerbated in these conditions, and suicide by inmates with schizophrenia or manic-depressive illness is common in jails and prisons. Data collected from New York State jails between 1977 and 1982 showed that half of all inmates who committed suicide had been previously hospitalized for treatment of a serious brain disorder (6). Suicidal tendencies are likely intensified by solitary confinement, which is often seen as a method of dealing with mentally ill patients who act out and are uncontrollable.
“Stigmatizing the Stigmatized”
Stigma, as defined by psychologist Erving Goffman, is the phenomenon by which an individual with an attribute that is deeply discredited by his or her society is rejected as a result of that attribute (7). It complicates treatment for the mentally ill, and can lead to help-seeking delay, underutilization and non-compliance (8). While many mentally ill individuals suffer from the stigma of having a mental illness, this particular population is also stigmatized as being convicts. Mentally ill inmates therefore face a double stigma in society, an experience which psychologist K. Anthony Edwards refers to as “stigmatizing the stigmatized” (5).
The double stigma association with this population is a major drawback created by criminalizing the mentally ill because it further impedes their access to community support. The mentally ill often find that even treatment is difficult to access due to their criminal histories. Being incarcerated and facing abuses within jails and prisons reinforces the stigma experienced by the mentally ill. Those exiting prison are handicapped by impaired social development and public reaction to their double stigma. There is evidence that mental illness stigma is stronger, as former mental patients are viewed less favorably than ex convicts (9-10).
It becomes a concern when the criminalized mentally ill seek jobs or try to assimilate back into the community, as their access to opportunities and resources is severely restricted. In one study, researcher Todd Callais argues that successful stigma management is the single most important determinant of success after leaving prison (11). The criminalized mentally ill who are assisted in dealing with the double stigma have better chances of contributing to society and staying out of the criminal justice system.
Recidivism Among the Mentally Ill
The lack of community support for the mentally ill often leads to recidivism, defined as a relapse into previous criminal behavior. One particular study focused on inmates in a large state prison and found that inmates with major psychiatric disorders (major depressive disorder, bipolar disorder, schizophrenia and non-schizophrenia psychotic disorders) had increased risks of multiple incarcerations over a 6-year period. Inmates with bipolar disorder were 3.3 times more likely to have had four or more previous incarcerations in comparison to non-ill inmates (3).
When mentally ill inmates are released, they are sent back into communities with no means of accessing Medicaid benefits, social disability payments or housing. The limited availability of community-based mental health services, the mass downsizing of state psychiatric institutions, and the limited capacity to discern mental health problems leaves many mentally ill people cycling between crisis hospitalization, homelessness, and the criminal justice system (3). It is often the case police officers and sheriff deputies become front line mental health workers in the community (11).
Many of the mentally ill who are in jails and prisons show higher resistance to psychiatric treatment when placed in the community. This is manifest in refusal of referrals, missing appointments, failure to adhere to medication regimens, and substance abuse. One psychologist attributes this resistance to anosognosia, a biologically based inability to recognize that one has a mental illness (12). In some cases, jails and prisons are they only place where the mentally ill receive care, however poor that care may be.
It is clear that the diversion of mentally ill into jails is in part caused by lack of other public health services. The movement of deinstitutionalizing the mentally ill has proved unsuccessful, and the lack of community support places released mental health inmates at a severe disadvantage. Incarcerating individuals with severe mental illnesses places a financial burden on correctional facilities, and it costs twice as much to treat the ill in jails and prisons as it would in assertive community treatment programs (4). Criminalizing the mentally ill works as a positive feedback system in supporting stigma and increasing mental illness rates.
There is an obvious failure to address the root causes of mental disorders while people are incarcerated. Correctional facilities have been established to deliver punishment and protect society, and more than one in five U.S. jails has no access to any kind of mental health services. It is unreasonable to expect these facilities to provide the necessary interventions for successful treatment of mental illness. Public health has fallen short in meeting the needs of those with mental illness in this regard, choosing instead to relegate them to the only place that cannot say no- jails and prisons.
Decriminalizing the Mentally Ill: Jail Diversion Programs as a Means to Accessing Care and Assimilating into Community Settings – Regina Ram
In reviewing the issue of criminalizing the mentally ill, it is clear that there are fewer public mental health resources available in our country in contrast to large numbers of incarcerated mentally ill who require treatment. Correctional facilities cannot and should not be expected to provide intensive treatment for mental illness. Furthermore, it is unlikely that we will see a return to institutionalizing the mentally ill, as most mental health hospitals have decreased in size and many no longer exist. The most logical response, then, seems to fulfill the original promise of deinstitutionalization- making access to community-based mental health services a reality for the mentally ill.
In particular, what appears to provide the best introduction to these services is jail diversion programs. While some mentally ill in the criminal justice system should remain there and receive treatment there given the seriousness of their offenses, many people with mental illness who have been arrested for nonviolent crimes can be diverted from jail to mental health programs. This would work to minimize the number of mentally ill who end up in prisons, and target the lack of community support that places released mental health inmates at a disadvantage.
Jail diversion programs begin when the mentally ill is introduced to the criminal justice system, which usually takes place in the form of an interaction with law enforcement officials. Specifically, the intervention can occur either at some point before arrest (pre-booking), or following arrest once they have been screened for mental illness and risk (post-booking) (13). In either case, it is assumed that a pre-trial diversion is a more effective means of reintegrating offenders into the community rather than incarceration.
I will focus on the use of post-booking jail diversion programs in particular. Steadman et al. defines a diversion program as a program in which a detainee is screened for the presence of a mental disorder and then evaluated by a mental health professional. The programs negotiate with prosecutors, defense attorneys, community-based mental health providers, and courts to produce a mental health disposition “as a condition of bond, in lieu of prosecution, or as a condition of a reduction in charges”. Most importantly, diversion programs link the detainee directly to community-based services (14). In essence, the programs seek to reduce potential time in jails and prisons and replace it with involvement in the mental health system and community integration.
I would argue that jail diversion programs are a stronger public health response to supporting the mentally ill, given that our current approach ignores the root problem of assessing mental health. Jail diversion programs address the problems of abuse of the mentally ill within jails and prisons, lessens the stigmas encountered by the mentally ill by keeping them out of prison, and provides a support system in the community to help the mentally ill who have already been incarcerated avoid recidivism.
Decreasing Issues of Abuse
Jail diversion programs that transition people into community-based mental health services limit the opportunity for abuse of the mentally ill within prisons and jails. They protect the mentally ill population by not sending them into situations where they could be misunderstood and seriously maltreated. Instead, the individuals are largely interacting with trained mental health personnel within a clinical team.
Avoiding this abuse helps maintain the mental health of those who would otherwise be incarcerated. The mentally ill do not experience the punishments, such as solitary confinement, that are known to exacerbate mental illness. Jail diversion programs can actually provide the opposite experience, in that some utilize group therapy with the mentally ill to help them learn interaction skills. Overall, these programs ensure that the mentally ill are relating with people who both recognize their conditions and are trained to properly assist them in controlling their circumstances.
Addressing the Double Stigma
One of the main strengths of jail diversion programs is that they can avoid criminalizing the mentally ill altogether. If it is an individual’s first offense, linking them to a community-based mental health center decreases the negative stigma and labeling that occurs in the formal criminal justice system (13). The low-risk population is never exposed to unnecessary stigma that could be disenfranchising. Keeping the mentally ill out of jails and prisons also reduces the chances that negative labels will be reinforced through harmful interactions.
While there is still a strong stigma connected with being mentally ill, the individuals are given a support team to help them learn to counteract this stigma. They are prepared for the demands of society through specific therapeutic strategies such as psycho-educational treatment, stress management, and anger management. Jail diversion programs provide the mentally ill with practical skills that can help them become gainfully employed and counteract stigma by contributing to society (14).
Providing Community Support to Avoid Recidivism
The same processes in jail diversion programs that help the mentally ill work against stigma in the community also help reduce recidivism by providing necessary services. Opportunities for counseling and job training give the mentally ill a means of support that can help them avoid criminal actions. Diversion programs also include a coordinated response between agencies within the criminal justice and mental health systems, which help maintain success with the mentally ill (13).
Discharge planning and follow up are critical in reducing recidivism among the mentally ill. In the most successful diversion programs, each individual who enters the community-based mental health program has a case manager that serves several needs. These are the people who identify the client, evaluate their mental health service needs, directly consult with the courts, and develop an appropriate treatment plan. Crucially, case managers link clients with necessary aftercare services, monitor service delivery, and work as client advocates. According to research, the most successful have experience in both the mental health and criminal justice fields (14).
What this does is ensure that the mentally ill individual has a place to go through case management, residential placement, and outpatient services. They are helped in finding permanent housing, developing life skills, and gaining suitable employment. These factors encourage the mentally ill to stay out of the criminal justice system by providing them a place within society. The strongest reasons why the mentally ill are incarcerated are based on the fact that they do not have the community services they require, and jails and prisons are the only places they can seek treatment. Community-based mental health centers fill that need, and therefore can reduce the unnecessary burden placed on the criminal justice system.
Draine, et al. points out that the experience of people with mental illness is often contextualized in disadvantaged social settings. He argues that poverty is an important moderator of the relationship between serious mental illness and social problems, and that is not sufficiently accounted for in research, service planning and policy (15). This fact, in particular, is what makes the issue of the criminalized mentally ill a public health concern. The population is vulnerable in several regards, and there is a need for public health to step in and stop the shuttling of the mentally ill into jails and prisons.
The most promising way to do that, I believe, is through jail diversion programs and community-based mental health centers. Providing the mentally ill with screening, evaluation, short-term treatment, and discharge planning addresses the shortcomings of criminalization. The mentally ill are spared from excess abuse, able to avoid double stigmatization, and are given the access they need to find success in community reintegration.
- Torrey EF. Editorial: Jails and Prisons- America’s New Mental Hospitals. American Journal of Public Health 1995; 85(12):1611-1613.
- Roskes E. A Model Program for the Treatment of Mentally Ill Offenders in the Community. Community Mental Health Journal 1999; 35(5):461-472.
- Baillargeon J. Psychiatric Disorders and Repeat Incarcerations: The Revolving Prison Door. The American Journal of Psychiatry 2009; 166:103-109.
- Treatment Advocacy Center. Briefing Paper: Criminalization of Individuals with Severe Psychiatric Disorders. Arlington, Virginia, 2007.
- Edwards KA. Stigmatizing the Stigmatized: A Note on the Mentally Ill Prison Inmate. International Journal of Offender Therapy and Comparative Criminology 2000; 44:480-489.
- Powell TA. The Prevalence of Mental Illness among Inmates in a Rural State. Law and Human Behavior 1997; 21(4):427-438.
- Corrigan PW. Understanding the Impact of Stigma on People with Mental Illness. World Psychiatry February 2002; 1(1):16-20.
- Link BG. A Modified Labeling Theory Approach to Mental Disorders: An Emprirical Assessment. American Sociological Review 1989; 54(3):400-423
- Lamberg L. Efforts Grow to Keep Mentally Ill Out of Jails. JAMA 2004; 292(5):555-556.
- Treatment Advocacy Center. Briefing Paper: Law Enforcement and People with Severe Mental Illnesses. Arlington, Virginia, 2005.
- Callais, Todd. Stigma and Ex-Convicts: Managing a Spoiled Identity as the Key to Post-Incarceration Success. Royal York, Toronto: American Society of Criminology http://www.allacademic.com/meta/p33740_index.html.
- Lamb HR. Editorial: Reversing Criminalization. American Journal of Psychiatry 2009; 166(1):8-10.
- Ogloff, JRP. Identifying and Accommodating the Needs of Mentally Ill People in Gaols and Prisons. Psychiatry, Psychology and Law 2002; 9:1-33.
- Steadman HJ. The Diversion of Mentally Ill Persons from Jails to Community-Based Services: A Profile of Programs. American Journal of Public Health 1995; 85(12): 1630-1635.
- Draine J. Role of Social Disadvantage in Crime, Joblessness, and Homelessness Among Persons With Serious Mental Illness. Psychiatric Services 2002; 53(5): 565-573