Doubl Jeopardy

Persons with Mental Illnesses in

the Criminal Justice System

A Report to Congress

from the

Center for Mental Health Services

Substance Abuse and Mental Health ServicesAdministration

Public Health Service

U.S. Department of Health and Human Services

Rockville, MD

February 24, 1995
Acknowledgments

The willingnessofso manypeopletogive generouslyof theirtimeand

expertiseto readdraftsof thisreportandtocommittheirreactionstopaper

is a majorreasonthatthisreportissocomprehensive,yet incisive.The

staffsofCMHS andNIMH throughthe IntemalWorkingGroupprovidedthe

originalimpetus.The 44 membersofthe Ad HocWorkingGroupon

PersonswithMentalIllnessesintheCriminalJusticeSystemprovideda

wide rangeofideasandviewsthat heavilyshapedthefinalproduct.

Throughthem,consumerandfamilyperspectiveswere vigorously

presentedalongwiththeviewsof mentalhealthandcriminaljustice

professionalsthatoftenare the onlyonesconsideredontheseissues.

Muchoftheorganizationandwritingof thisreportwasdoneby BonitaM.

Veysey,Ph.D.,andHenryJ.Steadman,Ph.D., of PolicyResearch

Associates,Inc.,and SusanSalasinofCMHS. SusanMilstreyWellsedited

and formatted the final draft.
Table of Contents

ExecutiveSummary ...................................................................................i

Preface.........................................................................................................1

Background......................................................................................1

The Scope of the Report...................................................................2

CHAPTER 1: The Human Face of the Problem ........................................4

PeopleWho Have BeenThere .........................................................4

Two Complex Systems.....................................................................7

CHAPTER 2: The Changing Context of Care............................................8

Background......................................................................................8

ShiftingResponsibilitiesfor Mental HealthServices .........................8

The Changing Criminal JusticeSystem..........................................10

The Recent Impact of the Advocacy Movement .............................11

ProfessionalGuidelines..................................................................14

The Legal Context ..........................................................................15

A DiversePopulation......................................................................16

CHAPTER 3: The Nature of the Population ............................................17

A Diverse Group.............................................................................17

Most Persons with Mental IllnessesAre Not Violent.......................18

ConsensusStatement on Violence and Mental Disorder:

Public Perceptionsvs. Research Findings......................................20

Persons with Special Needs...........................................................21

NeededServices ............................................................................25

CHAPTER 4: Definingthe Needs of Personswith Mental Illnesses

in the Criminal JusticeSystem................................................................26

Background....................................................................................26

Policeas FrontlineMentalHealthDecisionMakers........................28

LockupsandJailsas CommunityInstitutions.................................31

Prisonsas ContainedCommunities................................................34

ProbationandParole:UnchartedTerritory.....................................38

Diversionto CommunityServices...................................................41

PlanningCooperativeEfforts..........................................................42
CHAPTER 5: Solutions That Work..........................................................43

Bardersto ProvidingCare...............................................................43

CorePlanningPdnciples................................................................43

EffectivePolice/MentalHealthInteractions.....................................46

NotableProgram:MontgomeryCounty,Pa.,

EmergencyServiceProgram..............................................50

MentalHealthInterventionsinJailsand Lockups...........................52

NotableProgram:SummitCounty,Ohio,Jail

ADAPT Program.................................................................56

MentalHealthInterventionsinPrisons............................................58

NotableProgram:NewYorkState PrisonMental

HealthProgram..................................................................63

MentalHealthInterventionsfor Personson Probation

and Parole.....................................................................................65

NotableProgram:OregonSpecialNeedsRelease

PlanningProgram...............................................................70

Diversionto MentalHealthProgramsintheCommunity.................72

NotableProgram:HonoluluJailDiversionProgram............73

References................................................................................................75

APPENDIX: CMHS Ad-HocWorkingGroupfor MentalHealthand

CriminalJusticeSystems
Executive Summary

On October 1, 1992,the Center for MentalHealthSen/ices (CMHS) was

establishedas part of the ADAMHA ReorganizationAct (42 U.S.C.

290bb-31). This law requiresCMHSto produce a reportto Congress

conceming

"...the most effective methodsfor providingmental health services

to individualswho come into contactwith the criminaljustice

system, includingthose individualsincarceratedin correctional

facilities (including localjails and detention facilities),and the

obstaclesto providingsuch services."

Current Status Personswith mental illnesseswhocomeintothe contactwith the criminal

justicesystemare particularlyvulnerable.Theybeara doubleburden:the

stigmaassociatedwiththeirmentalillnessandthestressof potentialarrest

and confinement.Involvementwiththecriminaljusticesystemmay

exacerbatetheisolationanddistrustoftenassociatedwithmentalillnesses.

Atthesametime,individualswithmentalillnessespresentspecial

problemstothe criminaljusticesystem.Lackofknowledgeaboutmental

illnessesonthepartof lawenforcementandcorrectionsstaff,anda

shortage of appropriatementalhealth sewices, may meanthat these

individualsare left untreatedwith symptoms that may worsen.Although it is

in the best interestof all concemedto provide effective mental health

treatment for persons in the criminaljustice system, many obstacles stand

in the way of providingappropriatecare, including:

• lackof knowledgeon the partof law enforcementand corrections

personnelabouteffectivementalhealthprogramsandhowtoaccessthem;

• lackofunderstandingonthepartofthementalhealthsystemaboutthe

demandsandconstraintsofthe criminaljusticesystemand an

unwillingnestos workwithclientswithcriminalchargesorrecords;

• lackofcross-trainingamongcorrections,lawenforcement,and mental

healthpersonnel;and

• lackofcoordinationamongthecriminaljustice,mentalhealth,andsocial

servicesystems.
Inadequateor inappropriateinformationand fragmentedservicescan result

in persons with mentalillnesses receiving no services at all or receiving

inappropriatetreatment, includingarrest and jail, becauseworking

altemativesdo not exist in the community.To address the unmetneeds of

personswithmental illnesses in the criminaljustice system, the Center for

Mental HealthServices, a component of the Substance Abuse and Mental

HealthServicesAdministration,one of the eight Public HealthService

agenciesin the U.S. Departmentof Healthand HumanServices, was

chargedwiththe responsibilityfor preparing this report.

The Changing Dramaticchanges inthementalhealthservicedeliverysysteminthis countryhaveoccurredoverthelast 30 years. Promptedby the Context of Care developmentof new medications,changingtreatmentphilosophies,the

activismof thecivilrightsmovement,andsignificantnewFederalfunding

fora nationwidenetworkof communitymentalhealthcenters,thenumber

of patientsinState hospitalsdeclinedfrom560,000 in 1955 to 100,000in

1989 (NationalInstituteof MentalHealth,1991).

These changes caused the loss of State-operatedinpatientbedsand

resulted in a blurtingof fiscal and administrativeresponsibilitiesfor the care

of personswith severe mental illnesses,as well as a growingfragmentation

in service provisionas the number and breadth of service providers,both

inpatientand outpatient, increased.

In 1992,the FederalTask Forceon Homelessnessand Severe Mental

Illness reportedthat, in many communities,services to personswith mental

illnesses aredeliveredby an often complex and disconnectedset of

bureaucraciesthat are difficult for individuals and their caregiversto

negotiate. Housingis a particular problemfor this population. In 1992,

about5 percentof the nearly4 million personswith severe mental illnesses

in the U.S. were estimatedto be homeless at any given time.

At the sametime, the criminaljustice system has also undergonemajor

changes. In 1993,the Bureau of Justice Statistics reported that in the last

decade, the U.S.jail populationon any day increasedfrom 158,394to

444,584.Similarly,the prison population increasedfrom 329,000 to

824,133 inthe same period.Fully 2.3 percent of the U.S. adult populationis

in jail, in prison,or on paroleon any day, giving the U.S. the world's highest

incarcerationrate.

Burgeoning U.S. correctionspopulationsare due to several policy changes,

includingthe generallyharshersanctionsresultingfrom the policyof

"gettingtoughoncrime"andthemorerecent"war ondrugs."Inaddition,

stifferpenaltieshavebeenimposedthroughsentencingreformlegislation.
Asjail and prisonpopulationsincreased,andthenumberof personswith

mentalillnesseslivingat thefringeoftheircommunitiesrose,theabsolute

numbersof personswithmentalillnessesinjailsand prisonsalso

increased.Exacerbatingtheproblemisa highdegreeof co-morbidityof

severementalillnessesandsubstanceusedisordersamongjail and prison

inmates.

In its1992 report,Crimina/izingthe SeriouslyMentally I/1:TheAbuse of

Jails as Mental Hosp#a/s,theNationalAlliancefortheMentallyIII(NAMI)

foundthat:

. 29 percentofjailsthatrespondedtoa NAMIsurveyholdpersonswith

severementalillnesseswithoutanycriminalcharges;

. 20 percentofjailsthatrespondedhavenomentalhealthservices;and

. 46 percentofjailsthatrespondeddonotknowwhetherpersonswith

mentalillnessesreleasedfromjailreceiveoutpatientmentalhealth

servicesuponrelease.

As thenumberofjail detaineesand prisoninmatescontinuesto growat an

alarmingrate,an enormousstrainis placedontheresourcesofthese

institutions.There hasneverbeena greaterneedforresourcesdevotedto

mentalhealthcare inthesefacilities.

A Heterogeneous Personswithmentalillnessesare a heterogeneousgroup.They are men andwomenof differentages,culturalandethnicbackgrounds,and sexual Group preferences.The effectsof theirmentalillnessesrangefrompsychosis,to

severedisruptionsinemotions,andfunctionalimpairmentintheirabilityto

relatetoothersor sustainwork.Allof thesefactorsmustbe considered

whendevelopingmentalhealthprogramsinthecommunityand inthe

criminaljusticesystem.

Oneprevalentmythaboutpersonswithmentalillnessesis thattheyare

pronetoviolence.The fact isthatmostpersonswithmentalillnessesare

nomorelikelythanthegeneralpopulationtocommitviolentacts.

Allpersonswith mentalillnesseswhocome into contactwith the criminal

justice system havespecial needs.Yet special populationswithin this

group, including people withco-occurringsubstance use disorders,women,

ethnic and racial minorities, homelesspersons, persons with HIV/AIDS, and

youth, warrant particular attention.

iii
NeededServices Servicesfor personswithmentalillnesseswhocome intocontactwiththe

criminaljusticesystemare criticalandcanbe developedwithoutsubstantial

newfunding.Muchof whatis requiredisrethinkinghowto addressthese

problems.Thedevelopmentof specificservicestopersonswhocomeinto

contactwithpolice,whoare incarceratedinjailsor prisons,orwhoare

supervisedinthecommunitybyprobationor paroledepartments,canbe

helpedgreatlybytheadoptionof coreplanningprinciples.

Many recentanalysesof mentalhealthservicesforunderserved

populationsappropriatelyhaveemphasizedtheneedfor collaboration

betweenprivateandpublicsectorsand, intum,amongthelocal,State, and

Federallevelsofgovemment.The coreplanningprinciplesemphasizethe

needforcomprehensiveandintegratedservicesat theclientandsystem

levels,withparticularfocusontheneedfor communitycollaboration.

The criminaljusticesystemhasdifferingresponsibilitiefsorindividualswith

mentalillnessesat keycontactpoints.Lawenforcementofficersmust

decidewhethertoarrestan individualwhois incrisisoris creatinga

disturbanceortotransporthimor hertoa mentalhealthfacilityfor

treatment.Servicesthatmakethispossibleinclude24-houremergency

mentalhealthtreatmentfacilities,mobilecrisisteamsthatcanassistinthe

resolutionof theincident,transportation,and staffwhocanwaltwithan

individualfor an evaluation.

At Iockupsand jails,thesafetyof thedetainee,otherinmates,andcustodial

staffisthekey issue.Half ofalljail inmatesleavewithin24 hours.Key

servicesat thispointincludeidentificationof personswith mentalillnesses

throughroutinescreeningandfollow-upevaluations,and stabilizationofthe

individualthroughcrisisinterventionservices.Inaddition,tofacilitatethe

movementof personswithmentalillnessesbackintothe communityortoa

prisonsetting,dischargeplanningand casemanagementservicesare

important.

Prisonsarecontainedcommunities;inmateswithmentalillnesseshave the

righttotreatmentoimprovethe qualityof theirlivesandtoallowthemto

servetheirtimehumanely.The optimumlevelof availableservicesshould

duplicatethebestthatis availableinthecommunity,witha fullrangeof

inpatientandoutpatientreatmentsandmodalitiesavailableto allinmates.

Personsundercommunitysupervision(i.e.,probationor parole)alsoneed

a fullrangeof mentalhealthservices.Theseservicesshouldhelpmaintain

personswithmentalillnessesinthecommunity,keepsymptomatologyto a

minimum,and reducethe risksof recidivism.

iv
Diversionprogramshavebeen hailed as an importantservice for

individualswith mental illnesseswho do not belong in jail. Such individuals

need to be diverted from jail, either before arrest or after booking, to a

continuumof mental health and other community supportservices that

includesoutreach,case management,crisis intervention,housing,

vocationaltraining, and family support.

A Place to Begin The problemsdiscussedinthis reportarecomplexand multifaceted.No singlesolutionor programwilladdresstheneedsof allpersonswithmental

illnessesinthecriminaljusticesystem.However,thematerialcompiled

providesa placefor Federal,State,andlocalofficials,policymakers,mental

healthand correctionspersonnel,researchers,andadvocatesto begin

talkingabout,and planningactiontoachieve,effectivesolutions.

V
Preface

Background On October 1, 1992,the Centerfor Mental HealthServices(CMHS) was establishedas part of the ADAMHA ReorganizationAct (42 U.S.C.

290bb-31).This law requiresCMHS to producea reportto Congress

concerning"the most effectivemethods for providingmental health services

to individualswho come into contactwith the criminaljustice system,

includingthose individualsincarceratedin correctionalfacilities (including

local jails and detentionfacilities),and the obstacles to providingsuch

services."

To define the objectivesassociatedwith this goal, an intemal CMHS

workinggroup identifiedfour primaryareas of attentionas suggestedby the

languageof the ReorganizationAct. They are:

• (Identifyingthe) ... most effective methods for providing mental health

serv/ces. Individualwith s mentalillnesseswhocomeintocontactwiththe

criminaljusticesystemmaybe divertedintothementalhealthsystemor

treatedwithinthecriminaljusticesystem.InforrnatJonmustbeavailableon

therangeandtypeofmentalhealthservicesneededbyindividualsbothin

thecommunityandinthecdminaljusticesystem,thehumanandfiscal

resourcesneededtosupporttheseservices,and theanticipatedoutcomes

of anyinterventionforthecdminaljusticesystemandfortheindividuals

involved.Lawenforcementagenciesand localjailsmustbeseenas an

integralpartofcommunity-basedcareforthispopulation.

• (Providingtheseservices)... to individuals who come into contact with

the criminal justice system. Personswithmentalillnesseswhocome

intocontactwiththecriminaljusticesystemarea heterogeneousgroup.To

understandtheirneeds,a completediscussionofthisissuemustfocuson

thespecificcharacteristicof s thispopulation,includingthedegreeof

sevedtyofmentalillness,typesof crimescommitted,typicalprecipitating

events,andthespecialneedsof subgroupswithinthepopulation,suchas

women,homelesspersons,andpersonswithco-occurringsubstanceuse

disorders.
• ...including those individuals incarceratedin correctional facilities

(including local jails and detention facilities). Thereare manypoints

throughoutthecriminaljusticesystemwherepersonswithmentalillnesses

willbeidentified,includingpolicecontacts,locallyoperatedIockupsand

jails,prisons,andcommunitysupervision(probationand parole).The

responsibilitiesof the criminaljusticesystemfor persons withmental

illnesses,and the needsof such individuals,will vary at each point

throughoutthe system.Thesemustbe identifiedand clearlyunderstoodby

providersin both the mentalhealthand criminaljustice systems.

• (andidentifying)... the obstacles to providing such services. Obstacles

to providingappropriatecare for personswith mentalillnessesin the

criminaljustice systemincludehumanand fiscalconstraints,organizational

ownership(turf)issues,lackof knowledgeon the part of the cdminaljustice

system abouteffectivementalhealthprogramsand how to implement

them, and lackof understandingon the partof the mental healthservices

systemaboutthe demandsand constraintsof the criminaljustice system.

These barriersmust be identifiedand ways to overcomethese barriers

highlighted.

To insure that this reportrepresentsthe rangeof issues and concems of

the manyconstituentsinvolved, CMHSconvenedthe Ad Hoc Working

Groupfor Mental Healthand CriminalJusticeSystems consistingof

consumers,family members,mentalhealth providersto jails and prisons,

law enforcementand correctionsadministrators,Federal and State criminal

justice and mental health agency representatives,and a number of

nationally knownconsultants(see the Appendixfor a list of participants).

The Ad HocWorkingGroupmet in July 1993 to discuss the major issues

relatingto the report and to recommendmethods to implement model

service programs.The group alsorevieweddrafts of this report and offered

many suggestedchanges that are reflected herein.

The Scope of Thisreportcontainsfivechapters.ChapterOne, 'q'heHuman Face of the Problem,"presentsan overviewof theissues.ChapterTwo,"The Changing

the Report Context of Care,"providesa briefhistoryof policyinthisarea, including

discussionsoftheorganizationof mentalhealthservicesinthiscountryand

changesinthe criminaljusticesystemthatimpactpersonswhohave

mentalillnesses.The characteristicsof personswithmentalillnesseswho

comeintocontactwiththecriminaljusticesystem,includingseveral

subgroupswithspecialneeds,are discussedinChapterThree, 'q'he

Natureof thePopulation."

2
Chapter Four,"Definingthe Needs of Personswith MentalIllnessesin the

Criminal JusticeSystem,"discussesthe needs of persons with mental

illnesses at each stage of the criminaljustice system, including police

contacts,jails, prisons,and probation and parole, and outlines the

responsibilitiesof, and challengesto, the criminaljustice system at each

contact point.Finally,coordinatingessential mental health servicesfor

personswith mental illnessesin the criminaljustice system, including

examples of successful programs,are presentedin Chapter Five,

"SolutionsThat Work."

3
CHAPTER 1

The Human Face of

the Problem

People Who Statisticsalonecan neveradequatelyrepresentthe concemsof persons withmentalillnessesinthecriminaljusticesystem.Ustentothestoriesof

Have Been thosewhohavebeenthere.

There

James

James had been in an Ohio cityjail for six months. During that time, he was

treated for depressionand stabilizedwell. He had little family support in the

community,and he was somewhat uncomfortableabout his prospects

when the time came for his release.Because of this, mental health staff

withinthejail made concrete releaseplans withhim.

Thestaff madean appointmentfor him at the localmental health center

that was withina few hours of his scheduled release time. He did not,

however,receive a supply of, or a prescriptionfor, the antidepressant

medicationhe was treated withduring incarceration.

James kept his appointmentat the mental health center. However, he was

told that he could not get medication for at least two weeksbecause the

psychiatrist's schedule was full until then. Whenhe asked about housing,

he was told to come back the next day.

Thatnight,James committedsuicide.

Michael

Thefamily of a youngman from a rural county in upstate New York called

the police to assist their son. Michael wasacting strangelyand refused to

go to the hospital. Whena State trooper respondedto the call,Michael

grabbed the officers weaponand attempted to shoot him withit. The

troopersubdued Michael and arrested him. He was charged with attempted

murder and taken tojail.

Theforensicmanta/health coordinatorevaluatedMichael upon entry into

the facility.At the time, he wasexperiencingpsychotic symptoms. He had a

previous diagnosis of schizophreniabut had not been taking his prescribed

medication.He had also been using some marijuana and was hearing

voices tellinghim to kill.

4
Michael was transferred within24 hours to an inpatientpsychiatrichospital

with whichthe county contracted for services. He spent three months there.

Whenhe was retumed to thejail, the forensic coordinatorhad negotiated

withthe districtattorney,Michael'spublic defender,and the countyjudge to

reduce the sentence,in considerationof a plan for mentalhealth treatment

and communitysupervision.

Michael was sentencedto 6 months injail and 5 years of probation, which

required him to continue to receive mental health treatment.For good

behavior and the timehe spent in the forensichospital,Michael served one

month in the countyjail.

Whilehe was injail, Michael continued to receive mental health treatment,

and plans weremade for his discharge.He wasassigned an intensive case

manager who met withhim and coordinatedhis service needs before

release.Close communicationbetweencommunitymental health staffand

the probationofficer guaranteedcontinuity of care for Michael and helped

increase the likelihood that he wouldbe able to functionin the community.

Michael has required two brief hospitalizationsin the last 5 years, but he

has not had any further.contact withthe police. He recentlymoved out of

his family's home into supportedhousingand is employedby a sheltered

workshop.

Grace

Grace is a 60-year-oldwidow who lives alone in a suburbanPennsyivania

town. For severalyears she has been calling the local police to tell them

that people werebreaking into her house and that someone was harassing

her. Recently thepolice began to receive complaints from Grace's

neighbors.Thelast time, Grace had apparently gone to a neighbor's house

and threatenedtheir children,even grabbingone and twistinghis arm.

Whenthe police were called for this incident, they felt they had to arrest

Grace. Before doing this, however, they calleda mobile mental health crisis

team. Theoutreach workerswho respondedmet withGrace, the police,

and the neighbors. Theyalso contactedAging and Adult Services and

located a relative.

The crisis team consideredhavingGrace committedto an inpatient facility.

She waspsychotic, her home was filthyand in disarray,and she was very

suspicious of the team. However, the mental health outreach team and

Aging andAdult Services agreed to work with Grace.

5
Over the next few weeks, the outreachteam visited Grace several times.

She came to trust the workersand disclosedthat she had been

hospitalizedin the past and that she had had a drinkingproblem. With the

coordinatedeffortsof the mental health team and Aging and Adult Services

providingher withsupportand homecare assistance, Gracestabilized, and

her homeis in orderagain. Therehavebeen no calls to the police and no

complaints from the neighbors.

Steven

Twoyears ago, a young male veteranarrived in Honolulu from California

estranged from his familyand broke. He had a diagnosis of paranoid

schizophrenia. Withinthree months,he had amassed 11arrests for minor

misdemeanorcharges.

Each time Steven wasarrested, he wasseen by thejail diversionprogram,

which attemptedto connecthim to the VeteransAdministration (VA) office.

However,Stevenproved to be very resistantto treatment.On his eleventh

arrest, thejail diversionprogramdirectorconfronted Steven, tellinghim he

mightbe facing lengthyjail time if this situation continued.

WithSteven'spermission, theprogram directorcontacted Steven's father,

who admitted he was reluctantto have his son return home becausehe

refused treatmentand caused such disorder in the family's life. However,

given his failuresto functionin Honolulu, the father agreed to work with the

program director to developa plan for Steven's retum home.

Theprogram directorcontactedthe local VAprogram in Steven's

hometown, whichagreed to takehis case and to be with the father at the

airport when his son arrived.Theprosecutor and the program director

agreed that chargesshould be dropped,and the program director appeared

in court onSteven's behalf to explain the situation. Thejudge dismissedall

charges withprejudice,which means that the charges willremain

dismissedas long as Steven does not return to Honolulu.

One of the stipulationstheprogram director made was that he had to hear

from Steven or his father at two month intervalsuntil further notice. The

father was reliableabout checking in, and the notificationperiod was

extendedto six months.

After Steven wasback in California,the father called the program director

to thankhim. "ThankGod for the diversionteam," the father said. "Not only

did my son come home,but he is in treatmentright now. He is doingjust

fine." That was twoyears ago, and Steven is still doing well.

6
Two Complex Thestoriesof James, Michael, Grace, andSteven are compellingevidence of the need for communicationbetween the mental health and criminal Systems justice systemsand forcollaborationto meetthe needsof personswith

mentalillnesses.Suchcollaborationcontributestothesmoothoperationof

thecriminaljusticesystemandpromotescontinuityof care for personswith

mentalillnesses.Michael,Grace,andStevenbenefitedfromsuch

collaborativefforts;James'suicidewas a catalystforincreased

communicationand cooperationbetweenjail andmentalhealthstaff.

To betterunderstandtheproblemsthatexistatthe intersectionofthesetwo

complexservicesystems,ChapterTwolooksat thechangingorganization

of mentalhealthservicesinthiscountryand atthedevelopmentof policy

concerningthe responsibilitiesofthe criminaljusticesystemwithregardto

personswhohavementalillnesses.

7
CHAPTER 2

The Changing Context

of Care

Background The Governorof Virginiaexpresseddismaythathe was"forcedto

authorizetheconfinementof [personswithmentalillnesses]inthe

Williamsburgjail,againstbothhisconscienceandthelaw"becauseof lack

of appropriateservices.Thisoccurredin 1773 (Deutsch,1937).

Morethan200 hundredyearslater,we arestillfacedwiththesame

problem.The languagehaschanged,buttheissuesremain.Theyexisted

incolonialVirginia;in19thcenturyNewYork,wherethe 1894 Lunacy

Commissionconcludedthatthe presenceof personsconvictedof cdminal

offensesincivilhospitals"wasveryobjectionabletotheordinaryinmates"

and,therefore,a maximumsecurityhospitalforthecriminallyinsaneshould

bebuilt(SteadmanandCocozza,1974);andtodayinFlatheadCounty,

Montana,wherethelocaljailroutinelyacceptspsychiatricemergency

admissionsintheabsenceof anycriminalcharges(Torrey,et el., 1992).

Overtheyears,variousmovementsand reformshaveattemptedtosolve

theproblem,butperiodicallytheissueof personswithmentalillnessesin

ournation'sprisonsandjailsworsens.Policychangesoverthelast30

yearsin boththementalhealthandcriminaljusticesystemshavecreated

conditionsthathaveexacerbatedtheproblemof personswith mental

illnessesinthe criminaljusticesystem.

Shifting Over the last30 years therehavebeendramaticchangesinthe mental healthservicedeliverysystem.These includethedeclineoftheState

Responsibilities hospital,thegrowthof communitymentalhealthcenters,theexpansionof

for Mental the use of psychiatricservicesingeneralhospitals,thetransferof large

numbersof personswithseverementalillnessesto nursinghomesand

Health Services boardandcarefacilities,anda dramaticrise inthenumbersof personswith

mentalillnesseswhoareincarceratedor homeless.

Inthe past,a personwithseverementalillnesscouldexpecttospendmost

of hisor herlifeina State-operatedpsychiatricfacility.Now,personswith

mentalillnessescanliveinthecommunitywithmentalhealthsupports.

Withthelocusofcareshiftingawayfrominpatientservices,personswith

mentalillnesseshaveaccesstoa largernumberof mentalhealthservices

andprovidersanda widerrangeof programs.
These changeshave notalwaysproducedpositiveoutcomes.The reform

effort knownas deinstitutionalizationwas begun in the late 1950sand early

1960s,spurred in part by the advent of effective psychotropicmedications

and by changes intreatment philosophies.

During this time many long-term inpatientswere released from psychiatric

facilitiesto community-basedcare and living situations.At the same time, a

related policyof diversionwas begunthat discouragedhospitalizationand

encouragedaltemativesto inpatient care. The FederalGovemment,

through the Community Mental Health CentersAct of 1963,reinforced

these generalpolicies by fundingthe development of comprehensive

community-basedmental health services.

In addition,the creation of the Medicaidprogram further promoted the shift

of care from State psychiatriccentersto the community, most importantlyto

nursinghomes and general hospitals.Further,the SupplementalSecurity

Income (SSI) andSocial Security Disability Insurance(SSDI) programs

provideddirect assistanceto personswith severe mental illnessesliving in

the community.

One outcome of these policieswas a reductionacross the nation of the

State hospital inpatient censusfrom 560,000in 1955 to 100,000in 1989

(National Instituteof Mental Health, 1991).Butthese changes resulted in

more than simply the loss ofState-operated inpatientbeds.They also

resulted in a blurringof fiscal and administrativeresponsibilitiesfor the care

of personswith severe mental illnessesand a growingfragmentation in

service provisionas the number and breadth of service providers, both

inpatientand outpatient, increased.

Several Federally sponsored partnershipshave been developedto address

the fragmentation and lackof coordinationamongservice providersand

funders, includingthe National Instituteof Mental Health Community

SupportProgram, begun in 1978,that establisheda single point of

responsibilitywithin each State for the coordinationand care of persons

with severe mental illnesses.The Mental HealthSystemsAct of 1980

outlined the need for the creation of FederaVState/Iocaialliancesto develop

comprehensiveand coordinatedcommunity-basedcare for persons with

severe mentalillnesses.

9
Fundingcutbacksduringthe pastdecadehave resultedin systems-level

changes in the provisionof mental health services. In many communities,

that hasmeantthe net redu_on of servicessuch asemergencymentalhealth

care.Certainly,inadequatefundingisone factorassociatedwiththe increased

numbersofpersonswithmentalillnessesinthe criminaljusticesystem.But

equally,ifnot more,importantisthe lackof appropriatesewices, and the

unwillingnessof manycommunityprovidersto targetservicesto those

individualswiththe mostserious mentalillnesses,includingthoseinvolvedwith

the criminaljusUcesystem(Torreyet al., 1992).

One of the consequencesof the loss of 24-hour mental health emergency

services is the arrest and incarcerationof personswith mental illnesses in

crisis. In communitieswith few mental health resources,jails often have

become the default psychiatricfacilities (Torrey,et al., 1992).Jails are open

24 hours a day, and a personwho is charged with a crime cannot be

refused admissionregardlessof his or her mental or physicalcondition.

While the mentalhealth servicesystem is strugglingto developa

cost-effectivemodelthat provides care to all persons with mental illnesses,

that is easy to access and negotiate,and that is accountable, bridgesto

other systems are also being built. Like the mental health system, the

criminaljustice system has also undergonemajor changes in recent years.

The Changing In the last decade,the U.S. jail populationon any given day has increased from 158,394to 444,584 (U.S. Department of Justice, 1993).Similarly,the Criminal Justice prison populationinthe same period has increasedfrom 329,000to

System 824,133 (Bureau of JusticeStatistics, 1993). Fully 2.3 percentof the U.S.

adult populationis injail, in prisonor on paroleon any given day, giving the

U.S. the world's highest incarcerationrate.

Burgeoningcorrectionspopulationsare a product of several policy changes

in the U.S., includingthe generallyharsher sanctions resultingfrom the

policy of "gettingtough on cdme" and the more recent"war on drugs."In

addition, stiffer penaltieshave been imposedthrough sentencing reform

legislation.

Changing philosophiesregardingthe purpose and goals of punishment

have led manyStates toward presumptivesentencing--"an offense-based

sentencingsystem with clearlydefined punishments for specific illegal

activities"(Clear et al., 1993).These statutes take much of the discretionary

power out of the handsof judges and place itthe hands of the legislatures.

10
Presumptivesentencingstatuteshave beenpassedin20 States(Byme,

1992). The prisonpopulationhasdoubledinthelastdecadein largepart

becauseof reformsthatrequiremandatorysentencingfor drug,sex and

drivingwhileintoxicatedoffenses.

In addition,presumptivesentencingaffectsparolereleasedecisionsby

establishingmandatoryminimumlengthsof incarcerationfor all offenses.

Stateswiththesestatutesmustreleaseindividualswhentheyhaveserved

theirminimumtermminustimefor goodbehavior.Thesepersonsare

dischargedto communitysupervision.In 1977,only6 percentof the total

releasestothecommunitywere supervisedmandatoryreleases,butby

1990 thisfigurehadgrowntonearly30 percent.Atthesametime,

traditionaldiscretionaryparolereleasesdroppedby31 percent(Bureauof

JusticeStatistics,1991).

Clearly,thenumberofjail detaineesand prisoninmatescontinuestogrow

at an alarmingrate.Thisgrowthplacesan enormousstrainonthe

resourcesof theseinstitutions.Atthesametime,therehasneverbeen as

greata needforresourcesto be devotedtomentalhealthcare inthese

facilities.Ukewise,paroleand probationpopulationsare alsoincreasing,

requiringaccesstocoordinatedmentalhealthcare deliveredbycommunity

providers.

The Recent Patients' rightsadvocates,includingconsumerand familygroups,have

beeninstrumentalinthe developmentofa nationalagendatoaddressthe

Impact of the needsof personswithmentalillnessesinthe criminaljusticesystem.

Advocacv Severaloftheseeffortsare discussedbelow.

llW

Movement Patients' Rights Litigation and the Consumer

Movement

The mentalpatients'rights litigationand the consumer advocacymovement

have their roots in the civil rights movement of the 1950s and 1960s.The

politicalactivism aroundthe civil rights,antiwar,and women's movements

was also highlycritical of the role of psychiatryin preservingthe status quo

(Brown, 1985).The general distrustof psychiatrydue to its affiliation with

the "establishment"was focusedand targeted by consumers/survivors.

Liberationgroupsinthe 1960s and 1970s pointedto abuses of the system

exemplifiedby the warehousing of individuals,the excessiveuse of

seclusionand restraints,and forced medicationin State psychiatric

hospitals.

11
Keyissuesinmentalhealthadvocacylitigationwerethe righttotreatment

(e.g.,Rouse v. Cameron, Wyatt v. Stickney),therightto refusetreatment

(e.g.,Kaimowitz v. Department of Mental Health, Rogers v. Okin),

safeguardsoncommitmentproceedings(e.g., Donaldsonv. O'Connor),

and patientlabor(e.g.,Souders v. Brennan).Thesecases,amongothers,

establishedtheconstitutionalrightsof personswithmentalillnesses.

Consumergroupshavegrownin recentyearsandnowplaya criticalrolein

advocacyandpolicy.Consumersnowparticipateintheprovisionof

services,includingoperatingself-helpgroups,actingas protectionand

advocacystaff,and providingdirectservicesas casemanagersand

therapists.In addition,consumergroupsare increasinglyinvolvedinthe

policyarena,conductingresearchandlobbying.The mentalhealthservices

systems,fromthe Federaltothelocallevels,havebeguntosee the

importanceof havingconsumerconsultantswhendesigningservices,

researchandpolicy.Consumergroupshavea uniqueperspectiveon

mentalhealthservicesandwillcontinuetohavean impactonissues

relatingto personswithmentalillnesses.

Family Member Advocacy Groups

Two nationaladvocacyorganizationshavehada distinctimpactonpersons

withmentalillnessesinthe criminaljusticesystem:theNationalAlliancefor

the MentallyIII(NAMI) and theNationalCoalitionfortheMentallyIIIinthe

CriminalJusticeSystem(theCoalition).

Foundedin1979,NAMI isa nationalgrassrootssupportand advocacy

organizationforthefamiliesandfriendsof personswith mentalillnesses.

Thisorganizationcurrentlyhasmorethan140,000 membersand over

1,000affiliategroupsrepresentingall 50States.Atthenationallevel,NAMI

providespubliceducationand advocacyandoperatesa toll-free

HELPLINE.In addition,NAMI hasa ForensicNetworkthat advocateson

behalfof personswithmentalillnesseswhocomeintocontactwith the

criminaljusticesystem.Specifically,theForensicNetworkprovides

technicalassistancetofamiliesand professionalsand lobbiesonlegislative

issuesonboththeStateandnationallevels.

12
NAMI,withthe PublicCitizen'sHealthResearchGroup,hassponsoreda

seriesof studiesandreportsonissuesaffectingpersonswithsevere

mentalillnesses,includingWashington'sGrateSociety: Schizophrenics in

the Sheltersand on theStreets (1985), FiscalMisappropriationsin

Programs for the Mentally II1:A Report on Illegality andFailure of the

Federal ConstructionGrantProgram for CommunityMental Health Centers

(1990), Careof the Seriously Mentally II1:A Rating of State Programs

(1986, 1988, 1990),and Cnmina/izingthe Seriously Mentally II1:TheAbuse

of Jails as Mental Hospitals(1992).

Thewidedistributionand prominenceofthislatterreport,Crimina/izingthe

SeriouslyMentally/11has , probablydonemoretofocusattentiononthis

problemthananyothersingledocument.The impetusforthisreportcame

fromNAMImemberswhoexpressedfrustrationoverthe circumstances

thatledtotheincarcerationoffamilymembersandtheabusesexperienced

by individualswithmentalillnesseswhileinjail.The reportis basedon

informationsystematicallygatheredfrommentallyillindividualswho have

been injail andtheirfamilies,anda mallsurveysenttoall U.S. countyand

municipaljails.Amongitsmostnotablefindingsare:

• 29 percentof jailsthat respondedholdpersonswithseveremental

illnesseswithoutany criminalcharges;

• 20 percentofjailsthatrespondedhavenomentalhealthservices;and

• 46 percentofjailsthatrespondeddonotknowwhetherpersonswith

mentalillnessesreleasedfromjailreceiveoutpatientmentalhealth

servicesuponrelease.

The NationalCoalitionofthe MentallyIIIintheCriminalJusticeSystemisa

nonprofitorganizationfoundedin 1989to dealwiththe growingnational

crisisof increasingnumbersof individualswithmentalillnessesordual

diagnoseswhoare inthecustodyof criminaljusticeagencies.Withmajor

supportfromtheCenterfor SubstanceAbuseTreatmentof SAMHSA,the

Coalitionhasdevelopeda nationalagendatodevelopeffectivemodelsfor

screening,diverting,andtreatingthese individualsandtoestablish

comprehensivecommunity-basedsystemsof caretofacilitatetheir

rehabilitation.

Throughtheuseof innovativenationalforumsonjails,prisonsand the

juvenilejusticesystem,theCoalitionhas soughttobuildconsensusand to

designstrategicsolutionstotheproblemsitaddresses.Participantsin

theseforumsarecorrectionsprofessionals,judgesandcourt

administrators,mentalhealthtreatmentproviders,legislativeleadersand

policymakers,families,researchers,andrepresentativesof Federal

agenciesthathave responsibilityforthecareoftheseindividuals.

13
In additionto developinga knowledgebase, the Coalitiondisseminatesthe

information itgathers to those who can best use it. The Coalition has

developedtwo reports of importanceto this field, Respondingto the Mental

Health Needs of Youthin the Juvenile Justice System(1992), and Mental

Illness in America's Prisons. (1993).Both of these reportspresent

informationon state-of-the-artinterventionsto effectivelytreat or divert

personswith mental illnesseswho come into contactwith the criminai

justice system.

Professional The movementto improveconditionsinjailsand prisonshas been

accompaniedby a commitmentotheimprovementof healthand mental Guidelines health care.The genesisforthe developmentof standardsof care came

notfromadministratorsnorfromStateor Federalgovemment,butrather

fromprofessionalorganizations.The firstorganizationtopublishstandards

of careforjailsandprisonswas theAmericanPublicHealthAssociation

(APHA).

In 1976,APHA publishedStandards for Health Servicesin Correctional

Institutions.Whiledevotedprimarilytogeneralmedicalcare, thestandards

containedsixprinciplesfor adequatementalhealthcare,and represented

an importantfirststeptowardthedevelopmentof comprehensivemental

healthstandards.The AmericanMedicalAssociation(AMA)published

standardsforhealthsewicesfor prisonsin1979 andforjailsin 1981.A

separatedraftof mentalhealthstandardswas alsodevelopedat thistime,

butwas notpromulgated.

Thefirstcomprehensivestandardsfor mentalhealthcare incorrectional

settingswere developedby theNationalCommissiononCorrectional

HealthCare.The Commissionwascomposedof 28 professional

organizations,includingtheAMA, the AmericanBarAssociation,the

AmericanPsychiatricAssociation(APA),and the NationalSheriffs

Association.In 1987,theCommissionupdatedtheAMAstandards.This

organization'sprimarypurposeistoaccreditprisonandjailservices,and

thegroupalsofocusesoneducation,training,andresearch.

In 1982,theAPA createda Task ForceonPsychiatricServicesin

CorrectionalFacilitiestoaddressthespecificneedformentalhealth

standards.In 1989,the APA publishedthemostcomprehensiveset of

mentalhealthstandardsforjailsandprisonsthatcurrentlyexists.Manyof

the coreprinciplesandessentialservicesdiscussedthroughoutthis report

comedirectlyfromtheAPA guidelines.

14
The Legal Pmakes rovidinsense gmental fromhea

alth humanitar careto pian, ersons as well intashefcromrimina correctional aljusticesystem

Context managementperspective.However,evenintheabsenceofthese

necessities,jailsandprisonshavea substantialconstitutionalobligationto

providea minimumstandardof care.The followingdiscussiondraws

heavilyona reviewof case lawbyCohenand Dvoskin(1992).

Whiletheconstitutionalgroundsforthe rightsofindividualsdiffer for

convicted inmatesand unconvicteddetainees,what constitutes adequate

care is essentiallythe same. Thus, while the protectionof vulnerable

inmatesand the proactivetreatment of an identifiedserious psychiatric

disorder are required under Federal law, other issues such as staff training,

who provides the serviceand where, the treatment modality, administration

of the jail and treatment staff, and reimbursementor payment methods are

localand State decisions.

Cohen and Dvoskin (1992)state, "While the legal source of the right to

treatment for inmatesand detaineesdiffers(cruel and unusual punishment

v. due process),the case lawmakes no substantivedistinctions in terms of

what must be provided. Obviously,there are differencesin service delivery

systems; for example,jails experiencemore short-termcrises and suicides,

and fiscal and administrativerelationshipsmay vary. However, when the

courts addresswhat types of conditionsentitle which persons in

confinementto what type of medicalor psychiatriccare, the substantive

entitlementsare essentially the same."

Custodialfacilities have both the duty to protectand the duty to treat a

serious medical or psychiatriccondition.Case lawin this area has defined

the extent of these duties as they affect personswith mentalillnesses.

Duty to protect requiresa facility to providesafeguards so that the

inmate/detaineeis no worse off in custodythan he or she was upon arrival.

In additionto protectionfrom physicaland sexual assault,this also requires

that the facilityprotectthe individualfrom himself or herself.This includes

suicide prevention and early identificationand crisis intervention services to

keep the individual'sconditionfromdeteriorating.

In addition,the duty to treat requiresthat the custodial facility attempt to

alleviate knownsuffering. Once an individualis knownto be suffering from

a severe mentalillness,the facility is requiredto intervenethrough

appropriatestaff and treatmentsas determined by general professional

standards.

15
A case in NewYork, Langley v. Coughlin,actuallyprovidesa list of the

specificclaimsthat would indicateinadequate mental health care, and, in

conjunctionwith deliberate indifference,could justifya conclusion that an

individual's rightswere violated under the Eighth and Fourteenth

Amendments(Cohenand Dvoskin, 1992):

• Failureto take a completemedical(or psychiatric)record.

• Failureto keepadequaterecords.

• Failuretorespondtoinmates'psychiatrichistory.

• Failureto at leastobserveinmatessufferinga mentalhealthcrisis.

• Failuretoproperlydiagnosementalconditions.

• Failuretoproperlyprescribemedications.

• Failureto providemeaningfultrealmentotherthandrugs.

• Failuretoexplaintreatmentrefusal,diagnosis,andendingoftreatment.

• Seeminglycavalierrefusalsto considerbizarrebehavioras mentalillness

evenwhena priordiagnosisexisted.

• Personneldoingthingsforwhichtheyare nottrained.

Clearly,caselawindicatesthat the provisionofmentalhealthservicesto

personswithmentalillnesseswhocomeintocontactwiththecriminal

justicesystemisnota luxury,buta constitutionanel cessity.

A Diverse Furthercomplicatingthe provisionof mental healthservicesto personsin

the criminaljusticesystemis theheterogeneousnatureof thepopulation Population and the needsof such special groupsas women,persons of color,youth,

and personswith HIV/AIDS or other dual disorders. The characteristicsof

individualswith mental illnesseswho come into contactwith the criminal

justice system,and a discussionof their special needs, are discussed in

Chapter Three.

16
CHAPTER 3

The Nature of the

Population

A Diverse Group Peoplecome intocontactwiththe criminaljusticesystemfor many

reasons.Onlya smallportionof themhaveacutementaldisorders,butthis

groupdemandsdisproportionateattention,bothbecauseoftheirspecial

needsandbecauseoftheproblemstheyposeforlawenforcementand

correctionspersonnelandfortheproperadministrationof thecriminal

justicesystem.

Personswithmentaldisordersare a heterogeneousgroup.The effectsof

theirmentalillnessesrangefrompsychosis,toseveredisruptionsin

emotions,tofunctionalimpairmentsinthe abilityto relatetoothersor

sustainwork.They representdifferentages,gender,culturalandethnic

backgrounds,andsexualpreferences.They havea wide rangeof

experiencesandabilities,andtheyliveinmetropolitan,suburbanand rural

areas.A few havebeenviolent;mosthavenot.Allof thesefactors mustbe

consideredwhendevelopingmentalhealthprogramsinthecommunityand

inthecriminaljusticesystem.

Clearly,thereis anoverrepresentationof menand personsof color,

particularlyAfricanAmericans,incorrectionalfacilities.Men represent more

than 90 percentof the jail and prison populationsin the UnitedStates.

Further,nearlyhalf of all persons in U.S.jails and prisons are African

American,while persons of Hispanicdescent represent 14 percentand 17

percent of jail and prisonpopulations,respectively(Bureau of Justice

Statistics, 1993).

The magnitudeof this overrepresentationis clear when one considers that

only 11 percent of the U.S. populationin 1989was African American,and

all other non-White,non-Europeanethnic/racialgroups composed3

percent of the U.S. population(U.S. Departmentof Healthand Human

Services, 1993).This fact, alone, has implications for mental health

services provisionwithin the criminaljustice system in regardto such

fundamentalissues as languageand cultural diversity. In addition, some

groups,such aswomen and personswith HIV/AIDS,though representing

only a small percentageof the whole population,will require a

disproportionateamountof attentionto their special needs.

17
The currentdiagnosticmanualof theAmericanPsychiatricAssociation,

The Diagnosticand StatisticalManual of Mental Disorders, Third EditionRevised (DSM-III-R),listsapproximately300 identifiabledisorders.These

disordersvarygreatlyaccordingtothe degreeof functionalimpairment,

etiology,symptomatologyprognosis , andassociatedtreatment

interventions.The degreeof distressandtheabilitytoadapttosituations

willdifferdependingonboththetype andseverityof thementaldisorder.

ThisreportfocusesonadultswithmentaldisordersdefinedbyCMHS as:

someonewhocurrentlyorat anytimeduringthepastyear[has]

hada diagnosablemental,behavioralor emotionaldisorderof

sufficientdurationto meetdiagnosticcriteriaspecifiedwithin

DSM-III-R,thatresultedinfunctionalimpairmentswhich

substantiallyinterfereswithorlimitsoneor moremajorlife

activities(MentalHealthReport,June3, 1993).

Manymentalillnessesfollowa cyclicalcourse,allowingindividualsto

achieveorreturntoextremelyhighlevelsoffunctioningduringperiodsof

remission.Withtreatmentandsupportsprovidedona regularbasis,most

personswithmentalillnessescan functionwellincommunitysettings.

Most Persons The belief ina stronglinkbetweenviolenceandmentalillnessisfirmly

rootedinthemindsof manyU.S. citizens.It is importanttoevaluatethis with Mental belief objectivelybecausebeliefsdrivebothformalpoliciesand lawsand

Illnesses Are behaviortowardpersonswithmentalillnesses,and, if sucha linkdoesexist

and canbe specified,programmodelsandinterventionscanbe designed

Not Violent and implemented.

Infact, most peoplewithmentalillnessesare nomorelikelyto beviolent

thananyothermemberofthe community.However,some individuals,as a

resultoftheirmentalillnessesat certaintimes,dopresenta greaterrisk.

Researchershavefoundthatviolentbehaviorisdirectlylinkedtopsychotic

symptomsregardlessof whethertheindividualhaseverreceivedmental

healthservices(Link,1992),andthat personscurrentlyexperiencing

psychoticsymptomsmay beat increasedriskofviolence(Monahan,1993).

The recentNationalInstituteof MentalHealthEpidemiologicaCatchm l ent

Area studyrevealedthat90 percentof personswithcurrentmental

illnessesarenotviolent.Thisfactalonerefutesthedominantmedia

representationof mostpersonswithmentalillnesses.Infact, violent

behaviorofpersonswithmentalillnessesrepresentsonlya minor

contributiontoallviolentcrimes.Monahan(1992)statesthat:

18
"comparedwiththe magnitudeof riskassociatedwith the

combinationof male gender,young age, and lower

socioeconomicstatus, for example,the risk of violence presented

by mental disorderis modest.Compared withthe magnitude of

risk associatedwith alcoholismand other drug abuse, the risk

associatedwith major mental disorderssuch as schizophrenia

and affectivedisorder is modest indeed.Clearly, mental health

status makes at best a trivialcontributionto the overall level of

violence in society."

For those who might become violentduring acute episodesof mental

illness, several altemativesare possible.For example,such approachesas

conditionalreleaseand outpatientcommitmentshould be considered as a

way to compel cooperationwith a serviceplan for those persons who might

become violentwhen they do not complywith treatment.

In addition,IntensiveCase Managementprograms have shown

considerablepromisefor helping this population(Dvoskin and Steadman,

1994),and brief inpatienttreatment or crisis stabilizationservices may also

be warranted(Task Force on HomelessnessandSevere Mental Illness,

1992).Clearly appropriatelegal protectionsfor persons receivingvarious

forms of community supervisionare necessaryso that individuals' rightsare

properly balancedwith the community'sright to protection.

To the degree that theseservices are available,persons with mental

illnesses pose no greater threat to the communitythan other individuals. If

these elementsare not in place, some personswith mental illnesses may

commit violent acts that could lead to their arrest.

19
Consensus This statement was drafted by the John D. and Catherine T.

MacArthur Foundation Research Network on Mental Health and the Statement on Law, under the direction of John Monahan, Ph.D., in collaboration

Violence and with the National Stigma Clearinghouse.

Mental Disorder: "Mentaldisorder"and violenceare closely linked in thepublic mind.A

Public combinationof factorspromotes this perception: sensationalizedreporting by the media whenevera violentact is committedby a "formermental

Perceptions patient,"popular misuse of psychiatric terms (such as "psychotic"and

"psychopathic"),and exploitationof stock formulas and narrow stereotypes

vs. Research bythe entertainmentindustry. Thepublicjustifies its fear and rejectionof Findings people labeled "mentallyill,"and attempts to segregate them in the

community,by this assumptionof "dangerousness."

The experienceof people withpsychiatricconditionsand of theirfamily

memberspaints a picture dramaticallydifferentfrom the stereotype. The

results of severalrecentlarge-scaleresearchprojects conclude that only a

weakassociationbetweenmental disorders and violenceexists in the

community.Serious violenceby people with majormental disorders

appearsconcentratedin a small fraction of the totalnumber, and especially

those whouse alcoholand other drugs. Mental disorders---insharp

contrast to alcoholand drug abuse--account for a minisculeportion of the

violence that afflictsAmerican society.

Theconclusionsof those who use mental health services and of theirfamily

members,and the observationsof researchers,suggest that the way to

reduce whateverrelationshipexists between violence and mental disorder

is to make accessiblea range of quality treatmentsincluding peer-based

programs,and to eliminatethe stigma and discriminationthat discourage,

sometimesprovoke, andpenalize those whoseek and receive help for

disablingmental health conditions.

May 31, 1994

2O
Persons with Personswithmentalillnesseswho come intocontactwith thecriminal

justicesystemhavespecialneeds,as comparedtootherdetainees.Yet

Special Needs even within this group of personswithmentalillnesses,thereare

subgroupsthatwarrantparticularattention.Theseincludepersonswith

co-occurringsubstanceusedisorders,women,ethnicand racialminorities,

homelesspersons,personswithHIV/AIDS,andyouth.The needsof each

of thesespecialgroupsare describedinbriefbelow.

Persons with Co-occurring Substance Use Disorders

It is well known thatthereisa highincidenceofsubstanceusedisorders

amonginmatesinU.S. jailsand prisons.Between60 and 70 percentof

U.S.jail detaineeshavea historyof substanceabuse(AmericanJail

Association,1992).A 1991 Departmentof Justicereportfoundthat78

percentofthesurveyedinmatesreportedhavingusedsubstancesofsome

kind,excludingalcohol.And56 percentwereunderthe influenceof drugs

or alcoholat thetimeoftheirarrest.

AbramsandTeplin(1991)demonstrateda highprevalenceof co-occurring

disorders,as well.Ina randomsampleof malejaildetaineesinCook

County,IL,thelifetimeprevalencerateof co-occurringseveremental

illness(includingschizophrenia,mania,or majordepression)andalcoholor

drug abuseordependencedisorderswas72 percent.

Personswithco-occurringdisordershavespecialtreatmentneeds.For

example,suchindividualsmayneedtotakepsychotropicmedicationsto

controlpsychiatricsymptoms,whilemanysubstanceabuseinterventions

requireabstinencefromall drugs.Inaddition,symptomsof mentalillnesses

andof substancetoxicityoftenappearsimilar,makingit difficultfor

individualstoreceiveaccuratediagnosesand treatmentplans.

There are fewtreatmentprogramsforindividualswithdualdiagnosesin

localcommunitiesorwithinState andFederalcorrectionalsystems.Inmost

Stateprisonsystems,for example,personsreceiveservicesfromeither

mentalhealthorsubstanceabuseprograms.Insomecommunities,thereis

an increasingemphasisondevelopingintegratedmentalhealthand

substanceabusetreatmentmodelsforpersonswithdualdisorders(CMHS,

1993).Suchprogramsneedtoincludea focusonstafftrainingtohelp

providersinthe mentalhealth,substanceabuse,andcriminaljustice

systemsaccuratelyrecognizeandtreatpersonswithdualdisorders.

21
Women

Althoughwomenrepresentonlya smallpercentageofjailandprison

inmates,between5 and 10 percent,studiesshowtheyare morelikelythan

incarceratedmentohaveseverementalillnesses(Teplin,unpublished;

RiceandHarris, 1993).They are alsomorelikelythan men to be

diagnosedwith an affectivedisorder,which is easier to overlook since it is

less often associatedwith disruptive behavior.

Compoundingthe problemsof womenwith mental illnesses in the criminal

justice systemare issuesthat are not common or are non-existentamong

men. Amongthese concems that may require special attention are

pregnancy and primaryresponsibilityfor minor children,a history of

domesticviolence and early childhoodphysicalor sexual abuse, and

inadequate mentalhealth treatment and housinginjails and prisons.

In 1991,67 percentof women in prisonshad one or more children under

18, and 6 percentof all womenwho entered prisonthat year were

pregnant.This represents56,000minor childrenfor the 38,462women

incarceratedin U.S. prisons.Approximately70 percent of these women

livedwiththeir minor children priorto beingincarcerated(Bureau of Justice

Statistics, 1993).

Some women who are pregnant or who have minor childrenwill also have

mental illnesses,and women separatedfrom childrenor who are pregnant

are under increasedstress and may require mentalhealth services

targeted specificallyto these issues.These additionalstresses often can be

reducedby policiesinjails and prisonsthat allow children to visit and

programs that offer parentingcourses.

Mental healthand substanceabuse treatment programs that are offered to

women injails and prisons may need to assess and provide additional

services to women withhistoriesof physicalor sexual abuse. Among

persons withmental illnessesin general,women are more likely than men

to be victims of abuse,particularlysexualabuse (Carmen, Rieker, and

Mills, 1984;Jacobsonand Richardson,1987).

In addition,historiesof abuse are common among incarceratedwomen.

Rann (1993)foundthat 50 percentof female Michiganjail detainees had

been victimsof physicalor sexualabuse at some point in their lives. More

than 70 percentof women withdrug or alcohol abuse problems were

victims of violence, includingdomestic assault by adult partners, rape and

incest (NationalCouncilon Alcoholism, 1990).

22
Becausewomenrepresenta smallproportionof jailand prisonpopulations,

manyfacilitiesdonotprovidea fullrangeof mentalhealthservices,or

appropriatehousingoptions,forfemaleinmates/detainees.Further,

servicesthatare offeredareoftenbasedonthe needsof men.

Ethnic and Racial Minorities

Ethnicand racial minorities,particularlyAfrican-Americanand Hispanic

individuals,areoverrepresentedinU.S. jailsandprisons,comprising57

percentofjail populationsand65 percentofprisoninmates(Bureauof

JusticeStatistics,1993).Mentalhealthprogramsforsuchindividualsmust

bedesignedandimplementedbasedontheculturalexperiencesof the

personstheyare meanttoserve.Mentalhealthandcorrectionalstaff

shouldbe trainedtobesensitivetoculturalissuesand,totheextent

possible,shouldreflectthedemographicmixof thepopulation.

Persons Who Are Homeless

Personswith mental illnesseswhoarehomelessare amongthe mostlikely

individualstobearrested,andincarceration,ratherthan releaseonbond,

increasestheprobabilitthat y personswithmentalillnesseswillbe

homelessuponrelease(DennisandSteadman,1991).

Arrestratesfor homelesspersonswithmentalillnessesrangefrom20 to75

percent,andthemajorityoftheseindividualsare arrestedfor"trivial,

victimless,andnon-violentoffenses"(DennisandSteadman,1991). Many

homelesspeoplewhocommitminorcrimesdoso inordertoobtainbasic

necessities,suchas shelter,foodandmedicalcare.

Teplin(1987) notesthatarrestisoftenthe onlydispositionavailableto

policeinsituationswhere personsare notsufficientlydisturbedtowarrant

hospitalization,buttooilltobe ignored.Releaseonone'sown

recognizanceorlowbailis lesslikelyifthedetaineeisknownto be

undomiciled.

Typically,neitherthementalhealthorcriminaljusticesystemsare prepared

tomeetthefullrangeof mentalhealth,housing,andsupportneedsof

personswith mentalillnesseswhoarehomeless.Gelbergandcolleagues

(1988) recommendthatmentalhealth,drugand alcoholtreatment,housing

programs,and socialservicesbeprovidedin a sing_e,coordinatedsetting

for homelesspersonswithmentalillnesseswhohavecommittedminor

offenses.

23
Persons with HIV/AIDS

In 1991,51 percentof StateandFederalprisoninmateshadbeentested

forthehumanimmunodeficiencyvirus(HIV). Overall,2.2 percentwere

foundtobe HIVpositive,withwomen,African-American,and Hispanic

inmatesmorelikelythanCaucasianmentocarrythevirusthatcauses

AIDS.

Personswithmentalillnessesmaybe particularlyvulnerableto HIV/AIDS,

and individualswithadvancedcasesof AIDS mayexperienceorganically

basedpsychiatricdisorders(EvansandPerkins,1990). Inadditiontothe

dementiaaccompanyingthediseaseprocessitself,suicideandsuicidal

ideation,depression,andanxietymayalsooccur.

Clearly,inmateswith HIV/AIDSmusthave accesstoa fullrangeof health

and mentalhealthcare, includingpsychosocialandpharmacological

interventionsandAIDS-specificcounselingandsupportservices.Such

specializedservicesare helpfulnotonlytopersonscopingwiththe disease,

butalsoinpromotingHIV riskreductionfor uninfectedpersons(National

InstituteofJustice,1993).

Whilemanycorrectionalsystemsofferspecialcounseling,housingand

servicesto inmateswith HIV/AIDS,these programsareoftenunderstaffed,

sharingmentalhealthprofessionalswithmoregenericcaseloads.To meet

thementalhealthneedsof inmateswithAIDS, morethan halfof Stateand

Federalprisonfacilitiessponsorpeercounselingandsupportprograms.

TheyalsoreportusingcommunityAIDSserviceorganizationstoprovide

individualizedcounselingand supportwithintheirfacilitiesandtohelp

paroleesandotherscomingoutof prisonobtainneededservices.

Youth

The juvenilejustice system is a completelyseparatenetworkofcourts,

facilities,andserviceagenciesfromthe adultsystem.Theneedsof

juvenileswithmentalillnessesinthejuvenilejusticesystemareextremely

important,andcannotbecoveredadequatelyinthescopeofthisreport,

whichfocusesonadults.However,oneissuethatdoesmeritmentionis the

treatmentofyouthwhoarewaivedintoadultcourts.

24
In 1991, 1 percentof inmatesinState correctionafal cilitieswere 17 years

oldoryounger(Bureauof JusticeStatistics,1993).Youthinthe criminal

justicesystemhavehigherratesof mentalillnessthanyouthinthegeneral

population(Ottoet al., 1992).Theyaremorelikelytohaveconduct,

attentiondeficit,anxiety,andaffectivedisordersthanpsychoticdisorders,

withconductdisordersanddepressionmorecommonamongadolescents,

andanxietydisordersmoreprevalentamongyoungerchildren(Costello,

1989).

Youngpersonswithmentalillnessesboundoverinadultfacilitiespresent

severalmentalhealthissuestoadultcorrectionalfacilities.Becauseoftheir

youthand theirmentaldisabilities,theyareat increasedriskof sexualand

physicalabusebyotherinmates.Programsforyouthinadultfacilities

shouldattendtothe kindsof mentaldisorderscommonamongyouth,be

tailoredtothe interestsandproblemsofadolescents,andaddressthe

specialproblemsof victimization.Comprehensiveandintegrated

family-orientedservicesinthecommunitycanhelpdivertyouthfrom the

criminaljusticesystem.

Needed Services Just as personswith mental illnesseshave diverse needs,sotoo will those

needs vary dependingon the point at which they come intocontact with the

criminaljustice system.A personwhose acute psychiatric crisis brings him

or her to the attentionof the police may need immediatestabilization,while

a prison inmatewith severe mental illnesswill likely require ongoing

treatment and support.

And the responsibilitiesof the criminaljustice system for persons with

mental illnesseswill differ at eachstage, as well. An individualmay be

detained injail for a short periodof time, so that jail staff may focus

primarily onmaintainingcontinuityof anycommunity-basedservicesthe

person is receiving.Personnelresponsiblefor individualswith mental

illnesses on probationor parole inthe community may act as case

managers to brokera full range of health, mental health, housing,and

social servicesfor their clients.

These distinctions-- the varying needs of personswith mental illnesses at

differentstages of the criminaljustice system, and the differing

responsibilitiesof the criminaljustice system for persons with mental

illnesses intheir charge-- are explained in Chapter Four.

25
CHAPTER 4

Defining the Needs of Persons

with Mental Illnesses in the

Criminal Justice System

Racknrountl There are numerouspointsat whichindividualswithmental illnessesmay

come intocontact with the criminaljustice system. They may be arrested by

the police,heldfor a short periodof time in a Iockupor localjail, servea

sentencein prison, or be supervised on probationor parole in the

communityafter detention injails or prisons. Eachof these points in the

systemwill be describedin this chapter,with special emphasis on the

needs of personswith mentalillnesses at each point and the

responsibilitiesof the criminaljustice system for the individuals intheir care.

Special challengesat each stage will be highlighted.

Table4.1 displaysthe pointsof contact in the criminaljustice system, the

primary relatedmental healthtreatment issues, and the key services that

ideally should be available at each level.As indicatedin Table 4.1, the

primary decisionfor law enforcementofficers is to arrest or to transport an

individualto a mental health facilityand attemptto get him or her into

treatment.Services that make this choice possible includethe availability

and accessibilityof 24-hour emergency mental health treatment,mobile

crisis teams that can assist in the resolutionof the incident,transportation,

and staff who can waitwith an individualfor an evaluation.

The primary issuein both Iockupsand jails is the safety of the detainee,

other inmatesand custodialstaff. Inmates are briefly held pre-arraignment,

after not meetingbail, or while serving sentencesof less than one year.

Half of all inmates leave within 24 hours.Key services at this point include

identificationof personswith mental illnesses through routinescreening and

follow-upevaluations,and stabilization of the individualthrough crisis

interventionservices. In addition,to facilitate the movement of persons with

mental illnesses back into the community or to a prisonsetting, discharge

planningand case managementservices are important.

Prisonsare containedcommunities,where inmates spend a considerable

amount of time. Inmateswith mental illnesses,like persons with mental

illnesses in the general community, have the right to treatment to improve

the quality of their livesand to allow them to serve their time humanely.The

optimum level of availableservices should duplicatethe bestthat is

available in the community;there should be a full range of inpatient and

outpatienttreatments and modalitiesavailable to all inmates.

26
TABLE 4.1

Points of Criminal Justice Contact and

Primary Mental Health Treatment Goals

Location Main Treatment Issues Key Mental Health Services

Police Arrest or diversion to mental Emergency MH services

health treatment Mobile crisis teams

Transportation

Lookup Safety of detainee, other Screening

inmates and staff Evaluation

Crisis intervention

Jail Safety of detainee, other Screening

inmates and staff Evaluation

Crisis intervention

Discharge/transfer planning

Prison Do sentence time humanely Screening

Maximize participation in Evaluation

prison programs and Crisis intervention

community Long-term treatment

Special non-medical housing

Discharge/transfer planning

Community Supervision Maintain individual in the Access to a full range of

(1) Probation community community-based mental

(2) Parole Protect the community health services

27
Similarto the prison,personsundercommunitysupervision(i.e.,probation

or parole)need a full range of mental healthservices available for their use.

Theseservices should help to maintainpersonswith mentalillnesses in the

communityand, to the degree that symptomatologyis kept to a minimum

and that the mental disorderwas linkedto criminal behaviorin the past,to

reducethe risks of recidivism.

An issuethat often surfacesin discussionsof mental health services in

correctionalsettings is the conflict betweentreatment and security, or

therapyversus custody.Often it is taken as a given that the respective

ideologiesof the criminaijustice and mental healthsystems are inherently -

contradictoryand will produceconflictswherever the two intersect(see

Steadmanet el., 1985 for a reviewof the literature).

However,Steadmanand colleagues (1985), in a study of 43 U.S. jail

mental health programs,found that fundamental conflictsbetween mental

health and correctionsstaff were not frequent. In providingfor the safety of

detaineesand inmateswith mental illnesses,other detaineesand inmates,

and custodial staff, the goals of mental health treatment and corrections

actuallyconverge.Accordingly,correctionsstaff believethat appropriate

mental health interventionscan help them to do theirjob better.

Police as Lawenforcementofficersare frequently thefirstprovidersinthe cdminal

justicesystemtohavecontactwitha personwithmentalillness.In addition

Frontline Mental totheirroleas peacekeepersandcrimefighters,policespenda

Health Decision considerableamountof timeassistingcitizensand mediatingdisputes.The

policeofficerhasbeen describedintheliteratureas "philosopher,guide

Makers and friend"and "amateursocialworker"(Cumminget el., 1966),

"streetcomerpsychiatrist(Teplin " andPnJett,1992),and"psychiatristin

blue"(Menzies,1987).

There are severalwaysthatpersonswithmentalillnessescometothe

attentionof policeofficers.Theymaybe the objectof a callinvolvinga

citizenorbusinesscomplaint,an officermay observethem actingin an

inappropriate,bizarre,orcriminalmanner,or policemay havea courtorder

orwarrantforan emergencypsychiatricapprehension.In addition,police

receivecallsfrompersonswithmentalillnessesrequestingassistance.

28
In a study of mentalhealthcallsto police in a Denver suburb, 50 percent of

contactswere callsfrom friends or relativesrequesting police assistancefor

noncriminalactivity,30 percentwere calls from personswith mental

illnesses, 17 percentwere calls from community members who did not

know the individualpersonally,and 3 percentwere policeobservation

(Pogrebin,1986-87).Another study revealedthat of all policecontacts with

citizens,excludingtraffic violations,4 percent involved personswith

suspectedmental illnesses.Of these, 65 percentwere noncriminal and 35

percentwere suspects in a crime (Teplin and Pruett, 1992).

Making Difficult Decisions

Despitethesmallpercentagesofcomplaintsthat involvepersonswith

mental illnesses,these can be difficult cases for police to handle. There has

alwaysbeen an inherentconflict for officers in how to best serve the needs

of the communityand the needs of the individualwith mental illness. Law

enforcementofficers are often not sure how best to help.

In general,policeofficers feel competent to determinewhether an individual

meets the legal criteriafor emergency psychiatricdetention (Gillig et al.,

1990). Nonetheless,while officersmay feel confidentthey can identify

severe psychoticdisorders, it is not clear that they are well trained to

identifyother serious disorders,such as bi-polaror major depression.

Police may be unfamiliarwith what mental health services and facilities are

availablein the communityand how to contact them. Some communities

lack neededmental healthfacilities, while existing agencies often have

limitedspace for police referrals,restrictiveadmission criteria, complicated

admissions procedures,and prohibitivefinancial requirements. In addition,

the needfor a mental healthagency to restrict confidential information

about a clientmay conflict with the law enforcement officer's job of trying to

decide on the best dispositionfor a particularindividual.

While emergencystabilizationof an individual may be a high priority, some

communitiesdo not have 24-hour services or mobile crisis teams. Oftenthe

only options availableto police in lieu of arrest are transportation to a

community mental healthcenter duringthe hoursit operates or to a general

hospitalemergency roomthat may be reluctant to take problem cases

(Steadman,1990).Transportationof personswith mental illnesses can take

a considerableamount of an officer's time, and if the facility will not or

cannot take the individualdue to commitment laws or the unavailabilityof

beds,the problemremains unsolved. The officer must then decide whether

to arrestor releasethe individual.

29
Today,as inthe past,policeare reluctantto arrestpersonswithmental

illnesseswhocommitminorcrimesor arecreatinga disturbance.They also

are reluctanttohavetheindividualhospitalized,if informaloptionsare

available,suchas transportationtothe individual'sfamily(Cumminget al,

1966).

Whilea psychiatrichospitalizationispreferredtoarrest,manyofficerswill

geta signedcomplaintsothat,if thefacilityrefusestoadmittheperson,an

arrestcanbe made.Arrestisthesolutionof lastresort.'q'he policewill

arrestratherthanhospitalizethe majorityof mentallydisorderedpersons

who commit misdemeanorswhen they have prior knowledgethat the

personwill be releasedin a very short periodof time due to the shortageof

beds at the medical facility,or that the person's behaviorwill probably not

satisfy commitmentcriteria. In these instances,policewill put the person in

jail where they knowthey will be removedfrom the community"(Pogrebin,

1986-87:68).

Further,dispositiondecisions are often based on how long each altemative

will take. Psychiatrichospitalizationbecomesa less attractivealternative in

places that have lengthywaits for evaluation.

Officers are clear regardingwhat assistancethey want from the mental

healthsystem in order to perform their duties.Once a problemhas been

identified,proper resolutionrequiresinformation and, sometimes,

assistance.Officers state that the most helpful informationthey can have in

their encounterswith personswith mental illnesses is knowledge of any

pdor history of psychiatricand substance abuse problems, including the

potentialfor dangerousnessor suicide, and information about current

psychiatricstatus, includingwhether individuals are currently intreatment

and where (Gilliget al. 1990).

In addition, consultationwith community mental health professionalsand

availabilityof mobile mental health crisis teams that can respond within 15

minutes of a request have also been noted as important services (Gilliget

al. 1990). Open linesof communicationbetweenthe police and the mental

healthsystem and formal avenues for response will help law enforcement

officialsmeet their twin goals of protecting the public and helping persons

with mentalillnesses they are called on to aid.

30
Lockupsand After an arrest is made, an individualwill be held in a Iockupand possiblya

jail. A Iockupis "usuallya holdingfacility operated by police or other law Jailsas enforcementagencieswhere arresteesare heldwhile bookingandother

Community prearraignmentprocesses are beingcompleted"(Reed1987). They rarely

Institutions keep detaineesbeyond24 hoursexceptoverweekends.

JailsdifferfromIockupsinthattheyare placeswherepostarraignment

inmatesare detained,and are usuallyoperatedbythesheriff'sofficeorthe

municipalcorrectionalagency.The U.S. Departmentof Justice(1980)

definesa jailas "a locallyadministeredconfinementfacilitywith

authorizationtoholdpersonsawaitingadjudicationand/orthosecommitted

after adjudicationtoservesentencesofoneyearorless."

In 1991,therewereapproximately3,353jailsintheU.S., ranginginsize

from50 inmatesorless(59 percentofalljailsinthe U.S.) to 1,000or more

inmates.Jailswithratedcapacitiesof 250 or more(10 percentof all U.S.

jails)house63 percentof alljaildetainees(UnitedStatesDepartmentof

Justice,1990).

Mostjailinmatesare men (91percent),and 57 percentareAfrican-American,

Hispanic,ormembersofotherracialandethnicgroups.Fifty-onepercentof

jail inmatesare unconvicted(UnitedStatesDepartmentof Justice,1991).

Jailovercrowdingisat epidemicproportionsthroughouttheU.S. Notonly

are largenumbersofjailsantiquatedandbarelyable tomeet minimal

standardsofcare, butalsojailpopulationsare exploding.

From1980to 1992,thenumberof personsinjailonanygivenday inthe

UnitedStatesincreasedfrom 158,394to444,584 (Bureauof Justice

Statistics,1993).In 1990,jailswere functioningat 111percentcapacity

overall.And142 jurisdictions(28 percentof alljurisdictionscontainingjails

with100or morecapacity)hadat leastonejail undercourtorderto reduce

inmatepopulation(UnitedStatesDepartmentofJustice,1992).

AmongtheburgeoningpopulationsinU.S. jailsare largenumbersof

personswithmentalillnesses(seeTable4.2). A recentsurveyof a random

sampleof malejailadmissionsinCookCounty,IL,foundthat6 percenthad

a currentpsychoticillnessandwere inneedof treatmentservices(Teplin,

1994). AmongfemaleCookCountydetainees,the estimatesof mental

illnesswereevenhigher.Fully15 percentofthefemale detaineeshada

diagnosisof schizophreniaoraffectivedisorderandhadan acuteepisode

withinsixmonthspriortoarrest(Teplinetal., unpublished).

31
TABLE 4.2

Prevalence of Severe Mental Disorder

Among the General Population and Jail Detainees

Major Any Severe

Depression Schizophrenia Mania Disorder

GeneralPopulation* 1.1% 0.9 % 0.1% 1.8%

Male Jail Detainees** 3.4% 3.0% 1.2% 6.1%

FemaleJailDetainees*** 13.7% 1.8% 2.2% 15.0%

* From Teplin, L.A. 1990. "ThePrevalence of Severe Mental Disorder Among Male UrbanJail

Detainees." American Journal of Public Health, 80:663-669.

** Updated from Teplin, L.A. 1994. "Psychiatric and Substance Abuse Disorders Among Male

Urban Jail Detainees." American Journal of Public Health, 84(2):290-293.

*** Teplin, L.A., Abram, K.M. and McClelland, G.M. 1995. "The Prevalence of Psychiatric

DisorderAmong IncarceratedWomen: I. Pretrial Jail Detainees." Unpublished.

32
On a nationallevel,thiswouldindicatethat annually,approximately

700,000 admissionsto U.S.jails are individuals with acute and severe

mentalillnesses.An additional 10 to 15 percentof inmates have mental

health problemsthat put them at risk due to the nature and stress of the

environment.

Mental HealthServices in Jails

On the average,individualsspendveryshortperiodsoftimeinjail. During

thistime,thejailisattemptingtoperformitscustodialfunctionof safe

pretrialdetentionwhileaddressingthe mentalhealthproblemsof

individualswhoseaccesstocare ishighlyrestricted.

Often,when a personisdetained,heor sheis notevaluatedformental

healthproblems,ortheseproblemsare maskedby drugoralcohol

intoxication.Thiscanresultinan interruptionof servicesthatthedetainee

mayhavebeenreceivinginthe communityandleadtoan exacerbationof

hisor hersymptoms.Inthesameway,afteran inmateis stabilizedinthe

jail,lackofdischargeplanning,includingreferralto mentalhealthtreatment,

socialservicesandhousing,willleavetheinmate,again,withoutnecessary

supports.

To establishappropriateservicesforpersonswithmentalillnesseswhoare

detainedrequiresthatthejail beseenas butoneagencyina continuumof

communityservices(Steadmanet ai., 1990).Althoughthejail existsas a

separateentity,itsprimaryfunctionis "processingpeople,"anditis best

characterizedbyitsinteractionwithotherrelevantcriminaljusticeagencies,

includingthepolice,thecourts,thelegalcommunity(defenseanddistrict

attomeys),and,ultimately,communityservices.It is importanttohighlight

this"systemic"aspectofthejailandto approachmentalhealthservices

issuesinsucha fashion.

Exceptforthelargestjails,itis impracticaltoconsiderdevelopinga

comprehensiveset ofmentalhealthserviceswithina jail. Thisis warranted

neitheronthe basisofneednorintermsofthedollarsor physicalspace

available.Itisfar morepracticalforthe jailto makeeffectiveuseof such

localservicesas communitymentalhealthcenters,psychiatricunitsof

generalhospitals,privatepractitioners,universitydepartmentsof

psychology,medicine,and social work, andState mental hospitals.

"Effective use"doesnot necessarilymean actuallytransferring inmates, but

does mean capitalizingon the expertiseof the staffs of these programs and

planningservices inways that share program resources.

33
Over the pastdecade, directgovemmentalexpendituresfor corrections

haveincreasedby216 percent(UnitedStatesDepartmentof Justice,

1991). Despitethisincreaseinexpendituresandtheexpansionof physical

plants,at theendof 1990,Stateprisonswereoperatingat 18 to 29 percent

overcapacity,whileFederalinstitutionswere51 percentovercapacity.

In 1991,95 percentofthe U.S. prisonpopulationwas male,and32 percent

was overtheage of 35. Eventhoughonlya smallminorityof inmatesare

female, theproportionof womencontinuestogrow.Sixty-f'_epercentofthe

populationisAfrican-American,Hispanic,or otherracialand ethnicgroups.

Of themostseriouscharges,47 percentof U.S. prisoninmateswere

servingtimefor a violentoffense,25 percentfor propertyoffenses,21

percentfordrugoffensesand7 percentfor publicorderorotherminor

offenses(Bureauof JusticeStatistics,1993).

Level of MentalHealthServiceNeed

Clearly, the prison populationis differentfromthejailpopulationintermsof

seriousnessof offenseand lengthof confinement.However,likejails,a

sizableportionof prisoninmateshave mentalillnesses.Estimatesof severe

mentaldisordersamongprisoninmatesgenerallyrangefrom 6 to 15

percent(MonahanandSteadman,1983;SteadmanandCocozza,1993).

Inaddition,co-morbidityisan importantfactorinthemanagementof

personswithmentalillnessesin prison.Whilearrestsforall crimeshave

increasedby28 percentoverthepastdecade,arrests fordrug related

crimeshave increasedby126 percent(UnitedStatesDepartmentof

Justice,1991).Asof 1991,45 percentof U.S.prisoninmateswereserving

timefordrugoffenses.Further,79 percentstatedthattheyhad useddrugs,

excludingalcohol,inthepast,and62 percentsaidtheyuseddrugsona

regularbasis

The increaseinthenumberof drugarrestshasexacerbatedtheproblemof

prisonovercrowdingandcontributedtoan increaseinthenumberof

inmateswithcommunicablediseases,includingHIV/AIDS,tuberculosis,

andhepatitis.Thesefactors,combinedwithinsufficientprogramstotreat

substanceabuse,complicatetheprovisionof mentalhealthservicesto

prisoninmates.Healthandmentalhealthinterventionsmustfocuson

treatingindividualswith multipleproblems.

36
"Community Mental Health" in Prisons

The prison is its own full-fledgedcommunity,albeita containedone.People

eat, sleepandworkthere24 hoursa day.It hasitsownsocialnetworks

andsubgroups,itsownreligiouscommunities,anditsowneducational

systems.

Forthisreason,itis usefultoconceiveofprisonmentalhealthinthe

contextofprovidinga "communitymentalhealthsystemforeach prison"

(CohenandDvoskin,1992).Thisconceptualizationis crucialtothe

planningof appropriate,cost-effectivementalhealthservicesforprison

inmates.

The mentalhealthissuesofprisoninmates,infact, closelyparallelthoseof

personsinthecommunity.Sincemostinmateshavebeeninthecriminal

justicesystemforsometimepriortotransfertoprison,acutepsychiatric

problemsare notusuallythepredominantconcern.

Prisoninmateswithmentalillnessesneed intermediateandlong-termcare.

Becauseseverementalillnessestendtobe cyclicalandepisodicinnature,

the needsofinmateswiththesedisorderswillvarygreatlyoverthetime

theyareincarcerated.Reflectingthecommunitymentalhealthmodel,the

AmericanPsychiatricAssociation(1989)contendsthatessentialprison

mentalhealthservicesincludementalhealthscreening,evaluation,crisis

intervention,treatment,anddischarge/transferplanning.

In reviewingmentalhealthservicesuseby inmatesinState adult

correctionalfacilities,a 1988CenterforMentalHealthServices report

foundthat2.5 percentwere receiving24-hourpsychiatricinpatient

treatmentorresidentialserviceswithinthe p_son setting, 10 pementwere

receivingcounselingor psychotherapyfroma mentalhealthprofessional,5

percentwerereceivingpsychotropicmedications,and4 percenthada

psychiatricassessmentor evaluationcompletedduringthestudymonth

(thesepercentagesreflecta duplicatedcount).

Of course,notall inmateswithmentalhealthneedsare receivingservices

(GeneralAccountingOffice,1991).Morethan halfofthe Federalfacilities

surveyedstatedthattheyhadsomeinmateswhosementalhealthhadnot

beendiagnosed.

37
The failuretodiagnoseinmateswithmentalhealthserviceneedswas due

to inparttoinmates'abilitytosuccessfullyfunctioninthegeneralprison

population,andtoinadequatescreeningproceduresallowingsome

individualswithmentalillnessestogounrecognizedFurther, . manyinmates

diagnosedas beinginneed oftreatmentwere notreceivingany because

theyrefusedservicesortherewas a lackofavailablementalhealth

resources.Betterandmoreuniformmethodsof identifyingpersonswith

mentalhealthneedsandthefurtherdevelopmentof mentalhealthservices

canhelpinsurethatall prisoninmateswhoneed andwantsuchservices

receivethem.

Clearly,personswithmentalillnesses,regardlessofwhethertheyare

prisonersornot,sometimesrequireinpatientcare. The provisionof both

inpatientandoutpatientserviceswithintheprisonsettingfacilitatesthe

integrationof inmateswithmentalillnessesinthegeneralprisonpopulation.

Probation and Afterjailor inlieuofjail,personsmay besupervisedbyprobation

departmentsSimilarly, . communitysupervisionbyparoledepartmentsoften Parole: followsreleasefromprison.

Uncharted Likejail and pnson populations,the number of personswhoare under

Territory supervisionby probationand paroledepartmentshas increased dramaticallyinthepastdecade.As of December31, 1990,therewere

2,670,234 personssupervisedbyprobationdepartmentsand531,406

individualsupervisedby paroledepartments,representingone-year

increasesinthosepopulationsof 5.9 percentand 16.3percent,respectively

(BureauofJusticeStatistics,1993).Overallan estimated3 millionadultsor

1.7 percentoftheadultpopulationinonprobationorparole.

The percentof personsundercommunitysupervisionthroughprobationor

parolewho havementalillnessesis unknown.However,based on

prevalenceratesof mentaldisordersforjail admissionsand dataonprison

inmates,itcanbe assumedthatthe rateof mentaldisordersamong

paroleesandprobationersistwotothreetimeshigherthan thatof the

generalpopulation.Giventhe prevalenceof mentalillnessesinjails and

prisonsandthefactthatmanyseriousdisordersare undertreatedor

untreated,itisclearthata significantproportionof paroleesand

probationersrequirea rangeof mentalhealthservicesinthe community.

38
Probation

Criminaldefendantswhoreachthesentencingstageinadjudicationhave

pleadorbeenfoundguiltyof a crime.Sentencesmaytake severalforms,

includingincarcerationina jail or prison,finesorcommunityservice,and

probation.TheAmedcanBarAssociation(1970)definesprobationas "... a

sentencenotinvolvingconfinementwhichimposesconditionsandretains

authorityinthesentencingcourtto modifytheconditionsof sentenceorto

resentencetheoffenderifhe violatestheconditions.A sentenceto

probationshouldbe treatedas a finaljudgementforpurposesof appeal

and similarproceduralpurposes."

Probationsentences can be applied to felonies, as well as misdemeanors.

Individualsmay be sentencedto probationonly, or probation may be one

part of a sentencethat also includes incarceration.About 40 percent of

probationcases are split sentences, with 75 percent involvinga median

6-monthjail term, followed by three years of probation, and 25 percent

entailinga medianfour-yearjail term, followed by three years of probation

(Dawson, 1990).

There are three types of conditions that can be applied to a probation

sentence:(1) standardconditionsapplied to all probationers,such as

reporting regularlyand notifyingthe probation office of a change of address;

(2) punitiveconditions,including paying fines or performingcommunity

service;and (3)treatment conditionsthat are imposedto address special

needs of the individual,such as substance abuse or mental health

treatment.

In the past 20 years, the focus of probation has changed from rehabilitation

within a medical/socialwork modelto risk managementand brokering of

services.The earliermodel stressedthat probation officers provide direct

services such as counseling,much like a social worker. More recently,the

role of the probationofficer is much more that of a corrections officer.

Specialservices are brokered through the officer, but not provided by him

or her.

Typically,the probationofficerrefersindividualsto specializedcommunity

services,such as mentalhealth and substance abuse treatment,that are

availableto all membersof the community. The probationofficer's role as

brokeris critical, becausecommunity programs are often reluctantto

accept personswho are involvedwith the criminaljustice system and who

may be participatinginvoluntarily.

39
In additionto brokeringservices,someprobationdepartmentshave

provided treatment programs through the probationagency itself. While

persons receivingservices from genericcommunity agencies tend to have

higher rates of technicalviolations of their conditionsof probation due to

their unwillingnessto participate in treatment programsagainst their will

(Wilson, 1978), personsinvolved in programsoperated by the probation

agency have reducedrecidivismfor certain types of offenses (Gottfredson,

et al., 1977).

Parole

Usually,parole is a termthat describes both a releasemechanism from

incarcerationand a form of communitysupervision.Consistentwith this

concept, paroleis defined as "the conditionalreleaseof an inmate from

incarcerationunder supervisionafter a portionof the prisonsentence has

been served"(Clear and Cole, 1990).Recent changes in sentencing toward

determinatesentences and mandatoryrelease has eliminatedthe

discretionarypower of parole boards,but has not supersededthe need for

communitysupervisionof releasedfelons.

Duties of the paroleofficer are virtually the same as those of the probation

officer.Paroleofficersoften act as intensivecasemanagers,monitoringan

individual'sprogress and helpingto connect himor her to needed services

in the community.

Communication and collaboration betweencorrectionalstaff and

community service providersis essentialto help personswith mental

illnesses functionwell in the community and successfully completethe

terms of their probation or parole. Further,education of probationand

parole officers in some of the uniqueproblems that personswith mental

illnessesface in the communitycan help the officersaccommodate the

sometimes unusual,but not criminal, behaviorof those under their

supervision.

40
Diversionto Some individualswithmentalillnessesdo not belongin jail. In its 1988

reportExemplaryCounty Mental Health Programs,theNationalAssociation Cornm u n ity of countiesnoted"jailis inappropriattreatment e forpeoplewithmental Services illnesswhocommitmisdemeanorsornocrimeat all.Suchindividualsneed

to bedivertedfromjailtoa continuumof serviceswhichincludecrisis

intervention,outreach,residential,vocationaltraining,familysupport,case

management,andothercommunitysupportservices"(Adams,1988).

However,itisequallyclearpersonswithmentalillnesseswhocommit

..sedousoffenses"warrantcorrectionaldetentiontoaccommodatecriminal

justiceprocessingand communitysafety concerns"(Steadman,1990).

Theseindividualsarenotcandidatesfor diversion,butrequirepsychiatric

attention.Whenindividualswithmentalillnessescan be appropriately

divertedfromthecriminaljusticesystem,ithelpsreducejailovercrowding

and promotethesmoothoperationof jailprograms(NationalAssociationof

Counties,1988).

Individualswithmentalillnessesmaybe identifiedfor diversionfrom the

criminaljusticesystemat anypoint,includingpre-bookinginterventions

(beforeformalchargesare brought)and post-bookinginterventions(after

the individualhasbeenarrestedandjailed).Post-bookingdiversionefforts

can takeplaceinthejailorthroughthecourtsystem.

Regardlessof itstypeorlocation,a diversionprogramis onethat screens

individualsforthepresenceof mentaldisorders,evaluates thosepersons

determinedtobe inneedof mentalhealthtreatment,andnegotiateswith

prosecutors,defenseattomeys,community-basedmentalhealthproviders,

andthecourtstoproducea dispositionoutsidethe jail inlieuof prosecution

or as a conditionofa reductionincharges(whetheror nota formal

convictionoccurs).

Thisdefinitionincludesprogramsthatallowindividualsto awaittrialinthe

community,ratherthanjail. In addition,althoughitis notacknowledgedas

a formaldiversionprogram,thepleabargainis oftenusedto keep

defendantswithmentalillnessesoutofjail. Courtdecisionsmay rangefrom

droppingchargesaltogetherto requiringmentalhealthtreatmentas a

conditionof probation.

Diversionprogramsmaybeprimarilyoperatedbya mentalhealthservice

provideror bya componentofthecriminaljusticesystem,includingthe

policedepartment,jail,orcourts.However,tobe trulyeffective,diversion

programsmustinvolvetheclosecollaborationof allrelevantstakeholders.

The benefitsofsuchcollaborationare substantial.

41
In additionto reducingthe numberofpeopleheld unnecessarilyinjail,

diversionprograms help personswith mentalillnesses become connected

to appropriatecommunity-basedservices,insuringcontinuity of care. This

leads to minimumdisruptionin both the individual'slife and the jail's

programmingand security.Another importantbenefit is that diversion

programs can be developedwithout significantadditionalcosts. The

primary resourcesare spent in the developmentof working relationships

amongthe key players,includingpolice, courts, probation,jail staff, mental

health programs,and other community resources.

Ultimately,for diversionto be successful, a wide array of community mental

health and other support servicesmust be availableand accessible. Many

individualswith mental illnesseshave a range of needs, including

medicationmanagement,housing,drugand alcohol abuse treatment,

social services, and other supports.

Plannino Coordinatingthe effortsof the mental healthand criminaljusticesystemsto II l _ meettheneedsofpersonswithmentalillnessesis criticaltoinsurethe Cooperative proper functioningofthecriminaljusticesystemand toguaranteethe

Efforts provisionof appropriatecarefor individualswith mentalhealth needs.

Therearea numberofbarrierstothistype ofcooperation,however,

includinginsufficienthumanandfiscalresourcesanda lackof

understandingoftherolesthat personnelineachsystemcan, andmust,

perform.Waystoovercomethesebarriersandimplementjointprograms

thatservetheneedsof all involvedare highlightedinChapterFive.

42
CHAPTER 5

Solutions That Work

Barriers to There are numerousobstaclesto providingappropriatecare to persons

with mental illnessesin the criminaljustice system, including: Providing Care

. lackof knowledgeonthepartoflawenforcementandcorrections

personnelabouteffectivementalhealthprogramsandhowtoaccessthem;

• lackofunderstandingonthepartofthementalhealthsystemaboutthe

demandsandconstraintsofthe criminaljusticesystemandan

unwillingnesstoworkwithitsclients;

• lackof cross-trainingforcorrec'dons,lawenforcement,and mentalhealth

staff;and

• lack of coordinationbetweenthe criminaljustice, mentalhealth, and social

servicesystems.

As was apparentin the vignettes in Chapter 1, inadequateor inappropriate

information and fragmentedservices can result in persons with mental

illnesses receivingno services at all, or receiving inappropriatetreatment,

including arrest and jail, becauseworking altematives do not exist in the

community. Informationsharingand coordinatedplanningamong law

enforcement and correctionalpersonnel,mental healthagencies, and social

service providers--including housing,income support, and substance

abuse programs-- can help meet the needsof all parties involved.

This chapterhighlightsways to coordinate care for persons with mental

illnessesat key points in the criminaljustice system, including examples of

successful programs.

Core Planning Servicesfor personswith mentalillnesseswhocome intocontactwiththe

ilml= _l I__l criminaljusticesystemarecriticalandcan be developedwithoutsubstantial

i-,rlnclples new funding.Muchof whatis requiredis rethinkinghowto addressthese

problems.Comprehensiveand integratedservicesat theclientand system

levels,withparticularemphasisoncommunitycollaboration,areneeded.

43
Many recentanalyses of mentalhealthservicesforunderserved

populationsappropriatelyhaveemphasizedtheneedfor collaboration

betweenprivateandpublicsectorsand,inturn,amongthelocal,State,and

Federallevelsof govemment.A majorrecommendationofthe Federal

Task Forceon HomelessnessandSevere MentalIllnessstated,"Thereis

growingconsensusthata trulyintegratedsystemof care...requires

integratingbasiclifesupportswithspecializedservices;linkingservicesat

theclientandsystemlevels;coordinatingFederal,State,and local

resources;andprovidinga cleardelineationof authorityand of clinical,

fiscal,andadministrativeresponsibility"(p, xiv).

At theheartofwhatneedstohappentosignificantlyimprovethelivesof

personswithmentalillnesseswhocomeintocontactwiththe criminal

justicesystemare severalcoreplanningprinciples.Howeachof these

playsoutina specificjurisdictionfor a particularsetof problemswillvary

greatly.However,adherencetotheseprincipleswillgreatlyincreasethe

likelihoodof solutionsthatbenefitindividuals,theirfamilies,criminaljustice

professionalsandthecommunityat large.

Thesecore principlesare:

• Coordinatedandintegratedprogramsclearlyincreasethelikelihoodof

uninterruptedcare,betterpsychiatricoutcomes,andlowerrecidivism.

Especiallycrucialincriminaljusticecontexts,fullyintegratedsystemsof

care should includementalhealth,substanceabuseand other health

services,housing,assistanceobtainingfinancialentitlements,and

educationaland vocationalprograms.

• Accessto targeted, appropriate and flexible mentalhealthservices

should be availableto all personswith mentalillnesses,regardlessof

whetherthese individualsare women,people of color,youth,or persons

with specialtreatmentneeds.

• Interagencyworkinggroupsor planningteamscangreatlyenhance

thesuccessofintegratedservicesfor personswithmentalillnesses.These

interagencyworkinggroupsare importantacross all levelsof govemment:

Federal,State,and local.At the Federallevel,this groupwould be ableto

targetand coordinateeffortsbetweenall relevantdepartmentsto facilitate

the improvementof mentalhealthservicesto this population.At the local

level,the groupshould havethe authorityto planand implementa full

arrayof integratedservices.

44
• Representativesfrom key constituencies,includingmentalhealth

administrators, criminaljusUceoffidals,substanceabuseandother

relevantserviceproviders,andfamilyand consumeradvocatesshouldbe

involvedintheplanning,implementation,andevaluationof mentalhealth

servicesforpersonsincontactwiththecriminaljusticesystem.

• Creativeuseof existingresourcescanaccomplishmanyoftheneeded

changestothecriminaljusticeandmentalhealthsystemsinthe

developmentofaccesstoessentialmentalhealthservices,withoutthe

needfora massiveinfusionof newresources.

• Mentalhealthservices targetingthe co.-morbidityof severemental

illnesseswithalcoholanddrugusedisordersshouldbe a priority.Mental

healthserviceprovision,whethercommunity-basedorfacility-based,

shouldacknowledgetheneedtodevelopinterventionsandworking

relaUonshipsforpersonswithdualdiagnoses.

• Cross-trainingof mentalhealth,lawenforcementand corrections

personneliscrucial.Regardlessofwhetherwe discusspolicejails, ,

prisons,orcommunitysupervision,thedominanthemeisthe needfor

bothmentalhealthandcriminaljus,ce personneltobetterunderstandthe

demands,operations,andcontextof theothersystem.

• Theidentificationof needandtheprovisionofmentalhealthservices

shouldtake culturaldifferencesinto account. Becausethe persons

involvedwiththeU.S. criminaljusticesystem,and,therefore,inmental

healthtreatmentservicesinthesesystems,aredisproportionately

African-American,Hispanicandotherminorities,servicesshouldbe

providedthatareculturallysensitiveand thataregearedtoan individual's

uniquecircumstanceand s needs.

• The disseminationof existing knowledgeandthe generationof new

informationtosupporttheinformationneedsofStatesand local

communitiescouldgreatlyimproveserviceswithoutsubstantiallyincreased

costs.Thisreporthascollectedsomeofthebestideasavailableacrossthe

U.S.regardingtheprovisionof mentalhealthservicestopersonswho

comeintocontactwiththecriminaljusticesystem.However,this

informationmustfirstbe availabletocommunitiesif itistohaveany effect.

Theestablishmentofa comprehensiveinformationgatheringand

knowledgedisseminationplanshouldbe consideredtoprovidethe

necessaryinformationandtechnicalassistancetoimplementorenhance

services.
Effective Effectivepoliceresponseto citizenswithmentalillnessesrequires

cooperationandtheexchangeof knowledge,resourcesandservices

Police/Mental betweenlawenforcement,mentalhealth,andsocialserviceagencies.

Health Without such cooperation,police may resorttotheinappropriateuseof

Interactions arrest or of emergencypsychiatrichospitalization.

What officersmostwant andneedintheirinteractionswithpersons

suspectedof havinga mentaldisorderisinformationandaccessto

consultationandassistance.There are a numberof wayscommunities

havemettheseneeds,includingtheuseof designatedmentalhealth

professionals,specialrecognitionfor policeofficershandlingmentalhealth

cases,emergencyhotlinesand24-hourmobilecrisisteams,cross-training

of lawenforcementandmentalhealthpersonnel,andcommunityplanning.

In allof thesestrategies,itis importanttobalancecarefullycitizens'rights

toprivacywithlawenforcementofficers'needforinformation.Eachofthese

strategiesis outlinedbelow.

Designated Mental Health Personnel

Some policedepartmentsdesignatea mentalhealthprofessionaltohandle

casesinvolvingpersonswithmentalillnesses.Dependingonthe

characteristicsof the localityandthesizeof thedepartment,thisindividual

mightbe a policeofficerwhoistrainedinmentalhealthissues,a civilian

mentalhealthprofessionalwhoworksoutof thepolicedepartment,ora

mentalhealthprofessionalfroma communityagencywhocontractswith

thepolicedepartmento providecrisisconsultationand intervention.

Theseprofessionalsare available24 hoursa daytorespondtocallsfor

assistancefromofficersinthefield.Theymayofferadviceoverthe

telephone,gotothesitetoassist,orconductevaluationsintheoffice.

There are manyadvantagestoallpartiesinvolvedof havingdesignated

mentalhealthpersonnelrespondtopersonswithmentalillnesses.These

staffmeanthatpoliceofficershavea readilyavailablesourceof expertise

andsomeonewhois responsiblefor screening,transportation,waitingfor

an evaluation,andfollow-up.

Mentalhealthagenciesaremorelikelytoreceiveappropriatereferralsfrom

suchindividuals,whocan successfullynegotiateforcrisisinterventionand

otheroutpatientmentalhealthservices.Andpersonswithmentalillnesses

are lesslikelytobe arrestedonminorchargesorto beinappropriately

hospitalized.

46
Recognition for Handling Mental Health Cases

Police interactionswithpersonswithmentalillnesseswillbe enhancedif

officersbelievethattheirroleindeterminingtheappropriatedispositionis

valued.Thiscaninvolvenotifyingtheofficeroftheresultsof a referral,

allowingextratimeforthedispositionof suchcases,andevaluatingthe

managementof a mentalhealthcasein muchthesameway as an arrest.

Knowingthat heorshewillbe rewardedfordealingeffectivelywithpersons

withmentalillnessesisan incentiveforthefrontlineofficerto make

appropriatedecisionsregardingtheirtreatment.

Emergency Hotlines and 24-Hour Mobile Crisis Teams

Many policeencounterswithpersonswithmentalillnessesoccurwhen

mentalhealthfacilitiesareclosed.The availabilityof mentalhealthservices

after hourscanbe critical.Of particularimportanceare telephone

consultation,on-siteassistancein the form of mobile crisis intervention,and

the availabilityfor emergencyhospitalization.

Some communitieshave foundthat emergency hotlines(both police and

mental health)help solveproblems that arise between the systems.

Agreementsof mutualsupport, oftenwritten and formal, meanthat mental

health professionalsprovideconsultationand/or on-site handlingof a

difficultsituation and police respondto a callfor assistancewhen someone

becomesviolent in a mental health residence/facility(Finn and Sullivan,

National Instituteof Justice, 1987).

In addition,a special liaison (a management-levelpersonfrom the police

departmentand from the communitymental healthcenter) can help

alleviate problemsas they occur.The liaison has the authority to overcome

staff resistanceand program-levelbarriers.

Other communitieshave established24-hour mobile crisis teams that can

respondquickly to policecalls for assistance.These teams take charge of

the situationupon arrival (if the incidentis not criminal),and screen,

evaluate,and transportthe individualto an appropriatetreatment setting.

Some communitieshavecontracted with taxi services to transport

individualshome,when this is an option.These simple solutions save an

officer a substantialamountof time, allowinghim or her to retum to patrol

work.

47
In addition,around-the-clockavailabilityof hospitalor community-based

psychiatricevaluation,and specificguidelinesfor inpatientadmissions, can

help policeofficers makeappropriate referrals.Cooperative agreements

betweenpolice and screeningfacilities may be developedsuch that a

psychiatricfacilitywill identifyavailabletreatment slots elsewhere in the

system ifthere is no space within that facility.

Cross-Training

Cross-training is probably the most importantfactor in cooperativeworking

arrangements betweenthe mentalhealth and criminaljustice systems.

Policetraining generallyfocuses on characteristicsand diagnostic issues

relatedto mental illness,but hasfailed to address such issues as what

servicesare available inthe localarea, how to make appropriate referrals,

understandingconfidentialitystatutesand mental health law, and the goals

and outcomes of treatment. Ukewise,mental health professionalsare

rarelyeducated aboutthe criminaljustice system and the specific demands

and proceduresof policework.

In particular, it is essentialthat both policeand mental health staff have a

clear understandingaboutwhat informationcan be sharedabout individuals

and of the rationale,both ethicaland legal, for the policies.Access to

information is a very sensitive matterthat requiresa careful balancing of

individual rightsto privacy withthe community's right to protection.

Where police departmentshave a designatedmental health unit,

informationmaintainedon contactswith persons with mental illnesseswill

be availableto officerswithout involvinga breachof confidentiality. If the

department contractsfor crisis interventionservices, the crisis team may

not be allowed to share confidentialinformationwith the police, but team

membersmay usetheir knowledgeto resolve a problem themselvesor to

suggest methods for resolutionto the officeron site.

In additionto classroom or in-servicetraining, cross-training may involve

working inthe environment,i.e., mental healthworkers ridingin a patrol car,

or police observingin a psychiatricfacility.

48
Community Planning

Peoplewho comeintocontactwiththepolice,particularlythosewithmental

illnesses,havea highincidenceof co-occurringsubstanceabuseand

physicalhealthproblems.Inaddition,theyare likelytobe poorand inneed

ofhousingorothersocialservices.Helpingindividualswithmultiple

problemsoftenrequiressystems-levelintegration,whichultimatelysupports

andenhancestheeffortsoffrontlinelawenforcementandmentalhealth

personnel.

Ata minimum,communitiesmaywanttoconsiderthe developmentof a

standingmentalhealth/lawenforcementplanningcommittee,whose

primaryresponsibilityistoclarifytheresponsibilitiesof eachoftheagencies

involved.Sucha groupshouldrepresentmentalhealthcliniciansand

administratorslaw, enforcementand correctionsofficials,electedofficials,

andotherrelevantcommunityserviceproviders.The groupmaybe

supportedbya formalmemorandumofunderstandingand shouldhavethe

authoritytoplanandimplementa fullarray ofintegratedservicestomeet

theneedsofthispopulation.

Inparticular,a jointplanninggroupcoulddevelopstreamlinedprocedures

tofacilitateappropriateinpatientandoutpatientmentalhealthtreatment.In

addition,suchservicesas housing,alcoholanddrugtreatment,entitlement

assistance,andeducationandvocationaltrainingprogramsshouldbe

availableandaccessible.

Making Maximum Use of Resources

Theseapproachestoeffectivepolice/mentalhealthcollaborationusually

canbe accomplishedwithlittleor noadditionalfunding.Makingmaximum

useof existingresources,insomecasesbyjointlyfundingcooperative

efforts,can resolvea majorityof theissuespresentedherein.Some

overtimepayfortrainersand trainees,with occasionalsupportforoutside

consultants,areoftentheonlyaddedcosts.

Selection of Notable Programs

The NotableProgramsincludedinthisreportwere selectedbasedon

informationfrom a number of sources.The selectionof these programs

representsthe combined resourcesof the most currentresearch, the

opinionsof programdirectors, and the expert advice of the 60-person Ad

HocWorking Group.Based on these experiences and information,

programswere selectedthat were deemed especiallynoteworthy both

becauseof the quality of what was being done and becauseof the

transferability of their initiativesto other sites throughoutthe U.S.

49
Notable Program

Montnome The MontgomeryCounty, Pennsylvania,EmergencyService (MCES)

program wasdevelopedin 1974as a response to the legal mandate to

_-- II_uU nl[""y_ Pa.y provide 24-hour emergency mental health care and to meet the need for

Emergency readily accessible drugand alcohol emergency services,particularly for

persons who come into contact with the criminaljustice system. Through

Service close cooperation withlocal law enforcementand jail, MCES provides a

P rog ram range of services, includinginpatient treatment,training topolice, crisis

intervention withpersons withmental illnessesin the community and

mental health services tojail detainees.

Montgomery County EmergencyServiceis a nonprofit hospital. Its annual

inpatient budgetis approximately$7 million. Inpatientservices are paid

primarilyby Medicaid,Medicare, and third-party insurance. The hospital

also receives direct fundingfrom the countymental health department. In

addition, approximately$500,000is budgeted for all other services and is

paid for by county dollars,and services are billed to entitlementprograms

or privateinsurers as appropriate.

Police officers in Montgomery Countyreceive training on how to identify

and communicate withpersons withmental illnesses who are experiencing

crises. The officers carry a "copcard" withinstructionsfor what to do when

dealing witha person who has acute symptoms. In addition,police can

telephone MCES at its 24-hourhot line to consult witha mental health

professional. MCES may instruct the officerto bring the person in for

evaluation or may send out an ambulance to pick up the individual.

MCES also operatesa community outreachprogram in which crisis

interventionprofessionalsconduct a follow-up to further evaluate a situation

that may be unresolved.Finally,for persons withmental illnesses already in

jail, MCES has a forensic caseworker who develops treatment plans in the

jail setting and provides linkage to services after release.

50
A major reason for the success of thisprogram is its comprehensiveness.

MCES providesaccess to inpatient care, follow-upservices guaranteeing

properaftercare,emergencyand crisisinterventionservices,in-jailservices,

and cross trainingof mental health, law enforcement,correctionsand court

personnel.Of primary importanceis the Forensic TaskForce. Thisgroup of

individuals includesrepresentatives from emergency, outpatientand

inpatientmental health programs,police,jail, probation and parole,

defenders and prosecutors offices, and consumerand famity advocacy

groups. Thegroup has the authority to implementchanges in the systems

and functionas a watchdogorganization.

Contact: RobertBond, Director of CrisisServices

Phone: (215)279-6100

51
Mental Health Individualswith mentalillnessespresentspecialproblemstothejail

administrator.Lackof knowledgeaboutmentalillnessesonthepartofjail Interventions in staff andotherinmatesmeansthatpersonswithunusualbehaviorare

Jails and treated eitherwith fear orwithpunitivesanctions.Equallyas problematic,

personswithseveredepressionmaygovirtuallyunnoticedbecausethey Lockups do notcreatedisturbancesW. hen thishappens,they are left untreatedand

theirsymptomsmayworsen.

Becausejailshavea constitutionaldutytoprovidementalhealthtreatment

to individualswho requireit,and a responsibilityto providea safe and

secureenvironmentfor bothstaffandinmates,itisinthe bestinterestof all

concernedtostabilizepersonswhohavementalillnesses.Effectivemental

healthservicescan reducesecurityrisksbyhelpingpersonswithmental

illnessescontroltheirpsychiatricsymptomsand byeducatingstaffto

interactina morepositivewaywiththese individuals.

Screeningand evaluationarethe firststepstoidentifyingpersonswith

mentalillnesseswho requireintervention.Thisisthepointat which

individualswilleitherbe diverteddirectlyintomentalhealthtreatment

(inpatientoroutpatient)oridentifiedforin-jailservices.Thus,jailsshould

havebothpre-detentiondiversionoptionsandprovideorhaveaccess toa

fullrangeofmentalhealthanddischargeplanningservices.

Manyexpertsstressthe need tousecommunitymentalhealthresources,

ratherthandevelopingmentalhealthtreatmentprogramsinjails.The

creationand supportof a fullarrayofin-jailmentalhealthservicesnotonly

duplicateswhatmaybe availableinthecommunity,butalsomightcreate

an incentivefor criminaljusticepersonneltoincarceratepersonswith

mentalillnessesas a treatmentaltemative(Steadmanet al., 1989).The

developmentof workingagreementsto purchaseservicesfromcommunity

mentalhealthagenciesandtotransferindividualstoinpatientcarewhen

necessaryiscost effective,allowsforcontinuityof care, andsupports

developmentof thecommunityservicesystem.

Realisticallyhowev , er,therewillalwaysbe theneedfora minimumnumber

ofservicestobe providedinjails,particularlywheresuchservicesare not

readilyavailableinthe localcommunity.Amongtheseservicesare inpatient

bedseitherinjailorina localhospitalorpsychiatricfacility,

around-the-clockmentalhealthandnursingcoverage,treatmentplanning,

andtheavailabilityof psychotropicmedications.Inaddition,opportunities

forindividualandgroupcounselingandbehaviormanagementmay prove

useful.

52
Jailsthat donot providea full rangeof servicesshould,at a minimum,

provide screeningand evaluation, crisis interventionand short-term

treatmentwiththe availabilityof psychotropicmedications,and

discharge_transferplanning.

Screening and Evaluation

Screeninginvolvescontinuingassessmentsofthementalhealthstatus,

medicationneeds,andsuicideriskofindividualsbeingdetained.It maybe

doneformallybypersonneltrainedintheidentificationofpsychiatric

problemsusingstandardizedinstrumentsMore . commonly,screeningis

accomplishedinformallybyobservationof an individual'sbehavior,

appearance,andspeech.Screeningistheresponsibilityof all staff,

includingarrestingandbookingofficers,supervisorsand , othercorrections

personnel.

InIockups,thepurposeof screeningisto determinewhethertheperson

beingdetainedisdangeroustohimorherselfortoothersdueto symptoms

ofmentalillnessorissodisabledas torequiretheimmediateassistanceof

a mentalhealthprofessional.Evaluationsofthisnaturemustbe

accomplishedina timelymannerduetheacutenatureoftheproblem.

Screeningandevaluationinjailstendstobe morecomplexandcan be

seenas a three-stepprocess:routinementalhealthscreeningat intake,

morein-depthmentalhealthscreeningwithinthefirst24 hoursof

admission,andfollow-upmentalhealthevaluationwhen deemed

necessan].

Persons who are identifiedthrough these screeningprocedures as needing

a full mentalhealthevaluation should haveone immediately incrisis

situations or within 24 hours of a referral.Such evaluationswill determine

the level of each inmate'sneed for special housing and mental health

treatment.

The critical importanceof screeningbecomesapparent in the case of a

suicidal inmate. Individualsin detention are ninetimes more likely than

those inthe generalpopulationto commit suicide, and most suicides occur

in the first 24 hoursafter arrest (Jail Suicide Prevention InformationTask

Force, 1988). In 1986,97 percent of persons who committedsuicide in

Iockupsand 89 percentof all suicide victims injails had not been screened.

53
Personswhocommitsuicidewhile indetentionare mostlikely tobe male,

white,arrestedfora non-violentoffense,and intoxicatedat thetimeof

incarceration(JailSuicidePreventionInformationTask Force,1988).There

is alsosomeevidencelinkingtheprobabilityofsuicidewiththe presenceof

severementaldisorders.Whilementalillnessmay increasethe riskof

suicide,screeningandevaluationshouldbeseen as a preventivemeasure

for allpersonsdetainedinIockupsandjails.

Crisis Intervention and Short-Term Treatment

Crisisinterventionandshort-termtreatment arenecessary in responseto

an acute,psychiatricconditionthatpresentsthe possibilityan individualwill

be of imminentdangertohimor herselfortoothers. InIockups,crisis

interventionmayinvolveanimmediatetransferof theindividualtoan

appropriatementalhealthfacility.Specialprecautionsincludingcloseand

continualobservationuntiltransferare usuallyrequiredduringa crisis

situation.

Crisisinterventioninjailsmayinvolvetheprovisionof moreextensive

services,includinga briefmentalhealthevaluationto identifythe problemat

hand,andemergencytreatmentwherewarranted.Suchshort-term

treatmentmayincludetransfertothein-jailinpatientor medicalunitorto

anotherinpatientfacility,includingState, countyor generalhospital

settings.Othershort-termtreatmentinterventionsincludepsychotropic

medications,specialobservation,andsomeverbaltherapies.

Effectivecrisisinterventionandshort-termtreatmentservicesrequirethat

staffaretrainedto recognizeacutedistress,thatmentalhealth

professionalsare accessibleona 24-hourbasisto assistwithevaluations,

medications,andemergencyplacementsincommunityfacilities,andthat

specialhousingunitsareavailableforinmateswho requireclose

observationorextramedicalsupervisioninjail. Formalandinformal

workingagreementsbetweenjailsandcommunitymentalhealthproviders

insurethatindividualsincrisisreceiveappropriatecareandjailoperations

are notdisrupted.

54
Discharge/Transfer Planning

Dischargeortransferplanninghelpsindividualsbeingreleasedtothe

communityor beingsenttopdsonconnectwithappropriatementalhealth

services.Ina recentstudyof all U.S. jails,only26 percentreportedoffering

dischargeplanningservices(Morriset al., 1994).

DischargeplanninginIockupsis generallyrestrictedto communicatingwith

theappropriatereceivingfacility,includingthecourtandjail,toinsure

continuityof care. Aspart ofa jailmentalhealthprogram,discharge

planningisusuallythe responsibilityof a case managerwho is a mental

health professional.

Typically,this individual makes referralsor appointments with mental health

agencies for continuing mental health treatment after release, and notifies

State prisonofficials for those being transferred. In addition, case managers

can facilitate an individual's releaseby helpingwith arrangementsfor

housing, social services, and other supports. Medication managementand

independentliving skills training may be especially important.

Principlesfor effective dischargeplanninginclude the following(Griffin,

1990):

• Dischargeplanningmust be a clearlyarticulatedgoal ofthe jail

mentalhealthprogram.Makingita pdodtyhelpstojustifytheallocation

of resourcestowardthisimportanttask.

• Close collaboration between the criminal justice and mental health

systems is essential. Whetherthe relationshipsareformal or informal,it

is importantthat all key playersparticipateto insurecomprehensiveand

continuousservicesto personswith mentalillnessespreparingfor release.

• Discharge planningmust beginin advanceof releasefrom jail.

Becauseindividualstypicallyspenda veryshorttimeinjail,suchefforts

shouldbe integratedintothe ongoingevaluationandtreatmentprocess.

• Continuityof careshould be insured bydeterminingthatallindividuals

leavingjailhavereferralsforaftercareandthattheyareencouragedto

parlJcipateinmentalhealthservices.Case managersmayneedto

facilitatesuchongoingcare byworkingdirectlywithindividualsand by

expandingtheirnetworkof communityresources.

55
Notable Program

Summit County, TheSummit CountyJail UnitinAkron, Ohio, was renamed theAlcohol,

Ohio, Jail o_ugAbuse and PsychotherapyTeam (ADAPT)in 1992.Itsprimary responsibilitiesare: psychosociaiassessments, crisisintervention,

ADAPT Program management of acute psychotic episodes,monitoring of detoxification,

suicide prevention,prevention of psychological deterioration while

incarcerated, chemical dependencytreatment,educationfocused on

individualneeds, elective therapyservices including individual and group,

and, administrativeassessmentand planning for continuing services.

Theseservices are available to all inmates of the Summit CountyJail (rated

capacity 402) at no cost to the individualinmate. Referralsare made to

communityagencies for follow-upservices.

In addition to the use of traditionalmental healthproviders, the Summit

CountyJail createda Crisis InterventionSpecialistposition to address the

criticalneed to respond to crises quicklyand professionally. Thisstaff

member enables thejail to speed up the classificationprocess for persons

withmental illnessesand to more effectivelybring individuals' mental health

needs to the attention of mental healthstaff.

Inmates whoare at high risk may be housed in the mental health housing

units Wheretheyare more closelyobserved and monitored by professional

ADAPT staff and deputies.Theseinmatesmay include those who are

activelypsychotic, suicidal,or in withdrawal.Correctionsstaff for the mental

health unit are selectedjointly by theADAPT director and correctional

security supervisors. Thesedeputieswork only on the mental health unit.

Jail mental health servicesare enhancedby the use of a computerized

information trackingsystem. Thissystem is used to track all inmates who

have receiveda mental health evaluation. Theinformation containedin the

system includes demographics,diagnosis, staff time, and the number of

inmatesusing each typeof service.

Trainingfor staffof theSummit CountyJail is also provided and includes

such topicsas: recognitionof signs and symptoms of intoxication,

withdrawaland mental illness, suicideprevention, crisis intervention, and

stress management.

56
ADAPT does not provide follow-upservices in the community, feeling that

the communityresourcesare appropriatefor such services. They do

provide referralto community resourcesin attempts to provide for continuity of care.

TheSummit Countyjail employs a uniqueblending of resources to fund its

mental healthservices staff. Self-employed contractors make up the bulk of

this staff. Activelyseeldnggrants to supplement the county's budget has

enabled the mental health coordinator to retain additionalmental health

personnel. Currently there are two funding streams through mental health

services areprovided: positions for thejail staff are financedby the county,

whilethe self-employed contractorsare compensated with resources

obtained from variousgrants.

Contact: Rebecca Titus, Mental Health Coordinator

Phone: (216) 643-2145

57
Mental Health Consistentwiththe conceptofa "communitymentalhealthsystem,"prisons

shouldprovidea fullarrayof mentalhealthservices,beginningwith Interventions in screeningand evaluationandcrisisinterventionat the"frontdoor,"through Prisons psychotropicmedicationandmonitoring,individualandgrouptherapy,case

management,andspecializedhousinginprison,todischargeplanningand

referralat the"backdoor."Innon-prisoncommunities,the useof outpatient

servicescansignificantlyenhancean individual'sabilitytoliveandfunction

inthecommunity;thus,withsimilarhelp,inmateswithmentalillnessescan

loamtofunctioninthe prisongeneralpopulation.

Lackof financialresourcesandprisonovercrowdinghavecreated

significantbarrierstothe provisionof qualitymentalhealthservicesin

prisons.Inaddition,mentalhealthservicescanbe providedunderdifferent

auspices,typicallybythe Statedepartmentof mentalhealthor theState

departmentof corrections.InsomeStates,mentalhealthbudgetsare being

drasticallyreducedand correctionsbudgetsare continuingtoexpand.

Clearly,eachStatewilldifferinitsresourceallocationand mustdecide

independentlyonthe bestway tosupportprisonmentalhealthservices,

bothfiscallyand administratively(Cohenand Dvoskin,1992).

The informationinthefollowingsectionsdrawsheavilyfromtheworkof the

NationalCoalitionfortheMentallyIIIintheCriminalJusticeSystem.The

group's recentmonograph,Mental Illnessin America's Prisons, represents

currentthinkingabouthowtodesignanddelivermentalhealthservicesto

prisoninmates.

Screening and Evaluation

One ofthemajorreasonswhyprisoninmateswith mentalillnessesdo not

receiveservicesisthattheyare inadequatelyscreened.Ogloffand

colleagues(1993) recommendthatscreeningbe a two-stageprocess:a

briefmentalhealthscreeningfor everyinmateuponadmissionto the

prison,and a morein-depthmentalhealthassessmentforthosewho are

identifiedduringthescreeningprocessas needingfurtherevaluation.

Theseearlyassessmentshelppdsonstaff:(1) identifyinmateswhoareat

riskof injuringthemselvesorothers;(2) determinewhetheran inmateisso

disabledthat he orshecannotfunctioninthegeneralpopulation;(3)

assesstheneedtotransfertheinmatetoa mentalhealthfacilityoutsidethe

prison;and (4) decidewhethertheinmatewillbenefitfrommentalhealth

services.

58
American PsychiatricAssociationstandardssuggestthat a mental health

professionalor trained correctionsofficerscreen all inmates immediatelyon

admissionto the prison, using a standardizedset of instrumentswith a

low-thresholddesignedto detect any evidence of mental health problems.

Further screeningshould be part of a standard medicalworkup conducted

by health care personnel. Recordsaccompanyingan inmate may be

inadequate,making carefulassessments particularlyimportant.When they

are screened, inmates should be provided with informationabout mental

health servicesavailable inthe prison.

In additionto the formal screeningprocedures,corrections and mental

health staff must continuouslyobserve inmates for changes in behaviorthat

might indicate a worsening mental healthcondition. Some inmatesmay

developmental health problemswhile in prison, and the mental health

status of others may change duringthe time they are incarcerated.

Although correctionsofficers are likelyto be the ones who have the most

day-to-daycontact with inmates,additional personnel, including teachers,

librarians,nurses, and other supportstaff, should be trained to recognize

mental health problems (Ogloff,et al., 1993).

This training should include recognitionof so-called positive symptoms,

such as hallucinationsor delusions,and of negativesymptoms, including

withdrawal. Often, non-disruptiveinmatesdo not come to the attention of

the mental health staff even thoughthey may be inacute need of services.

Clearly, diagnosis of mental health problemsis an importantfeature of

screening and evaluation. However,as Ogloff and colleagues (1993)

caution, diagnosisis not equivalentto impairedfunctioning."Very often

mentallyill inmatesare not disruptiveand will not harm themselves,while

many disruptiveinmatesare not mentallyill. Therefore, rather than just

focusing on identifyingmentalillness,it is importantto consider inmates'

psychosocialfunctioning."Giventhe stigma associatedwith mental illness,

it may not benefitan inmate to be designated mentally ill if he or she can

function well within the prisoncommunity and/or ifthere are no appropriate

mental healthservices or programs availableto meet his or her specific

needs.

59
Crisis Services

Regardlessof the effectivenessandthoroughnessofthescreening

process,mentalhealthcrisescanoccuratany time.Crisisservicesmust

be availabletoallinmatesona 24-hourbasis;a timelyresponseis critical

tostabilizetheinmateandpreventfurtherdisruptiontothe individualandto

theprison.Effectivecrisisinterventionprogramsshouldincludestepsto

reducetheprobabilitythat a crisiswillrecur(CohenandDvoskin,1992).

Crisisservicesgenerallyinvolvea mentalhealthevaluationtodetermine

thenatureofthe problem,followedbyemergencytreatment.Such

treatmentmayincludetransfertoinpatienttreatment(eitherwithinthe

prisonor outside)ortospecialmedical/psychiatrihousing c units,theuseof

emergencypsychotropicmedications,andtheuse ofspecialobservation.

Emergencytreatmentservicesgenerallywill notexceed 72 hours,after

which the services the inmate receivesbecome part of his or her on-going

treatment plan.

For theseservices to be effective, all correctionsstaff must be trainedto

recognizewhen an inmate is in crisis. It is importantto underscorethat

attentionmust be given to both the "positive"and "negative"signs of mental

illness,that is, withdrawaland loss of appetite should be given as high a

priorityas hallucinationsand delusions.In addition, mental health and

medicalpersonnel must be available on a 24-hour basis.

When a crisis occursit may be necessaryto removethe inmate from the

generalpopulation.Inpatienthospitalizationcan often be avoidedthrough

the useof short-termcrisis beds within the prison setting (Cohen and

Dvoskin, 1992).

Mental Health Treatment Services

One ofthe primaryissuesinreviewingmentalhealthtreatmentfor

prisonershastypicallybeenthelackofdiscussionregardingwhattypesof

servicesandmodalitiesareeffective.Certainly,thereissupportforthe

effectivenessofpsychotropicmedication.However,medicationdoesnot

workforallpeopleand,giventhesometimessevereside-effects,maybe

refused.Norwouldmentalhealthprofessionalsgenerallyrecommend

medicationaloneas an appropriateintervention.

6o
Thus, mentalhealthservicesin prisonmustincludea wide array of

approaches.Riceand Harris (1993)cite supportfor the useof behavioral

interventionswiththis population.They suggest a two-pronged approach

designedto reinforceappropriatebehaviorsand to address specific deficits

with skills training. Such techniques have been usedsuccessfully in

Canadianprisons.

Assertiveoutreachand case managementare key components of effective

mental healthservices within the prisonsetting (Cohen and Dvoskin, 1992).

This is especiallytrue for groupswith special needs,such as combat

veterans, adult survivorsof childhood physicalor sexual abuse, victims of

physicalor sexual assaultin prison,or inmateshoused for long periods in

disciplinary segregation.

Special Housing

To meet the needs of inmateswith mental illnessesoverlongperiodsof

time,a continuumofhousingoptionsmustbeavailablewithintheprison

setting.Inadditiontocrisisbedsandaccesstoinpatienttreatment,long

termresidentialtreatmentunits(RTUs)complementtheneedsofinmates

withmentalillnesses.

Inmateswithseverementalillnessesoftenhavetroubledealingwiththe

stressesofprisonlifeandare particularlyvulnerabletoabusefromstaff

andotherinmates.RTUs,whichfeatureseparatehousingandtherapeutic

interventions,candramaticallyimprovean inmate'squalityof lifewhile

providinga saferenvironment.Theseservicescan betransitionalin nature

or be a permanenthousingoptionfor thosewho need it.

Specialized residentialunits do not necessarily require24-hour a day

medical coverageand can be a cost-effectivealtemative to psychiatric

inpatienttreatmentwithout compromisingthe inmate's mental health care.

In a study of New York State prisons,Condelli and colleagues (in press)

found that such programs reducepsychiatriccrises, disciplinaryviolations,

suicide attempts,and hospitaltransfers.

Inpatient Services

Psychiatricinpatient services are a necessary component in the continuum

of care, but are notrequired to be operated by the prison. If the other

aspects of the continuumof care notedherein are present, the number of

inpatient stays can be minimaland the averagelength of stay typically short

(under 60 days).

61
If the prisonor prisonsystemdoeshave a psychiatricinpatientfacility,

these units may want to seek accreditationby the Joint Commissionon the

Accreditationof Health Care Organizations(JCAHO).While there is no

mandatefor prison psychiatricinpatientfacilities to be accredited, such

accreditationof civil facilities presumesa minimum of constitutionally

adequatecare (Woe v. Cuomo).

Discharge Planning and Referral

Dischargeplanninghelpsinsurecontinuityof care forinmates,butthisis

morecomplicatedintheprisonsettingthaninjailsbecauseprisonsare not

typicallylocatedinthecommunitiestowhichinmatesare released.Formal

orinformalinkagesbetweenStatefacilitiesandlocalprovidersare seldom

developed.

Typically,transferstootherStateprisonsorto psychiatricfacilitiesare

relativelyeasytofacilitate.Butthereisoftenlittlethata dischargecase

managercandotoguaranteethatsomeonereleaseduponcompletionof a

sentencewill receiveneededmental healthservicesin hisor her own

community. Resourcedevelopmentis neededto enhancethe connections

betweenthe criminaljustice and mental healthsystems at the State and

local levels.

A strong workingrelationshipbetween prison-basedcounselorsand State

parole agenciescan be an importantindirect mechanismfor insuring

continuity of care for persons releasedon parole. Parolesupervisioncan

require participationin mentalhealth treatment programs.While parole

boards are often reluctantto release inmates receivingmental health

treatment,it is likely that more such individuals would be releasedto their

communitiesif formalagreementsfor their care and supervisionwere

developedamong prison administrators,parole officers,and local mental

health providers.

Specific policiesand proceduresgoveming the methodof transfer, the

exchange of medical recordsand information,and the means of notifying

the receivingfacility or agency should be developedat each institution. In

addition,there should be a designatedmental health professional whose

responsibilityit is to planfor inmate transfer or discharge.

62
Notable Program

NewYork State New YorkStateprovidesmental health services to individuals who have

been sentencedthrough one psychiatric centerand 11satellite units

Prison Mental throughouttheStateprison system. The Central New YorkPsychiatric

Health Program Center, a 191-bedhospital that operatesunder the auspices of the New YorkStateOffice of Mental Health (OMH),is a fulty-accreditedpsychiatric

inpatient facility.Although its perimeter security and procedures are as

stringent as any maximumsecurily prison, within that perimeter the facility

functionsas a psychiatric hospitalwith a widerange of environments

offeringvariouslevels of unrestrictedmovement.

The satellite unitsprovide a range of services to eachprison cluster. These

include screeningand referral;crisisbeds, withan average stay of less

than 10days; long-term residentialtreatmentunits called intermediatecare

programs; outpatienttreatment,which usuallyincludes medication and_or

psychotherapy,for thoseliving in the generalpopulation;and pre-discharge

planning servicesfor inmatesabout to be released orparoled.

Screening and Referral

At New York'sreception correctionsfacilities,satellite units focus on

screening and follow-upevaluationsof incoming inmates to determine

those who are likety to have a highlevel of need for mental health services

duringtheir incarceration.

After inmatesare screeneda follow-upreview is conductedto discuss

whether the inmate needsor wantsservices and the proposed

requirements.Eachinmate is given a mental health service designation,

which determinesto whatinstitutionan inmate is transferred, so that at any

given time those inmatesmost liketyto need intensive services will be

housed in institutionswithsatellite units.

Crisis Beds

Each satellite unithas a crisisbed capacity of approximate_ 10beds.

Theseare for short-termplacements that allow inmates to receive

treatment aimed at stabi/izingcrisessuch as acute psychoses or suicide

attempts. Treatmentinc/udesmedicationsand verbal crisis-oriented

therapy.

63
Intermediate Care Programs (Residential Care)

For some inmates, the generalprison population can be so stressful that

they are in a constant state of crisis. New York realizes that this group

needs a level of service less intensive than crisisbeds or inpatienthospital

care, but more intensive and supportive than generalpopulation outpatient

care. Theintermediatecareprograms were createdto meet this need.

Outpatient Services

Each satellite unit maintains an outpatient caseload of general population

inmates who receive regulartreatment,most often medicationand_or

psychotherapy. Thislevel of treatment is meant to help the inmate live and

work withinthe generalprison community.Satellite unit staff provide

consultationon all aspects of the prisonprogram and security operations to

help maintaina safe and secure environmentfor all staff and inmates.

Pre-Discharge Planning Services

Severalyears ago, OMH determined that the weakestpart of the service

deliverysystem wasthe pre-dischargeplanning services for those inmates

preparingfor release or parole. Each satellite unit now has a discharge

coordinator who works closelywith the Divisionof Paroleand theState and

local mentalhealth service network.Current initiativesinclude negotiations

to developa process of Medicaidreview to enable newly discharged

parolees to avoid long delaysin receivingneeded mental health services in

the community;and an IntensiveCase Managersprogram devoted

exclusivelyto parolees withmental illness.

Thisprogram is expected to reduce the relianceon crisis-orientedcare and

is designedto tailorservices to the client.Specially trainedparole officers

will be assignedto work as a team with several intensive case managers,

withprogressive sanctionsaimed at reducing technical violationsby giving

parole officersmore choices (as opposed to revocation)for responding to

episodesof treatment failure.

Contact: Dr. Joel Dvoskin,Associate Commissionerfor Forensics

Phone: (518)474-3290

64
Mental Health The first monthsarea criticalperiodin thetransitionof an individualfrom

jail orprisontocommunityliving.Forpersonswithmentalillnesses,

Interventions for entitlementbenefitsand stable housingare importantcomponentsto

Persons on success.However,thesemaybeespeciallyproblematicfor newlyreleased

Probation and parolees.

Priorto1985,prisoninmateswereeligiblefor Medicaidcoverageduring Parole their first and last months of incarceration.Currently,prisoninmatesarenot

eligibleto receiveFederalentitlementsm includingSupplementalSecurity

Income(SSI),SocialSecurityDisabilityInsurance(SSDI), or Medicaid--

whiletheyareinprison.The earlierpracticebothallowedfor diversionof

mentallyillindividualsintotreatmentprogramsandfacilitatedthereferralof

clientstoservicesafterrelease.Medicaidcanbe as an incentiveto

providerstoacceptdifficultclientsthattheywouldotherwisereject.

Anotherdifficultyfacingtheseindividualsandtheirprobation/paroleofficers

is thereluctanceof manymentalhealthservicesagenciestoprovide

treatmenttopersonswitha criminalrecordortothoseindividualswhoare

participatinginservicesinvoluntarilyAt . thesametime,probationand

paroleofficersmayfinditdifficultto helppersonswithmentalillnesses

completetheirsentencesiftheyare unawareof thebehavioralandsocial

problemstheseindividualsmayexperienceas partof theirdisorders.

Clearly,themostimportantcomponentofeffectivementalhealthservice

provisiontopersonsonprobationor paroleisclosecollaborationbetween

probation/paroloefficersandcommunitymentalhealthproviders.

Cross-trainingofstaffmay be criticaltothe successofthesecollaborative

efforts.

Accessing Community Treatment

Individualswithmentalillnesseson probationandparole,likeother

communitymemberswithsimilarproblems,requiretheavailabilityof a full

rangeofmentalhealthservicesthatareaccessible,appropriate,and

relevanttotheirneeds.Mentalhealthtreatmentmaybe a conditionof

probationor paroleforsomeindividuals;forothers,participationinsuch

servicesisvoluntary.

65
Some probationand paroleagencieshavedevelopedstandingcontracts

with community providers.These workingagreementssupport the activities

of both systems and the clients theyjointly serve. Communityagencies that

work with individualson probationand paroletend to be familiar with

corrections practicesand are more receptiveto nonvoluntaryclients (Cole,

et al., in press).Such arrangementsmay also allow for parole/probation

officersto intervenein emergenciesthat involve personsunder supervision

at the mental health service providersite.

In addition, probationand paroleofficers may take advantage of mental

healthintensive case managementprograms,where they exist. These

programstypically provide supportfor many domainsof living, including

housing,mental health and other support services, and finances. The

intensityof the services and the funding is flexible.Such programs appear

to be effective in reducingthe inappropriateuse of psychiatricservices and

the number of days spent in hospitals and jails by some of the most

difficult-to-serveindividuals.

While such arrangementsinsure access to treatment for many individuals

with mental illnesses,problems may arise when the mental health agency

is not equippedto serve personswithvarying levels of disability, or with

differing needs and interests.In addition,the highco-occurrenceof

substance use disordersin this populationmay require the involvementof

other serviceproviders.Interagencycollaboration among key organizations

is requiredto make these effortswork. Communityplanningcommittees

that involveprobationand parolestaff, substance abuse and mental health

providers,housingprograms,and local social services agencies can

develop a networkof flexible services. Formal agreements and memoranda

of understandingmay insure access to treatment for persons with mental

illnesseson probationor parole.

Informationexchangeand mutualsupport betweenparticipatingagencies is

critical. In particular, issuesof client confidentialitymust be explored. While

community supervisionofficers must be informedof an individual's

non-participationin services when treatment is a condition of release,many

mental healthconsumers object to the idea of complete information

exchangebetweenthe mental health and criminaljustice systems.

Discussionswith consumer advocacy groups may allow a clearer

understandingof the kindsof circumstances under which information may

be exchanged.

66
Staff Training

Staff trainingis a key componentat alllevelsof cdminaljustice/mental

healthinteractions.Foreffectivecommunitysupervisionof personswith

mentalillnesses,probationandparolestaffandmentalhealthproviders

mustunderstandeachothers'roles.In particular,communitysupervision

staffneedtounderstandthe effectsof mentalillnesseson dailyfunctioning.

Probationandparoleofficersmayhaveinternalconflictsbetweentheir

rolesas facilitators/helpersforpersonsundertheircareandas enforcersof

probationand parolesentences."Oddbehaviorbyclientsmay be

interpretedfromanorganizationalviewpointhatemphasizesclient

compliance,ratherthana clinicalstandpointhatseeksto interpretbehavior

in termsofa needforintervention.Thiscouldresultinhigherrevocation

ratesformentallyilloffenders,basednotonlyonthe offenders'behavior,

butalsoonthe inadequatetrainingofparolestaff"(Clear,et al., inpress).

To increasethe likelihoodof successfor personswith mental illnesses,all

communitysupervisionstaffshould be trained to identify the symptoms of

mental illnesses,to understandsome of the unique problems and issues

facing persons with mentalillnesses in the community, and to

accommodatethe sometimes unusual,but not criminal,behavior of those

under their supervision.By the same token, community mental health

providersneed to be informedaboutthe demands and nature of the

criminaljustice system and the need to work with personswho have mental

illnessesto help them meet the conditionsof their probation and parole.

Special Accommodations for Persons with

Mental Illnesses

Personswithmentalillnessestendtohavehighratesoftechnicalviolations

oftheirprobationandparolesentences.Toaccommodatetheirunique

needs,manycommunitysupervisiondepartmentshavedevelopedsome

specializedservicestohelppersonswithmentalillnessesbecome

successfullyintegratedintothecommunityandmeettheirconditionsof

release.

Technicalviolationsoftheconditionsofreleasetendtobe allor nothing

decisions.Alternativestrategiesallowforcontinuousmonitoring,increased

communicationbetweencommunitysupervisionandotherprovider

agencies,greaterclientresponsibility,andsanctionsthatallowforsome

mistakeswithoutresultinginan immediatereturntojailor prison.

67
Specialized Caseloads

Personswithmentalillnessesonprobationorparolemaybe assignedtoa

specializedcommunitysupervisioncaseload.Suchspecializedcaseloads

tencltobe smaller,andtheprobation/paroleofficerinchargeofthese

clientshasspecialskillsandknowledgethatmay facilitatethe integrationof

the individualwith mentalillnessintothecommunity.

SometimestheseservicesaretransitionalPe. rsonswithmental illnesses

whoare newlyreleasedfromjail orpdsonmay beassignedtoa specialized

caseload.Becausetheseindividualsmayhavemoredifficultyadjustingto

communitylivingafterincarceration,havefewernaturalresources(e.g.,

employment,socialsupports,housing),and requiresupervisionofspecial

conditionsfortreatment,suchearly,intensivesupervisiontailoredtothe

specificneedsof eachpersoncanbe important.Once theindividualis

stabilizedinthecommunity,he or shemaybe transferredtoa generic

caseload.

In addition,persons with mentalillnesses may require more intensive

supervisionat a later date. It is importantthat probation and parole

departments be able to monitorand reassign individualsbased on current

need.

Relapse Prevention

Relapsepreventionisa recentmodelthathas gainedwide support

(Palmer,1992).Thisapproachfocusesonthedevelopmentof socialand

emotionalsupports that reinforcean individual'sresistancetofurther

criminal behavior.

The key to this effort is the probation/paroleofficer who acts as an intensive

case manager, maintaining up-to-dateinformation on the individual's

progressin treatment programs and in employment,family, and social

environments.Effective monitoringallows the officer to anticipate periods of

increasedstress, exacerbationof symptoms, and possible criminal activity

and to intervene to avoid recidivism.This approachincorporatesand

articulatesthe shared responsibilitiesof the client,community supervision

staff, and service providersin the overall outcomes.

68
Progressive Sanctions

Progressivesanctionsfortechnicalviolationsis anotherstrategythatmay

be usedaloneorin conjunctionwithothermodelstoreducerecidivismfor

personswithmentalillnesses.Thisapproachrecognizesthefactthatmany

personswithmentalillnessesonprobationand paroleare ina "catch-22"

situation.

Termsofprobationandparoleoftenmandatementalhealthtreatmentfor

individualswith mentalillnesses,anda client'srefusaltocooperatewiththe

treatmentplanmay resultinan increasednumberoftechnicalviolations

(Clearand O'Leary,1983).Thepurpose,however,ofmentalhealth

treatmentinthiscontextistoincreasetheprobabilityof successful

completionofprobation/parole.Thus,ifcommunitysupervisionstaffadhere

tostrictsanctionsfortechnicalviolationsin regardtotreatmentcompliance,

specialneedsclients,particularlythosewithmentalillnesses,are likelyto

fail.

To avoidthisproblem,theuseofprogressivesanctionsissuggested.The

essentialcomponentofthiseffortistoavoidan Uallornothing"approachto

successorfailureintreatment.Forexample,as describedbyClearand

colleagues(inpress),Uclientsmightinitiallybe requiredtocheckinwith

theirparoleofficerweekly,butafterfailingtoshowupforseveralpsychiatric

clinicappointments,theparoleofficermightincreasethe frequencyto

severaltimesperweek. It isthenatureofseriousmentalillnessto have

periodicexacerbationsandremissions,andprogressivesanctionsallowthe

systemtoprovideresponsiveincreasesinstructurewithoutnecessarily

returningthepersontoprison._

Forthisstrategytobe effective,openlinesof communicationand

cooperationmustbe maintainedbetweenprobation/paroldeepartments

andcommunitymentalhealthandotherserviceproviders.

69
Notable Program

_._=..nr_nnn Special in June 1992, collaborationbetween the Health Services Divisionand ReleaseServicesproduced a pilot program to improve release planning for Needs Release long-stinmates ay withmental health or medical problems who are Plannino retuming to the community.Previously,planning release for persons with

r_::jOro-ram_ mandentfralustrating illnessestaskor mbeedcaicauselprobl of their emscomplex had beenneeds a compl andex, thetime lack-coofnsuming

appropriateresourcesin many communities.

To reducethe problems associated withrelease to the community, Oregon

developedthe Special NeedsRelease Planningprogram, funded entirely

by theOregonDepartment of Corrections. Up to six months prior to his or

her releasedate, a packet of information, including criminalhistory and

psychiatric evaluations,is sent to the county mental health and county

parole and probation offices. Theseofficessend staff to evaluatethe

inmate and, then work togetherto developa communityplan, including

linkage to mental health services withmedication monitoringand the

establishmentof neededsupports, including housingand entitlement

benefits (particularlya Medicaidcard).

In addition,parolees withmental illnesses who are returned to prison on

technical violationsare interceptedand sent directly to theSpecial

Management Unitwhere their symptoms are stabilized. Thisshortens the

process, and inmatesare usually retumed to the community in 60 to 90

days.

Thisinitiativehas developedreferral agreementsand protocols withmany

serviceprovider agencies,streamlinedapplicationprocedures for Social

SecurityAdministrationbenefits, establishedworking agreements with four

county communitymental healthagencies, and developed a procedure to

enable civil commitmentof severely mentallyill inmates to State psychiatric

centers. In addition, the team approachbetween community mental health

and probation_paroleencourages cooperationand reduces the probability

that a newly releasedinmate will fall through the cracks.In view of the

successof the program, parole boards are increasingly referring inmates

that could benefit from these special services.

70
In its first 18 months of operation,the Special Needs ReleasePlanning

Program has servedapproximately 150persons, two-thirdsof whom had

diagnoses of severe mental illnesses. Of these, 80 continue to be

monitored in the communityby the program.

Thisproject has succeededin establishinga single point ofreferral for

releaseplanning for complex cases,has leveraged resources that had not

been available to this populationpreviously, has impactedpublic safety and

saved cost associated withrecidivism,and has benefited clients who

require assistanceto retum to the community safely.

Contact: RonWard, CorrectionsCounselor

Phone: (503) 945-2834

71
Diversionto The mosteffectivetypesof jailmentalhealthdiversiondonotend whenthe

detaineeleavesthejail.In orderforjailandcourtdiversionprogramsto be Mental Health successful,theymustbe partof a comprehensivearrayof otherjail

Programs in the services including screening,evaluation,short-termtreatment,and

dischargeplanning(i.e.linkage)thatare integratedwithcommunity-based CommUnity mental health, substanceabuse, housing,and social services.

The best diversionprogramsdo not simplylook to keep personswith

mentalillnessesoutofjail.Theysee themas citizensofthe communitywho

requirea broadarrayofcommunity-basedservices.Theyrecognizethat

duetothenatureof mentalillnesses---andwithouttheassistanceto

overcomethe barrierscreatedbyfragmentedservicesandthelackof

socialsupportsandotherresoumes_hese individualsmay returntojail.

As previouslynoted,jail diversionprogramscanbe dividedintopre-booking

andpost-bookinginterventions.Pre-bookingdiversionoccursatthe pointof

contactwithlawenforcementofficers.If thisisdoneeffectively,as

describedearlierinthischapterinthesection"EffectivePolice/Mental

HealthInteractions,p" ersonswithseriousmentalillnesseswillbe diverted

priortoarrest.

Effectivestrategiesfor post-bookingdiversiondifferfromthosepriorto

arrest.Basedoninformationrecentlygatheredas partof a National

Instituteof MentalHealth-fundedstudy(Steadmanand Morris,submitted),

thefollowingsixfactorsrepresenthekey componentsassociatedwith

effectivecourt-andjail-baseddiversionprograms:

. servicesintegratedatthecommunitylevelwithcorrections,mentalhealth,

thejudiciary,andsocialservicessuchas housingand entitlements;

• regularmeetingsof keyagencyrepresentalJvestoencouragecoordination

ofservicesandsharingof information;

• liaisonstomanagetheintera_onsbetweenthecorrectional,mental

health,andjudicialsystems;

• a strongleaderwithcommunicationskillsandan understandingof allof

thesystemcomponentsandtheinformalnetworks;

• earlyidentificationof detaineeswithmentalhealthtreatmentneedswho

meetthediversionprogram'scriteria;and

• nontraditional casemanagementservices,involvingcasemanagerswho

arefamiliarwithboththe criminaljusticeandmentalhealthsystemsand

whoareculturallyand raciallysimilartotheclientstheyserve.

72
Notable Program

Honolulu Jail The HonoluluJail Diversionprogram is a court-basedprogram that

transfersmisdemeanantswithmental illnesses from thejail into mental Diversion health treatment.TheJail DiversionProgram was begunin 1988 with

Program Robert WoodJohnson Foundationfunds. SinceJuly 1991,the program's funding has come from the State'sgeneral fund, administered by Adult

Mental HealthServices, Department of Health.

Potentialparticipantsare identified through the followingprocedure. During

the prearraignmentinterview, non-mentalhealth staff screen all detainees

and flag those whoappearto have acute mental illnesses.Arrestees are

moved at 6 a.m. every morningfrom the HonoluluPolice Department to the

Arraignment Court. Diversionstaff interview the identified detainees to

determine whetherthey are appropriatefor diversion.

Theprogramis entirely voluntary.Individuals who choose to participate in

the program are asked to sign a release of information form allowing

program staff access to their medicaland mental health records. By the

time of arraignmentat 8:30 a.m., the Diversion Program's Case

Coordinator has arrangedfor mental health services and negotiated the

acceptance of the diversionplan withthe district attorney's office, the public

defender,and thejudge.

If the detaineeagrees to participatein the recommendedmental health

services, he or she is releasedon his or her own recognizance by the

Arraignment Courtafter a court date is set. TheJail Diversionprogram staff

arrange for a same day appointmentat the CMHC, VA outpatient clinic, or

other appropriatecommunity-basedmental health program. Program staff

drive the client to the appointmentand wait while the client is seen.

Much of the successof the program is due to the program's ability to

respondquickly,to arrange referralsand to the availability of the Case

Coordinatorto transportand waitfor clients to be seen. In addition,

extensive follow-ushelp to assure a successful outcome. Clientsare called

every 60 days at a minimum to findout how theyare doing, whether they

are stillparticipatingin services, and whether further assistance is needed.

73
Court docketsprovided by thejudiciary are reviewed each day for the next

day's cases.Any Jail Diversionprogram client scheduledto appearis

called,and if he or she needs help getting to court,the Case Coordinator

will provide transportation.Case Coordinatorsaccompany all clients to trial

court.

TheJail Diversionprogram maintains clientcharts on all participants, ff

serviceproviders lose contact witha client, this file canbe used to help

locate and reconnect theperson to services.

Thisprogram diverts misdemeanantsfromjail whileawaiting trial,

substantially reducingthe time an individual willspend incarcerated

regardlessof the outcome of the trial. Using assertivecase management,

the probabilitythat clients will miss court dates (avoidingbench warrants)

and drop out of treatmentis also decreased.

The keys to the successof this program are: (1) the presence of an

effectiveleader whois familiar withcorrections, the courts and the mental

health system in Honolulu;(2)information sharing betweenmental health

and thejail diversionprogram; (3) aggressive case management with same

daymental health clinic visitsand real access to services; and (4)

multiculturalstaff who work well with the clients in the program.

Contact: James Miller,Jail DiversionProject Supervisor

Phone: (808)586-4683

74
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APPENDIX

CMHSAd-Hoc Working Groupfor

Mental Healthand CriminalJustice

Systems
Center for Mental Health Services

Ad Hoc Working Group for the Mental Health and

Criminal Justice Systems

John Allen Sue Dickinson

On Our Own Computer Center Chair

213 Monroe Street NAMI Forensic Network

Rockville, MD 20850 202 Briarwood Drive

(301) 309-8794 Simpsonsville, SC 29681

(803) 967-7583

Paul Appelbaum, M.D.

University of Massachusetts Mike Gatling

Medical Center Executive Assistant

Department of Psychiatry American Correctional Association

55 Lake Avenue, North 8025 Laurel Lake Court

Worcester, MA 01655 Laurel, MD 20707

(508) 856-3983 (301) 206-5100

Pamela Casey, Ph.D. Voncile Gowdy

Institute on Mental Disabilities and the Management of Special Populations

Law Mentally Disabled Offenders

National Center for State Courts National Institute of Justice

300 Newport Avenue 633 Indiana Avenue, NW, Room 842

Williamsburg, VA 23187 Washington, DC 20531

(804) 253-2000 (202) 307-2951

John Clark, M.D. Ron Honberg, J.D.

Chief Medical Officer National Alliance for the Mentally III

Los Angeles County Sheriff's Dept. 2101 Wilson Blvd., Suite 302

441 Bauchet Street, Room 6044 Arlington, VA 22201

Los Angeles, CA 90012 (703) 524-7600

(213) 974-0149

Steve Ingley

Ray J. Coleman Director of Professional Services

Associate Director American Jail Association

King Co. Department of Adult Detention 1000 Day Road, Suite 100

500 5th Avenue Hagerstown, MD 21740

Seattle, WA 98104 (301) 790-3930

(206) 296-1269

Judith Johnson

Ronald Diamond, M.D. Green Door

Associate Professor of Psychiatry 1623 16th Street

University of Wisconsin Washington, DC 20009

600 Highland Avenue (202) 462-4092

Madison, Wl 53793

(608) 251-2341 Mental Health Center

(608) 263-6098 University of Wisconsin
Charles Meeks Judith Regina, R.N.

National Sheriffs Association Woodburn Community Mental

1450 Duke Street Health Center

Alexandria, VA 22314 3340 Woodburn Road

(703) 836-7827 Annandale, VA 22030

(703) 246-4431

Michael O'Toole

National Institute of Corrections Don Richardson

Jail Division 3139 Colby Avenue

1960 Industrial Circle, Suite A Los Angeles, CA 90066

Longmont, CO 80501 (310) 391-2823

Raymond Patterson, M.D. Susan Rotenberg

Superintendent National Coalition for the Mentally III in the

Clifton T. Perkins Hospital Criminal Justice System

450 Dorsey Run Road 2470 Westlake Avenue, N., Suite 101

P.O. Box 1000 Seattle, WA 98109-2282

Jessup, MD 20794-1000 (206) 285-7422

(41 O) 792-4022

Jayne Russell

John Petrila, J.D., L.L.M. Program Administrator

University of South Florida Maricopa County Justice and Law

Department of Law & Mental Health 301 West Jefferson

The Florida Mental Health Institute Phoenix, AZ 85003

13301 Bruce B. Downs Blvd. (602) 506-1381

Tampa, FL 33612-3899

(813) 974-2011 Matt Russell

Director of Legislative Affairs

Robert T. M. Phillips, M.D., Ph.D. National Mental Health Association

Director Forensic Services 1021 Prince Street

Department of Mental Health Alexandria, VA 22314

Whiting Forensic Institute

P.O. Box 70 Ron Schraiber

O'Brien Drive Consumer/Survivor Mental Health

Middletown, CT 06547 Research and Policy Work Group

24844 Newhall Avenue #3

Walter Y. Quijano, Ph.D. Newhall, CA 91321

Psychologist (213) 488-0031

Montgomery County Jail

2040 Loop 336 West, Suite 105 Lawrence Soloman

Conroe, TX 77304 Acting Director

(409) 549-2226 National Institute of Corrections

500 1st Street, NW, Suite 1002

Barbara Rankin Washington, DC 20001

7002 Harrods Landing

Prospect, KY 40059

(502) 228-2807
James Stephan Federal Representatives

Bureau of Justice Statistics

633 Indiana Avenue, NW, Room 1142 Peggy Clark

Washington, DC 20531 Public Health Advisor

(202) 616-3289 Community Support Program

Division of Demonstration Programs

Jim Stratoudakis, Ph.D. Center for Mental Health Services

Mental Health Director Substance Abuse and Mental Health

Fairfax County Mental Health Services Services Administration

3340 Woodburn Avenue 5600 Fishers Lane, Room 11C-26

Annandale, VA 22003 Rockville, MD 20857

(702) 207-7743 (301) 443-3606

Linda Teplin, Ph.D. Ingrid Goldstrom

Northwestern University Medical School Survey and Analysis Branch

215 East Chicago Avenue #708 Division of State and Community

Chicago, IL 60611 Systems Development

(312) 908-3712 Center for Mental Health Services

5600 Fishers Lane

Rebecca Titus, M.S.W. Rockville, MD 20857

Mental Health Coordinator (301) 443-3343

Summit County Jail

205 East Crosier Street Dawn Jahn

Akron, OH 44311 Center for Mental Health Services

(216) 643-2145 Substance Abuse and Mental Health

Services Administration

Mary K. Vaughn 5600 Fishers Lane, Room 15-105

Acting City Manager Rockville, MD 20857

City Hall, 29th Floor (301) 443-0001

414 East 12th Street

Kansas City, MO 64106 G. Bryan Jones, Ph.D.

(816) 274-2474 Refugee Mental Health Branch

Center for Mental Health Services

Ron Waters Parklawn Building, Room 18-49

Consumer Self-Help Center 5600 Fishers Lane

2195 Lejano Way Rockville, MD 20857

Sacramento, CA 95833 (301) 443-2130

(916) 737-7100

Ronald W. Manderscheid, Ph.Do

Marthagem Whitlock, Ph.D. Survey and Analysis Branch

Department of Special Services Division of State and Community

Department of Mental Health and Systems Development

Mental Retardation Center for Mental Health Services

706 Church Street 5600 Fishers Lane

Nashville, TN 37219 Rockviile, MD 20857

(615) 741-2517 (301) 443-3343
Harriet McCombs, Ph.D.

Program Development and Special

Populations

Center for Mental Health Services

5600 Fishers Lane, Room 13-103

Rockville, MD 20857

James Pittman

Acting Director

Division of Program Development and

Special

Populations Projects

Center for Mental Health Services

Parklawn Building, Room 7C-105

5600 Fishers Lane

Rockville, MD 20857

(301) 443-2940

Susan Salasin

Director

Mental Health and Criminal Justice

Program

Division of Program Development and

Special Populations

Center for Mental Health Services

5600 Fishers Lane, Room 13-103

Rockville, MD 20857

(301) 443-7790

Henry J. Steadman, Ph.D.

President

Policy Research Associates, Inc.

262 Delaware Avenue

Delmar, NY 12054

(518) 439-7415

Bonita M. Veysey, Ph.D.

Policy Research Associates, Inc.

262 Delaware Avenue

Delmar, NY 12054

(518) 439-7415