Is the Local Jail Your Local Mental Hospital?
By Michele Russell-CJPF Research Associate
September 2, 2003

This nightmare is a reality for approximately 200,000 homeless persons who suffer from severe mental illness such as schizophrenia or bipolar disorder. This is nearly one third of the homeless population (Treatment Advocacy Center, January, 2003). Drug and alcohol abuse are common in this population. These serious conditions are often untreated and lead to additional incarcerations.

The "How?" and "Why?" of It All

Before the 1960's, America generally hospitalized the mentally ill in state hospitals. As a result, most of the seriously mentally ill, not believed to be dangerous to themselves or others, were locked up against their will. Many of these institutions had inhumane conditions. Often, there was inadequate treatment. Later, the development of modern psychoactive medications allowed relief from symptoms and there was great hope that the mentally ill need no longer be locked up. Advocates of the mentally ill began questioning treatment policies in the state hospitals. The combination of newer medications and advocacy led to the formation of the Joint Commission on Mental Illness and Health in 1955, which recommended community alternatives to state hospitals (H.R. Lamb).

The Commission's report led to a federal interagency committee appointed by President Kennedy in late 1961. The National Institute of Mental Health (NIMH) recommended that 2,000 community mental health centers (CMHC's) be built by 1980, but less than a quarter of the estimated need was ever funded. Only 482 centers received federal funding from 1963 to 1980 (E. Torrey and M. Zdanowicz, 1999). Meanwhile, patients were being discharged in large numbers.

The Community Mental Health Act of 1964 provided block grants to states to establish and run the CMHC's. These centers were set up to provide case management, medication management, and other support services to substitute care for the hospitals that were rapidly closing.

Patients were being released to rundown boarding houses because redevelopment and gentrification eliminated acceptable low-rent options. Discharged patients were rarely connected with the CMHC's. Lack of referrals, paranoid symptoms, and inadequate disability benefits, led to a surge of people with serious mental illnesses living on the streets.

Drug Use Among the Homeless

Various coping measures are part of the tragic lifestyle of surviving on the streets. One of the more common maladaptive coping skills is drinking alcohol and using drugs. Whether it's to subdue delusions and hallucinations, cope with depression, stay warm, or to escape the horrors of one's reality, heavy drug and alcohol use are prevalent among the nations homeless.

Having a mental illness in conjunction with drug and/or alcohol abuse is defined as a co-occurring disorder, or dual diagnosis. There are an estimated 7 - 10 million adults in America with co-occurring disorders. Different estimates suggest that forty-one to sixty-five percent of the individuals with a substance abuse disorder also have a lifetime history of at least one mental disorder. Estimates from the Epidemiologic Catchment Area (ECA) study and the National Comorbidity Study (NCS) found that 23%, or 44 million, Americans have a mental health disorder and that 15%, or 6.6 million, of these people have a substance abuse disorder. (SAMHSA Report to Congress, 2002).

These studies were conducted over a decade ago. A revised NCS study currently being conducted suggests the statistics remain similar.

The combination of these afflictions in the homeless population is often lethal. People with co-occurring disorders who are homeless are more likely to have greater health difficulties, more susceptible to victimization, less likely to have contact with families, and more resistant to offers of help (E. Drake, F. Osher, M. Wallach 1991). Of the nearly 39% homeless who suffer from serious mental illnesses, an estimated 50% experience a substance abuse disorder (SAMHSA Report to Congress, 2002).

Criminalization of the Mentally Ill

Increasingly, homeless people with mental illnesses are housed in jails and prisons. This placement occurs as a result of this population's tendency to commit nuisance crimes, such as common misdemeanors, or to self-medicate with illegal drugs. A revolving door from jails to the streets and back has been common since the surges of released patients.

The numbers starkly demonstrate the population shift from hospitals to prisons. In 1955, 559,000 people were in state mental hospitals. Currently, there are only 70,000. The prevalence of mental illness has not decreased. The mentally ill are still in our society. They have been moved to another institution. In the past decade alone, 40 state hospitals have closed while 400 new prisons have opened (The Sentencing Project, January 2002). This demonstrates that the mentally ill have not been deinstitutionalized from hospitals to treatment centers, they have been transinstitutionalized from hospitals to prisons.

In the 1970's, Michigan's mental institutions housed approximately 28,000 mentally ill persons and prisons housed about 8,000. Presently, there are fewer than 3,000 mentally ill people in mental hospitals and about 45,000 in the state's prisons (The Sentencing Project, January 2002).

Crimes committed by the mentally ill generally fall into three categories: First, illegal acts which are a by-product of mental illness such as disorderly conduct, trespassing, disturbing the peace or public intoxication. Second, economic crimes to obtain money for subsistence such as petty theft, shoplifting, or prostitution. These first two categories would be largely avoidable if better community resources existed. The third category consists of more serious offenses such as burglary, assault, robbery, or rarely, murder or rape.

What happens to the mentally ill once incarcerated? Symptoms of mental illness can be exacerbated by imprisonment. Paranoia is likely to increase in such an environment, as well as depression. There is a grave lack of mental health treatment in prisons and jails, which is a likely contributor to the high rates of suicide in jails. Suicide is the leading cause of death in jails. Ninety-five percent of jail suicides are being committed by those with a treatable psychiatric illness. The sad fact is that these suicides are predictable and preventable. Over 50% of suicides are committed within the first twenty-four hours of incarceration, with 29% committed within the first three hours (Open Society Institute, 1996).

Barriers to Treatment

Lack of adequate treatment is the main contributing factor in why this population commits additional crimes upon release. The many barriers to providing adequate treatment range from policy issues to inappropriate family response and lack of resources.

Policy barriers include a lack of organization among federal and state agencies, insufficient training, cumbersome certification regulations for clinicians seeking joint credentials, and a lack of overlap of assessment tools among varying disorders.

Funding is the most common feature of the remaining barriers. The patchwork of funding sources to treat persons with co-occurring disorders complicates the provision of treatment. This patchwork is made up of federal, state, local, private, education, criminal justice, and child welfare sources. Eligibility regulations and requirements vary from source to source creating a bureaucratic tangle, which often overwhelms the staff caring for the individual who is still suffering.

Program and clinical barriers include a lack of the following: service models, administrative guidelines, quality assurance procedures, and outcome measures for the treatment of co-occurring disorders. Mental health staff are often inadequately trained. Funding does not exist for re-training or cross training. Mental health providers are reluctant to diagnose clients if reimbursement is unavailable.

Other barriers include the stigma of mental illness. Combining this stigma with substance abuse disorder blocks patients from receiving appropriate care. Families are often uneducated about the severity and complications of co-occurring disorders and there is a lack of wrap-around services that would include families as sources of support.

Lack of cultural competence among providers often leads to inappropriate diagnoses. Programs often end too soon or insurance does not cover necessary treatment. The combination of these barriers keeps the doors of jails and prisons spinning for this vulnerable population.

Costs

The economic burden of mental illness is divided into two categories. Direct costs, which include the expense of treatment, and indirect costs, which refer to losses in productivity.

Direct mental health service costs were approximately $69 billion in 1996. This included psychiatric hospitalizations, psychotherapy sessions, and treatment at mental health clinics (Geballe, 2001). Substance abuse treatment alone cost $13 billion in 1996.

Indirect costs include lost work time by patient, and of family caretakers as well. In 1990, the most recent year for which statistics are available, these costs amounted to $79 billion in indirect costs. This was broken down from three categories. Morbidity - the loss of productivity in usual activities because of illness, comprised 80% of all indirect costs with a total of $63 billion. Mortality - lost productivity due to premature death, compiled $12 billion. Incarceration equated to $4 billion (Surgeon General's Report, 1999).

Multitudes of studies have proven that drug and alcohol treatment reduces the costs involved in recidivism. Other programs, such as The Center for Alternative Sentencing and Employment Services (CASES) provide Alternative to Incarceration Programs (ATI's) that significantly reduce overcrowding and the costs thereof. New York City's ATI's have cut crime and recidivism rates, therefore decreasing the jail population. According to the city's Department of Correction, it costs $62,595 per year for the care of one inmate while the annual cost of ATI's services per person is between $1,400 to $13,000 (ATI Report, CASES). This is the cost estimate for the average inmate. The cost savings for an inmate with severe mental illness would be even greater.

Solutions

In recognizing the disturbing numbers of persons with co-occurring disorders who are homeless and incarcerated, many measures have been taken towards prevention and treatment. These measures stretch across agencies, paradigms, and funding sources.

Diversion from criminal justice programs attempts to lower recidivism rates and save money. In 2000, Congress passed America's Law Enforcement and Mental Health Project Act, which allowed for the federal funding of mental health courts. These are modeled on drug courts which became popular in the 1990's and offered treatment options instead of incarceration. They operate from a philosophy that diversion is cost effective and beneficial to the individual offender as well as the greater community. Currently, there are about twenty-five mental health courts in operation, but there are no common regulations governing the courts besides the overall protection of one's constitutional rights (Bazelon Center, January 2003).

Mental health courts became a response to the crises in community mental health care, the drug epidemic of the 1980's and 1990's, the startling increase in homelessness over the past twenty years, and jail overcrowding. The first goal of the courts is to break the cycle of escalating mental illness and criminal behavior fueled by the lack of community mental health services and treatment options in prisons and jails. The second goal is to provide sufficient treatment options instead of the usual criminal restrictions for offenders with mental illness.

Mental health courts have a separate docket with a judge, prosecutors and defense attorneys who have all had training on how to work with defendants with mental illness. It is a voluntary process on behalf of the offender who also has the right to withdraw. Types of offenses covered range from non-violent crimes, such as trespassing or disorderly conduct to more violent crimes.

The Sentencing Project proposed a new approach encompassing significant changes, such as diversion programs, on all levels of the criminal justice system from initial police contact and pre-booking to probation and parole. Their report also highlights the importance of screening and treating persons with serious mental illness who are already incarcerated, as well as calling for adequate discharge planning.

The Urban Justice Center is currently suing the New York City jail system. Of the 30,000 inmates who received mental health treatment while incarcerated, only 7% received any discharge planning. The remaining 93% were either released from court with no resources or were simply dropped off at a subway station between 2:00 A.M. and 6:00 A.M. with two tokens and $1.50 in their pocket. (The Sentencing Project, January 2002).

Specialized units of police, who have received intensive training on how to identify and work with the mentally ill population, are becoming more and more common. One such unit is the Memphis Police Crisis Intervention Team (CIT). Memphis has a twenty-four hour crisis center with a no-refusal policy for those brought in by the police. Training defense attorneys regarding interview techniques are also recommended (The Sentencing Project, January 2002).

A more preventative and global measure for this issue is to provide more affordable housing in general. Residential stability is crucial to the successful treatment of mental illness and prolonged sobriety. Not only is there a lack of affordable housing, people with co-occurring disorders often have uncertain sources of income or erratic behavior. They are often considered difficult tenants, and communities do not want them in their neighborhoods. Many eligibility requirements for housing programs exclude those with co-occurring disorders.

Another issue must address federal benefits. Currently, all federal benefits are terminated upon incarceration. Upon release, such persons are usually without any income and have to re-apply for health care, housing, food and other support. Reapplication is a laborious and time-consuming process even for the healthy and composed. For someone with a mental illness it can be utterly overwhelming. The Building Bridges Model Benefits Law from the Bazelon Center for Mental Health Law proposes to change these procedures. From simply suspending benefits while someone is incarcerated to identifying those who need benefits, and then assisting them in the acquisition of income support, this model law strives to reduce these obstacles to life support and treatment.

Overall, changes are currently in process. This is good, but they must continue to evolve. Serious mentally ill persons need adequate supportive services that jails and prisons are not equipped to provide. Criminalizing this population is not the solution. The solution lies in continual evaluation of existing programs and continual evolution of new programs. These programs must be inclusive and work with multiple disciplines to encompass the various challenges the seriously mentally ill face in our society.

Bazelon Center for Mental Health Law. (January 2003) The Role of Mental Health Courts. Available at http://www.bazelon.org/issues/criminalization/publications/mentalhealthcourts/role.htm Accessed July 14, 2003

Bazelon Center for Mental Health Law. (June 2003) Building Bridges: An Act to Reduce Recidivism by Improving Access to Benefits for Individuals with Psychiatric Disabilities upon Release from Incarceration. Available at http://www.bazelon.org/issues.criminalization.publications/buildingbridges/index/htm Accessed July 15, 2003

Brady, K. & Myrick , H. (2003). Current Review of the Comorbidity of Affective, Anxiety, and Substance Use Disorders. Current Opinion Psychiatry 16(3):261-270. Available at http://www.medscape.com/viewarticle/452725 Accessed June 30, 2003

The Center for Alternative Sentencing and Employment Services (CASES). Alternatives to Incarceration Programs: Cut Crime, Cut Costs, Help People and Communities. Available at http://www.cases.org/Papers/ATIs.htm Accessed July 22, 2003

Disability Information Network: Minnesota State Council on Disability. (January 2003) 11th Annual Legislative Roundtable, January 9, 2003. Available at http://www.disability.state.mn.us/pubs/roundtable/rndtble2003.html Accessed July 7, 2003

Drake, Robert E., Osher, Fred C., and Wallach, Michael A. Homelessness and Dual Diagnosis. American Psychologist, November 1991, Vol. 46, No. 11, 1149-1158. Available at http://www.psychosocial.com/dualdx/dualdx1.html Accessed July 7, 2003

Fazel, S., (February 2002) Serious Mental Disorder in 23,000 Prisoners: A Systematic Review of 62 Surveys. The Lancet, Volume 359, No. 9306. Available at http://www.thelancet.com/journal/vol359/iss9306 Accessed July 1, 2003

Geballe, S., (June 2001) The Economic Costs of Mental Illness and Benefits of Treatment. Available at http://www.ctkidslink.org Accessed July 1, 2003

Lamb, H. Richard. Deinstitutionalization and the Homeless Mentally Ill. Available at http://www.interactivist.net/housing/deinstitutionalization_1.html Accessed July 21, 2003

The National Coalition for the Homeless. (June 2001) Mental Health Services and Homelessness. Available at http://www.natinalhomeless.org/mentalhealth/html Accessed July 7, 2003

The National Coalition for the Homeless, (April 1999) Addiction Disorders and Homelessness: NCH Fact Sheet #6. Available at http://www.natinalhomeless.org/addict.html Accessed July 7, 2003

The National Coalition for the Homeless. (April 1999) Mental Illness and Homelessness: NCH Fact Sheet #5. Available at http://www.nationalhomeless.org/mental.html Accessed July 7, 2003

The National Resource Center on Homelessness and Mental Illness (June 2003) Question #1: How Many People are Homeless? Why?. Available at http://www.nrchmi.com/facts/facts_question_1.asp Accessed July 1, 2003

The National Resource Center on Homelessness and Mental Illness (June 2003) Question #3: Why Are So Many People with Serious Mental Illness Homeless? Available at http://www.nrchmi.com/facts/facts_question_3.asp Accessed July 1, 2003

Office of the Surgeon General. (1999) Mental Health: A Report of the Surgeon General. Available at http://www.surgeongeneral.gov/library/mentalhealth/home.html Accessed July 1, 2003

Open Society Institute. (November 1996) Research Brief: Mental Illness in the US Jails: Diverting the Low Level Non-Violent Offender. Occasional Paper Series, No. 1. Available at http://www.soros.org/crime/research_brief_1.html Accessed July 1, 2003

The Sentencing Project. (January 2002) Mentally Ill Offenders in the Criminal Justice System: An Analysis and Prescription. Available at http://www.sentencingproject.org Accessed July 11, 2003

SAMHSA Report to Congress. (October 2002). Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Illness. Chapter 1 - Characteristics and Needs of the Population - Understanding Co-occurring Disorders. Available at http://www.samhsa.gov/reports/congress2002/chap1ucod.htm Accessed June 26, 2003

SAMHSA Report to Congress. (October, 2002). Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Illness. Chapter 2 - The States Respond: The Impact of Federal Block Grants. Available at http://www.samhsa.gov/reports/congress2002/chap2bg.htm Accessed June 26, 2003

Treatment Advocacy Center. (January 2003) Fact Sheet: Many Americans with Untreated Psychiatric Illness Have Nowhere to go: Homelessness: Tragic Side Effect of Non-Treatment. Available at http://www.psychlaws.org/generalresources/fact11.htm Accessed July 1, 2003

Document #2

Drug Policy: A Smorgasbord of Conundrums Spiced By Emotions Around Children and Violence By Eric E. Sterling. Valparaiso Law Review. Spring 1997, Volume 31, Number 2. This 49-page law review comment in a 500-page symposium volume, "Juvenile Crime: Policy Proposals on Guns, Violence, Drugs and Gangs," addresses the complexities of drug policy and how it is shaped by concerns about children and public safety. Discusses availability of illegal drugs, drug use by children, the "right" to use drugs, crack markets and violence, drug dealing by adolescents, the handicap of drug prohibition on urban redevelopment, and issues regarding medical marijuana. The following excerpt responds to an article by Mark A.R. Kleiman.