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