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Abstract It is inevitable that first responders in the justice system will come into contact with mentally ill people on a regular basis. While there are some specialized programs in the justice field to meet the needs of the mentally ill there is very little training for most line officers. Most officers do not know how to properly communicate to these people and their reports may reflect incorrect information regarding mental illness. Research shows that an increasing number of people with serious mental illness are entering the justice system every day. New training and standards for police officers must be devised if departments want to continue to protect and serve the public in the most professional way possible. Introduction Deinstitutionalization is the process of state run mental health facilities being shut down in the attempt to allow people with serious mental illness to receive help from the community. "State mental hospital populations are reduced by discharging long-term residents, shortening hospital stays, and attempting to reduce the number of admissions" (Steadman, Monahan, Duffee, Hartstone, & Robbins 1984). While the intentions were good, the act itself has become "one of the most well-meaning but poorly planned social changes ever carried out in the United States" (Torrey, Kennard, Eslinger, Lamb, and Pavle 2010). This event has had a huge impact on the criminal justice system, causing jails and prisons to become the main healthcare provider for people with Serious Mental Illness in the United States. "The police are typically the first and often the sole community resource called on to respond to urgent situations involving persons with mental illness" (Lamb, Weinberger & DeCuir 2002). While this is a true statement, and something most of us take for granted, we must really think about what it means. Due to the criminalization of mental illness in the past few decades, more and more people with serious mental illness are on the street. While many of these people are non-violent in nature the general public views them as a nuisance and desire the local police to handle and/or remove these people from their vicinity. Because of this, police are constantly in contact with people who have a serious mental illness, though many officers lack the necessary training to properly to handle these people. With all of these issues it is difficult for the average police officer to know how to identify and report on offenders who have a serious mental illness. A benefit of expanded training would include using proper terminology and types of mental illnesses in daily report writing when encountering these people. Deinstitutionalization has not worked as planned. The current figures indicate that at least 16% of inmates in prison have a serious mental illness (Torrey et al 2010). With the decrease in state run mental hospitals jails and prisons are now primary health care providers for the mentally ill. All the act of deinstitutionalization has done is shifted costs from hospitals into prisons where many people cannot get adequate treatment for their symptoms. The burden is now on the justice system, and the public, to care for these people. Healthcare in prison was constitutionally mandated by the Supreme Court in 1976 in the case of Estelle v. Gamble (Slate & Johnson 2008). While treatment must be provided, the resources available are not always the best options for individuals. Costs are also higher for caring for inmates with a mental illness, which affects local and state budgets, taxes, and how money is allocated. Restructuring of the mental health care system is something that will have to be done in the near future if we truly want to shift the burden of caring for those with SMI from corrections back to a more stable, hospital, or community setting. Literature Review The study of deinstitutionalization and its subsequent effects on the mentally ill is a subject that has continually gained more interest year after year since the idea was first introduced. Because of this there are many different, reliable sources with diverse points of view and compelling arguments about deinstitutionalization. Many different areas are covered, from the basic study of deinstitutionalization, the response and training of law enforcement officials, mental health courts, and the fact that jails and prisons now house more mentally ill people than health facilities. One interesting thing to note is that unlike other subjects where there are clear pros and cons and two sided arguments, almost all of the research done on deinstitutionalization shows that the overall picture and effects of deinstitutionalization is the same. There are two main sources for the initial research into the correlation between mental health facilities and the number of people incarcerated. The first was written by Penrose in 1939 and the second by Henry Steadman, John Monahan, Barbara Duffee, Eliot Hartstone, and Pamela Clark Robbins written in 1984. Penrose's research was done in Europe while Steadman's was a continuation of Penrose's initial findings in the United States. Penrose's theory was that countries with fewer resources for treating mentally ill offenders would have more people in jails and prisons, and vice versa, and he examined several European countries and his data indicated that his theory was correct (Penrose 1939). Steadman and his team combine the research done by Penrose in 1939 to show a direct correlation between Penrose's results and their look at prison populations in the United States. Because of Steadman the idea of deinstitutionalization became known on a large scale by American readers and proved that Penrose's initial findings were true in the United States as well as Europe (Steadman et al 1984). Moving away from the big picture look at deinstitutionalization, research is typically done regarding the current state of affairs with jails, prisons, and the justice system, or with community outreach and response regarding people who are mentally ill. While examining research regarding justice system response we find that most authors agree with the fact that deinstitutionalization has caused more harm than good, causing our jails and prisons to become mental healthcare providers. Lamb and Weinberger examine the problem of housing so many people with a serious mental illness in jails and prisons. They agree that our correctional institutions have become the number one treatment options for mentally ill individuals, with the current number of inmates with an SMI at 16% (Lamb & Weinberger 1998). This confirms the same number from several other sources including Torrey and Slate & Johnson, as well as a recent study from Steadman, Osher, Robbins, Case, and Samuels in an attempt to see if SMI in the jail and prison population had changed any in recent years. Knowing the mental capacity of a jail population is important so we can understand the affects deinstitutionalization has had on our correctional system, as well as being able to know how many of those jailed need special attention and care because of their illness. In addition to finding that the number of prisoners with a SMI had not changed from 16%, they also found that proper resources were not being allocated to mentally ill inmates. (Steadman, Osher, Robbins, Case, and Samuels 2009). One of the main focuses in research right now is on community attitudes and outreach for people with mental illnesses. This includes both the criminal and non-criminal, return to work approaches, and risks associated with re-entry into the community. The goal of a 1987 article written by Wilmoth, Silver, & Severy was to understand community reaction towards the mentally ill and different forms of treatment. These include different types of group homes for various forms of illness, outpatient care, and state run hospitals. The research actually showed support for deinstitutionalization as opposed to using state run institutions for treating patients (Wilmoth, Silver & Severy 1987). It is unknown if the survey participants realize that without these state facilities the majority of treatment for people with a serious mental illness comes from the justice system. Due to deinstitutionalization there has been a great increase in the number of mentally ill persons living in the community. Kelly and McKenna examined the effect of criminal activity, stigma, and public perception of the mentally ill communities. People with a SMI experience increased harassment and rejection from the general public (Kelly & McKenna 2004). Lack of resources can be a problem in many areas, and it is not enough to simply treat a person's illness and cut them loose from the health system. These people need to be cared for and supported if they are to make a successful transition back into our communities. The research being conducted is important because it can inform the public about what is really happening behind the scenes in the mental health community. Because of the limited treatment options available, one of the largest problems with having jails as a healthcare provider is the effects that mental illness has on reentry into society (Lurigio, Rollins, & Fallon 2004). Reentry is one of the biggest and most difficult problems that mental ill offenders face today. While some communities are prepared for it, most places simply do not have the manpower or resources to aid these people to be successful. Simply understanding the effects of deinstitutionalization is not enough. We must also explore different hands-on treatment options for placing individuals back into society. Brucker's research is to remind us that we must move on from just studying the effects that deinstitutionalization has had on the mentally ill. Returns to work programs are designed for assistance to aid people with SMI in living normally within the community and to teach them how to contribute to society in some capacity (Brucker 2006). These sources give us a clear picture of deinstitutionalization and the effect it has had on our justice system. There is a correlation between the lack of health resources and the number of mentally ill people in the justice system. Community based health care is looked on favorable, but the resources for it simply do not exist at this time. Many things hold back the mentally ill from being normal members of society, both from lack of resources as well as perception from the general public. The most important thing that can be done now is to allow this research to reach the public in greater numbers. Not many sit around reading scholarly journals; therefore the information about deinstitutionalization and the mentally ill is simply not being heard by enough people. Prevention/Intervention Strategies When it comes to the criminalization of the mentally ill through the process of deinstitutionalization there have been a few strategies employed to handle the situation, though none directly related to report writing. However, these include both preventive strategies, such as group homes and medical care, as well as intervention strategies from law enforcement, including the introduction of mental health courts and crisis intervention teams. There has also been a significant lack of training for first responders in indentifying, reporting and handling a person with a serious mental illness properly. The successes and failures of these strategies have varied greatly from state to state, and there does not seem to be one right answer in the matter. The current trend in the law enforcement community of properly managing potential offenders with a mental illness is through the use of crisis intervention teams, or CITs. CITs are made up of police officers that have been specially trained in assessing mental illnesses, as well as the appropriate action to take when facing a dangerous situation involving a mentally ill offender. (The CIT model has been a joint effort between law enforcement and health officials but is strictly operated by sworn law enforcement. Overall, the implementation of CITs across the country seems to be effective. The big revelation in the article is how much better prepared and trained the CIT officers were to handle a mentally ill person than other police officers. Not only did CIT officers say they were 100% prepared to handle the mentally ill, as opposed to the 65.4% officer that said they were prepared, the officers in CIT said that their confidence in the untrained officer preparedness was only 30.5% (Compton, Bahora, Watson, Olivia 2008). This truly shows how under trained our first responders are, as the CIT officers were once untrained as well. They know how complicated mental illnesses are, and how much you have to learn to be prepared to deal with them when the time comes. The other strategy that is being employed today is the introduction mental health courts into the judicial system The use of mental health courts has been one avenue in the justice system geared at helping and treating the mentally ill rather than simply locking them into jails and prisons for their entire sentence. While the concept behind mental health courts is appealing, is the process being carried out as it should and are mentally ill offenders being treated more fairly in the system? "In the past 2 years, mental health courts have proliferated from just 25 to over 80 today. Because of concerns about large numbers of people with mental illnesses cycling through the criminal justice system, most commentators have spoken favorably about this latest problem-solving court" (Seltzer 2005). What all goes into a mental health court? Schneider, in his 2008 article, states that "judges and lawyers are supplemented by any number of psychiatrists, psychologists, case workers, and social workers who collaborate on how the particular needs of the accused can effectively be met." The idea was to open up the operation of the court to everyone would be able to assist the mentally ill in some form or another. This way cases could be looked at objectively and not as a simple case of blind justice, or locking someone up and throwing away the key. While the guilty offenders will still be punished, the assistance of doctors and social workers allows for several different viewpoints for the best course of action. "The traditional punishment-based response of the criminal justice system to individuals who are in need of correction has failed both society and the mentally disordered accused and is, in fact, counter-productive" (Schneider 2008). While the idea is a good one, what makes a mental health court a mental health court? The definition can be unclear at times. Steadman, Davidson, and Brown wrote in 2001 that "almost any special effort by the courts to better address the needs of persons with serious mental illness who engage with the criminal justice system can qualify as a mental health court by current standards. In its diffusion, the concept has come to have little meaning." They also suggest some criteria for defining a mental health court, but so far no one definition or set of standards is used to determine what is and isn't a mental health court. So do mental health courts actually work? There is no clear yes or no answer in this case. Articles written by McNeil & Binder and Boothroyd, Poythress, McGaha, & Petrila look to address this issue. McNeil & Binder's primary goal was to "determine whether participation in mental health court was associated with a longer time without recidivism compared with treatment as usual" (2007). Of course, their research did not lead to a simple explanation. Recidivism of mentally ill offenders doesn't just rely on whether or not they were involved in a mental health court. It depends on type of mental illness, severity of crime, involvement in other criminality, treatment methods, and punishment levels. Boothroyd and company's research examined the Broward mental health court. They reemphasize the fact that there is no clear definition on what makes a mental health court but "most of those in existence today share several common characteristics" (2003). Their research detailed the process a mental health court takes in hearing a case, as well as who is involved. The article includes a section on linking offenders to mental health treatments in an effort to aid their illness and reduce the chance of recidivism. However as they state in their results "no significant difference was found in the behavioral health service penetration rates between sites prior to enrollment into the study" (Boothroyd et al 2003) but that levels of treatment were increased from those who went through the mental health court setting. However, there is still no clear answer on the reliability of mental health courts to curb criminality and recidivism. People may see this as a fault in the criminal justice system, but this could be due to the misunderstanding of what the system is supposed to do. Raleigh Police Crime Prevention Officer Scott Womack stated "people always talking about the system failing...but it's not failing if it doesn't recognize nor prevent what it was not designed to the involuntary commitment process does exactly what it is supposed to do identify folks in crisis (i.e.: a psychotic state) and impress treatment upon them to alleviate the dangerous state, it was never designed for prevention or long-term remedial care" (personal communication, 11/17/11). When deinstitutionalization first started occurring, the idea was to create community health centers for the patients (Slate & Johnson 2008). This would get them out of state run facilities and into their neighborhoods. Unfortunately, the dream of these community health centers was never realized and these patients, now with nowhere to go, started getting arrested for various reasons. While group homes do exist, they are often overcrowded and underfunded. This has lead not only to the increase of mentally ill offenders in the care of jails and prisons, but has made routine policing much more difficult. If the idea of these community run health care centers could be revitalized, it may counteract some of the effects of deinstitutionalization. Until then, the mental health court system must be revised, with national rules and regulations, and the training of our first responders needs to be increased. Plan of Action The damage that has been caused by deinstitutionalization and the ongoing shutdown of mental health hospitals is not fixable. Because of this, the best place to fight the effects of what has happened is on the street with our first responders. It is inevitable that police officers will come into contact with mentally ill people on a regular basis. While there are some specialized programs in the justice field to meet the needs of the mentally ill there is very little training for most line officers. Research shows that an increasing number of people with serious mental illness are entering the justice system every day. New training and standards for police officers must be devised if departments want to continue to protect and serve the public in the most professional way possible. While police officers "have the power to transport persons for psychiatric evaluation and treatment when there is probable cause to think that they are a danger to themselves or to others because of their mental condition" (Lamb, Weinberger & DeCuir 2002), the option for treatment may not always be available or close at hand. Without knowing what to look for in a mentally ill person an everyday line officer may mistake the person for being hostile, non-compliant, argumentative, or otherwise unwilling to cooperate. Reports may be written incorrectly, and the lack of knowledge may lead to more difficult situations, escalations in use of force, and safety concerns for both the person and the officer. In the article "Law Enforcement Responses to People with Mental Illness," written in 2009, authors state that due to their experiences police officers now realize the need for training more than ever and local consultants are available for help on a call by call basis. However policymakers "need more than personal experiences; they need data that quantify the nature and extent of the problem in order to commit resources and energy toward a potential response" (Reuland, Schwarzfeld, & Draper 2009). This is a common occurrence no matter where you look. Everywhere officers need more training but the resources and funding just isn't available. It may not be until further, more serious problems with mentally ill offenders are reported that new training will be implemented for everyone. Why should the public be concerned with this issue? Simply because of the number of people who end up prison every year, and the number of those who have a serious mental illness. Recent studies show us that at least 16% of all inmates have a serious mental illness (Torrey et al 2010). This number may not sound like much until you look at how many people are incarcerated every year, somewhere around 1.6 million. This does not include the very large amount of people who come in and out of local jails every day, all year long. Because of these high numbers every law enforcement officer in the country, whether it be local, state, or federal, will come into contact with the mentally ill on a regular basis. While training standards need to be updated, this is not to say that there is not some select training in place in a few areas, as well as crisis intervention teams. These teams specialize in people with serious mental illness, and what training that is available to officers may offer some assistance but are not up to the level it should be. The CIT model currently has over 400 teams in place throughout the country (Watson, Morabito, Draine, & Ottati 2008). While CIT teams are a specialized area in law enforcement, Watson states "Training such as the CIT curriculum may influence an officer's knowledge and attitudes about mental illness…officers who can reliably understand how these factors relate to mental illness may be more apt to decide to access mental health treatment in lieu of arrest." Of course, the mental health option is not always available, and local jails play their part again in the health care system. Crisis Intervention Teams involve specially trained officers who respond to calls involving mentally ill people as well as having to "act as liaisons to the mental health system" (Watson et al 2008). While the concept of CIT is a great idea, there are still many departments around the country who have no CIT team or model to build one from. The type of training they receive is a prime example of what every first responder should be taught in basic training. The results show the training works. A 2008 study, headed by Michael Compton, details the results of CIT teams. In Memphis, TN, CIT officers responded they were 100% prepared for situations involving the mentally ill, as opposed to 65.4% of other officers who said they felt prepared. Also, CIT officers only felt confident that 30.5% of regular officers would properly handle a situation involving a mentally ill person. They also found more help from the health care system. It is this kind of training and confidence to respond to situations involving the mentally ill that must be implemented for every police officer on duty. An increase in confidence in handling mentally ill people would not only improve officer performance in the field, it would reduce injury, recidivism, arrests, allow for more accurate and detailed reports, and increase the use of mental health resources in the community. "There is still a lot to learn about law enforcement encounters with people with mental illnesses and specialized responses" (Reuland, Schwarzfeld, & Draper 2009). It is the current data we have that we can use to model new training programs for first responders. Between CIT successes, help from local mental health facilities, and the need for officer safety, there are plenty of sources from which to start. First, new training standards should be implemented early in one's law enforcement career. New officers should begin to learn these skills while in basic law enforcement training (BLET), or while in the academy of their department. By starting to learn new skills early officers can continue to implement them throughout their career. While it will not always be an option, those departments with CIT resources should be using the specially trained officers to both train new recruits, as well as instructors on proper procedure. Hands on experience with the CIT program would be a great eye opener for trainees as well. In departments that do not have a CIT program, further training will have to be performed, possibly by bringing in CIT professionals to aid in the beginning stages of the new training programs. When the training staff has been fully certified in the training of new recruits, and on-the-job training of current officers, this will continue to become an easier task. In service training will be a must for departments who wish all officers to be in compliance with the standards. This can be done by bringing officers into a classroom setting or, in the best case scenario, by having officers join CIT for periods of time (when this option is available). Again, the CIT program is not in place everywhere but will be essential and instrumental in training officers when it is an available resource. The biggest issue facing the new training and standards is the budget. In this economy departments are not willing to spend any more than they have to, and many may view the new training as a waste of time. They must be convinced with the ever growing number of people with a serious mental illness coming in contact with their officers that training cannot be overlooked. Tales of success from CIT programs across the country may help, but starting training in small numbers and closely monitoring and watching (positive) results will greatly aid in a budget allocation for across the board training. Reuland stated that "No two communities are identical, and, although this research provides a broad understanding of some common issues many communities face, it does not obviate the need for an in-depth review of local problems and resources to address them" (2009). This could not be truer. What works for training in one area may not necessarily work in another. Because of this, once the new training standards have been put in place, actions of officers must be monitored. This includes number of calls involving the mentally ill, whether they are violent or non-violent, what kind of action was taken on the scene, if the person was arrested, or if the person was delivered to someone in the mental health field. All of these factors can form a guideline on how to shape and modify training for each local department. Departments must be able to observe, adapt, configure, and change training as needed for the best results. Lamb (2002) tells us that: Across the United States, persons with mental illness have been killed or seriously injured during attempts to manage their crises. These events have outraged the community and frustrated law enforcement and mental health professionals, and rightly so. If we are to reduce these tragic mistakes and ensure better safety for all, we must develop an effective working partnership between the law enforcement and mental health systems. New training for every police officer is not just a good idea; it must be implemented in the future, and soon. More and more people who are mentally ill are coming into contact with the justice system every day. A misstep by the police could lead down any number of roads, including harassment, abuse, unneeded arrests, injury, and death. If we can properly train first responders on identification of mental illness, and the proper way to handle a situation, a new breed of law enforcement professional can emerge that will continue to protect and serve everybody in the years to come. Works Cited Amy Watson, M. M. (2008). Improving police response to persons with mental illness: A multi-level conceptualization of CIT. International Journal of Law and Psychiatry , 359-368. Arthur J. Lurigio, A. R. (2004). The Effects of Serious Mental Illness on Offender Reentry. FEDERAL PROBATION Vol 68 No 2 , 45-52. Brucker, D. (2006). Re-Entry to Recovery : A Promising Return-to-Work Approach for Certain Offenders With Mental Illness. Criminal Justice Policy Review Vol 17 , 302-313. Dale McNeil, R. B. (2007). Effectiveness of a Mental Health Court in Reducing Criminal Recidivism and Violence. Am J Psychiatry 164 , 1395-1403. Henry Steadman, J. M. (1984). THE IMPACT OF STATE MENTAL HOSPITAL DEINSTITUTIONALIZATION ON UNITED STATES PRISON POPULATIONS. Journal of Criminal Law and Criminology Vol 75 No 2 , 474-490. Kelly, S. M. (2004). Risks to Mental Health Patients Discharged Into the Community . Health, Risk, & Society , 377-385. Lamb, H. R. (2002). The Police and Mental Health. American Pyschiatric Associates , 1266-1271. Lamb, H. W. (1998). Persons with Severe Mental Illness in Jails and Prisons: A Review. American Psychiatric Association , 483-492. Michael Compton, M. B. (2008). A Comprehensive Reveiw of Extant Research on CIT Programs. Journal of the American Academy of Psychiatry and Law 36:1 , 47-55. Penrose, L. (1939). Mental Disease and Crime: Outline of a Comparative Study or European Statistics. Medical Psych. , 1-15. R. Slate, W. J. (2008). The Criminalization of Mental Illness: Crisis and Opportunity for the Justice System . Durham: Carolina Academic Press . Roger A. Boothroyd, N. G. (2003). The Broward Mental Health Court: process, outcomes, and service utilization. International Journal of Law and Psychiatry 26 , 55-71. Rueland, M. S. (2009). Law Enforcement Responses to People with Mentall Illnesses: A Guide to Research Informed Policy and Practice. New York, NY: Council of State Governments Justice Center. Schneider, R. D. (2008). Mental health courts. Current Opinion in Psychiatry 21 , 1-4. Seltzer, T. (2005). MENTAL HEALTH COURTS: A Misguided Attempt to Address the Criminal Justice System's Unfair Treatment of People With Mental Illnesses. Psychology, Public Policy, and Law , 570-586. Steadman, H. O. (2009). Prevalence of Serious Mental Illness Among Jail Inmates. Psychiatric Services , 761-765. Torrey, E. F. (2010). More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Survey of the States. Arlington, VA: Treatment Advocay Center & National Sheriff's Association. Wilmoth, G. S. (1987). Receptivity and Planned Change: Community Attitudes and Deinstitutionalization. Journal of Applied Psychology , 138-145. |
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