Deinstitutionalization of the mentally ill has posed significant challenges for communities across the United States. Between 1955 and 1994, the number of mentally ill adults hospitalized in public psychiatric facilities was reduced by approximately half a million (Torrey, 1996). While conditions inside public hospitals were sometimes poor, these institutions provided comprehensive psychiatric, medical and residential services. In the wake of their demise, a major challenge has been developing alternative community-based services for individuals suffering from schizophrenia and other severe mental disorders. The 1963 Community Mental Health Center Act sparked the development of community mental health care centers nationally, but these centers were ill-equipped to meet the multiple needs of severely mentally ill adults. Many individuals failed to engage in care as a result, often becoming isolated, homeless and drug-addicted. Currently, it is estimated that half of all people with severe mental illness are not receiving treatment (Kessler et al., 2001).
During the same period, the number of jails and prisons increased rapidly in the United States. The number of individuals incarcerated in state and federal prisons per 100,000 in the community quadrupled from 100 to over 400 between 1965 and 1996 (Maguire and Pastore, 1997). Similar trends have been noted in jails across the nation. With a combined rate of approximately 700 per 100,000 residing in jails and prisons, the United States currently has the highest incarceration rate in the world, with the exceptions of Russia and Rwanda (Human Rights Watch Prison Project, undated).
The Scope of the Problem
Within this rapidly growing jail and prison population, adults with severe mental illness are over-represented. Lamb and Weinberger (1998) estimated the prevalence of severe mental disorders within correctional facilities to range between 6% and 15%, rates that are significantly higher than the yearly incidence of 2.8% in the general population (National Advisory Mental Health Council, 1993). Given these prevalence rates, it is likely that there are now more severely mentally ill adults residing in state prisons than in state hospitals. The reasons for this are not clear, but probably involve a combination of clinical, social and political factors. National advocacy organizations including the National Alliance for the Mentally Ill (NAMI) and the National Mental Health Association have expressed concern about this incarcerated population and have called for new strategies to address the problem.
Criminal Justice System
Preventing incarceration of mentally ill adults requires an understanding of both the criminal justice and mental health systems. Significant potential for new intervention strategies lies at the interface between these systems. However, most mental health care professionals know relatively little about the criminal justice system. The Table shows the sequence of events within the criminal justice system that are encountered by mentally ill individuals who are arrested. For the purpose of simplicity, these events are grouped into four phases: entry, processing, corrections and release. New approaches to preventing arrest and incarceration are being developed that correspond to each phase of the criminal justice process. These approaches can be understood as broadly falling under the heading of "jail diversion" interventions.
New Intervention Strategies
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