Entry of severely mentally ill adults into the criminal justice system typically involves contact with law enforcement officials. An estimated 7% of all police contacts involve people suffering from mental illness (Deane et al., 1999). Unfortunately, police often lack the training necessary to handle such individuals without resorting to unnecessary and sometimes lethal force (Amnesty International, 2001). In response to lack of training, police departments in several communities have adopted new intervention strategies. The most well-known example is the Crisis Intervention Team (CIT) program in Memphis, Tenn. (Dupont and Cochran, 2002). This program provides 40 hours of training in psychiatric and substance use disorders, including use of crisis de-escalation techniques, to police officers who volunteer for it. While CIT uses specially trained officers, other police-based diversion models involve partnerships between police and mental health care professionals. Examples include the Psychiatric Emergency Response Team (PERT) in San Diego and the Community Service Officer Unit in Birmingham, Ala. (Council of State Governments, 2002). These new models enable police to intervene safely and effectively and to bring severely mentally ill people to emergency departments rather than to jails whenever appropriate.
The processing phase involves a complex series of events involving contact with public defenders, district attorneys and judges. Depending on the nature and circumstances of the alleged crime, mentally ill individuals may be detained in jail during this phase of the process. In order to divert severely mentally ill people from the criminal justice system during the processing phase, several new jail-based and court-based strategies have been developed in recent years. Examples of jail-based diversion programs are the Montgomery County Emergency Service (MCES), Inc., program in Pennsylvania (Draine and Solomon, 1999) and the Bernalillo County jail diversion program in New Mexico (Council of State Governments, 2002). The MCES program provides an array of services, including close coordination with jail staff in order to screen all detainees for mental illness. When mentally ill people are identified in the jail, MCES staff works with lawyers and judges to negotiate treatment as a condition of release. The Bernalillo County program involves a team that receives referrals about mentally ill individuals from jail staff, lawyers and judges. The team performs intensive evaluations to determine if conditional release is appropriate and then supervises the mental health treatment of those individuals who are released.
Court-based diversion programs, or mental health courts, have been proliferating since the Law Enforcement and Mental Health Project Act was passed in 2000, authorizing the funding of demonstration projects. According to a national survey recently conducted by NAMI and partners, there are currently over 90 mental health courts operating in 32 states (NAMI et al., 2004). These mental health courts vary significantly in terms of eligibility criteria, methods of resolving charges and other critical dimensions. However, all involve judges in the process of supervision and treatment. Also, all mental health courts have the goal of promoting treatment as an alternative to further involvement with the criminal justice system.
In the corrections phase of the criminal justice process, the primary options are incarceration or court-mandated supervision in the community through probation. Jails are locally operated, short-term correctional facilities that are generally used for sentences less than one year, while prisons are state- and federally operated facilities that are used for longer sentences. Once a severely mentally ill adult has been sentenced to jail or prison, the major challenges become promoting safety and providing mental health treatment. Suicide is currently recognized as the leading cause of death in jails and the third leading cause of death in prisons. Half of all jail suicides occur within the first 24 hours of incarceration, usually among inmates who have not been screened for suicidality (Hayes, 1989).
In order to promote safety in correctional facilities, the American Correctional Association has developed suicide-prevention guidelines. Although compliance with these and other similar guidelines is often poor, some novel programs have been developed recently. For example, the New York State Local Forensic Suicide Prevention Crisis Service Model is a statewide suicide prevention program that includes a mandatory eight-hour training curriculum completed by all correctional staff. This program emphasizes careful screening with corresponding levels of supervision and intervention and has been associated with decreased suicide rates in New York jails and prisons (Cox et al., 1989).
Data from the Bureau of Justice Statistics indicated that 59% of mentally ill individuals in jails and 40% of those in prisons receive no mental health treatment (Ditton, 1999). Among those receiving services, the most common form of treatment was medication, usually without any form of counseling. In the absence of necessary treatment, mentally ill people are at increased risk for fights and other disciplinary problems within correctional facilities. In managing such problems, jail and prison staff typically resort to punishment. New and more effective intervention strategies are currently being developed. An example is the Intensive Mental Health Unit utilized by the Connecticut Department of Corrections. This behaviorally oriented strategy uses a three-level system where inmates are placed at first in seclusion and can gradually earn privileges for good behavior and treatment compliance (Mitka, 2001).
As shown in the Table, release from jail or prison is not actually a discrete phase in the criminal justice process but rather an event that can occur at each phase of the process. A primary challenge for criminal justice staff planning the release of severely mentally ill adults is to access treatment and support services in the community. This challenge can persist even when jail diversion programs are in place. A national survey of diversion programs found that few had specific procedures to follow diverted detainees or to ensure that initial linkages to treatment services were maintained (Steadman et al., 1994). In other words, diversion programs as a group may be more effective at diverting patients from jail than engaging patients in treatment.
Engaging Diverted Individuals