J. Steven Lamberti, MD

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).

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.

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.

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.

New intervention strategies are needed to promote ongoing engagement in community-based treatment and support services among severely mentally ill adults diverted from the criminal justice system. Examples of two nationally recognized models are the Thresholds Jail Program in Chicago and Project Link in Rochester, N.Y. (Council of State Governments, 2002). Both programs use assertive community treatment (ACT) to engage clients in clinical, residential and social services through active outreach and around-the-clock availability. Each program coordinates with multiple components of the criminal justice system to promote continuity of care and to utilize legal leverage to promote adherence when necessary. Use of ACT to engage severely mentally ill offenders in partnership with criminal justice representatives is an increasingly common diversion strategy. A national survey conducted in conjunction with the National Association of County Behavioral Health Directors recently identified 16 such programs operating in nine states (Lamberti et al., 2003). This approach can be understood as representing a newly emerging Forensic Assertive Community Treatment or FACT model of care.

Beyond the emergence of promising new intervention strategies, everyday clinicians can make a substantial impact in reducing recidivism among people with severe mental illness by following six basic strategies.

. Control of psychotic symptoms and associated behaviors is the key to preventing unnecessary arrest and incarceration. Consider the use of long-acting decanoate medications and atypical antipsychotic drugs to promote adherence and maximize effectiveness.

. Watch for early warning signs of impending psychotic relapse and intervene promptly whenever they occur.

. In addition to psychosis, drug use and drug-seeking behaviors are major risk factors for arrest and incarceration. Encourage involvement in combined substance use/mental health treatment interventions.

. Risk of arrest and incarceration increases in the absence of consistent treatment. Home visits, telephone calls and other measures should be used to promote ongoing engagement in care whenever possible.

Partner with family and community supports

. They play a critical role in monitoring for signs of relapse and in intervening when disruptive behaviors occur. Make extra efforts to partner with residential service providers in order to prevent homelessness, another major risk factor for arrest.

Collaborate with local criminal justice representatives

. Actively seek opportunities to collaborate with police, probation and parole officers, and judges whenever they become involved with your patients. Enlist their support of the treatment plan, including the use of legal leverage to promote adherence when necessary.

Preventing unnecessary arrest and incarceration of severely mentally ill adults is a major challenge that requires coordination of mental health and criminal justice services. The goal of such coordination is ultimately to promote engagement of people suffering from severe mental illness in community-based care. It should be noted that close monitoring of treatment by criminal justice representatives has been associated with increased incarceration rates in some programs due to technical violations (Solomon et al., 2002). To prevent this problem, it is essential that diversion programs function as intensive treatment and support programs rather than simply as extensions of the criminal justice system. Research is needed to further develop and evaluate the effectiveness of these new combined models of service delivery.

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Articles

Adults who are severely mentally ill are over-represented in U.S. jails and prisons, leading to an interface between the mental health and criminal justice systems. New intervention strategies involving both systems, such as mental health courts and forensic assertive community treatment, could divert patients away from the criminal justice system and promote engagement in community-based treatment and support services.

J. Steven Lamberti, MD

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New Approaches to Preventing Incarceration of Severely Mentally Ill Adults