Policy, Practice and Perception: Implications in the Criminalization of the Mentally Ill

1. 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

2. Criminalization of the Mentally Ill New trends or long term problem Contributory factors Perceptions/Public Policy Promising alternatives

3. Policy Issues • Realignment CA Mental Health 1991 • Funding/Responsibility shift • State to county responsibility/authority State Hospital Population

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. Accountability • Who is accountable/responsible • Lack of clarity • “fall between cracks” • Conflicting laws/standards • Welfare and institution code vs. penal code

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. Contributory Factors: Stigma • Failure to access treatment because of stigma • Perception of nexus of violence and mental illness • Media sensationalism • Blame • NRA - Monsters

23. 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

24. 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

25. Summary of Issues - Responsibility State vs. Local Law Enforcement vs. Mental Health Mental health vs. Substance Abuse “No One”

26. 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

27. 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

28. 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

29. 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

30. Promising Practices/Opportunities Policies that work Programs that work Potential opportunities

31. 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

32. Promising Programs (Con’t) • Law Enforcement Training/Partnership • CIT (Crisis Intervention Training) for Law Enforcement • Smart/PET teams • Mobile Crisis

33. Promising Program (con’t) • Court/Criminal Justice Involvement • Mental health/behavioral health court • Drug courts • Diversion • MIOCR programs

34. 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

35. Policy that Works (Con’t) • Mental Health Services in Jails/Prisons • Connected with community programs • Screening/case management • Dedicated trained staff

36. Policy that Works (Con’t) • Stigma Reduction • Media education • Court/Law enforcement education • Public education/awareness

37. Advocacy Involvement • NAMI • Strong advocacy for recognition/treatment alternatives • Client Groups • Peer Support/Self help • Promoting less stigmatizing alternatives

38. 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

39. Los Angeles Mental Health Community Partnerships Early Intervention programs/Prevention Stigma reduction programs Jail programs

40. 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%

41. 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

42. Opportunities (Con’t) • Prison Realignment AB 109 • New dollars for criminal justice system approaches • Local decision making • Role of prevention, diversion, and treatment

43. Opportunities (Con’t) • Utilization of Research finding • Program success rates • Cost Reduction Data • Return on Investment (ROI)