SAKS INSTITUTE FOR MENTAL HEALTH LAW SPRING SYMPOSIUM: CRIMINALIZATION OF THE MENTALLY ILL STEPHEN MAYBERG, PhD APRIL 11, 2013 Policy, Practice and Perception: Implications in the Criminalization of the Mentally Ill
Dec 17, 2015
SAKS INSTITUTE FOR MENTAL HEALTH LAW
SPRING SYMPOSIUM: CRIMINALIZATION OF THE MENTALLY ILL
STEPHEN MAYBERG, P hDAPRIL 11 , 2013
Policy, Practice and Perception: Implications in the Criminalization
of the Mentally Ill
Criminalization of the Mentally Ill
New trends or long term problemContributory factorsPerceptions/Public PolicyPromising alternatives
Policy Issues
Realignment CA Mental Health 1991 Funding/Responsibility shift State to county responsibility/authority
Civil Commitments/LPS
Forensic Commitments
1991 3300 600
2012 550 6000
State Hospital Population
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
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
National Policy Trends
Community Care vs. Institutional CareDeclining state hospital bedsState hospitals/ IMD’s – no 3rd party paymentCourt decisions stressing communities
instead and community programs
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
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
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
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
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
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
Accountability
Who is accountable/responsible Lack of clarity “fall between cracks”
Conflicting laws/standards Welfare and institution code vs. penal code
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
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 jailMedication in jail usually cannot be
involuntaryConsequence: Disconnected system
Revolving door
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
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
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
Vacaville Continued
Employment marginalFamily History– more apt to be single,
disengaged from familyHistory of violenceConsequence: Complex factors must be
addressed to prevent criminal behavior
Policy Implications for Treatment
Cognitive/Outpatient treatment may not be effective
Structured environment may be requiredCoordination of substance abuse/mental
health treatment essentialEducational/Vocational programs integral
part of approach
Contributory Factors: Homelessness
Substance use/Mental illnessHostile living environmentCrimes of opportunity/Quality of life crimesHigh visibilityLack of coordinated resources or
responsibility
Contributory Factors: Stigma
Failure to access treatment because of stigma Perception of nexus of violence and mental
illnessMedia sensationalismBlame
NRA - Monsters
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
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
Summary of Issues - Responsibility
State vs. Local Law Enforcement vs. Mental HealthMental health vs. Substance Abuse“No One”
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
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
Summary – Lack of Resources
Limited long term or structured careLack of specialty trained professionalsLack of specific programs addressing unique
needs of this populationLack of 3rd party participation
CONSEQUENCE Jails/Prisons have become our defacto mental health
treatment programs
Summary – Legal System
Involuntary medication difficultInvoluntary commitments difficultLegal system may encourage accepting
charges rather than treatmentCriminal Justice system not always well
informed about mental illness and options Administrative Office of Court Findings
Programs that Work
AB 34/2034 SteinbergHomeless 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
Promising Programs (Con’t)
Law Enforcement Training/Partnership CIT (Crisis Intervention Training) for Law
Enforcement Smart/PET teams Mobile Crisis
Promising Program (con’t)
Court/Criminal Justice Involvement Mental health/behavioral health court Drug courts Diversion MIOCR programs
Policy that Works
24/7 Mental Health availability in crisis Point of contact responsibility Crisis training/consultation
Co-Occurring programsViolence programs
Bullying Domestic violence Anger management Trauma based approaches
Policy that Works (Con’t)
Mental Health Services in Jails/Prisons Connected with community programs Screening/case management Dedicated trained staff
Policy that Works (Con’t)
Stigma Reduction Media education Court/Law enforcement education Public education/awareness
Advocacy Involvement
NAMI Strong advocacy for recognition/treatment
alternativesClient Groups
Peer Support/Self help Promoting less stigmatizing alternatives
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
Los Angeles Mental Health
Community PartnershipsEarly Intervention programs/PreventionStigma reduction programsJail programs
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%
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
Opportunities (Con’t)
Prison Realignment AB 109 New dollars for criminal justice system approaches Local decision making Role of prevention, diversion, and treatment