In the US, we're more likely to jail the mentally ill than get them help

Washington D.C., Dec 29, 2017 / 17:11 pm

People with severe mental illness are much more likely to be incarcerated than treated for their disorders, say advocates, and changes need to be made in order to break the vicious cycle of prison and homelessness.

"We don't have a mental health professional in half the counties in America. We need to do something about that," Doris A. Fuller of the Treatment Advocacy Center said at a panel in Washington, D.C. earlier this year.

Almost 400,000 inmates in the U.S. prison system are estimated to be mentally ill. For many with severe mental problems like schizophrenia or bipolar disorder, their untreated illness may have played a primary role in landing them in prison.

"The going in and out of jail is a challenge. And many of the times it is because of the mental illness," said Karen Ostlie, director of behavioral health services for Catholic Charities of the Archdiocese of Washington, D.C.

"So that's the same as across the country, is you get a lot of people that are incarcerated because of their mental illness," she told CNA, and it might be for something small like "trespassing if they're homeless and they're trying to find a warm place to sleep at night."

The mentally ill are 10 times more likely to be incarcerated than hospitalized.

And if they are released from the criminal justice system back into society, without receiving the proper treatment, they may very soon end up back in jail.

In the span of five years in Miami-Dade County in Florida, 97 people – primarily homeless men and people with schizophrenia – were arrested a total of 2,200 times, said Judge Steve Leifman of the Miami-Dade County Court Criminal Division.

The panel discussion, hosted by the American Enterprise Institute in Washington, D.C., discussed the criminal justice system and the U.S. mental health crisis. Participants explored the scope of the problem after the release of a new report "Emptying the 'New Asylums'" on reducing the number of inmates waiting in prison to be treated at a state hospital.

"We have a population of inmates behind bars in America today with mental illness that's about the size of the city of Oakland, California," Fuller stated, noting that an average of 5,000 people with "serious mental illness" are booked in jails per day.

They are arrested for a number of crimes ranging from the small, like trespassing or public urination, to violent felonies. Many crimes among this population are the result of someone's untreated mental illness, such as schizophrenia or bipolar disorder, panel members argued.

The mentally ill are 10 times more likely to be incarcerated than hospitalized, according to the Treatment Advocacy Center. An estimated 40 percent of those with severe mental illness are incarcerated at some point in their lives.

A shortage of mental hospitals

Some 90,000 people in prison have been judged "incompetent to stand trial." In all but three states, they must then be treated back to a competent state. Usually they are sent to state mental hospitals for this, yet there are far too few beds available for them there.

In the first half of the 20th century, the U.S. housed far more people in mental hospitals, but starting in the 1950s, a push to "deinstitutionalize" the system – as well as federal cases brought against hospitals for horrific abuses there – led to budget cuts and the closing of hospitals rather than states working to reform them, Leifman said.

Thus, state hospital beds for the severely mentally ill fell dramatically from 337 per 100,000 persons in 1955 to only 11.7 per 100,000 in 2016.

As a result, severely mentally ill persons are "languishing" in jail and even dying there, advocates warn. "Incarcerating pre-trial and convicted criminal offenders with serious mental illness is so common today that jails and prisons are routinely called the 'new asylums.' They are anything but protective," said the report "Emptying the New Asylums" by the Treatment Advocacy Center.

The prison system does nothing to help an existing case of mental illness, and all too often exacerbates it. Studies have shown the deleterious effects of prolonged solitary confinement on someone's mental condition, and for those with serious mental illness, a prolonged stay in prison can cause crippling damage to their health.

"If you want to really improve your public safety, improve the community mental health system."

There may be no immediate option for people in this situation, said Kianna Richardson, a correctional support specialist with Catholic Charities of the Archdiocese of Washington, D.C. The jail or prison cannot release someone who is not competent to stand trial onto the streets without treatment.

"It would be kind of difficult just to work with them, because they may refuse services, and in turn, they may go through the same cycle and commit another crime," she told CNA.

One way to help seriously ill inmates get the treatment they need more quickly would be to make "small changes" to the waiting system at state hospitals, said participants at the AEI panel.

The Treatment Advocacy Center contracted with the University of North Carolina and North Carolina State University to gather and analyze data from five state hospitals. Their findings led them to believe that changes could benefit the system.

In Florida, for instance, where 120 inmates per month will need to be treated for illnesses before they stand trial, "if you divert two of them, the average bed wait drops from 12 days to 3 days," Doris A. Fuller noted. In Wisconsin, if eight beds were added to the state hospitals, the average waits for a bed would fall from two months to two weeks.

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The importance of post-jail treatment

However, even after mentally ill inmates are released from jails and state hospitals, if they are not properly treated in their communities, they are at high risk of recidivism.

"Putting someone in jail with mental illness for even a few days and then releasing them – which everyone gets released – is not an improvement of public safety," Leifman insisted at the panel. "Most of them have serious trauma issues, and jail re-traumatizes people."

"If you want to really improve your public safety, improve the community mental health system," he added.

Matthew D. Chase of the National Association of Counties pointed to the example of Leon County, Florida, which established a system where non-profits met officials at the jail at midnight to take in homeless individuals and inmates with serious mental issues.

They were sent to various groups who worked with mental health, domestic violence and substance abuse cases, among others, he said, where previously these people would have gone straight onto the street.

Other groups like Catholic Charities of the Archdiocese of Washington, D.C. are actively ministering to this population, providing case management and long-term psychiatric treatment for inmates and those who have been released from the justice system.

Kianna Richardson, a correctional support specialist with Catholic Charities of the Archdiocese of Washington, D.C., sees clients with arrest records, most of whom are "non-violent offenders."

She provides 60-day case management for those "with severe and persistent mental health diagnoses who are returning from Charles County detention center back to the community." She insisted that "it's crucial for them" to receive treatment.

"Hopefully that will help them avoid being incarcerated in the future," she said, and "reduce their recidivism rate."

Housing and employment are the biggest challenges for this population, she insisted. If they have untreated mental health problems and an arrest record, they have a much lower chance of getting a job and holding it down. If they have no job, they can't pay for a place to live.

Also, in the county where she works – Charles County, Md. – the temporary shelter stays open only during the winter months, meaning that the homeless may have no options from April through September.

Washington, D.C. is one of the highest cost-of-living metropolitan areas in the U.S., and this poses a unique challenge to the city's homeless population, said Karen Ostlie of Catholic Charities, D.C., who has worked in mental health in the district for 20 years.

"There's a lack of affordable housing," she said. "That can be very difficult, when somebody doesn't have a stable place to live, to stabilize that person, for them to follow through with their mental health treatment."

Catholic Charities provides psychiatric treatment, and the ACT (Assertive Community Treatment) team "works with about 120 of our consumers," Ostlie explained, including "some of the most disengaged" and "seriously ill consumers."

They also work with other clients who had long-term hospitalizations at St. Elizabeth's, a psychiatric facility in Southeast D.C.

The ACT team will find and meet the homeless where they are, seeking to engage them in treatment, she said. But there are challenges – even if they receive prescription medication upon being discharged from mental hospitals, if they have no stable home, it is harder for them to keep the medication and take it as ordered.

The goal is to get the patients to engage in treatment with a psychiatrist, Ostlie said. They also work to get benefits for the patients and to help them apply for the appropriate housing, such as a single occupancy room or a group home.

"With some of our most seriously ill consumers, part of the difficulty with finding housing, other than the cost of apartments, is that they can't manage in a shared group home situation, or their behaviors are so challenging that the folks that run the group homes won't accept them or they leave or they don't want to deal with the rules."

Drug abuse is another significant challenge among this population, she said. Not only can it make mental illness worse, but even if patients go through treatment for it, they can easily fall back into addiction by returning to their former place on the streets.  

"The key is to change the way we think about these things," Leifman said at the panel, insisting that there must be a greater national focus on improving mental health in communities rather than just incarcerating the perpetrators of crimes. "So much of our money is now going into correctional cost."

"There is no other illness in this world that is permissible to send people out into homelessness in the middle of the night," he said, but when it comes to mental illness, "people don't bat an eye."

This article was originally published on CNA Feb. 21, 2017.