H. Richard Lamb

Mentally Ill Persons in the Criminal Justice System: Some Perspectives

There is an increasing number of severely mentally ill persons in the criminal justice system. This article first discusses the criminalization of persons with severe mental illness and its causes, the role of the police and mental health, and the treatment of mentally ill offenders and its difficulties. The authors then offer recommendations to reduce criminalization by increased coordination between police and mental health professionals, to increase mental health training for police officers, to enhance mental health services after arrest, and to develop more and better community treatment of mentally ill offenders. The necessary components of such treatment are having a treatment philosophy of both theory and practice; having clear goals of treatment; establishing a close liaison between treatment staff and the justice system; understanding the need for structure; having a focus on managing violence; and appreciating the crucial role of case management, appropriate living arrangements, and the role of family members.

Incompetency to Stand Trial: Appropriateness and Outcome

Of 85 persons (38% of those found incompetent to stand trial in Los Angeles County in 1983), 92% were currently charged with felonies and 62% with crimes of violence. Eighty-seven percent had a history of serious physical violence against persons and 68% had prior felony arrests. This study indicated that in this jurisdiction, incompetency to stand trial is not being used to divert mentally ill persons, charged with minor offenses, into intermediate or long-term psychiatric hospitalization to circumvent obstacles such as restrictive commitment laws and rapid hospital discharge policies. The lack of adequate postrelease planning and follow-up for most of these chronically and severely mentally ill offenders was clear. Neither the criminal justice nor the mental health system is inclined to take responsibility for their care. Mandatory community treatment on release is recommended.

Deinstitutionalization at the Crossroads

Much has gone wrong with deinstitutionalization. To get back on course, the author says, we should acknowledge that while deinstitutionalization was a positive step, it has gone too far--that some of the long-term mentally ill now in the community need highly structured residential care. The long-term mentally ill should be made the highest priority in public mental health, and a comprehensive system of care that recognizes their heterogeneity needs to be established. Vigorous rehabilitation efforts aimed at helping them attain higher levels of functioning should be continued, but mental health professionals should also give high priority to those who function less well and recognize the gratification that can be derived from working with them. The more favorable long-term outcome of schizophrenia should not be confused with the lesser improvements that can be made over the short or intermediate term. Professionals need to come to grips with the bureaucracy, politics, and inefficiency of our largest cities and should also actively advocate for involuntary treatment when it is clinically indicated.

CONCEPTUAL ISSUES IN THE EVALUATION OF THE DEINSTITUTIONALIZATION MOVEMENT

Publisher Summary There are marked discrepancies between the knowledge of the principles of effective community-based treatment for persons afflicted with chronic mental disabilities and the implementation of these principles. The chapter discusses the philosophical underpinnings of deinstitutionalization. Deinstitutionalization is a dynamic and continuing series of adjustments involving all the elements of service delivery system. Although it is possible to find isolated programs that provide humane and relevant services for portions of the target population of deinstitutionalization, there is ample evidence that the movement has yielded results that are, in a global sense, less than satisfactory. Existing evaluation studies tend to focus on one program at a time and to assess exclusively that programs outcomes for the isolated portion of the target population that it serves. The result is a corpus of discrete evaluation studies that pertain to a variety of local mental health and human services efforts on behalf of the chronically mentally disabled. The deinstitutionalization movement is an entity in which the whole is different from the sum of its parts.

The carrott and the stick: Inducing local programs to serve long-term patients

Both financial and philsophical considerations have led to the dramatic shift in California of longterm patients from state hospitals to the community. Unfortunately local mental health programs frequently give low priority to the severely and chronically mentally ill. The state chose not only to engage in the wholesale discharge of patients from state hospitals but also to provide a number of financial inducements and penalties to motivate local programs to serve these patients. Although there have been many problems, local programs have developed a wide range of community treatment and rehabilitation programs for longterm patients.

Mental health courts as a way to provide treatment to violent persons with severe mental illness.

WHILE THE GREAT MAJORITY OF PERSONS WITH severe mental illness (eg, schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, and other psychotic disorders) are not violent, there is a small minority who may become aggressive when stressed. For instance, in a US national study of persons with schizophrenia and violent behavior, the prevalence of serious violent behavior in the past 6 months was 3.6%. Many persons with severe mental illness and a history of violence reside in jails and prisons. As an example, a recent study in a large US metropolitan jail found that 72% of persons with severe mental illness had a history of arrests for a violent offense. In this Commentary we discuss how mental health courts could divert violent persons with severe mental illness from the criminal justice system to the mental health system and ensure that they receive needed treatment. Why does this minority of persons with severe mental illness become violent when under stress or pressure? Individuals with severe mental illness who are psychotic are more likely to become violent if they do not adhere to their treatment regimens. Substance abuse also has been shown to increase the risk of violent behavior in persons with severe mental illness. Moreover, some individuals with mental illness have anosognosia, a biologically based inability to recognize that one has a mental illness. In recent decades, there has been a growing literature on anosognosia in which researchers have identified various parts of the brain (such as the ventricles, frontal and temporal lobe subregions, medial temporal and inferior parietal regions, and subcortical structures) in which pathology is associated with anosognosia. This biologically based lack of insight of having a severe mental illness may be one of the predictors of violence in persons with schizophrenia; thus, demonstrating a relationship between poor insight and violent behavior. Criminalization and Mental Health Courts Since the latter part of the 20th century, there has been an increase in the number of persons with severe mental illness who have been placed in US jails and prisons. As of December 2006, using estimated percentages from the US National Commission on Correctional Health Care, at least 341 000 severely mentally ill persons were incarcerated representing a substantial proportion of the total jail and prison population of 2.3 million. These include many who have a history of violence. Despite this, there is a shortage of mental health treatment resources in jails and prisons. The large-scale criminalizationofpersonswithseveremental illness has stimulated a variety of modalities to reduce the risk of violence for individuals with severe mental illness. One approach is to divert these persons from jails and prisons into treatment inthementalhealthsystem.Ameansforaccomplishing this is through special courts called mental health courts. At first, these courts were established to hear cases of persons with mental illness who were typically charged with misdemeanors. In recent years, these courts extended their purview to serve persons with mental illness charged with nonviolent felonies. Some courts now consider cases of mentally ill persons who are charged with violent felonies. Ideally, in mental health courts all courtroom personnel (ie, judge, prosecutor, defense counsel, and other relevant professionals) have experience and training in mental health issues and available community resources. These courts are characterized by hearing specialized cases involving defendantswith mental illness, using a nonadversarial team of professionals (eg, judge, attorneys, mental health clinician), and using some way to monitor adherence that may involve sanctions by the court. In addition, mental health courts have links to the mental health system that can provide treatment as well as needed services and support after discharge from jail to help enable the persons to successfully reenter their communities. By diverting persons with serious mental illnesses charged with

Does deinstitutionalization cause criminalization? The penrose hypothesis.

WhenLionelPenrosepublishedhis study,“MentalDiseaseand Crime:Outlineof aComparativeStudyofEuropeanStatistics”1 75years ago,hehadnowayofknowing thathis researchwould still be the subject of interest, and even controversy, in major psychiatric journals 3 quarters of a century later.2 Penrose found an inverse relationship between prison and mental hospital populations.He theorized that if one of these forms of confinement is reduced, the other will increase. According to this theory, where prison populations are extensive,mental hospital populationswill be small, andviceversa. Writing before the advent of full-scale deinstitutionalization, Penrose could not have known that, in time, his hypothesis would be criticized by those who believe that there is no relationship between deinstitutionalization and criminalizationof personswith seriousmental illness andwould be cited by those who believe that there is. Mundt and colleagues, writing in this issue of JAMA Psychiatry,2 point out that both the Penrose study and a worldwide analysis performed in 2004,3 which found no support for the Penrose hypothesis, were based on crosssectional data. They indicate that longitudinal data are necessary to determine whether there is a direct association between decreasing numbers of hospital beds and increasing prison populations. Longitudinal data from the United States4 cast doubt on a direct association between decreasing numbers of beds and increasing prison populations. Further research pointed toward a potential role of the economy and suggested that both the numbers of psychiatric beds and the sizes of prison populations might be driven by broad economic factors.5 With all these factors in mind, as reported in this issue of JAMA Psychiatry, Mundt and colleagues2 performed a large, well-designed study in 6 South American countries. Using longitudinal data and taking into account economic growth, they still found a statistically significant association between the numbers of psychiatric beds and the sizes of prison populations. While the data did not prove that the decrease in numbers of psychiatric beds actually caused the increase in prison populations in South America, it did not disprove it either. Thus, this study is compatible with those who postulate, based on clinical evaluation of persons with serious mental illness who are incarcerated, that a driver of criminalization is deinstitutionalization. In my view, many of the persons with serious mental illness that one sees today in our jails and prisons could have just as easily been hospitalized had psychiatric beds been available. This is especially true for those who have committed minor crimes. If, in fact, jails and prisons can substitute for psychiatric hospitals, what is it that these various institutions can provide that many persons with serious mental illness need? A needed modality that all these institutions offer is structure. Structure is provided in the form of a safe, secure setting and of staff who can monitor and contain inappropriate and aggressive behavior, formulate an appropriate treatment plan, and monitor psychiatric medications. Although these needs can generally be met in community settings, for a significant minority of persons with serious mental illness, a highly structured setting is needed. Surely, for those persons with serious mental illness who have committed petty crimes, when a highly structured setting is needed, psychiatric inpatient treatment is preferable to incarceration in a jail or prison. Clearly, deinstitutionalization resulted in large numbers of persons with mental illness being moved from hospital to community settings. As the hospitals closed, many tens of thousands of persons were discharged into the community to face the stresses of the world. Moreover, a new generation of persons with serious mental illness, who had never been hospitalized, grew into adulthood. Many decompensated to the point where 24-hour structured care became necessary. However, the hospitals had been permanently closed, and large numbers of these persons had to be sent to other alternatives. Before deinstitutionalization, a large proportion of persons with serious mental illness would have lived their lives instatehospitals.Althoughtheconditions in thehospitalswere generally abysmal, these persons were not treated as criminals, nor did they live on the streets for long periods of time, as is true now for a sizeable minority of those who have been discharged. Community care has proven successful (provided that adequate community treatment resources are available) for the great majority of persons who formerly would have resided in state hospitals. However, funding shortages and giving priority to persons who are likely to be treatment adherent and nonviolent lessen the potential success of community treatment for persons who today are at risk of becoming criminalized. It is widely thought that many persons with serious mental illness who have been criminalized could be treated successfully in the community, if there were adequate and accessible community treatment facilities.6 Related article page 112 Opinion

One-to-one relationships with the long-term mentally ill: Issues in training professionals

In training mental health professionals to work with long-term mentally ill persons, the importance of the one-to-one relationship needs to be emphasized. As advocated here, this should be a reality-based, problem solving approach. No part of this work is more important than giving these persons a sense of mastery over their internal drives, their symptoms, and the demands of their environment. Trainees need to be taught that it is important to be active in these one-to-one relationships; this includes giving advice. Insight, as defined in this article, is not to be neglected as a goal for the long-term mentally ill.In training mental health professionals to work with long-term mentally ill persons, the importance of the one-to-one relationship needs to be emphasized. As advocated here, this should be a reality-based, problem solving approach. No part of this work is more important than giving these persons a sense of mastery over their internal drives, their symptoms, and the demands of their environment. Trainees need to be taught that it is important to be active in these one-to-one relationships; this includes giving advice. Insight, as defined in this article, is not to be neglected as a goal for the long-term mentally ill.

Reform of mental health laws : not repeating the mistakes made in the United States

Psychiatrists, lawyers and others from other countries have come to Japan and recommended sweeping changes in the Japanese mental health laws and mental health ~ y s t e m . ~ They advocate deinstitutionalization in Japan and replacing, on a mass scale, hospital treatment with community treatment, they advocate a radical reduction in hospital beds, and they advocate dropping the need for treatment standard in the use of involuntary treatment and replacing that standard with one that primarily stresses civil liberties. In other words, they want Japan to do the very things that have proven disastrous in the United States. My theme today is that while there is some merit in partially implementing such policies, you could make no worse mistakes than to deinstitutionalize on a mass scale without careful planning and adequate community resources, radically reduce the numbers of your hospital beds to the point where many mentally ill persons who need them do not have access to them, and drop the need for treatment standard in the use of involuntary treatment. Before discussing mental health laws in detail, I would like to first discuss dein-

Understanding and Treating Offenders with Serious Mental Illness in Public Sector Mental Health

This article begins with the history of the rise and fall of the state hospitals and subsequent criminalization of persons with serious mental illness (SMI). Currently, there is a belief among many that incarceration has not been as successful as hoped in reducing crime and drug use, both for those with and those without SMI. Moreover, overcrowding in correctional facilities has become a serious problem necessitating a solution. Consequently, persons with SMI in the criminal justice system are now being released in large numbers to the community and hopefully treated by public sector mental health. The issues to consider when releasing incarcerated persons with SMI into the community are as follows: diversion and mental health courts; the expectation that the mental health system will assume responsibility; providing asylum and sanctuary; the capabilities, limitations, and realistic treatment goals of community outpatient psychiatric treatment for offenders with SMI; the need for structure; the use of involuntary commitments, including assisted outpatient treatment, conservatorship and guardianship; liaison between treatment and criminal justice personnel; appropriately structured, monitored, and supportive housing; management of violence; and 24-hour structured in-patient care. Copyright