Spring symposium criminalization of the mentally ill Stephen mayberg P h D April 11 2013 Policy Practice and Perception Implications in the Criminalization of the Mentally Ill Criminalization of the Mentally Ill ID: 340943
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SAKS Institute for Mental health lawSpring symposium: criminalization of the mentally illStephen mayberg, PhDApril 11, 2013
Policy, Practice and Perception: Implications in the Criminalization of the Mentally IllSlide2
Criminalization of the Mentally IllNew trends or long term problemContributory factorsPerceptions/Public Policy
Promising alternativesSlide3
Policy IssuesRealignment CA Mental Health 1991Funding/Responsibility shiftState to county responsibility/authority
Civil Commitments/LPS
Forensic
Commitments
1991
3300
60020125506000
State Hospital PopulationSlide4
Policy Impact: RealignmentFinancial IncentivesCounty choice/flexibilityState pays for forensic care
State hospital beds
County pays LPS
State pays – NGI, IST, MDO, SVP
IST Costs
Counties – Misdemeanors
State - FelonySlide5
Resource IssuesCounty mental health allocation insufficient for all servicesLimited long term care availableDeclining state hospital beds
24 hour acute care
Short term – Crisis use
Average stay less than 7 days
Follow up capabilities inconsistent
Responsibility and resourcesSlide6
National Policy TrendsCommunity Care vs. Institutional CareDeclining state hospital bedsState hospitals/ IMD’s – no 3
rd
party payment
Court decisions stressing communities instead and community programsSlide7
Policy Decisions - FundingMediCal (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 participationSlide8
Program Development Practice/PolicyIncentive to develop programs is in areas where monies can be leveragedLaw enforcement more likely to be funded at local level with county dollars
Public Safety
Politically more acceptableSlide9
Liability/Public PerceptionLocal mental health programs concerns about responsibility for forensic patientsADVERSE EVENTSMedia coverage – “Blame”
Torts/liability
Local political pressures
Accountability/responsibilitySlide10
Liability Perception ImpactConditional Release from Parole for Mentally Ill Inmates (CONREP)Extensive Service/Treatment Array – 100% state fundedCounties have right at first refusal
Very few counties participate
Consequence: lack of coordination with local programsSlide11
Conflict About Responsibility for CareParole outpatient versus county mental healthScreening, evaluation, and recommendationsProbation vs. County Mental Health
Who should provide/pay for serviceSlide12
ConflictVoluntary vs. Involuntary treatmentLPS 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 implementedSlide13
AccountabilityWho is accountable/responsibleLack of clarity“fall between cracks”
Conflicting laws/standards
Welfare and institution code vs. penal codeSlide14
Court Decisions ImpactSell – U.S. Supreme court rules IST’s cannot be involuntarily medicated without criteria/hearingJameson vs. Farabee – California Courts – inmates cannot be forcibly medicated without hearing
Consequence –
decompensation
Barriers complicate ability to treatSlide15
IST ProcessIncentives for state hospital treatment vs. jailReduces 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 doorSlide16
ImpactInadequate or insufficient treatment resources available in 24 hour institutionsMentally ill in jail/prison opt to not get treatmentRecidivism common
Mentally ill parolees most likely to be revoked/reoffendSlide17
Other Contributory FactorsSubstance Abuse70% SI Adults have substance abuse issues9
0% 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 AbuseMore likely to become part of systemSlide18
Contributory FactorsVacaville Mental Health StudyEvaluations on consecutive admissions over two time periodsFindings
Average IQ - low to low average
Education – 8
th
grade
Social Economic Status (SES) -low
Brain Injuries – 65%Fighting, Falls, Drug UseSlide19
Vacaville ContinuedEmployment marginalFamily History– more apt to be single, disengaged from familyHistory of violence
Consequence: Complex factors must be addressed to prevent criminal behaviorSlide20
Policy Implications for TreatmentCognitive/Outpatient treatment may not be effectiveStructured environment may be requiredCoordination of substance abuse/mental health treatment essential
Educational/Vocational programs integral part of approachSlide21
Contributory Factors: HomelessnessSubstance use/Mental illnessHostile living environmentCrimes of opportunity/Quality of life crimes
High visibility
Lack of coordinated resources or responsibilitySlide22
Contributory Factors: StigmaFailure to access treatment because of stigma Perception of nexus of violence and mental illnessMedia sensationalism
Blame
NRA - MonstersSlide23
Contributory Factors: Public PerceptionPerception: community safer with individuals locked up rather than treated in outpatient or in the communityNIMBY issues for community program placement
Elected officials tend to fund programs that lock up or promise “public safety” before funding community programsSlide24
Public Perception ContinuedTolerance/ExpectationsParolee “Acting out” vs. Mentally IllDifferential response from press, media, community
Funding for Control Agencies (Law Enforcement) rather than treatment programs
Prison realignment experience -AB 109Slide25
Summary of Issues - ResponsibilityState vs. Local Law Enforcement vs. Mental HealthMental health vs. Substance Abuse
“No One”Slide26
Summary of Issues - FinanceInsufficient funds for mental health/substance abuse treatmentNo 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 availableSlide27
Summary of Issues – StigmaPerception: individual concerns inhibits treatment seeking behaviorPerception: 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 mediaSlide28
Summary – Lack of ResourcesLimited long term or structured careLack of specialty trained professionalsLack of specific programs addressing unique needs of this population
Lack of 3
rd
party participation
CONSEQUENCE
Jails/Prisons have become our defacto mental health treatment programsSlide29
Summary – Legal SystemInvoluntary medication difficultInvoluntary commitments difficultLegal system may encourage accepting charges rather than treatment
Criminal Justice system not always well informed about mental illness and options
Administrative Office of Court FindingsSlide30
Promising Practices/OpportunitiesPolicies that workPrograms that workPotential opportunitiesSlide31
Programs that WorkAB 34/2034 SteinbergHomeless Mental Health ServicesSignificant reduction in hospital days
Significant reduction in jail days, arrests
Cost effective – 50% reduction in costs
Defined responsibility, broad based approachSlide32
Promising Programs (Con’t)Law Enforcement Training/PartnershipCIT (Crisis Intervention Training) for Law EnforcementSmart/PET teams
Mobile CrisisSlide33
Promising Program (con’t)Court/Criminal Justice InvolvementMental health/behavioral health courtDrug courts
Diversion
MIOCR programsSlide34
Policy that Works24/7 Mental Health availability in crisisPoint of contact responsibilityCrisis training/consultation
Co-Occurring programs
Violence programs
Bullying
Domestic violence
Anger management
Trauma based approachesSlide35
Policy that Works (Con’t)Mental Health Services in Jails/PrisonsConnected with community programsScreening/case management
Dedicated trained staffSlide36
Policy that Works (Con’t)Stigma ReductionMedia educationCourt/Law enforcement education
Public education/awarenessSlide37
Advocacy InvolvementNAMIStrong advocacy for recognition/treatment alternativesClient Groups
Peer Support/Self help
Promoting less stigmatizing alternativesSlide38
Best Practices/OpportunitiesProposition 63/Mental Health Service ActTarget At-Risk PopulationsLos Angeles County Mental Health examples
Cultural Competence Outreach
Urgent Care
24/7 Full Service Partnership (FSP)
Homeless programsSlide39
Los Angeles Mental HealthCommunity PartnershipsEarly Intervention programs/PreventionStigma reduction programs
Jail programsSlide40
Best Practice/OpportunitiesCo-Occurring ProgramsSpecific programs designed for mentally ill/substance abuse forensic patients
PROTOTYPES as example
Target population
Broad array services
CONREP
Recidivism less than 10%Slide41
OpportuniesHealth Care ReformParity for Mental Health/Substance Abuse now requiredReduces Stigma
Expands access
Expanded eligibility
3
rd
party payment for uninsured population
Incentives for treatmentSlide42
Opportunities (Con’t)Prison Realignment AB 109New dollars for criminal justice system approachesLocal decision making
Role of prevention, diversion, and treatmentSlide43
Opportunities (Con’t)Utilization of Research findingProgram success ratesCost Reduction Data
Return on Investment (ROI)