AACP Position Paper: Mental Health and Incarcerated Populations
April, 2018 - Overview:
Among the most difficult issues facing community psychiatrists is how we can adequately meet the needs of people with mental health and substance use issues who have been involved in the criminal justice system and how we can protect those who are at risk of becoming involved. In the past several decades, the incarcerated population of the United States has approximately quadrupled. Mass incarceration is a significant problem with more than 2 million, or nearly 1 in 100, Americans behind bars at any given time. Minority populations are particularly affected by these practices, with Hispanic and African American males 2.5 and 6 times more likely to be incarcerated than White males.
Approximately 60-80% of inmates have substance use problems and 10-20% have serious mental illness, with significant overlap between the two populations. Exposure to trauma is present for almost all incarcerated individuals, occurring in all phases of their lives, leading to high rates of trauma related psychiatric disorders. Arrest, legal processing, disruption of their living situation due to detention, and incarceration itself, are all additional traumas, which exacerbate these conditions.
This striking reality calls for considerable attention to the intersection between mental health and the criminal justice system prior to, during, and after incarceration with an aim to end the imprisonment of people struggling with their mental health.
Unfortunately, access to quality mental health services is not available to a large segment of the US population even prior to entering jail or prison. Lack of access to effective community treatment yields an unacceptably high risk for incarceration as a direct result of symptomatic behavior. In addition, the vastly increased use of incarceration as society’s primary response to drug use means that there has been a dramatic increase in the number of individuals with substance use disorders behind bars.
Despite Constitutional guarantee to health treatment while incarcerated, correctional mental health services are often inadequate. Inmates usually receive disrupted and minimally acceptable treatment – often focused solely on psychopharmacology – rather than a range of treatment options. Ineffective screening procedures leave many individuals in need without being identified as having a mental illness.
In addition, conditions in jails and prisons exacerbate mental illness. Confinement, overcrowding, exploitation, limited autonomy, and idleness all increase stress and the likelihood of exacerbation of illness, as does disconnection from family and community supports. Because of vulnerability to other inmates or inability to comply with regulations, mentally ill inmates are frequently housed in punitive segregation, where isolation leads to further deterioration of their conditions.
There is little continuity of care between correctional and community mental health and addiction services. Community providers are rarely contacted at the time of incarceration, and individuals whose condition may have deteriorated in prison are often released directly to the community absent meaningful transition planning with regard to medication supplies, appointments, insurance coverage, or other services. Such lack of planning places individuals at high risk for homelessness, exacerbation of psychiatric conditions, hospitalization, and re incarceration.
A highly disproportionate number of the people who suffer from these circumstances are minorities, particularly African Americans. Institutionally structured racism’s effects reach far beyond the inmates incarcerated with mental illness and substance use issues, but extend also into their communities and society at large. We will never be able to significantly address the racial tensions in our society if we cannot eliminate the inequities in the treatment of minorities both within and outside our penal institutions.
The dedicated clinicians working within correctional settings are frequently overworked and under resourced. The important work they strive to do is often undermined by the trying conditions against which they struggle.
Addressing these issues adequately relies on adherence to principles embraced by community psychiatry:
Individuals with mental illnesses and substance use disorders involved in the criminal justice system are members of the community.
All members of the community should have access to humane and just treatment from the institutions that are supposed to serve them and maintain the health of our communities. • Individuals with severe mental illness and/or substance use disorders who have involvement with law enforcement or the criminal justice system must receive quality care and rehabilitation
Agencies and providers within law enforcement and the criminal justice system are our partners in serving the overall population or public health needs of our community. • Public health and public safety go hand in hand in contributing to overall community health and well-being. Assisting individuals in our communities to recover and to live healthy and meaningful lives in the community benefits everyone in society.
The elimination of injustice, racial and ethnic prejudices, and all forms of discrimination against those with greatest need should be the priorities of our government and institutions.
Goals:
To improve the condition of persons with mental illness and substance use disorders behind bars, we must accomplish the following tasks: Improve access to community mental health and substance use disorder services to improve early diagnosis and optimal treatment of individuals suffering from mental health and addictive disorders who are at increased risk for incarceration if left untreated.
Create diversion programs and community-based alternatives to arrest and incarceration in order to reduce symptom burden and recidivism. These programs include:
law enforcement officers certified in Crisis Intervention Training (CIT);
effective mental health and drug court programs
collaborative community courts with relationships to local neighborhoods.
Improve jail and prison conditions that have negative effects on the mental health of inmates, including:
reducing overcrowding;
reducing overcrowding;
providing diverse programing that encourages wellness and recovery, including options for education, spiritual engagement, creative arts, and exercise;
supporting regular and non-cost prohibitive contact with family and other community supports (in person, via phone, via camera as desired);
minimizing use of punitive or protective segregation and super-maximum control units. • eliminate the use of long term solitary confinement, particularly for persons with severe mental illness.
Identify and eliminate discriminatory practices which put minorities at higher risk for extended sentences, mistreatment, and recidivism.
Improve screening and treatment of mental health and addictive disorders in correctional settings, requiring:
early and effective screening for mental health and addictive disorders upon entry including assessment of suicide risk and complete medication history;
training for the identification and support of mental health problems by correctional officers; • joint treatment planning with community providers and relevant support systems to allow continuity of care on entering a correctional facility;
timely forensic evaluation and transfer of individuals who may be incompetent to stand trial; • recovery-oriented psychopharmacology, psychotherapy, dual diagnosis, and psychiatric rehabilitation services;
improved formulary options for medications including medication-assisted treatment (MAT) for substance use disorders using options such as methadone and buprenorphine/naloxone; • rigorous and comprehensive suicide prevention programs;
comprehensive and coordinated health care services.
5. Establish evidence-based programs designed to effectively reintegrate inmates into the community following release, including:
transitional treatment planning with established appointments and an adequate supply of any necessary medications to bridge individual until their appointments;
assistance with securing relevant benefits, including financial assistance and health insurance, to be activated upon release;
forensically-oriented, proactive case management services;
forensic assertive community treatment (FACT) teams.
available and affordable housing, including supportive housing programs which do not discriminate against individuals with forensic histories;
specialty parole/probation services;
Forensic Assertive Community Treatment (FACT) Teams.
6. Provide organizational support for these changes, including:
creating oversight bodies to ensure that correctional services meet quality standards for mental health and dual diagnosis services to inmates;
encouraging and publicizing cost studies for these interventions;
educating legislatures, other policy makers, and the public concerning the effective nature of these recommendations;
creating alliances with governmental, professional, advocacy, and correctional organizations to support these recommendations;
developing task forces with relevant stakeholders, including incarcerated and previously incarcerated individuals themselves and their families, to continue to address the problems of inmates with mental illness and co-occurring disorders;
advocating to end mass incarceration of Americans, particularly persons from ethnic and socio economic minorities.
7. Reform the punitive system of current drug policy, allowing treatment and rehabilitation programs to have a dominant role.
8. Advocate for an end to long term solitary confinement.
9. Advocate for the elimination of racial disparities due to discrimination within and outside the criminal justice system.
Action Items for Improving Criminal Justice System for People with Mental Illness.
There are many ways in which individual psychiatrists can have an impact on attaining the aforementioned goals. Many of these actions were identified and elaborated in a more comprehensive review of the issues related to Mental Health and the Criminal Justice System by the Committee on Psychiatry and the Community of the Group for the Advancement of Psychiatry referenced below. Some of these actions are as follows:
Communication: One of the most critical issues in creating better outcomes for people with mental illness in the criminal justice system is communication. There are a number of places in the chain of processing of an individual where a lack of communication exacerbates the consequences of involvement with corrections. Some of these are listed below:
Family members
Community police officers
Legal representation
The courts
Jail and prison psychiatrists, correctional staff
Community providers
Transition Planners
Keeping channels of communication open increases the likelihood that some continuity of care can be maintained and that potential problems can be identified and addressed before they are overwhelming
Partnerships: Many professionals and organizations have a role to play in addressing the needs of people with MI in the corrections systems. Even though they may have similar goals, working alone, they will have limited effectiveness. Working together, success is much more likely. Community Psychiatrists and the organizations they work with can partner with several other agencies and individuals working with people involved with corrections to create better outcomes and facilitate the communication outlined above. Some of the entities that we may partner with are listed below.
Law enforcement
Judiciary
District Attorneys and Public Defenders
Family and Advocacy Organizations
Probation and Parole
Entitlement Administrators (Health insurance, cash assistance, housing etc.)
Housing Agencies
Child and Family Services
Systems Change: Psychiatrists can play a significant role in the improvement of the quality of services provided to people who have been in the corrections system. Improved access and engagement can often prevent involvement with law enforcement and decrease the likelihood of recidivism. Removing the barriers within the treatment community is a critical aspect of keeping people out of jail and prison. Services may be improved in some of the following ways:
Create hospitable, welcoming environments
Confront stigma and fear
Create integrated services (mental health, physical health, substance misuse) • Comprehensive treatment and transition planning
Support Services
Mobile and Crisis Services.
Trauma informed, resilience promoting clinical services
Treatment alternatives to extended solitary confinement
Advocacy: Ultimately, systems wide structural and policy change must occur if we expect to eliminate the most egregious effects of incarceration on people with MI. In order for this to occur it will require us to be involved with systems change on many levels. All of the actions considered above require that psychiatrists and other professionals be willing to make efforts beyond their job descriptions and compensation arrangements, and in many cases beyond their training. This can occur on the local, state and federal levels individually and in partnership with others fighting for the same changes. Some avenues for involvement include the following:
Professional Organizations
Community and Family Orgs
Letter and Editorial Writing
Administrative Committees
Lobbying
Community Organization (i.e. Stepping Up Initiatives)
Even in the absence of major shifts in policy and administration, these are a few things that psychiatrists can do to improve outcomes for individuals with mental health and substance use disorders when they have been involved with the criminal justice system. Our vigilance and activism will be required if we are to impact this most egregious public health problem.
References
Anestis, Joye C., and Joyce L. Carbonell. "Stopping the revolving door: Effectiveness of mental health court in reducing recidivism by mentally ill offenders." Psychiatric Services (2014).
Christopher, Paul P., et al. "An empirical ethics agenda for psychiatric research involving prisoners." AJOB primary research 2.4 (2011): 18-25.
Frazier, Beverly D., et al. "The impact of prison deinstitutionalization on community treatment services." Health & Justice 3.1 (2015): 1-12.
Louden, J. E., et al. "Applying the sequential intercept model to reduce recidivism among probationers and parolees with mental illness." The sequential intercept model and criminal justice: Promoting community alternatives for individuals with serious mental illness (2015): 118-131.
McNiel, Dale E., and Renee L. Binder. "Effectiveness of a mental health court in reducing criminal recidivism and violence." American Journal of Psychiatry (2007).
Munetz MR, Griffin PA: Use of the Sequential Intercept Model as an approach to the decriminalization of people with serious mental illness. Psychiatr Serv 57(4): 544-549 (2006) 16603751
Torrey, E. Fuller, et al. "The treatment of persons with mental illness in prisons and jails: A state survey." Treatment Advocacy Center (2014).
Wilson, David B., Ojmarrh Mitchell, and Doris L. MacKenzie. "A systematic review of drug court effects on recidivism." Journal of Experimental Criminology 2.4 (2006): 459-487.
Group for the Advancement of Psychiatry: People with Mental Illness in the Criminal Justice System: Answering a Cry for Help. Washington DC, American Psychiatric Press, 2016
The Stepping Up Initiative.https://stepuptogether.org/