B. Mental Health
Mental health is defined as “a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity” (Satcher, 1999, p. 4). Conversely, mental illness is associated with interpersonal dysfunction and increased risk of homelessness and drug/alcohol abuse. Mental illness can also lead to abnormal social behaviors that draw the attention of law enforcement. Even though the appropriateness of criminalizing and incarcerating mentally ill persons remains a controversial ethical debate, the criminal justice system remains the primary form of mental health care for a sizeable portion of society. The criminal justice system is now responsible for the provision of mental health services through the identification of evidence-based interventions. To be considered successful, these interventions must improve the mental he/palth of individuals while also justifying distal goals such as lowering recidivism, maintaining fiscal responsibility, and reinforcing public safety.
In 1939, Penrose wrote that “criminality, insanity and mental deficiency are, all three, relative terms, for the difference between normal and abnormal implied in each of them is a matter of degree” (p. 2). Penrose identified a population whose aberrant behavior was labeled either criminal or mentally ill in relation to the parameters of social standards. The presence of a marginalized group that migrates between the mental health and criminal justice systems is still evident. The most noteworthy example of this migration centers on the deinstitutionalization of state mental institution patients that began in 1955. Deinstitutionalization involved the reassignment of patients out of state mental institutions and into community mental health centers. Deinstitutionalization was stimulated by advancements in psychotropic medication (e.g., Thorazine) that enabled better control of patients’ symptoms. Despite having earnest goals, the proponents of deinstitutionalization inadvertently shifted the burden of care of the mentally ill to the criminal justice system.
Studies estimate that the prevalence rate of psychiatric morbidity is now 10 times greater in prison samples when compared with the community (Brugha et al., 2005). Incarcerated populations are also estimated to contain between two and five times the rate of individuals with severe and persistent mental illnesses, such as schizophrenia/ psychosis, major depression, bipolar disorder, and posttraumatic stress disorder, when compared with mainstream society (Lamberti & Weisman, 2004). The association between mental illness and substance abuse compounds problems. One study found that the preponderance of offenders were under the influence of substances at the time of arrest and estimated that 90% of inmates with severe mental illness experienced a substance use disorder during the life course (Abram & Teplin, 1991). Current practices of mental health by the criminal justice system include treatment in the form of psychotropic medications and/or therapeutic interventions.
Changes in practices are also evident in the accommodation of the mentally ill by the criminal justice system. The war on drugs carried harsh and punitive sentencing that resulted in the mass incarceration of mentally ill and/or substance-addicted people. As a result, the criminal justice system devotes significant institutional resources to an increasingly sick population. A case in point is the Los Angeles County Jail, where a daily population of 3,300 severely mentally ill inmates constitutes the largest de facto mental institution in the United States (The Sentencing Project, 2002). Furthermore, the state of California now treats more mentally ill people in prison and jails than all hospitals and residential treatment centers combined (12.5% vs. 10%, respectively; Beck & Maruschak, 2001). The adoption of a public health perspective has allowed for the inclusion of programs that can direct suitable mentally ill individuals into more appropriate avenues of care. These initiatives include jail diversion programs and drug courts that redirect suitable mentally ill offenders away from the criminal justice system.
1. Jail Diversion Programs
The traditional models of law enforcement provided minimal guidance regarding how to respond to mentally ill people. As a result, police officers used rigid techniques that promoted the warehousing of the mentally ill within correctional facilities. Inadequate training on the etiology and manifestation of specific mental disorders were also associated with police officer injuries. In response, jail diversion programs were created as an interface between the criminal justice and mental health systems. According to Steadman (2002), mentally ill misdemeanants should be diverted into community mental health facilities that provide services in an appropriate and fiscally responsible manner. Not eligible for diversion are mentally ill offenders who commit violent and serious crimes, because these felonies constitute a threat to public safety.
Diversion programs can be separated into prebooking or postbooking depending on the time point of the criminal justice system intervention. The Crisis Intervention Team (CIT) within the Memphis (Tennessee) Police Department is the most publicized form of prebooking jail diversion in the United States. The CIT program was devised to offer law enforcement personnel specialized training and resources in order to divert suitable mentally ill offenders into community health facilities. This diversion occurs in lieu of the alternatives: release or arrest of the offender. This program provides 40 hours of training in psychiatric and substance use disorders, including use of crisis de-escalation techniques. Prebooking programs require the commitment of police officers, and discretionary decisions are conducted at the street level. Postbooking programs, on the other hand, target the intervention within the court or correctional milieu. During these processes a mental health professional identifies misdemeanant offenders who are eligible for transfer to a facility for the provision of psychiatric services. Jail diversion programs are ideally coupled with the defragmentation of social services, which can allow for streamlined reintegration back into the community. The Memphis CIT program is still in need of a public health/criminal justice program evaluation in order to test its efficacy, yet it is included here as an example of innovation and synergy.
2. Drug Courts
In recent years, the field of criminal justice has become reluctant to employ strictly punitive responses to drug and alcohol addiction and has moved toward an acceptance of treatment-oriented responses. Drug courts are based on the recognition of comorbidity between mental illness and drug/alcohol addiction.They afford the offender the opportunity to meet treatment, screening, and technical mandates in order to have charges dropped. Failure to meet these requirements can lead to criminal sanctions, including incarceration and restitution. There are currently 2,000 drug courts in the United States, and research supports a 10% to 20% reduction in recidivism among participants (Draine, Wilson, & Pogorzelski, 2007).
The adoption of the public health perspective by courts can enable mentally ill/drug-addicted offenders the opportunity to reframe their interaction with the criminal justice system. Few would argue that punitive criminal justice policies in the area of drug abuse have maintained community health or reduced recidivism. Instead, these punitive responses have overwhelmed the criminal justice system and alienated communities (Bobo & Thompson, 2006). Conversely, efficacious drug courts link vulnerable populations with much-needed community services. The offender faces the decision of whether to address health deficits through these services or risk incarceration. Beyond these issues that bring the fields of public health and criminal justice together is the social health of citizens.