The Within the mentally ill, the War on

The criminalization of mental illness has been a matter of contention among criminal justice and mental health professionals for the past few decades. Because of the deinstitutionalization of the mentally ill, prisons and jails have become the de facto mental health institutions. About 16% of the 1,175,000 federal and state inmates have mental illness (Rowe & Baranoski, 2011). Prisons and jails such as Los Angeles County Jail, Rikers Island Jail in New York, and Cook County Jail in Illinois are among the largest providers of psychiatric care (Johnson, 2011). The former having treated about 3,300 inmates a day in 2010 (Peterson, Skeem, Hart, Vidal, & Keith, 2010). A hypothesis was generated by Ambromson in 1972 to explain the prevalence of mentally ill persons in jails and prisons. This hypothesis, known as the criminalization hypothesis states that persons with serious mental illnesses (PSMI) become involved and are overrepresented in the criminal justice system because of the unavailability of mental health resources in their community (Peterson et al., 2010; Lord & Bjerregaard, 2014). Opposers to the hypothesis contend that the number of PSMIs in jails and prisons is reflective of the increasing number of persons incarcerated in the U.S (Lord & Bjerregaard, 2014). There are several factors that have caused this increase of incarceration: (1) War on Drugs; (2) “tough on crime” policies; (3) deinstitutionalization of mental illness; and (4) police interactions. War on Drugs and Tough on Crime The War on Drugs was a federal government campaign to prohibit the production, distribution, and consumption of illegal substances aiming to reduce the illegal drug trade. This campaign, manifested by President Richard Nixon in 1971, was a controversial set of drug policies that had a negative effect on minority communities such as African Americans and the mentally ill. Within the mentally ill, the War on Drugs policies was a continuum of oppression by the criminal justice system. Persons with mental illnesses are more likely to suffer from homelessness, unemployment, and substance abuse. Oftentimes substance use can trigger mental illness in persons predisposed to psychiatric disorders (Lord & Bjerregaard, 2014). Persons diagnosed with mental illnesses customarily have a comorbidity of mental illness and drug addiction due to their attempts of self medicating to alleviate their psychiatric symptoms and relieve side effects of antipsychotic medications (Lurigio, 2012). Among the large numbers of incarcerated individuals, 75% have an Axis I diagnosis and a substance abuse issue (Lurigio as cited in James & Glaze, 2006). The increased number of PSMIs incarcerated was not only a result of the War on Drugs policies but also “tough on crime” policies. In the late 1980’s tough on crime policies were enacted; mandating mandatory minimum sentences. These policies such as the Three Strikes Law (1994) were extremely detrimental to the mental health community. The Three Strikes Law aimed to deter recidivism conducted by repeat offenders to lower the rate of violent crimes. However, these laws did not seek repeat offense within the same crime, but crimes in general. Lurigio (2012), identified three typologies of persons with mental illnesses in prisons and jails: (1) Persons arrested and criminalized for disruptive behavior, (2) persons arrested for survival crimes, such as shoplifting and prostitution, and (3) persons arrested for serious index crimes, including homicide, battery, etc. Laws such as these created a system of criminalising the mentally ill without consideration of why they committed said crimes. Although incarceration rates are affected by the tough on crime and War on Drugs policies, the determining factor for the criminalization of mental illness began with the deinstitutionalization of mentally ill persons. Deinstitutionalization of mental illnessBefore the process of deinstitutionalization began, 559,000 persons were admitted to state psychiatric hospitals out of a total national population of 165,000,000 (Lamb & Weinberger, 2017). With the introduction of psychotropic medications (chlorpromazine), community treatment interventions, and development of federal programs, such as Supplemental Security Income and Medicare, the provision of state psychiatric hospitals declined. Baillargeon, Hoge, & Penn (2010) define deinstitutionalization as a shift in care from state psychiatric hospitals to community based treatment agencies. This shift was outlined by the Joint Commission on Mental Illness and Health (JCMIH) in 1961. The JCMIH aimed to reduce prolonged hospitalization by creating community based programs in mental health clinics and intensive psychiatric treatment centers. This commission additionally halted the construction of state psychiatric hospitals and converted hospitals into treatment centers for PSMIs. In addition to the development of the JCMIH, there were several acts executed to further the process of deinstitutionalization; one being The Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963. This act provided financial motivation for states to support and launch a community based system of care (Baillargeon et al., 2010). The Lanterman-Petris-Short (LPS) Act of 1967, ceased involuntary psychiatric hospitalization of persons suspected of having mental illness and limited the duration of hospitalization. A similar law passed in 1998 in Jamaica claimed that a “patient cannot be detained involuntarily for longer than 28 days” (Hickling, Robertson-Hickling, & Paisley, 2011). These acts consequently led to only the most impaired and/or dangerous persons being involuntary admitted. As a result, the lack of resources and inability to access necessary treatment and social support services left a large number of formerly institutionalized persons homeless and impoverished. Such persons then had no choice but to turn to illicit drugs and alcohol to medicate their symptoms, eventually leading to criminal acts. Researchers Davis, Fulginiti, Kriegal, and Brekke (2012) asserts that shifting individuals from an institution of care (state hospital) to multiple institutions and care facilities does not represent deinstitutionalization but “transtitutionalizaiton”. The key difference between transtitutionalization and deinstitutionalization is the ‘transfer’ of care from one institution to many. Within the era of deinstitutionalization, the Civil Rights Movement led to the examination of patients rights; and the abuse and inhumane conditions inflicted by state psychiatric hospitals (Kim, 2014). Although deinstitutionalization was meant to be an altruistic act by the federal government, it failed tremendously. Three inferences can be made as to why it failed: (1) lack of planning before and during deinstitutionalization, (2) financial resources were scarce, and (3) public resistance to community treatment (Lamb & Weinberger, 2017). Once state mental hospitals began releasing thousands of chronic and severely unstable patients into the community, the expectation was made that community mental health clinicians would play the major role in socially controlling the patients. The government, however, was mistaken. Many clinicians were not comfortable with treating offenders with serious mental illnesses and did not in fact want to be agents of social control.  The treatment goals for many of the community based centers were to stabilize psychotic symptoms to reduce criminal behavior. However, much of the criminal acts enacted by mentally ill persons were attempts to contribute to society. These attempts were a result of society redefining criminals as mental patients, leaving no room for them to define themselves (Rowe & Baranoski, 2011). Deinstitutionalization also caused for an outburst of violent behavior amongst released offenders. By the 1970s, violent behavior episodes were increasingly reported (Torrey, 2015). These behaviors continued to be prevalent within U.S leading to confrontations between law enforcement and mentally ill individuals.Police vs. Mentally ill Police brutality has been an going issue within the African American community for centuries, stemming from slavery, Jim Crow laws, and the civil rights movement. However, interaction and confrontations between law enforcement and the mentally ill did not become prevalent until the process of deinstitutionalization began. Law enforcement are the first responders to any crime or emergency. Between 7% and 10% of all police contacts involve persons with serious mental illnesses (Lord & Bjerregaard, 2014). These contacts became expectations as police reform developed. Inadequate training of law enforcement has resulted in arrests, known as “mercy bookings”, where persons with serious mental illnesses are placed in jails to receive treatment, food, and lodging (Lurigio, 2012).  Persons with mental illnesses that are arrested commit misdemeanor crimes due to public disturbances. Other, more serious crimes include threatening to harm others or themselves. As a result of inadequate training, police departments employ the assistance of mental health professionals to implement training programs. Such programs include police based mental health response where mental health professionals are hired by police departments to provide real time consultations at the scene to officers (El-Mallakh, Kiran, & El-Mallakh, 2014). Another program is the mental health based specialized mental health response in which mobile mental health teams are called to the scene by officers only when necessary. Society’s perceptions of the mentally ill imprisoned in jails and prisons is that they are acting out because of their symptoms. However, 10% of persons with mental illnesses are incarcerated, 90% having committed felony crimes (Lurigio, 2012). Law enforcement’s interaction with persons with mental illness can further be helped by encouraging and escalating society’s interaction with individuals diagnosed with mental illness as it “provides an opportunity to facilitate social reintegration of people with mental illness into the community” (Pattyn, Verhaeghe, & Bracke, 2013). Alternatives to incarceration During the 20th century, mental health courts emerged to divert persons with mental illness from the criminal justice system to mental health system. Having alternatives to incarceration would decrease prejudice amongst society against persons with mental illnesses and create reform that will renovate and standardize treatment of the mentally ill. One alternative to incarceration created by criminal justice and mental health professionals are jail diversion programs. Jail diversion programs were developed to “reduce incarceration rates for persons with psychiatric disorders who commit low level offenses by diverting them from the criminal system to mental health system” (Rowe & Baranoski, 2011). This is only accomplished through negotiations between mental health professionals, clients, and the court to have charges dropped or reduced in exchange for the client/inmate agreeing to obtain mental health treatment. Unlike the deinstitutionalization process of the revolving door phenomenon, stabilizing symptoms and sending them back to jail risking them not taking medication and being returned to the hospital, the treatment goal of the jail diversion programs is to reintegrate offenders into the community by medicating, housing, and socially and educationally rehabilitating (Lamb & Weinberger, 2017). Collaboration between the mental health system and criminal justice system have created three models of alternatives. The prebooking model, being the first, is to prevent arrest and incarceration by intervening mentally ill persons at risk of criminal behavior. An example of this includes mobile crisis intervention teams, an open line of communication between law enforcement and mental health professionals directly responding to individuals with symptomatic behavior before criminal acts. The second model, forensic assertive community treatment model, provides outreach and social services to mentally ill persons at risk of homelessness and hospitalization. And the third, postbooking model, is the mental health court; combines court supervision and community based treatment services based on the principle of therapeutic jurisprudence (Baillargeon et al., 2010). Another alternative to incarceration are assisted outpatient treatment programs. These programs allow mentally ill persons to have the opportunity to live and interact with the community as long as they follow their treatment plan. Although these alternatives would be an improvement when compared to the deinstitutionalization process, they still have their faults. Behavioral health systems can only manage patients’ symptoms, they cannot “help them to become socially integrated within society” (Rowe & Baranoski, 2011). To overall eliminate the criminalization of the mentally ill, police officers must be trained on the signs and symptoms as well as de escationaltion techniques needed when interacting with PSMIs, crisis intervention teams must be employed nationwide, and jail diversion and mental health courts must be implemented.