Melissa Bailey, M.A.
Licensed Professional Counselor and Senior Fellow at the Center for Health Care
Strategies, New Jersey - Monday, June 29th, 2020
Addressing the
Criminalization of Mental Illness by Increasing Sensitivity of First-Responders
According
to the Bureau of Justice Statistics, two million
adult arrests, or roughly 16.9 percent, in the United States each
year involve people with serious mental illness.
And for
children, it’s estimated that roughly 70 percent of
youth in the juvenile justice system have a mental health
condition.
Providing
adequate physical care for incarcerated individuals already poses a unique set
of challenges and providing appropriate mental health care can seem impossible.
Recognizing ways that we can better work to keep these populations out of the
criminal justice system in the first place is the first step to addressing the
large discrepancies of care these individuals face when seeking help for their
mental health needs.
The High Cost of Treating Mental Health Through the Prison
System
Roughly 40 percent of
individuals who are incarcerated are diagnosed with one or more mental
illnesses, with some studies suggesting
that number could be as high as 64 percent for local jails, 56 percent for
state prisons, and 45 percent for federal prisons. Of these individuals who are
incarcerated, approximately half were
homeless at the time of arrest, and women who are incarcerated are more likely
to have mental health needs than men.
The
financial cost of treating mental health in the prison system is high—costing
approximately $50,000 per
individual who is incarcerated with psychiatric disorders, or
$15 billion a year. Moving these individuals to an inpatient psychiatric
placement would cost an average of $5,500 per admission
if the individual was uninsured, and preventive care, like an assertive
community treatment program, would cost approximately $10,000-$15,000 for
the entire year.
Beyond
financial cost, the even more startling cost is the impact on the mental health
of individuals who are incarcerated.
Roughly 75 percent of
individuals with a mental illness who are incarcerated receive acute inpatient
psychiatric care through the prison system, not through a mental health
provider. Suicide rates in prisons are triple what
they would be outside the correctional system—with suicide accounting for one-third of
all deaths in jails—and those rates are climbing. State prison suicides
jumped 30 percent between
2013 and 2014 (the latest number published by the U.S. Bureau of Justice
Statistics), and as mass incarceration continues to pack facilities to
full-capacity, providing adequate support to lower those numbers is unlikely.
When a Crisis Becomes a Crime
The US
local, state, and federal jails and prisons hold 2.3 million individuals—and
an estimated 920,000 individuals with mental illness. With the large reduction
in inpatient psychiatric beds that began in the 1970s, this means that the
prison system is now, by default, the nation’s largest psychiatric
hospital.
But the
high rates of mental illness in the prison system do not make mental illness a
predictor of crime. Many of the arrests made follow minor incidents such as
public urination, sleeping on the street, or public nuisance. Other times, the
police respond to a 911 call when someone with a serious mental illness is
having a crisis and may be yelling, behaving erratically, or otherwise creating
what is perceived as a public nuisance.
While
the petty crimes are what the police were called to address, when an officer
shows up without training to help these individuals, the situation can
escalate. Mental illnesses can be exacerbated by the stress of interacting with
law enforcement, and before long the situation may escalate to the point that
the individual is arrested for failure to obey, assault, or something more
serious.
I’m not
suggesting that there aren’t incidents where someone has, in a state of
psychological distress, done something that warrants arrest. But by and large,
additional training can reduce extreme and costly over-precautions when it
comes to responding to populations with mental health needs that may contribute
to extreme behaviors.
During
my three years as a state Deputy Commissioner and Commissioner for Vermont’s
Department of Mental Health, we had four separate incidents where an individual
was killed by law enforcement after they responded to a mental health-related
call. People with untreated mental illness are as much as 16 times more
likely to be killed by law enforcement. In light of current
conversations across the United States about excessive police action,
particularly in the Black community, we need to expand and invest more in
training to help first responders identify and deescalate mental health crises
and avoid unnecessary harm.
A Way Forward: Bringing New Skills to the Scene
Allocating
resources to train first responders to identify and address mental illness can
help prevent unnecessary incarceration of those with mental health disorders
for petty crime or otherwise avoidable escalations of police encounters when no
crime has been committed. Better yet, though, allocating resources to develop
special crisis response teams that are trained specifically to handle
individuals with mental illness can ensure that these individuals are directed
to where they’ll get the most appropriate care for their conditions and needs—and
often with better outcomes and at a lower cost than a correctional
facility.
Community
crisis response and Crisis Intervention Teams use is a growing area of interest
for community, city and state leadership in an attempt to mitigate negative
police-community interaction. In Washington, for example, the Pierce County
Fire Department realized that it was responding to a
significant amount of 911 calls for individuals with mental and behavioral
health needs. Realizing it was unequipped to effectively address these crises,
the department’s paramedics partnered with a local physician network to develop
a Mobile Community Intervention Response Team (MCIRT) that was
specially-trained to work with mental health patients. With MCIRT, the
county’s EMS services have seen a 47 percent reduction in EMS transport, a 36
percent reduction in ED visits, and a 42 percent reduction in hospital
readmissions.
While
the aim of the MCIRT was to address high utilization of EMT and ED services, a
similar model could also be used to address the disproportionate arrest rates
of those with mental illness and substance use disorder.
In
Vermont, a grant to the Vermont Care Partners combines
Department of Mental Health and Department of Public Safety funding to provide
training for law enforcement and mental health crisis workers in collaborating
together during crisis situations. The reactions to this program have been
overwhelmingly positive, and I am optimistic that such programs will ultimately
strengthen our ability to care for and respond to individuals with mental
health conditions.
Beginning with the End in Mind
In an
ideal world, municipalities would have ample resources to fully fund these
educational and skill building initiatives. Law enforcement and other
first-responders would be thoroughly trained to deescalate psychiatric
distress, cities would have fleets of mobile mental health units the way they
have fleets of fire engines, and we’d even have psychiatric urgent
care/same-day options for those who need walk-in help at a lower acuity level
than the ED or psychiatric inpatient admissions.
Unfortunately,
that’s not the case. Working for the state of Vermont, I saw firsthand the
difficult discussions surrounding budgets, knowing full-well that hiring social
workers, therapists, and others we needed would be challenging to fund. As
such, we’re left with a delicate balancing act between needs of individuals in
mental health distress, community safety needs in general, and resources being
directed toward other types of community prevention options.
While I
don’t have an exact path to get our system from where it is today to a more
balanced approach in the use of government, community, and health care
resources, the more successful initiatives I have seen in VT and in other
states begin with the end in mind— the goal of avoiding arrest and connecting
people with supportive resources and necessary treatment. Rather than interacting
with individuals simply because of their behavior, we can look for ways to
address the person’s needs by connecting them with appropriate mental health
resources. Instead of arresting people, we can examine the issues that
contribute to the behavior and lead to the interactions with police and try to
change the current trajectory.
Beginning
with the end in mind is rarely the easy—or least expensive option—at least in
the beginning. But the far-reaching benefits include better health for
individuals and communities and contribute to long-term effective use of
funding resources and likely even cost savings.
Related
Reading: Implicit Bias
and Racial Disparities of Care: Recognizing and Addressing the Role of Implicit
Bias in Vulnerable Patient Care
Melissa
Bailey is a Senior Fellow at the Center for Health Care Strategies (CHCS) where
she promotes programs for individuals with mental and behavioral health needs.
Prior to her work at CHCS, she was the Commissioner for the Department of
Mental Health at the State of Vermont. She has done significant work for child
and family mental health and has a Masters in Mental Health Counseling from
Johnson State College.
This
article is provided through a collaborative effort with Collective Medical.
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