NYAPRS Note: The New York Times regularly puts a controversial public policy issue to debate in its ‘Room for Debate’ series. Some years ago, after the Newtown tragedy, it ran such a debate around “Can Mental Health Care Reduce Gun Violence?” (http://www.nytimes.com/roomfordebate/2013/01/17/can-mental-health-care-reduce-gun-violence). This morning, it asks what it will take to help get and keep people with serious mental health conditions out of prison, jail and homelessness.
There’s a broad range of opinions. Several urge that we can stop avoidable incarcerations by putting in place a robust network of community behavioral health supports, services and housing, making food, clothing and social and peer supports available and by providing improved police training, community alternatives and prison reforms. Some include more hospital beds in this equation. And one asserts that, while “there seems to be a huge emphasis on assisted outpatient treatment…despite plenty of high-quality evidence showing that it does not work….(as) a fig-leaf used to cover politicians’ failure to provide decent routine care to all who need it.”
There’s been a another similar debate in Washington as to whether taxpayers should invest tens of billions of dollars in making more hospital beds and court mandated community treatment available…..or to instead use such funding to fill in the major cracks in our community and criminal justice systems.
NYAPRS members have spent a lifetime in working for the latter and continue to urge policy makers to avoid fig leaves like more or bigger institutions and involuntary community treatment.
Getting the Mentally Ill Out of Jail and Off the Streets
New York Times May 9, 2016
The federal government hasaccusedSouth Dakota of unconstitutionally warehousing the mentally ill and disabled in nursing homes. Meanwhile,at least 16 percentof the nation’s jail and prison inmates are estimated to be mentally ill and about 40 percent of the mentally ill have been incarcerated. Many of the homeless are also mentally ill.
Deinstitutionalization, which began decades ago, was supposed to improve treatment, but was not followed by funding for better care.
Do we need to return to mental hospitals and other forms of institutional commitment to treat those with severe mental illness? Or are there other, more effective means of treatment?
TOM BURNS, SOCIAL PSYCHIATRY PROFESSOR
Tom Burns is a professor emeritus of social psychiatry at the University of Oxford.
As one of a rapidly dwindling band of psychiatrists who started their careers working in the old asylums, I dread the emergence of any rose-tinted nostalgia for them. They were terrible places and we are well to be rid of them.
In Europe, patients may stay in hospitals for weeks, or occasionally months, in order to stabilize. In the United States — with its emphasis on immediate risk as the condition of detention — discharge is often after just a few days. Undoubtedly, on both sides of the pond, we have overshot the mark and modern services now have too few beds. But that is an argument for more beds, not a return to the institutionalization of the mentally ill.
The mentally ill need skilled case managers in their communities. Alternatives are fig-leaves to cover the failure to provide decent care.
We have learned, after more than 30 years of research, what works in terms of community care for the severely mentally ill. The bedrock of care is a durable relationship with a skilled case manager (in Europe, usually a nurse, in the U.S., a social worker). That case manager needs to be mobile, reaching out to their 20 to 25 patients around two to three times per month. Case managers need to work within a multidisciplinary team that can coordinate on health and social care; at a minimum, many of these patients need regular supervision to get their medicine and have reasonable accommodation.
No system or treatment is perfect and the tragedy of persisting mental illness is all too clear. To an outsider, however, the U.S. system is a conundrum. How can such a rich and well-educated society tolerate such publicly dysfunctional provisions for the mentally ill?
The extreme fragmentation of care in the U.S. is striking: There are too many services with their own complex contractual, referral and eligibility procedures. Patients (and their families) already have enough uncertainty to deal with. They need simpler, more comprehensive services with easy access. Greater clinical and budgetary integration with inpatient care and social services is also surely possible.
There seems to be a huge emphasis on assisted outpatient treatment — court-ordered treatment for those who cannot live safely in their communities — despite plenty of high-quality evidence showing that it does not work, no matter how you cut it. Why is this? To me it looks like a fig-leaf used to cover politicians’ failure to provide decent routine care to all who need it.
It may also be that America’s traditional emphasis on personal freedoms fits poorly with the needs of the severely mentally ill. Isaiah Berlin’s distinction of two forms of liberty — "freedom from" oppression and "freedom to" live a decent life — is surely relevant here: Overzealous protection of very ill patients from effective compulsory hospital treatment is no real freedom if it leaves them to "die with their rights on" or results in them being imprisoned.
AYESHA DELANY-BRUMSEY AND CHELSEA DAVIS, VERA INSTITUTE
Ayesha Delany-Brumsey is the director of, and Chelsea Davis is a research associate at, the Substance Use and Mental Health program at the Vera Institute of Justice.
For many, mental illness goes hand-in-hand with drug use, either because substance use exacerbates their symptoms or because they self-medicate with drugs. In jail, almost three quarters of people with serious mental illness also have a drug addiction.
We cannot decouple these two health needs when delivering care. But the justice system-first response to both of these issues intensifies the problem. In jail, those with mental illness and substance abuse are separated from their communities and family support systems, saddled with criminal records, and too often deprived of services that would help them live full lives. The justice system has a limited ability to effectively and holistically treat people because the kind of care it delivers is determined by legal and punitive decisions, not clinical needs.
Mental illness goes hand-in-hand with drug use, either because substance use exacerbates symptoms or because drugs are used to self-medicate.
To help develop an alternative approach, we recently conducted a study of individuals who have been entangled with the justice system because of drugs and mental health problems. The results, also supported by a growing body of research, challenge the long-held assumption that people with mental illness commit crime primarily because of their illness.
We found that a complex mix of issues — for example, substance use, trauma, loneliness, poverty, unemployment and homelessness — connect the justice system's response to mental health problems. When we asked what might prevent future arrests, people talked about needing stable homes, jobs and stronger relationships. Many more people mentioned the need to stay away from drugs than receive mental health treatment, despite the fact that every study participant had an identified mental health disorder.
That is not to say that providing mental health care is unimportant: The study highlights the need to provide mental health care in conjunction with addressing other needs, including addiction, housing and employment.
People with mental health and substance use problems need counseling and medication-assisted treatments, like methadone maintenance. Community programs should expand the use of harm reduction practices, such as naloxone distribution, which aim to mitigate the harms of drug use. Police must work with these programs and refrain from making arrests around harm-reduction clinics, like syringe exchanges, so people can engage in recovery without fear of arrest.
Housing-first models, in which people who are chronically homeless are provided permanent housing and support services as needed — without any preconditions, such as abstaining from substance use — have been shown to keep people with mental illnesses housed, with reduced recidivism and improved wellbeing. This and other similar multifaceted interventions that recognize that people with mental illness have other needs, facilitate long term recovery and are far more supportive that what is available through the justice system.
ANN-MARIE LOUISON, CASES
Ann-Marie Louison, the director of adult behavioral health programs at the Center for Alternative Sentencing and Employment Services, is the co-founder of CASES' Nathaniel Project, the first alternative-to-incarceration program in Manhattan for adults with serious mental illness.
A small number of individuals with serious mental illnesses need long-term hospital care, but no one should need this level of care forever. In the 1990s, I worked as a social worker in a state-run mental health hospital of this kind in New York City; the patients received good care there. But back then, there were a fair number of patients that "lived" in the hospital for many years.
Now, the focus of such treatment should always be to support each individual to return safely to his or her community, which, in turn, must have adequate support to address housing, treatment and the social needs of the individual.
A small number of individuals with serious mental illnesses need long-term hospital care, but no one should need this level of care forever.
Affordable housing with onsite support services is a proven method of support for those who may wind up homeless otherwise. In New York City, congregate housing — which includes shared apartment buildings, scattered site supported housing and community residences — is supplemented with case management and treatment supports. It provides a holistic, systemic approach to mental health service that sustains the dignity of the individuals and their families. It keeps recovery central and protects public safety.
A small minority of individuals may need outpatient commitment — for example, a court mandate to medicate — in order to engage and participate in community services, but this is not necessary for the majority of people with mental illnesses.
Unfortunately, there is not enough housing to address the need, and not enough support to get people out of inappropriate institutions and off the streets and out of jails — even though we know these services work. For example, the housing retention rate for those who were shuttling in and out of jails and the shelter system in New York City — and then got supportive housing through the FUSE model developed by the Corporation for Supportive Housing — was more than 90 percent over two years. They had a 53 percent reduction in jail days, and a 92 percent reduction in shelter days — saving more than $15,000, an amount that essentially paid for two-thirds of the program cost.
Alternative-to-incarceration program for adults with serious mental illnesses are also very important. Individuals who go through them, on average, spend less time in jail and get more comprehensive treatment. These programs decrease the risk to public safety.
Services that work often incorporate mobile Assertive Community Treatment (ACT) teams, care managers, outpatient clinics, peer support and family, vocational and employment services. Even so, they are significantly less expensive than long-term institutional treatment, which doesn't even work. We should focus on making sure services like ACT and supportive housing have adequate government funding so they can be more than a bandage for a broken system.
People with mental illness can have full, healthy and safe lives in the community when the right services — including at the front and back door of the justice system — are available to them.
JAMIE FELLNER, HUMAN RIGHTS WATCH
Jamie Fellner, a senior advisor at Human Rights Watch, is the author of "Callous and Cruel: Use of Force against Inmates with Mental Disabilities in U.S. Jails and Prisons."
Jails and prisons have become de facto mental health facilities: prisoners have rates of mental illness two to four times greater than for the general public. Yet prisons and jails are the worst possible place for people with serious mental health problems.
Because of understaffing, limited programs and correctional cultures of discipline and punishment, men and women behind bars with mental health conditions are often untreated or under-treated, and have scant help coping with unbearably stressful environments.
The police must be able to recognize the symptoms of mental health crises, and need facilities other than jails to which they can take people in such crises.
When they fail to follow the rules or are disruptive, officers often respond by placing them in solitary confinement – a toxic environment for most people, but especially those prone to psychosis or depression. Staff use of force is also all too common: Many prisoners with mental illness have been beaten until their bones are broken and organs are injured, deluged with chemical sprays, shocked with electric stun devices, and strapped to chairs and beds for days.
This violence only aggravates their conditions and makes future treatment more difficult. In the worst cases, staff force kills them.
Reforms are needed inside jails and prisons. But the single most important way to keep people with mental illness safe from unnecessary or abusive force behind bars is to keep them out of the criminal justice system entirely.
Their first brush with the law starts with the police, who are often on the front line of dealing with people in a psychiatric crisis that may involve unlawful behavior. Many police are not trained in how to recognize the symptoms of mental health crises, and respond inappropriately. Some cities, like Portland, Ore., have reportedly made great strides in training their officers in de-escalation techniques for responding in such crises without force. But such training is not yet widespread. A recent Police Executive Research Forum survey found that the average young officer receives only eight hours of de-escalation training, compared to 58 hours of firearms training and 49 hours of defensive tactical training.
But even the best trained police need more facilities other than jails to which they can take people experiencing such crises. Communities need robust networks of mental health services — networks that are all too lacking today. The also need more mental health hospital beds. An untold number of men and women sit in jails today waiting for vacancies in those hospitals where they can get the level of care they need.
Wholly apart from mental health care, fewer people with mental illness would end up behind bars if we stopped criminalizing minor symptoms of mental illness, as well as homelessness, poverty and substance abuse. It would also help to have more tolerance for bizarre or discomfiting, but harmless, public behavior.
A societal shift toward compassion and respect for the human rights of people we may not understand is long over-due.
DOMINIC SISTI, PROFESSOR OF MEDICAL ETHICS
Dominic Sisti is the director of the ScattergoodEthics Program and assistant professor of medical ethics at the Perelman School of Medicine at the University of Pennsylvania. He is on Twitter (@domsisti).
Behind the bars of prisons and jails in the United States exists a shadow mental health care system where nearly half a million inmates have a serious mental illness like schizophrenia. In hospitals, severely mentally ill patients languish for months in acute care units, which are designed to stabilize patients, not to help their long-term recovery.
High quality, ethically administered psychiatric asylums would provide the seriously mentally ill with a place to stabilize and recover.
To give these people the care they deserve, we need to bring back psychiatric asylums. Not the dismal institutions that were shuttered in the past, or settings of gothic fiction, but asylums based on the true meaning of the word: places of sanctuary and safety for vulnerable people. The current system too often fails to protect and care for individuals who have serious mental illness in the appropriate place and at the appropriate time.
Mental health treatment should be provided in a seamless continuum that ranges from outpatient care, to community services and supportive housing, to inpatient medical care. But the system is so utterly disjointed, uncoordinated and poorly funded, that those who need help, instead end up in jails and prisons, or warehoused in nursing homes and other group housing facilities.
The Supreme Court was right to have ruled in the 1999 Olmstead decision that individuals with physical or mental disabilities should be provided treatment in the least restrictive setting. But the court also warned that people who need more support, in therapeutic institutional settings, should continue to receive it.
The few state hospitals that remain, though, have months-long wait lists, and private psychiatric facilities cost tens of thousands of dollars per month. The dramatic decline in psychiatric beds has been well documented.
In any other branch of medicine, such a dearth of services would stoke public outrage. Yet in mental health care, it is routine for sick individuals to cycle through the same emergency rooms weekly — or find themselves in jails and prisons — only to be sent on their way with a blister pack containing a week’s worth of medication before they deteriorate again.
High quality, ethically administered psychiatric asylums would provide the seriously mentally ill with a place to stabilize and recover; they are a necessary part of a comprehensive mental health care system. In contrast to those of the past, modern asylums would be settings that restore hope, support recovery and provide an array of treatments. Their quality and costs should be fully transparent and they should be integrated into the broader health care system, perhaps as a part of an accountable care organization.
It is challenging to estimate the cost of long-term psychiatric care. New or modernized facilities would cost several hundred millions of dollars. But when public dollars are now being spent to accommodate mentally ill people inside prisons, isn’t there is a strong moral case to instead invest in places to care for our society’s most vulnerable people the right way?
FRED OSHER, COUNCIL OF STATE GOVERNMENTS
Fred Osher is the director of Health Systems and Services Policy at the Council of State Governments Justice Center.
The answer is not simply to build more psychiatric facilities, but rather to fulfill the promise of deinstitutionalization by providing effective treatment and supports in the least restrictive setting.
Unfortunately, many people do not have access to proven interventions. Too many people have no health insurance; there have been too many budget cuts to treatment dollars, and there are too few providers available to deliver care. These obstacles should lead to a call to action, not a call to further confine people with mental illness.
The movement to deinstitutionalize people with mental illness that began in the 1960s shifted the majority of fiscal responsibility from the states to the federal government. But the Community Mental Health Act of 1963, signed into law by President Kennedy, was never adequately funded. Resources that once paid for food, clothing, housing and rehabilitation, in addition to psychiatric treatment, didn’t follow the people into the community.
The answer is not simply to build more psychiatric facilities, but rather to fulfill the promise of deinstitutionalization by providing effective treatment.
Then, in 1981, President Reagan signed the Omnibus Budget Reconciliation Act, which established block grants for the states to provide mental health care, but further cut federal spending by 30 percent. It only worsened the situation.
Finally, in the aftermath of the 2008 recession, states were forced to cut over $4 billion in public mental health funding. With funding in free-fall, jails, prisons and nursing homes became the de facto places to warehouse people with serious mental illnesses.
The number of people with serious mental illnesses who are incarcerated or homeless is three to five times higher than in the general population. There is a wide range of empirical evidence that shows, with appropriate treatment and community supports, people can recover, achieve their goals, and contribute to our society.
For homeless individuals with mental illnesses, a place to stay with added support services can enable them to thrive. Supported employment is a method of getting people competitive jobs despite their disabilities. Medications, including those that can halt the devastating effects of addiction, allow people to resume their roles as students, parents and employees. Assertive community treatment models meet people where they live and assist in connecting them to needed services.
The challenges are great, but the willingness to address them is growing. Last month, Stepping Up, an initiative to reduce the number of people with mental illnesses in jails, held a national summit in Washington, D.C. where teams of law enforcement, court, corrections, and mental health professionals and county leaders gathered to develop comprehensive plans to address the issue in their jails.
People with mental illnesses have unique needs, and their overrepresentation in jail, prison and other ill-equipped settings is a national tragedy. The toll it takes on them, their families, and our nation’s commitment to fair treatment for all is immeasurable.