Sherry Siller, University of New Haven
Formally, deinstitutionalization began on a large scale in the early 1950s, at a time when the number of institutionalized people was at a record high of 559,000 (Deas-Nesmith, McLeod-Bryant, & Carolina, 1992). As a policy, deinstitutionalization mandated a shift in the caring of individuals with mental illness from state run environments to the community. The goal of deinstitutionalization was the large-scale elimination of the long-term care, state-run, residential facilities for the mentally ill (Pow, Baumeister, Hawkins, Cohen, & Garand, 2015). Ultimately, this goal can be broken down into several components: (1) the release of individuals from psychiatric hospitals who are capable of caring for themselves with medication; (2) the transfer of mentally ill individuals to community based care centers, and the diversion of new admissions to alternative, locally run facilities; (3) the development of specialized services to monitor and care for, as needed, the noninstitutionalized (outpatient) mentally ill population; and (4) to reduce the costs associated with long-term institutionalization (Lamb & Bachrach, 2001; Sutherland, 2015).
Deinstitutionalization as a whole consists of the sum of its parts, meaning it is not just one specific action that caused the mass decline in state run psychiatric facilities for the mentally ill, but several actions and policy changes occurring in roughly the same time interval. Furthermore, its goals were achieved through multiple initiatives, at both macro and micro levels. The purpose of this paper is to critically examine this multifaceted approach toward reducing the number of long term mentally ill cared for by the states. It also will examine how deinstitutionalization has impacted the current rates of mental illness and the current initiatives aimed at reducing the number of mentally ill incarcerated.
Jails and prisons today have largely become replacements for state psychiatric facilities, holding as many as 10 times the number of mentally ill (AbuDagga, Wolfe, Carome, Phatdouang & Torrey, 2016). Jails and prisons are not designed or operationalized for the caretaking that comes with housing the mentally ill. They often do not have the resources, staff or budgets that are required to meet the needs of the incarcerated who have serious mental illnesses. At any time in the general population, an estimated 4% of adults have a serious mental illness (Center for Behavioral Health Statistics and Quality, 2016). Diagnoses for mental illness include but are not limited to disorders such as schizophrenia, bipolar disorder, and major depression. These illnesses affect an estimated 14.5% of men and 31% of women in jails (Vera Institute, 2015). Additional figures put the amount at an estimated 20% of state prisoners and 21% of jail inmates who have some recent history of mental illness (Vogel, Stephens & Siebels, 2014). These numbers indicate that incarcerated persons have a rate of mental illness that is four to six times higher than in the general population. Furthermore, attempts to address this current issue using diversion-based programs have met with mixed results at best.
Historically, “custodial institutions” arose as a socially acceptable way to remove society’s problems (the poor, the criminals, and the insane) by placing them in prisons, asylums or alms/workhouses (Kim, 2014). This led to a growth in the number of asylums and prisons, with peak building completed in the 1920s. It was not until the Second World War that the scientific community really began to pay attention to mental illness. Draftees were screened out of service at a rate higher than at any time before, due to strides in the field of psychiatry. Almost 2 million, or 12% of the 15 million men examined, were screened out of service (Pols & Oak, 2007). This later inspired the National Mental Health Act of 1946, which brought the discussion about mental health into a public space and shed light on an issue that had been and still is stigmatized. This legislation provided funding for professional training on issues related to mental health, research into psychological disorders, and preventative services for the public.
With research into psychiatric disorders, advances in medicine and psychiatry, and the introduction of antipsychotic drugs like chlorpromazine in the early 1950s to treat schizophrenia and bipolar disorder, psychiatric hospitals began to see a drastic reduction in the number of people receiving long-term care. Advances in psychopharmacology are thought to be one of the key components in the deinstitutionalization process. Antipsychotic medication was so effective that many patients who would have faced hospitalization for years or decades became well enough to return to their homes and communities, with some even being cognitively capable for employment for the first time (Pow et al., 2015). Successful reintegration into such communities, however, would require a careful amount of support and supervision of these released patients to ensure they took their medication, received proper medical care, and were able to be self-sustainable. Unfortunately, this never properly materialized in the decades since the deinstitutionalization process began.
The facilitators of deinstitutionalization policy firmly believed that community based care would be better and more humane than state run psychiatric hospitals. These hospitals were often overcrowded, without enough staff, and abusive. Some described them as “prison-like” institutions (Chow & Priebe, 2013). The mentally ill would spend their entire lives in these hospitals, with all their activities tightly scheduled, often isolated, physically and emotionally abused. With these problems in mind, President Kennedy passed the 1963 Community Mental Health Act. This legislation marked a shift in the effectiveness of outpatient care toward the perspective that one’s social network and community had a significant role to play in treatment outcomes (Stoll & Raphael, 2014). The fundamental goal of the legislation was the elimination of large and costly state-run residential facilities for the mentally ill by the transferring of these individuals to community care centers where they could be treated while living at home and working (Smith, 2013). The legislation included approximately $329 million in funding for some 1,500 mental health centers with services directed at those who had been recently released from psychiatric hospitals, however, only half of those centers were ever built. Those that were built did not receive adequate funding, and there was no long-term plan to fund these new facilities beyond the initial funding offered through the legislation (Smith, 2013). Two years later, with the adoption of Medicaid in 1965, states were further incentivized to cut the number of long-term psychiatric beds. State governments were able to shift the financial burden from their budgets and onto the federal government (Kim, 2014).
Outcomes of these policies were felt almost immediately. Discharge rates went up dramatically, due to an increased use of antipsychotics. The number of state hospitals and psychiatric beds available closed or dropped and continues to drop (Vogel, Stephens, & Siebels, 2014). There was also a change to the law on involuntary commitment, in that an individual could not be involuntarily committed unless they were a danger to themselves or others, further increasing discharge rates. In the 50 years since these policies occurred, the number of occupied state hospital beds went from 339 per 100,000 to 21 per 100,000 and the number of institutionalized decreased from 559,000 to 130,000 in the 1980s and to 71,619 by 1994(Lamb & Bachrach, 2001; Sutherland, 2015;Torrey, Kennard, Eslinger, Lamb and Pavle 2010). In looking at these figures, the goal of downsizing the number of long-term psychiatric facilities was successful. Unfortunately, the transfer of care was not.
Community care centers (i.e., treatment facilities, supervised homes) in a local environment are theoretically better able to provide for more immediate needs in the community in that they allow individuals to go home to a family at night or work for a living. Ultimately, however, the move toward a community care model was a cost saving measure, as was the larger process of deinstitutionalization (Sutherland, 2015). It lifted the burden of care from the states and placed it into a social control model within communities. Furthermore, the assumption that community care was a more therapeutic approach had not been tested empirically (Lamb & Bachrach, 2001). This is not to say that community care for mental illness is not effective – it can be – when properly funded and reaching the intended population. Outcome measures have shown that in communities where deinstitutionalization occurred and special services for community care were well developed, people with mental illnesses did benefit (Lamb & Bachrach, 2001). Most of these facilities, however, never received the funding needed to implement the quality of care necessary for the clients they serve. Funding for mental health and these facilities declined even further over the last several decades, culminating with massive cuts in the wake of the 2008 economic crash (National Alliance for Mental Illness, 2015). Though some states have steadily increased funding since the 2012 Newtown, Connecticut, school shooting, whether this funding is reaching the population who needs it most is debatable (NAMI, 2015).
In addition to the transition of the mentally ill to community care centers, there was an interesting phenomenon that occurred in the wake of the deinstitutionalization process. Researchers have coined this “trans-institutionalization,” because while deinstitutionalization sought to remove people from psychiatric facilities, what it actually did was shift them elsewhere. Many of the more severely impaired entered into a revolving door system of psychiatric care, via psychiatric units in general hospitals. This was largely due to the lack of treatment follow-ups and access to medication (Shen and Snowden, 2014). Those who did not have a home or familial support entered various types of community based institutional housing (if it existed). Many became homeless due to a lack of adequate community level housing. This disproportionately affected poor and minority communities. These were often communities that desperately needed funding for community care mental health centers, but did not receive it, or did not have sufficient infrastructure in place for individuals to obtain treatments (Deas-Nesmith, McLeod-Bryant & Carolina, 1992).
There is a consistent link between mental illness, homelessness, and incarceration. Multiple studies have shown an increased prevalence of homeless individuals with mental illnesses in jails and prisons (Fox, Mulvey, Katz, & Shafer, 2013).For individuals who needed 24-hour care and had significant impairments, but no access to psychiatric beds, many found themselves in jails and prisons (Shen and Snowden, 2014). State prisoners who had some type of mental health problems were also twice as likely to have been homeless in the year before their arrest (James & Glaze, 2006). Because these individuals are part of a vulnerable population, they are more likely to be homeless, more likely to not be able to work, more likely to be victimized, and more likely to have police interactions that end in arrest (Fox, et. al., 2013; Vogel, Stephens, & Siebels, 2014). For those with chronic or severe impairments, this posed serious issues to their physical safety and security, as well as their mental health, particularly among those who did not have adequate living arrangements.
With the increased release of psychiatric patients, inadequate community care treatment, decreased access to medication, and increased level of homelessness among this population came an unexpected and profound impact on the criminal justice system. Police frequently have become the first point of contact for a disturbance or violent event involving a mentally ill person (Lamb et. al., 2004). While police often are ill prepared to handle interactions with the mentally ill and are unable to recognize the signs of a mentally disturbed individual, today many departments are actively working on increasing officer training to combat this issue (Vogel, Stephens, & Siebels, 2014). Furthermore, individuals with mental illnesses are more likely to cycle through the criminal justice system repeatedly, at disproportionately high rates (Alarid & Rubin, 2016). While many mental health care centers do treat diagnosed disorders, far fewer offer services to treat co-occurring substance use disorders frequently seen in jail inmates.
Today, even fewer mental health facilities accept individuals for treatment with a history of criminality (Alarid & Rubin, 2016). This leaves a paucity of services accessible to an increasingly vulnerable population. For many, their only access to any type of treatment is in a jail or prison. Based on a BJS mental health report, nearly 25% of state prisoners and jail inmates with a mental illness had been incarcerated at least three times. About 74% of state prisoners and 76% of local jail inmates who had some type of mental illness met the criteria for a co-occurring substance use disorder (James & Glaze, 2006). That figure may be subject to some change, given the restructuring of substance use disorder criteria with the publication of the DSM-5. Further, of all the people who need mental health services, only about 33% of state prisoners, 25% of federal prisoners, and 16.6% of jail inmates actually receive any kind of treatment or service (Vogel, Stephens & Siebels, 2014).
Police departments are not the only areas of the criminal justice system seeing a rise in the handling of mentally ill individuals. The facilities that have to hold these individuals are also feeling an increased amount of strain. Jails and prisons can attract the sort of individual who has more severe mental health problems, which often could be treated with a regiment of strict medication and therapy. These individuals might have otherwise stayed free of criminal activities had they received access to the appropriate care. Between 1968 and 1978 researchers found overall increases in the numbers and percentages of prisoners with histories of hospitalization in a psychiatric facility because of deinstitutionalization (Steadman, Monahan, Duffee, Hartstone, & Robbins, 1984). In another study that followed patients released from an Ohio state hospital, about half had become homeless within six months of their discharge date, and about a third had been arrested and jailed (Belcher, 1988). In a survey of the 50 states, Torrey et al. (2010) reported that the number of mentally ill incarcerated rose by double digits, with some states reporting as much as a 77% increase. These figures comprised anywhere between 15-51% of jail and prison inmates.
Jails and prisons are not built to function as warehouses for the mentally ill. The strain of having to find resources to serve this population frequently puts undue pressure on an already stretched budget. Such strain frequently limits the amount of services these individuals can obtain when prisons and jails are not staffed properly to handle an influx of mentally ill inmates. In a survey of jail staff, researchers found that three-quarters of jails reported seeing higher numbers of mentally ill inmates compared to a decade ago (AbuDagga et al., 2016). The researchers also described the recidivism rates as higher and the need for continuous supervision to monitor the inmates. Inmates with serious mental illnesses needed to be watched more closely for suicide; they had to be segregated from the general population with more frequency; they had higher rates of disruption during normal jail activities and they had higher rates of both abusive behavior and being abused by other inmates. Jail staff also reported very limited training to care for and attend the needs of these mentally ill inmates. Almost half of the jails surveyed reported that 2% or less of their staff and sheriff’s deputies’ initial training was dedicated to understanding and dealing with inmates who are seriously mentally ill (AbuDagga et. al., 2016). A little over half of the jails indicated making housing or staffing changes to accommodate inmates with serious mental illnesses, while also noting that resources and funding limitations were the main constraining factors in their ability to offer mental health treatments and medications.
When observing and evaluating programs state by state, budgetary concerns have comprised a large amount of the reports regarding what services can be offered to the mentally ill. In 2015, only 24 states increased their budgets for mental health. This is down from 29 states in 2014 and 36 states in 2013 (NAMI, 2015). Medicaid today is the single biggest payer of mental health services in the country, and the primary financier of community mental health services (NAMI, 2015). It should be concerning to all parties invested in mental health and the criminal justice system that with the continued political talk about cutting funding for Medicaid, these mental health problems in jails and prisons will be exacerbated.
While it is clear from the numbers of available inpatient psychiatric beds that deinstitutionalization was ultimately successful in the goal of reducing long-term care facilities, it was a complete failure in many other aspects. There was no follow through on the community level care that was to be provided for the mentally ill once they were released. Individuals with a low socioeconomic status and of minority populations were disproportionately affected. Many of those released from institutions or those who would have gone to a psychiatric institution found themselves shifted into criminal institutions. As a result, new programs have emerged in recent years, with the goal of trying to alleviate some of the strain placed on police, jails, and prisons, which do not have the resources to incarcerate and provide for inmates who are mentally ill.
Diversion programs emerged in the 1990s as way to reduce and divert the growing number of mentally ill individuals incarcerated. Today there are 560 diversion programs in nearly every state dedicated mostly to either drug treatment or mental health (Alarid & Rubin, 2016). Utilizing mental health courts (MCHs) is also a type of diversion, and today, almost every state has a mental health court (Council of State Governments Justice Center, 2017). MHCs are similar to other types of diversionary problem-solving courts, like drug and reentry courts. They work on the premise of identifying eligible participants through mental health screenings and assessments and placing them in judicially supervised treatment programs (Kim, Becker-Cohen, & Serakos, 2015).These diversion programs can be either pre-booking or post-booking. Pre-booking diversion programs typically do not result in any charges filed against the individual and are utilized most often for less serious offenses. Pre-booking or pre-arrest also focuses on the development of Crisis Intervention Teams (CITs), which train law enforcement for de-escalation crises that involve a mentally ill individual, as is the case for Miami-Dade’s pre-arrest diversion program (Fuller, Sinclair, Lamb, Cayce, & Snook, 2017). Post-booking programs identify individuals after they have been arrested, usually for a more serious crime, and they can spend a varied amount of time in jail before being diverted into a program.
Evaluations of these programs are limited and empirical studies are rare. Evaluations can be made more difficult because local implementation of MHCs and priorities for treatment options are substantially different in each jurisdiction (Kim, Becker-Cohen, & Serakos, 2015). Steadman and Naples (2005) found that diverted participants experienced fewer arrests a year after program completion, when compared to the year before. Other studies found no significant results between diversion programs (Boccaccini, Christy, Poythress, & Kershaw, 2005). Compliance rates in diversion programs also were slightly lower for individuals with dual diagnoses (Alarid & Rubin, 2016). In two studies on MHCs that utilized randomized control trials, researchers found statistically significant improvements in clinical outcomes for the people who participated in the treatment groups, but no measurable differences in recidivism rates (Gary Bess Associates, 2004; Cosden, Ellens, Schnell, & Yamini-Diouf, 2005). Overall, there is not enough research to effectively evaluate the success or failure of diversion programs. Of the studies that have been done, results have been mixed, particularly on the subject of recidivism.
Recently, a new program called the Step Up Initiative started in 2015 with the goal to reduce the number of people with mental illness in county jails. This program is still in the middle of developing its action plan, and only 350 counties (11% of counties in the U.S.) have joined the initiative as of March 2017 (NACo, 2017). It appears to be following a strong evidence based approach and a strategic planning model. It is doing this by establishing commitments at a local level from stakeholders in government, mental health, and the criminal justice system. A number of programs in the past had been developed with insufficient data on the target populations and without the evidence, resources, or training to treat the mentally ill involved in the justice system (Haneberg, Fabelo, Osher, & Thompson, 2017).
The Step Up Initiative seeks to address these issues by developing preliminary assessment data at the county level and using that data to determine where resources are needed most, if counties are targeting the appropriate populations, what the baselines are for each county, and how progress is being tracked. It is asking the communities who sign on to the initiative to ask six key questions to assess the existing efforts to reduce the number of people with mental illnesses in jail: (1) Is county leadership committed; (2) Do they conduct timely screening and assessments; (3) Is there baseline data; (4) Has a comprehensive process analysis and inventory of services been performed; (5) Have policy, practice and funding improvements been prioritized; and (6) Is progress tracked (Haneberg, Fabelo, Osher, & Thompson, 2017). At this point in time, however, the initiative is new and has not been evaluated.
The rise in mentally ill incarcerated individuals we see today in jails and prisons can be in many ways attributed to the policies of deinstitutionalization. While many of the psychiatric institutions that were open in the early half of the 20th century were abusive environments, many people did benefit from their closure and return to a community level of care. The policies surrounding the closure of these institutions did not have any real strategic plan for the transfer of individuals into community care. Community level care can be effective, but these facilities should have been built and staffed long before patients were released. This did not happen. As a result, many previously institutionalized patients found themselves homeless or in the criminal justice system. Today, we are feeling the effects of that poor planning with the high rate of incarcerated people who suffer from mental illness.
New programs have been developed to address the issue, but their effectiveness is uneven. While there are administrative bodies that use evidence-based approaches toward developing treatment frameworks, the number of moving parts involved at all levels of the criminal justice system can make adequate implementation difficult for sustainable development. It is possible to make social control models of community care work better for the people most in need, but services need to be adequately funded and staffed. Without these basic necessities, it is likely that the rate of mentally ill individuals being incarcerated will continue on the trajectory it has for the last several decades.
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