Reversing Criminalization from the American Journal of Psychiatry

January 2009

"As of June 2007, there were at least 360,000 persons with major psychiatric disorders, and perhaps as many as half a million, in our jails and prisons. With such huge numbers, can we really say that deinstitutionalization has taken place? There numbers underscore a pressing need for reliable hard data about these severely mentally ill persons who have been criminalized. In an article in this issue, Baillargeon et al. provide valuable hard data. They found that inmates with major psychiatric disorders, and especially those with bipolar disorders, had a substantially increased risk of multiple incarceration. Clearly, this study tells us that criminalization is not being reversed... Incarceration poses a number of important problems and obstacles to treatment and rehabilitation. Even when quality psychiatric care is provided, the inmate/patient still has been doubly stigmatized - as both a mentally ill person and a criminal... The correctional facility's overriding need to maintain order and security; as well as its mandate to implement society's priorities of punishment and social control, greatly restricts the facility's ability to establish a therapeutic milieu and provide the necessary interventions for treating mental illness successfully...
"The community treatment of persons with severe mental illness who are or may become offenders has become an increasingly important and urgent issue. Diversion is of little value unless there are community treatment resources to which mentally ill offenders can be diverted. We need a vast expansion of modalities such as assertive community treatment - community-based, sometimes court-ordered, mobile mental health treatment teams that provide an array of treatment, rehabilitation, and housing services that are available 24 hours a day: intensive case management; the ready availability of psychiatric medicines; adequately and appropriately structured and supportive therapeutic housing arrangements; treatment of co-occurring disorders; vocational rehabilitation; and close working relationships between mental health and criminal justice professionals - to name but a few of these needed resources...
"It is essential to facilitate access to psychiatric hospital care for patients who need it. It is important to acknowledge that the community is not necessarily the most benign treatment setting for all mentally ill people at all times. Success in reducing criminalization in this population will require access to hospital care for those who need it, for as long as they need it.
"Currently, a large number of people with severe mental illness receive their acute psychiatric inpatient treatment in the criminal justice system rather than in the mental health system. Clearly, if there were not a shortage of acute inpatient beds in the mental health system, many acutely psychotic persons might not come first to the attention of law enforcement officers, or if they did, they could be transported to acute psychiatric facilities rather than arrested. In most cases, acute psychiatric inpatient treatment should be the responsibility of the mental health system. As Baillargeon et al. point out in their article, acute inpatient beds should be a high priority in community mental health, and lengths of stay should not be unreasonably short.
"Another important resource that can help preevent criminalization is assisted outpatient treatment. Assisted outpatient treatment is court-ordered civil committment that is initiated by the mental health system to ensure that persons with metnal illness and a history of hospitalizations and/or violence participate in services to the community; it is for those who are capable of living in the community with the help of family, frriends, and mental health professionals, but are resistant to psychiatric treatment, including medication. Without such treatment they may relapse and require hospitalization or be arrested, incarcerated, and criinalized. Such at-risk individuals are ordered to participate in outpatient psychiatric treatment with their progress closely monitored by the court..."