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Policy, Practice and Perception: Implications in the Criminalization of the Mentally Ill. SAKS Institute for Mental health law Spring symposium: criminalization of the mentally ill Stephen mayberg, P h D April 11, 2013. Criminalization of the Mentally Ill. New trends or long term problem
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Policy, Practice and Perception: Implications in the Criminalization of the Mentally Ill SAKS Institute for Mental health law Spring symposium: criminalization of the mentally ill Stephen mayberg, PhD April 11, 2013
Criminalization of the Mentally Ill New trends or long term problem Contributory factors Perceptions/Public Policy Promising alternatives
Policy Issues • Realignment CA Mental Health 1991 • Funding/Responsibility shift • State to county responsibility/authority State Hospital Population
Policy Impact: Realignment • Financial Incentives • County choice/flexibility • State pays for forensic care • State hospital beds • County pays LPS • State pays – NGI, IST, MDO, SVP • IST Costs • Counties – Misdemeanors • State - Felony
Resource Issues • County mental health allocation insufficient for all services • Limited long term care available • Declining state hospital beds • 24 hour acute care • Short term – Crisis use • Average stay less than 7 days • Follow up capabilities inconsistent • Responsibility and resources
National Policy Trends Community Care vs. Institutional Care Declining state hospital beds State hospitals/ IMD’s – no 3rd party payment Court decisions stressing communities instead and community programs
Policy Decisions - Funding • MediCal (Medi-Caid) not available for single adults (forensic population) • State hospitals, IMDs, jails, prisons mental health services not reimbursable • Loss of MediCal eligibility in jail and juvenile hall • 100% county (or state) cost for forensic services • No federal participation
Program Development Practice/Policy • Incentive to develop programs is in areas where monies can be leveraged • Law enforcement more likely to be funded at local level with county dollars • Public Safety • Politically more acceptable
Liability/Public Perception • Local mental health programs concerns about responsibility for forensic patients • ADVERSE EVENTS • Media coverage – “Blame” • Torts/liability • Local political pressures • Accountability/responsibility
Liability Perception Impact • Conditional Release from Parole for Mentally Ill Inmates (CONREP) • Extensive Service/Treatment Array – 100% state funded • Counties have right at first refusal • Very few counties participate • Consequence: lack of coordination with local programs
Conflict About Responsibility for Care • Parole outpatient versus county mental health • Screening, evaluation, and recommendations • Probation vs. County Mental Health • Who should provide/pay for service
Conflict • Voluntary vs. Involuntary treatment • LPS Law variably implemented • “Fungible” definition of WI 5150 • Police vs. First Responders • Jail vs. hospitals • Can reflect lack of clarity • Impact training, resources, responsibilities • Laura’s Law – Outpatient commitment • Only 1 county has implemented
Accountability • Who is accountable/responsible • Lack of clarity • “fall between cracks” • Conflicting laws/standards • Welfare and institution code vs. penal code
Court Decisions Impact • Sell – U.S. Supreme court rules IST’s cannot be involuntarily medicated without criteria/hearing • Jameson vs. Farabee – California Courts – inmates cannot be forcibly medicated without hearing • Consequence – decompensation • Barriers complicate ability to treat
IST Process • Incentives for state hospital treatment vs. jail • Reduces jail census, jail treatment cost, court time • Incentive – Defense attorneys/inmates: hospital better than jail environment • Credit time served – hospital in lieu of jail • Medication in jail usually cannot be involuntary • Consequence: Disconnected system • Revolving door
Impact • Inadequate or insufficient treatment resources available in 24 hour institutions • Mentally ill in jail/prison opt to not get treatment • Recidivism common • Mentally ill parolees most likely to be revoked/reoffend
Other Contributory Factors • Substance Abuse • 70% SI Adults have substance abuse issues • 90% forensic mentally ill have co occurring diagnosis • Drug Use/Possession • Illegal – Criminal Justice Contact • Substance Abuse Behavior • Impulsive, lower frustration tolerance, aggression • Consequence: Untreated Substance Abuse • More likely to become part of system
Contributory Factors • Vacaville Mental Health Study • Evaluations on consecutive admissions over two time periods • Findings • Average IQ - low to low average • Education – 8th grade • Social Economic Status (SES) -low • Brain Injuries – 65% • Fighting, Falls, Drug Use
Vacaville Continued Employment marginal Family History– more apt to be single, disengaged from family History of violence Consequence: Complex factors must be addressed to prevent criminal behavior
Policy Implications for Treatment Cognitive/Outpatient treatment may not be effective Structured environment may be required Coordination of substance abuse/mental health treatment essential Educational/Vocational programs integral part of approach
Contributory Factors: Homelessness Substance use/Mental illness Hostile living environment Crimes of opportunity/Quality of life crimes High visibility Lack of coordinated resources or responsibility
Contributory Factors: Stigma • Failure to access treatment because of stigma • Perception of nexus of violence and mental illness • Media sensationalism • Blame • NRA - Monsters
Contributory Factors: Public Perception Perception: community safer with individuals locked up rather than treated in outpatient or in the community NIMBY issues for community program placement Elected officials tend to fund programs that lock up or promise “public safety” before funding community programs
Public Perception Continued • Tolerance/Expectations • Parolee “Acting out” vs. Mentally Ill • Differential response from press, media, community • Funding for Control Agencies (Law Enforcement) rather than treatment programs • Prison realignment experience -AB 109
Summary of Issues - Responsibility State vs. Local Law Enforcement vs. Mental Health Mental health vs. Substance Abuse “No One”
Summary of Issues - Finance Insufficient funds for mental health/substance abuse treatment No Federal dollars (MediCal) available for treatment of most forensic populations Incentive in construction of laws/regulations for state to pay rather than counties for forensic populations Paradox: Counties responsible and funded for rest of MH system a disconnect Priority funding for Law Enforcement vs. Mental Health when monies are available
Summary of Issues – Stigma • Perception: individual concerns inhibits treatment seeking behavior • Perception: public concerns of stereotypes of mentally ill • Mental illness and violence • Perception: community concerns, 24 hour care is “safer” than community treatment • Fear of Violence/unpredictability consistent and reinforced by media
Summary – Lack of Resources • Limited long term or structured care • Lack of specialty trained professionals • Lack of specific programs addressing unique needs of this population • Lack of 3rd party participation • CONSEQUENCE • Jails/Prisons have become our defacto mental health treatment programs
Summary – Legal System • Involuntary medication difficult • Involuntary commitments difficult • Legal system may encourage accepting charges rather than treatment • Criminal Justice system not always well informed about mental illness and options • Administrative Office of Court Findings
Promising Practices/Opportunities Policies that work Programs that work Potential opportunities
Programs that Work • AB 34/2034 Steinberg • Homeless Mental Health Services • Significant reduction in hospital days • Significant reduction in jail days, arrests • Cost effective – 50% reduction in costs • Defined responsibility, broad based approach
Promising Programs (Con’t) • Law Enforcement Training/Partnership • CIT (Crisis Intervention Training) for Law Enforcement • Smart/PET teams • Mobile Crisis
Promising Program (con’t) • Court/Criminal Justice Involvement • Mental health/behavioral health court • Drug courts • Diversion • MIOCR programs
Policy that Works • 24/7 Mental Health availability in crisis • Point of contact responsibility • Crisis training/consultation • Co-Occurring programs • Violence programs • Bullying • Domestic violence • Anger management • Trauma based approaches
Policy that Works (Con’t) • Mental Health Services in Jails/Prisons • Connected with community programs • Screening/case management • Dedicated trained staff
Policy that Works (Con’t) • Stigma Reduction • Media education • Court/Law enforcement education • Public education/awareness
Advocacy Involvement • NAMI • Strong advocacy for recognition/treatment alternatives • Client Groups • Peer Support/Self help • Promoting less stigmatizing alternatives
Best Practices/Opportunities • Proposition 63/Mental Health Service Act • Target At-Risk Populations • Los Angeles County Mental Health examples • Cultural Competence Outreach • Urgent Care • 24/7 Full Service Partnership (FSP) • Homeless programs
Los Angeles Mental Health Community Partnerships Early Intervention programs/Prevention Stigma reduction programs Jail programs
Best Practice/Opportunities • Co-Occurring Programs • Specific programs designed for mentally ill/substance abuse forensic patients • PROTOTYPES as example • Target population • Broad array services • CONREP • Recidivism less than 10%
Opportunies • Health Care Reform • Parity for Mental Health/Substance Abuse now required • Reduces Stigma • Expands access • Expanded eligibility • 3rd party payment for uninsured population • Incentives for treatment
Opportunities (Con’t) • Prison Realignment AB 109 • New dollars for criminal justice system approaches • Local decision making • Role of prevention, diversion, and treatment
Opportunities (Con’t) • Utilization of Research finding • Program success rates • Cost Reduction Data • Return on Investment (ROI)