The Problem

People with mental illness are significantly overrepresented among the segment of the population in contact with the criminal justice system.  Approximately 5 percent of the U.S. population has a serious mental illness.[1]  The U.S. Department of Justice reported in 1999, however, that about 16 percent of the population in prison or jail has a serious mental illness.[2]  Of the 10 million people booked into U.S. jails in 1997, at least 700,000 had a serious mental illness; approximately three-quarters of those individuals had a co-occurring substance abuse disorder.[3]  A study conducted in New York State found that men involved in the public mental health system over a five-year period were four times as likely to be incarcerated as men in the general population; for women, the ratio was six to one.[4]

Impact of the Problem on People and Systems

How elected officials and the public understand mental illness as it relates to the criminal justice system often is informed by newspaper and television headlines, which typically focus only on the most egregious manifestations of the problem:  a screwdriver-wielding woman with mental illness shot dead by officers who subsequently tell of being frightened and confused themselves; a crime victim outraged that, before assaulting her, a person with a history of untreated mental illness bounced between community mental health centers, state hospitals, and the local jail. 

Although these tragedies sometimes drive policymaking, they are not the cases involving mental illness most familiar to police officers, prosecutors, defense attorneys, judges, corrections administrators, parole and probation officers, and other criminal justice personnel.   These criminal justice practitioners are all too familiar with the following scenarios: 

• A police officer returns countless times to a house or street corner in response to a call for assistance involving the same person with a history of mental illness; each time, the officer is unable to link the person to treatment.
• Month after month, a prosecutor charges the same person with committing a different public nuisance crime, and, each time, the defendant with mental illness pleads guilty to time served.
• Jail and prison administrators watch their systems swell with these individuals, who spin through the revolving door of the institution.  Corrections officials' job is to keep these inmates alive, even if that means isolating them in administrative segregation with no outside contact for weeks on end.  When the release date comes around, freedom for many prisoners is only temporary, unless they are among the few for whom reentry has meant planning and linkage with community supports.
• A parole officer already struggling with an overwhelming caseload is assigned an individual with mental illness released from prison; the officer receives only limited support from the community-based mental health program.  The parolee is rearrested and returned to prison when he commits a new crime - urinating on a street corner and making lewd gestures to frightened people passing by - displaying in public the symptoms of his untreated mental illness.

Each of these situations frustrates criminal justice officials; they know they are failing the person who suffers from mental illness and his or her loved ones.  Encounters between people with mental illness and law enforcement sometimes end in violence, jeopardizing the safety of consumers and officers.  Once incarcerated, people with mental illness become especially vulnerable to assault or other forms of intimidation by predatory inmates. [5]  People with mental illness also tend to decompensate in prisons and jails - environments that exacerbate the symptoms of mental illness - and there they are at especial risk of harming themselves or others.   Upon their return to the communities they left behind during their incarceration, they discover that their criminal records have, in many cases, made it even harder to obtain access to treatment.

Criminal justice officials may lose sight, however, of the lives these individuals lead.  These are sons and daughters, fathers and mothers, who struggle daily to fend off symptoms of mental illness. Without adequate treatment, their disease may disable them significantly.  Some experience delusions and may be convinced that strangers are planning to attack them.  In other cases, depression immobilizes them; overcome with a sense of hopelessness, their physical strength deteriorates.  Many of them are people who've spent years trying to mask torments or hallucinations with alcohol or any street drug they could scrape together enough money to buy and now are dependent on these substances to avoid withdrawal states and further decompensation.  Often, their exhausted families have run out of the funds and emotional resources to take care of them. 

Sometimes, when the criminal justice and mental health systems let someone with mental illness fall through the cracks, a stranger is harmed and justifiably motivated to demand accountability from the person with the mental illness and the public health system that failed.  More often, when a person with a mental illness does assault someone, the victim is a family member, friend, or acquaintance.[6]  Whether relatives or strangers, the victims are usually left to make sense of the baffling interface between the criminal justice system and the mental health system.[7]  

The current situation not only exacts a significant toll on the lives of people with mental illness, their families, and the community in general, it also threatens to overwhelm the criminal justice system.  Police departments dedicate thousands of hours each year transporting people with mental illness to hospitals and community mental health centers where staff often are unable to admit the individual or quickly return him to the streets.  Judges, prosecutors, and defense attorneys race through backlogged dockets, disposing of most cases in minutes, but find that the symptoms and behaviors of the growing numbers of defendants with mental illness who appear in their courtrooms cannot be processed as quickly.  On any given day, the Los Angeles County Jail holds as many as 3,300 individuals with mental illness - more than any state hospital or mental health institution in the United States.[8]  Without adequate planning to transition inmates with mental illness back into the community, many will quickly return to jail or prison; recidivism rates for inmates with mental illness can reach over 70 percent in some jurisdictions.[9] 

Every criminal justice professional would agree that the system has inherited a problem of enormous scope and complexity.  Police, courts, and corrections officials feel they're boxed in.  Resources are stretched to the limit: they're tight on money and even tighter on time.  Under the circumstances, many have tried to find a way to serve people with mental illness more efficiently.  But with limited options and resources, especially in rural areas, many criminal justice practitioners are frustrated because they know what they're doing isn't enough. 

Origins of the Problem

Understanding why this problem has become so acute in recent years requires some familiarity with the dramatic shifts in mental health and criminal justice policy over the course of recent decades. 

Few institutions have attempted so complete a change over the previous 35 years as has the nation's public mental health system.  Once based exclusively on institutional care and isolation, the system has shifted its emphasis almost entirely to the provision of community-based support for individuals with mental illness. In 1955, state mental hospital populations peaked at a combined 559,000 people; in 1999 this number totaled fewer than 80,000.[10]  There are many reasons for this change; fiscal reality, political realignment, philosophical shifts, and medical advances, in no particular order, have all played a part.  These forces and others have converged to create a reality that few could have envisioned when the Community Mental Health Centers Act was signed into law in 1964.[11] 

For many clients who utilize this system, successful community integration has indeed been achieved.  Reliable data on the success of community mental health are difficult to find, but anecdotal experience shows that many people with active or past diagnoses of mental illness live and work "normally" in communities across the country. Their very success in achieving recovery helps them to mix unremarkably with their families, neighbors, and coworkers. 

The mental health system today has powerful and effective medications and rehabilitation models with which to work.  The professionals in the system know much about how to meet the needs of the people it is meant to serve.  The problem comes, however, in the ability of the system's intended clientele to access its services and, often, in the system's ability to make these services accessible. The existing mental health system bypasses, overlooks, or turns away far too many potential clients.  Many people the system might serve are too disabled, fearful, or deluded to make and keep appointments at mental health centers. Others simply never make contact and are camped under highway overpasses, huddled on heating grates, or shuffling with grocery carts on city streets. 

The lack of affordable, practicable housing options for individuals with mental illness compounds the difficulty of providing successful treatment.  Without housing that is integrated with mental health, substance abuse, employment, and other services, many people with mental illness end up homeless, disconnected from community supports, and thus more likely to decompensate and become involved with the criminal justice system.  Most studies estimate that at least 20 to 25 percent of the single adult homeless population suffers from some severe and persistent mental illness.[12]

It is against this backdrop that officials in the criminal justice system have in recent years encountered people with mental illness with increasing frequency.   Because of sensational news headlines or other sources that stigmatize mental illness, some criminal justice professionals may be prone to making the incorrect assumption - which most of the public makes - that mental illness by definition incorporates violent behavior.[13] They may respond to situations on the street, in a courtroom, or at a parole board hearing on the basis of common but erroneous perceptions.  In such instances, police, judges, and releasing authorities may be especially wary about releasing people with mental illness into the community.

 

Violence and Mental Illness

Popular beliefs about violence and mental illness do not jibe with reality.  The results of several recent, large-scale research projects conclude that only a weak statistical association between mental disorder and violence exists.[14]   Serious violence by people with major mental disorders appears concentrated in a small fraction of the total number, and especially among those who use alcohol and other drugs and those without access to effective services.[15] Indeed, the vast majority of people with mental illness are not violent; they are more likely to be victims of crime than they are likely to harm others.[16]

Compounding the problems stemming from the stigma associated with mental illness, changes to criminal justice policies during the course of the last two decades have prolonged the involvement of people with mental illness in the criminal justice system.  For example, in response to community or government leaders' demands to increase quality of life and to reduce crime and fear of crime, many police departments have instituted "zero tolerance" policies, arresting people committing offenses such as loitering, urinating in public, and disturbing the peace.[17]  Many individuals netted as a result of these tactics were people demonstrating in public the symptoms of untreated mental illness.  The majority of these people also have a co-occurring substance abuse problem.  As legislatures have increased the length of prison sentences (and frequently made them mandatory) for the possession or sale of some illegal substances, growing numbers of people with mental illness have been incarcerated - and for longer periods of time. 

Already overcrowded and overburdened, prisons and jails typically are without the resources to ensure the availability of effective mental health treatment and appropriate medications.  In these cases, a person with mental illness is likely to decompensate, exacerbating the symptoms of his or her mental illness.  As a result, the person may act out and fail to follow prison rules, which in turn extends the period of incarceration for the individual.  For these reasons, people with mental illness tend to stay in jail or prison considerably longer than other general population inmates.  For example, on Riker's Island, New York City's largest jail, the average stay for all inmates is 42 days, but it is 215 days for people with mental illness.[18]    

Inmates with a mental illness who leave prison or jail are typically provided with just a short (two weeks or less) supply of medications and enough money to take a one-way trip on public transportation.  Without housing, linkage to a community-based mental health treatment program, or other much needed services, the person typically returns to the type of behavior that originally contributed to his or her incarceration.