Getting Started
The policy statements in this report make up a compendium
of ideas, recommendations, and innovative examples that have worked well in
different places around the country and therefore should at least be considered
for implementation in other communities.
Collectively, they provide a comprehensive vision for the criminal
justice and mental health systems' response to people with mental illness. To appreciate this vision (and the range of
measures that exist to begin to address the problem) and to inform an agent of
change's decision of where to start, reading the entire report - regardless of
the reader's area of expertise - is essential.
Unless efforts in a jurisdiction to improve the response
to people with mental illness who are in contact with criminal justice system
are already well-advanced, simply becoming familiar with the report's
organization and the target population will not make it clear which policy
statement to implement first. In fact,
each policy statement is a possibility for an agent of change to consider; no
single one is an essential first step to initiating change.
It will be tempting for some readers to focus only on the
implementation of those policy statements over which they have the must
influence. Police professionals, for
example, will likely gravitate toward those policy statements that address law
enforcement's contact with people with mental illness. Prosecutors may quickly fast-forward to
Policy Statement 9: Prosecutorial Review of Charges.
Although focusing the application of the report in a
community to a limited number of policy statements, at least at the outset, is
probably advisable, readers should not overlook a central message of this
document: actions that law enforcement,
courts, or corrections officials take have ramifications for the entire
criminal justice system. For example,
how a police officer responds to an incident involving a person with a mental
illness informs the decision that a prosecutor makes in charging the defendant,
which, in turn, is an important factor a judge will take into account when
setting bail. Corrections
administrators rely on information obtained during the pretrial phase and at
sentencing to develop a treatment plan while the inmate is incarcerated;
reports regarding the extent to which such a plan is successful inform
community corrections authorities release decisions and plans for supervision
of a person with mental illness released to the community.
Considering the implementation of the policy statements
that, on their face, appear to address the mental health system only is also
essential. Just as criminal justice
professionals must appreciate a system-wide response to the problem, so must
they appreciate what needs to happen for the mental health system to be accessible and effective. A community
mental health system that does not meet these two criteria is unlikely to
successfully engage an individual with mental illness in treatment, and thus
will quickly cause criminal justice officials to lose confidence in the
community's capacity to support people with mental illness.
Many agents of change, especially those policymakers (such
as legislators or county executives) whose authority spans many or all of
recommendations in the report, will wonder which policy statement to implement
first. Accordingly, deciding where to
start - especially when familiar with the existing obstacles to improving the
systems - can be difficult. In more
than one community, reform efforts have been derailed before really getting under
way because those involved could not decide where to begin. Similarly, attempting to implement many or
all of the policy statements in this report could overwhelm a community.
Aside from differences in the size and nature of the
jurisdictions where the problem plays out, there is great variability in the
history, politics, resources, and leadership of each community. These are the factors that typically steer
agents of change to distinct policy statements. The single, most significant common denominator shared among
communities that have successfully improved the criminal justice and mental
health systems' response to people with mental illness is that each started
with some degree of cooperation between at least two key stakeholders - one
from the criminal justice system and the other from the mental health
system. Accordingly, deciding where to
begin will depend on the people brought together to address the problem and the
resources available to them in their community.
In sum, sparking a dialogue and cultivating a relationship
between criminal justice and mental health stakeholders is, for those
communities where such collaboration does not already exist, where the agent of
change should start. Similarly,
criminal justice or mental health professionals should avoid forging ahead with
the implementation of a particular policy statement without first ensuring that
their action plan has taken into account the implications for the entire
criminal justice and mental health systems.
For these reasons, getting started translates into
facilitating communication and building cooperation among criminal justice and
mental health stakeholders. A precedent
for such cooperation and communication that involves criminal justice or mental
health stakeholders exists in nearly every community. Indeed, policymakers and practitioners typically appreciate the
value of collaboration, and they invariably have some experience seeding or
maintaining an effort that depends on two or more organizations working
together.
Still, effecting collaboration between the criminal
justice and mental health systems can be particularly vexing. Accordingly, the remainder of this
introduction reviews important issues to consider for communities where
representatives of the two systems have yet to begin working together or where
such efforts have stalled.
Recognizing the Complexities of the Mental Health System
Exploratory discussions with stakeholders in the mental
health system will, sooner or later, focus on their capacity to make mental
health services available to those who need them most. Before an agent of change reaches out to
representatives of the mental health system, it is essential that he or she
appreciate how the mental health system works.
As mentioned earlier, the advent of new treatments and
service system models is, in many ways, revolutionizing the mental health
system. No less dramatic has been the
change in orientation from grim acceptance of the supposed irreversibility of
the decline associated with mental illness that characterized all thinking
about the condition just a few decades ago to the burgeoning belief in recovery
today expressed by researchers, clinicians, advocates, families, and - most of
all - consumers. Recognition that
people with mental illness can and do get better has given hope to many
individuals. It is also changing the way people think and talk about mental
illness and thus altered the course of policy.
With a foundation of hope and recovery, the system sees
reintegration into the community as perhaps its highest priority. Clinical decisions, funding structures, and
other incentives are aligned in many places to direct people with mental
illness toward community integration.
Administrators, advocates, consumers, and experts see hospitalization as
a costly alternative residing at the far end of a continuum that should include
a rich offering of community-based interventions. Agreement in the field dissolves, however, when stakeholders
discuss where to turn when mental health treatment systems have failed to
successfully engage an individual in treatment. Conflicting views on involuntary commitment illustrate this
tension. Some see involuntary inpatient or outpatient treatment as the ultimate
intrusion, a dehumanizing deprivation of rights to be avoided at all costs.
Others hail involuntary treatments as necessary and lifesaving tools that must
be employed when an individual's judgment is impaired. Most in the field feel
torn and seek a balance that respects both realities.
The trend away from hospitalization and the embrace of
recovery have led to a new view of the place of control in mental health
treatment. Just as laws and policies in
effect in most states steer mental health clients toward treatment in the
"least restrictive setting," so do treatment professionals speak of
ensuring patients the greatest possible degree of control over their own
treatment choices. In recent years,
mental health advocates and professionals have reexamined the use of coercive measures in mental health
treatment settings. Many practitioners have worked hard, for example, to reduce
the use of restraints and punitive seclusion in clinical settings, recognizing
that they have no therapeutic value and can only be justified when physical
safety is at issue, and laws and regulations have been rewritten to reflect
this new understanding. Appreciating
the mental health system's views regarding coercion may be particularly
difficult for someone working in the criminal justice system, where coercion is
inherent at every juncture to ensure people obey laws and follow rules. Yet, the use - and perceived use - of
coercion has become the subject of much concern and debate within the mental
health community. Most of the recommendations offered in this report address
issues that arise when people with mental illness are in contact with - or are
under control of - the criminal justice system, and they reflect the powers at
that system's disposal. By the same
token, the report takes into account the mental health system's values and
largely steers away from making recommendations that would apply coercive
measures to people with mental illness on whom the criminal justice system has
no hold.
In addition to understanding key values of the mental
health system, an agent of change should become familiar with its complex
organizational structure. Understanding
how a system is organized largely depends on learning how it is funded. When it comes to the mental health system,
this can be a true challenge. No
rational organization chart can possibly be drawn that accurately depicts the
administration and delivery of mental health services in this country. In contrast to the criminal justice system,
which has a fairly straightforward structure, the mental health system draws
revenue from a dizzying variety of sources:
Medicaid, Medicare, state general revenue funds, local matches, federal
Mental Health Block Grants (grants administered by three or more federal
agencies), and patient fees, just to name those most common. In some states,
funds are funneled through managed-care frameworks. In others, counties present an additional level of
administration. "System,"
indeed, may be a misnomer for what is often a patchwork of programs, services,
and complex funding structures.
Solutions to many of the problems encountered by the
criminal justice system might logically be found in the mental health
system. Sadly, the mental health system
in too many places has been too beset by internal challenges and lack of
support to address some of the most visible signs of its failure. For the public mental health system to
assist the criminal justice system in addressing the needs of people with
mental illness, policymakers and community change agents will need to ensure
that it has sufficient resources and public support.
Getting Criminal Justice and Mental Health Stakeholders to the Table
In some jurisdictions, the greatest challenge to
initiating successful cross-system collaboration is simply getting prospective
partners to the table. Often,
successfully assembling key leaders in the jurisdiction depends on the
stakeholders appreciating what the improved collaboration can produce.
Benefits likely to appeal to key leaders in the mental
health and criminal justice system include the following:
- Improve the lives of people with mental illness and
reduce the frequency of their contact with the criminal justice system
- Enhance public safety
- Use criminal justice resources more efficiently
- Improve the safety of line staff and of the
environment in which they work
- Reduce taxpayer expenditures
- Increase
public confidence in the justice system
- Gain access to resources
- Enlist allies capable of attracting support from
policymakers previously unmoved by the need to bolster the mental health system
In addition to these gains, collaborative discussions will
themselves increase understanding and reduce the assignment of blame. Tight
budgets and growing problems have led to friction among criminal justice
practitioners, mental health professionals, and advocates in many communities.
Bringing all parties together to address the problems can be painful, but it is
the only way to engage in problem solving effectively.
There are concrete means of eliciting commitments from
stakeholders to work together. Making
funding support contingent on such cooperation is one way. For example, in California, the legislature
sought to foster a collaborative response to the inappropriate involvement of
individuals with mental illness with the criminal justice system by
establishing crime reduction grants. To
receive these grants, counties must create a diverse strategy committee to
develop a comprehensive plan of cost-effective measures to reduce crime and the
criminal justice costs associated with individuals with mental illness.
Legislation also can prompt joint ventures through the
establishment of task forces, which bring together all relevant stakeholders
and develop a foundation for future cross-system partnerships to improve the
criminal justice system's response to people with mental illness. An increasing number of state legislatures
(and in some cases governors) have taken such steps.
For example, in Colorado, following several independent
studies of mental illness in the criminal justice population, the state general
assembly created a task force to examine how people with mental illness in the
criminal justice system are treated.
This task force consisted of more than two dozen members, including representatives
from the judicial system, the corrections system, local law enforcement, mental
health services, the legal community, consumers, and family members of
consumers. The general assembly also
established a six-member legislative oversight committee that monitors the work
of the task force and submits annual reports, including legislative proposals.
Sometimes opportunities to engage potential partners and
to form a core group of prospective partners emerge from a high-visibility
incident. A well-publicized tragedy
involving a person with a mental illness and the criminal justice system often
generates an atmosphere of crisis, in which elected officials feel pressured to
promote quick solutions, which are likely to overlook complex, effective
responses. Accordingly, decision makers
should use such incidents to stimulate follow-up responses that are long term
and thoughtful. To that end, in the
wake of such tragedies, community and government leaders should ensure that
organizations begin discussions about working together more closely.
A tragedy in Seminole County, Florida, in 1998 prompted
such a response. A deputy in the sheriff's office was
shot and killed as he approached the residence of Alan Singletary, who had a
history of mental illness and whose family had for years sought help for him.
After a 13-hour standoff, Singletary was also killed. This tragic incident highlighted many of the deficiencies of
Seminole County's mental health delivery systems that are common to many
communities: inadequate coordination of
services, lack of resources, and insufficient information available to officers
in the field and at the scene of a crisis.
In response, the sheriff established a task force that meets monthly to
discuss system coordination issues as well as potential legislative proposals. The task force includes the state attorney,
the public defender, probation officials, the Seminole Community Mental Health
Center, representatives of the judiciary and the County Commission, and other
various stakeholders. The slain
deputy's widow, Linda Gregory, and Alan Singletary's sister, Alice Petree,
also serve on this task force.
Defining the Scope of the Problem(s)
Once a core group of stakeholders has made a commitment to
improve the criminal justice and mental health systems' response to individuals
with mental illness, they need to identify and focus their shared
objectives. Leaders of successful
partnerships state time and again that, long after launching their joint
venture, reminding each other of the mission that originally focused the
initiative has enabled them to overcome disagreements or missteps that
subsequently threatened the collaboration.
In defining the problem, stakeholders may agree on a
limited number of discrete goals, and the problem-solving approach may require
a partnership between just two organizations.
For example, in Connecticut, the court and the Department of Mental
Health and Addiction Services (DMHAS) focused their attention on the inability
of judges to obtain a mental health assessment of a defendant or to gain access
to mental health treatment for the defendant in a timely manner. (In attempting to address the problem
independently, judges were ordering an examination for competency to stand
trial, which resulted in the hospitalization of the defendant for a minimum of
three weeks.) The partnership between
the judiciary and the DMHAS led to the deployment of mental health clinicians
to each court to conduct on-site assessments shortly after arrest and to
arrange for treatment in the community as a condition of pretrial release.
In some cases, agents of change may determine that the
circumstances call for a coalition comprising a diverse group of stakeholders
spanning much of the criminal justice and mental health systems. Such a coalition may be necessary when the
core group of stakeholders establishes that the problem is large in scope and
requires multiple responses. In other
cases, leaders in the community may have succeeded in narrowly defining the
problem, but they recognize that potential responses (or the issue itself) are
controversial and certain to draw the attention of the media. In this event, a
broad coalition ensures diverse support for an initiative that could attract
criticism.
The success of such groups depends, in part, on the number
of stakeholders involved and on the diversity of perspectives - including
representatives of criminal justice and mental health entities from state and
local government, private mental health professionals, victims, advocates, and
consumers and their families - committed to the coalition's success.
Conducting a Community Audit
A community audit will enable criminal justice officials
to identify the mental health system representatives in their jurisdiction -
including large and small service providers and those that serve isolated,
ethnic, or low-income communities. In
conducting this audit, partners should also identify providers outside of the
mental health community who deliver services to some of the same clients. Drug treatment providers and low-income
housing administrators are two examples.
Good sources for conducting the audit include larger
mental health clearinghouses or providers, the Internet, the yellow pages, the
news media, and staff within the criminal justice agency. Criminal justice officials should also
contact agencies and organizations of which they are members, officers, board
members, or trustees. The audit should
apply a snowball approach, where identified contacts are asked to contribute names
of additional relevant stakeholders.
In addition to leads identified during the local audit,
organizations with a national perspective, including national membership
associations, can provide some additional valuable referrals.
Ensuring the Investment of the Principals
Whether part of a collaborative effort between just two
organizations or a member of a broad-based coalition, each organization should
be represented by the chief executive or his or her designee. Involvement by the principals signals to
their subordinates and other stakeholders that the organization is committed to
the initiative.
The chief executive for a police department (chief,
sheriff, or public safety director), the courts (presiding judge), the
prosecutor's office (district attorney), the local jail, or another criminal
justice entity is likely to be fairly obvious.
The lead individual in mental health circles, however, may be less
apparent. Agents of change should turn
to existing cross sections of mental health organizations, such as county-level
mental health planning committees, for assistance in identifying an appropriate
leader in the mental health community.