Mental Illness Within the Criminal Justice System: An Overview

Luke Siebert, B.A.
ILPPP Research Assistant
MPH Candidate Spring 2020

The following post provides an overview of mental illness within the criminal justice system in jails throughout the nation and Virginia, in particular. It also covers outcomes of policy actions that have been enacted to address mental illness in the criminal justice system.

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Of note: It is important to understand that there is a distinction between jails and prisons. Jails typically house inmates for a short period of time whereas prisons house inmates for longer-term incarceration. The distinction is important to note, as the Virginia Department of Corrections (DOC) takes responsibility for managing prisons, whereas the Virginia sheriffs’ offices operate the local jails (regional jails include sheriffs on their boards). As such, the mental health services afforded and programs provided are different for prisons than jails. Prisons are not discussed in this post.

INTRODUCTION

According to the National Alliance on Mental Illness (NAMI), between 25 and 40 percent of Americans with a mental illness will be jailed or incarcerated at least once in their lifetime. (5) The incarceration of these individuals can be attributed to a number of different factors and policies. Persons suffering from mental illness are frequently stereotyped as violent, dangerous, or “crazy” due to their portrayal in the mass media. Law enforcement officers serve as the primary responders to mental health crises, creating interactions between people with mental illness and law enforcement that otherwise may not exist. Many of these officers lack the mental health training necessary to work well with persons experiencing a mental health crisis. Out of 18,000 police departments across the country, only 3,000 have their officers undergo Crisis Intervention Team (CIT) training. (7) The lack of mental health services in the community also contributes to the rising number of mentally ill individuals that cycle through the criminal justice system. Even if mental health services are available, getting treatment is often complicated by issues related to transportation, both to and from treatment facilities, and inadequate staffing. The bottom line is this: Jails have effectively become the largest mental health treatment facilities in the United States. (2)

In this blog post I aim to provide an overview of mental illness within jails. To do so, I will provide statistical background on jail populations, discuss policies that currently exist within jails related to mental illness, and identify current shortcomings within the system. I will conclude with an overview of programs and initiatives that have been implemented, both in Virginia and elsewhere, that aim to reduce the prevalence of the mentally ill in jails.

STATISTICS ABOUT MENTAL ILLNESS IN VIRGINIA JAILS

            In 2017, the Compensation Board of Virginia published their annual report on the prevalence of mental illness in jails and the services provided to those with mental illness. (3, the 2018 report is expected in November) While jails have a higher number of mentally ill men than women, the proportion of female offenders suffering with a mental illness is much higher than the proportion of men. The number of inmates with a mental illness continues to rise as well, with Virginia experiencing a 15 percent increase in the mentally ill population in their jails from 2016 to 2017*. Of the 7,450 mentally ill inmates, 80 percent were charged with crimes that were considered to be non-violent. (3)

            Thus far, jails have been largely unable to accommodate the mentally ill properly. Per the Compensation Board’s report, only 21 out of 54 surveyed jails had mental health units or bed areas that were separated from general population areas. (3) Many jails also reported a severe shortage of beds available for inmates with mental illness. When asked, the majority of jails indicated that their greatest funding needs were related to staffing, medication, and jail expansion so as to include more mental health beds. (3)

POLICIES IN THE JAILS

            While issues of proper accommodation for mentally ill inmates remain unsolved, some progress has been made towards assessing the wellbeing of incoming inmates. As of July 1st, 2017, all local and regional jails within the state of Virginia are required to screen every booked individual for mental illness using either the Brief Jail Mental Health Screen (BJMHS) or the Correctional Mental Health Screen (CMHS) instrument. (3) While 49 out of the 54 jails participating in the Compensation Board survey reported screening for mental health prior to the implementation of this new mandate, the instruments used were not consistent from jail to jail. Considering mental health professionals do not always conduct these screenings, requiring consistent use of an easily understood and validated instrument is crucial for ensuring that jail staff can properly assess the mental health of incoming inmates. (3)

            In the event that an inmate screens positive for mental illness, a referral is supposed to be issued for a comprehensive mental health assessment (MHA). (3) Assessments differ from screenings in that they help inform treatment or case planning. Additionally, assessments aid in addressing an individual’s immediate need for services. (9) Contrary to mental health screenings, MHAs are conducted by mental health professionals. (3) Of the 54 jails surveyed, referral rates of positively screened inmates ranged from 1 to 45 percent. Per the Compensation Report, Virginia’s state average referral rate of positively screened inmates is 18 percent. The time from referral to MHA varied drastically per jail as well. While some jails were able to have an inmate’s MHA conducted within 4 hours of the referral, others sometimes took longer than 72 hours. (3)

            The utilization of MHAs is crucial, both for inmates dealing with mental illness and for the jails or correctional facilities housing them. MHAs can provide jail staff with information about an inmate’s condition that might not otherwise be known. (9) For example, inmates with suicidal tendencies can be identified ahead of time in order to ensure that proper arrangements are made to keep them safe. Medications can be organized by the jails to ensure that individuals suffering from mental illness keep their symptoms at bay. Furthermore, individuals who have an undiagnosed mental illness can receive a diagnosis and begin receiving treatment. (9)

SOME AREAS NEEDING IMPROVEMENT

Although mental health policy in jails, and in the state of Virginia generally, has seen improvements over the past few years, there are still plenty of areas in which the system could be improved. For example, solitary confinement is still utilized as a form of punishment for inmates who violate jail rules. Those sent to solitary are confined in a tiny cell for 23 hours a day. In prisons, inmates assigned to a solitary unit typically must stay there for at least 15 consecutive days, with many staying 30 days or more at a time. (8) No data on length of stay was found for inmates in jails.

Mentally ill offenders are disadvantaged by solitary confinement more so than other inmates. Several studies have found that inmates with mental illness are more likely to act out than others, thus subjecting them to potential placement in solitary confinement units. (2) Acts such as self-injurious behavior, which are more common amongst those with mental health problems, may be classified as forms of misconduct and punished**. The disproportionate placement of mentally ill offenders in solitary confinement is even more troubling when considering the number of negative psychological effects provoked by significant time spent in solitary. These effects include hallucinations, paranoia, and insomnia, all of which could be made worse should an inmate already have a pre-existing mental illness. Social segregation subjects individuals to stress, isolation, and conditions offering little to no structure, none of which mirror life outside of a jail cell. (2) In 2017, approximately 1,335 mentally ill inmates in Virginia were placed in solitary confinement. (3) Delegate Hope recently introduced HB795, a bill that would have reduced the amount of time an inmate belonging to a vulnerable population could spend in isolation to no more than 15 consecutive days, or 20 days in a 60-day period, except in the case of extenuating circumstances. This bill, which included mentally ill offenders as members of the “vulnerable population”, was left in the Militia, Police, and Public Safety Committee. (6)

Medications serve as another potential barrier to the wellbeing and success of an inmate during their time in jail. According to the 2017 Compensation Board’s Report, not all psychotropic medications are provided by jails***. (3) In the event that medication is not provided by the jail, it is the responsibility of the inmate to have a third party, such as a family member or physician, bring them their medication. (3) This is potentially problematic, as inmates may not have the insight into their illness necessary to make the effort to reach out, or they may not have any reliable third party contacts outside of the jail, particularly if they are homeless.

While inmates with mental illness experience a plethora of problems in jail, problems exist after inmates are discharged as well. Inmates discharged from jail are forced to reintegrate into a world that is drastically different from jail, all while trying to concurrently manage their illness. Jails often fail to provide mentally ill inmates with any type of assistance with arranging appropriate treatment upon their release, drastically increasing the likelihood of recidivism. For example, in Virginia, inmates are given only 15 days worth of medication and a prescription upon discharge (N. Goodloe, personal communication, July 23, 2018). Often times it takes much longer than 30 days to receive an appointment with a mental health provider. Individuals who fail to see a mental health provider may resort to self-medicating or may discontinue taking their medication altogether, worsening their symptoms. Mary Zdanowicz put it succinctly: “Non-adherence with treatment leads to relapsing symptoms in a mental health system that encourages choice until the person becomes dangerous. Then police are called and the cycle continues.” (12)

NEW POLICY EFFORTS AND PROGRAMS

 After examining the state of mental illness in jails, resources available to inmates, and areas in which the system needs reform, it is evident that there is much room for improvement with regards to the rights and treatment of these individuals. Below I will discuss a number of initiatives that have been implemented with the goal of keeping non-violent offenders with mental illness out of jails and connecting them with mental health services. The examples presented are illustrative and do not include a comprehensive review of efforts in every state.

VIRGINIA

            Virginia has implemented a number of programs and initiatives in the hopes of better treating offenders with mental illness. Seven mental health dockets have been created across the state with the goal of diverting some mentally ill offenders from the criminal justice system. (10) Several more are in the early stages of development. Mental health dockets are specialized dockets created within the court system that afford offenders with serious mental illness (SMI), specifically those who are charged with less serious crimes, treatment options so that they can better manage their illness. The docket aims to reduce the recidivism rate of offenders with SMI by treating them rather than simply incarcerating them. Mental illnesses considered to be “serious” include major depression, schizophrenia, bipolar disorder, and any other mental disorders causing serious impairment. Charges may be dropped altogether after completion of the mandated treatment, but sometimes they are simply reduced in severity. Although individuals participating in the program are not punished with time in jail, they must comply with a number of requirements, with failure to comply potentially resulting in re-incarceration. (10)

The utilization of mental health dockets is a somewhat new initiative that aims to increase public safety and treatment engagement, improve the quality of life for participants, and reduce costs. (10) Thus far, mental health dockets appear to be meeting those goals. Participation in the mental health dockets has been shown to decrease the number of new charges incurred by an individual and lower recidivism rates. Defendants whose cases went through a mental health docket were also able to gain access to treatment quicker than those not involved in the dockets. It should be noted that cost savings have yet to be determined, as results are not consistent. This is perhaps due to the different qualifications different mental health dockets have for participation, such as severity of illness and treatment required. (10)

            Virginia has also recently allocated new funding to several jails. In an effort to develop and better the quality of mental health services in jails for current inmates and recently released inmates, the Department of Criminal Justice Services (DCJS) allocated a total of $3.5 million to six regional and local jails as part of a pilot program. (11) Hampton Roads Regional Jail, Prince William Adult Detention Center, Middle River Regional Jail, Western Virginia Regional Jail, Richmond City’s Sheriff’s Office, and Chesterfield County’s Sheriff’s Office were the six jails chosen by the General Assembly. During the program’s first six months of operation, each pilot site saw an increase in the number of treatment plans administered, the amount of peer support and therapy provided during incarceration, and the number of inmates connected to post-release services. Although pilot sites have cited far more successes than challenges, this is not to say that notable challenges do not exist. The most common challenges across the six sites are the transient nature of the inmates (moving from jail to jail) and the difficulty experienced when trying to find suitable, affordable housing for recently released inmates. (11)

            The creation of Crisis Intervention Teams, or CITs, in Virginia and other states has proven highly effective as well. The program initially started in Memphis, Tennessee and has since then been implemented across the country. (1) The goal of CIT is to train officers on how to respond effectively to calls, either criminal or non-criminal, involving individuals with mental illness. Individuals experiencing a mental health crisis may have a difficult time thinking clearly, especially if confronted by police officers about a serious situation. It is here that CIT officers utilize techniques involving patience and shared understanding to help de-escalate situations, as opposed to more confrontational and directive strategies that they would typically use. With more officers trained to respond to calls involving individuals with mental illness, fewer of these individuals end up detained or arrested. (1)

            Lastly, the 2018 General Assembly recently approved a number of budget amendments to increase the amount of funding available to implement programs that could help keep individuals with mental illness out of the criminal justice system. Funding was allocated to establish new Crisis Intervention Assessment Centers in up to six un-served rural communities, Intercept 2 programs in up to three rural communities, and CIT training programs in up to six rural communities. Allocations were approved on a yearly basis. Under item 312(T.2), a total of $2,700,000 was approved for the establishment of Crisis Intervention Assessment Centers, with $900,000 set aside for the first year and $1,800,000 for the second year. Under item 312(T.3), $1,315,296 was approved for the establishment of CIT training programs, with $657,648 provided both years. Finally, under item 312(NN), $1,417,326 was approved for the establishment of Intercept 2 programs, with $708,663 to be used each year. 

FLORIDA

            In Miami-Dade County, Florida, officials have implemented a diversionary program that includes mental health training for both police officers and 911 dispatchers. (4) The goal of this training is to help better prepare first responders to recognize and act in the case of a mental health emergency. Thus far results have been positive, as jail populations have declined by over 2,000 inmates in the past five years. (4)

Florida also recently changed its data management system with the hopes of increasing data sharing so as to prevent people from falling through the cracks of the criminal justice system. (4) In 2012, Otsuka partnered with IBM and the South Florida Behavioral Health Network to try and find a way to integrate criminal justice, mental health, substance use, and social support services data. Research found that case management after incarceration was crucial for the rehabilitation process, as individuals who had access to case management were 50 percent less likely to recidivate than those that did not. (4)

ILLINOIS

            Chicago, Illinois is home to the Cook County Jail—the largest jail in the United States. The Cook County Jail is also effectively the country’s largest mental health treatment center. (5) The jail has put into place several new measures with the intention of improving the quality of life for individuals with mental illness who are facing charges. If eligible, inmates are signed up for CountyCare during intake. CountyCare is a health insurance program designed to help low income inmates pay for prescriptions and mental health care. Additionally, Cook County has a new building called the Mental Health Transition Center that focuses on preparing inmates for their transition back into the community. Individuals work in a group setting to learn how to cope with their mental illness and successfully reintegrate into society. (5)

CONCLUSION

Mental illness in the criminal justice system is a complicated issue. Although the criminal justice system has implemented several programs and policies that are working well, there is still much to be done. Virginia continues to make improvements, and there is reason for continued optimism, as mental health has risen to the forefront of issues targeted by policymakers in the state, as well as the country at large. It is important to continue following the progress made within Virginia’s criminal justice system. It may also be beneficial to look to other states, such as those mentioned above and others, in order to learn from their challenges and successes.  

Notes:
*Each year, LIDS requests that Virginia jails fill out a survey. This survey is typically dispersed in June, data is collected by July, and then a report is created summarizing the findings. The data submitted by the jails is self-report. As such, data counts may not always be completely accurate. It should also be noted that not every jail opts to participate in the survey. 
**Even if self-injurious behavior is not viewed as a form of inmate misconduct, solitary may be seen as the only “safe” housing option because it removes mechanisms for self-harm.
***While jails are the only place that people have a constitutional right to health care, jails are only required to buy necessary items to provide such care at the cheapest cost available. For example, although jails may have some antipsychotics available in their formulary, they may not have the antipsychotic an inmate is accustomed to taking, or even a generic variation of their standard prescription.

References

1. CIT International. CIT is More Than Just Training...It’s a Community Program. Retrieved from http://www.citinternational.org/Learn-About-CIT
2. Clark, K. (2018). The Effect of Mental Illness on Segregation Following Institutional Misconduct. Criminal Justice and Behavior, 1-20.
3. Compensation Board. (2017). Compensation Board Mental Illness in Jails Report. Retrieved from http://www.scb.virginia.gov/docs/2017mentalhealthreport.pdf
4. Docherty, J. P. (2017, October 20). Creating New Hope for Mental Illness and The Criminal Justice System. Retrieved from https://www.nami.org/Blogs/NAMI-Blog/October-2017/Creating-New-Hope-for-Mental-Illness-and-the-Crimi
5. Ford, M. (2015, June 8). America’s Largest Mental Hospital Is a Jail. The Atlantic. Retrieved from https://www.theatlantic.com/politics/archive/2015/06/americas-largest-mental-hospital-is-a-jail/395012/
6. HB795, 2018 Session. (Virginia 2018). Retrieved from http://lis.virginia.gov/cgi-bin/legp604.exe?181+sum+HB795
7. Madhani, A. (2016, October 2). Police departments struggle to get cops mental health training. USA Today. Retrieved from https://www.usatoday.com/story/news/nation/2016/10/02/police-departments-struggle-cops-mental-health-training/91297538/
8. Nolan, D. & Amico, C. (2017, April 18). Solitary by the Numbers. Frontline. Retrieved from http://apps.frontline.org/solitary-by-the-numbers/
9. Substance Abuse and Mental Health Services Administration. (2015). Screening and Assessment of Co-occurring Disorders in the Justice System. Retrieved from https://store.samhsa.gov/shin/content/SMA15-4930/SMA15-4930.pdf
10. Virginia Department of Behavioral Health and Developmental Services. (2016). The Essential Elements of Mental Health Dockets in Virginia. Retrieved from http://www.dbhds.virginia.gov/library/forensics/ofo%20-%20mental%20health%20docket%20report%20final.pdf
11. Virginia Department of Criminal Justice Services. (2017). Report on the Virginia Department of Criminal Services Jail Mental Health Pilot Programs. Retrieved from https://www.dcjs.virginia.gov/sites/dcjs.virginia.gov/files/publications/corrections/dcjs-jail-mental-health-pilot-program-full-report.pdf
12. Zdanowicz, M. (2007). Mental Health Polices Are Cause for Alarm in the Corrections Community. Sheriff Magazine, 7-10. Retrieved from https://mentalillnesspolicy.org/wp-content/uploads/sheriffs-forensics.pdf