Summit County Alcohol, Drug Addiction, and Mental Health Services Board and Northeastern Ohio Universities

• Author: Mark R. Munetz, M.D.; Jennifer L.S. Teller, Ph.D.
• Position: The Challenges Of Cross-Disciplinary Collaborations: Bridging The Mental Health And Criminal Justice Systems
• Pages: 935-950

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Summit County Alcohol, Drug Addiction, and Mental Health Services Board and Northeastern Ohio Universities College of Medicine. Direct correspondence to Mark Munetz, Chief Clinical Officer, Summit County ADM Board, 100 West Cedar Street, Suite 300, Akron, Ohio 44307, or e-mail mmunetz@neoucom.edu or munetzm@admboard.org.

Kent State University, Department of Sociology.

I The Different Worlds Of The Mental Health And Criminal Justice Systems

The criminal justice and mental health worlds are very different. ¹ We come from different traditions, we speak different languages, and to some degree we have different values, expectations, and goals. Furthermore, few of us expected or desired to work in both the criminal justice and mental health worlds, and few of us have been trained or educated to understand the other world. A few examples, from the point of view of the mental health professional, of our differences and similarities are illustrative.

In the mental health world, we work with patients, clients, or consumers; in the criminal justice world, we work with perpetrators, defendants, or offenders. In the mental health world, the institutions are hospitals and there is great pressure to reduce utilization and to develop community-based alternatives; in the criminal justice world, the institutions are jails and prisons and there is great pressure to reduce utilization and develop community-based alternatives. In the mental health system, there is encouragement to use police power such as civil Page 936 commitment reluctantly, with an emphasis on the least restrictive alternative; the criminal justice system routinely uses police powers with an emphasis on public safety. The mental health system deals with illness, "the mad," while the criminal justice system deals with behavior, "the bad." The mental health system, especially the community-based public mental health system, uses a team approach where it is not always clear who is in charge and the role of the psychiatrist may be unclear. The criminal justice system is authoritarian and adversarial; on the street it is clear the police officer is in charge and it is even clearer in the court that the judge is in control. The mental health world deals with illnesses that are chronic, where relapse is common and not unexpected; in the criminal justice system, recidivism is similarly common and not unexpected.

Our work is further complicated because, coming from different worlds, we tend to have biases. With only slight tongue-in-cheek, it is helpful to be aware of what some of these biases might be. Consider the following. Criminal justice professionals may view mental health professionals as generally odd, if not frankly ill, because mental health professionals are often stigmatized in the same way as their patients;² conversely, mental health professionals may view police officers and judges as autocratic. The mental health world may look to the criminal justice world as a group of fuzzy thinkers who are far too process oriented, take much too much time to reach conclusions, and generally see everything as gray; the criminal justice world looks to mental health professionals as a world of rigid thinkers who decide things much too quickly, who see everything in a complex world as black and white, with sharp and well-defined boundaries. The mental health world may believe that the criminal justice system fails to appreciate the debilitating nature of mental illness and wants to hold people accountable for behavior which lacks criminal intent and that they may not be able to fully control. The criminal justice system may believe that the mental health system fails to hold accountable people who, despite having an illness, are living successfully in their communities and must be held accountable for their behavior. We each look at the other's world and it appears chaotic and impossible to understand. In both worlds we use indecipherable jargon, seemingly using language to confuse and muddle each other.³

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The mental health world may believe that criminal justice does not appreciate the great pressures it is under to care for the endless stream of patients it is asked to serve; and the criminal justice world sees mental health as not appreciating the pressures it is under to deal with its endless stream of perpetrators, defendants, and victims. And we each see the other as having the pot at the end of the rainbow, of being a source of resources that each of us greatly need and desire.

These biases, perhaps reflecting society's stereotypes about both the mental health and criminal justice systems, make it hard, but certainly not impossible, to begin to work together. Our experience strongly suggests that mental health and criminal justice clearly have more in common than not. Fundamentally, both care deeply and passionately about the people served and want to help them live more productive, happier lives. Realistically, both also want to protect their worlds, including their staffs and the people they serve. There is a political context to both the mental health and criminal justice worlds. In a variety of ways both need voter support to support funding for mental health and to re-elect judges, sheriffs, and other government officials. And both fear the sensational newspaper headline involving one of their "customers."

The first step in successful collaboration is the desire to work together on solutions. Sometimes, unfortunately, this happens only after a headline- grabbing tragedy. Increasingly, however, communities are recognizing the need to work proactively without such a public catastrophe. In part, the recognition comes through the realization that the fundamental and realistic commonalities shared by the mental health and criminal justice systems could potentially span the boundaries artificially erected between the two systems.⁴

II The Realization That The Boundaries Require Spanning

In 2002, there were 1,440,655 Americans confined in state and federal prisons and another 665,475 in local jails.⁵ This incarceration rate of 701 per 100,000 allowed the United States to overtake Russia and become the world leader in incarcerating its citizens.⁶ There were 6.6 million Page 938 Americans incarcerated, on probation, or parole in 2001, representing a 258% increase since 1980.⁷ As of June 30, 2002, the nation's prison and jail population exceeded two million for the first time in its history.⁸

A recent report from the U. S. Department of Justice reveals that at the end of 2001, more than 5.6 million adults have served time in state or federal prison.⁹ The report estimates that if incarceration rates remain unchanged, 6.6 % of United States residents born in 2001 will go to prison at some time in their lifetime, with the risk estimated to be nearly one in three for black males, one in six for Hispanic males, and one in seventeen for white males.¹⁰ The risk of going to prison had increased by six for women between 1974 (0.3%) and 2001 (1.8%) and three times for men during the same time period (3.6% to 11.3%).

Seventy percent of prison inmates were convicted of non-violent crimes, with 31% representing drug offenses.¹¹ Similarly, a quarter of jail inmates were incarcerated for a drug offense in 1996, compared with 10% in 1983, and 60% of jail inmates in that year reported they were under the influence of alcohol or other drugs at the time they committed their offense.¹²

It is in this context that there has been increasing attention to the substantial numbers of individuals in the criminal justice system suffering from serious mental disorders. More than a decade ago, the National Alliance for the Mentally Ill published a report on what they called the criminalization of the mentally ill.¹³ In this 1992 report, the authors indicated a prevalence of serious mental disorders of 7.3%, a ten-fold increase from findings in the late 1800s after Dorothea Dix successfully Page 939 completed her mission to create mental asylums in all the states to replace jails as the primary residence for people with mental illness.¹⁴

More recent reports suggest an even higher prevalence of serious mental disorders among jail and prison populations. The Bureau of Justice Statistics estimated that in mid-year 1998, there were 283,800 mentally ill offenders incarcerated in U.S. jails and prisons, representing 16% of state prison, 7% of Federal prison, and 16% of local jail inmates.¹⁵ It is almost becoming a clich that the largest institutions for mental disorders in the U.S. are now our large, urban jails.¹⁶ The Los Angeles County jail is said to house more than 3,300 seriously mentally ill people.¹⁷ The most careful studies of the prevalence of serious mental disorders in jail populations have been conducted by Linda Teplin.¹⁸ Teplin's work, as summarized by Henry Steadman¹⁹ of the National GAINS Center,²⁰ indicated that while 1.8% of the general population has a point prevalence of three serious mental disorders-schizophrenia, mania, major depression-6.1% of male jail detainees and 15% of female jail detainees will have one of these diagnoses. Furthermore, 72% of males and 75% of females with one of these diagnoses also have a concomitant substance use disorder.

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While the lifetime risk of incarceration of people with serious mental disorders is not known, it is clearly substantially higher than that of the general population. In a study of one county's one-year incarceration rate among an identified population of individuals with serious mental disorders, 7.9%, or 209 of 2,645, of the known population with a serious mental...