Treatment of mental illness in the community, rather than in the criminal
justice system, can save communities and local taxpayers money over time.
But reversing the widespread criminalization of mentally ill people
requires an educated cadre of clinicians to make the case before legislators
that diversion of individuals with mental illness from jails and prisons and
into treatment in the community is the right thing to do.
And it will also require long-term follow-up studies to prove the
That was the message that psychiatrists took home last month from a
conference in Washington, D.C., titled "Effectively Approaching Elected
Officials on Shifting Resources to Community-Based Services for Persons With
Mental Illness in Contact With the Justice System."
The day-long forum was cosponsored by APA, the TAPA Center for Jail
Diversion, and the Council on State Governments (CSG). It was a follow-up to
an expert conference convened on the subject in February by then APA president
Marcia Goin, M.D. (Psychiatric News, March 19).
Goin and APA President-elect Steven Sharfstein, M.D., were part of the
policy forum's panel of experts, which also included A. Kathryn Power,
director of the federal Center for Mental Health Services, and Michael
Thompson, director of Criminal Justice Programs at the CSG. In addition,
representatives from 10 APA district branches (DBs) were flown in to attend
the conference, with all their expenses for the conference paid by the TAPA
Goin told Psychiatric News that last month's conference was part
of APA's continuing commitment to reverse the trend to incarcerate people with
mental illness—an issue she made a priority during her presidency. She
said the TAPA Center invited the DB presidents with the goal of providing
practical tools for representatives from some of APA's largest DBs to return
home and begin advocating for diversion from the criminal justice system and
for treatment in the community.
"This collaboration with the Council on State Governments and with
TAPA helps to lead the way in a very practical sense to effective advocacy in
our state legislatures for resources being directed toward treatment of
patients, not incarceration," she said.
At the conference, Thompson, of the CSG, presented practical information on
how to successfully approach legislators about the value of spending money for
diversion rather than imprisonment, stressing the importance of forging
alliances with the criminal justice and corrections communities.
Henry Weinstein, M.D., chair of APA's Corresponding Committee on Jails and
Prisons, presented an APA Resource Kit on Criminalization of the Mentally Ill
that included, among other items, APA's Guidelines on Psychiatric Services in
Jails and Prisons, APA's Fact Sheet on Criminalization of People With Mental
Illness and Jail Diversion, as well as the proceedings of the February
conference convened by Goin.
Weinstein said that the issue is an urgent one and that those psychiatrists
who attended last month's conference were in the "vanguard" of the
movement to reverse the criminalization of the mentally ill.
"As everyone knows, there are more mentally ill housed in jails and
prisons these days than there are in psychiatric hospitals," Weinstein
told Psychiatric News. "This is a very important population for
APA to focus on, and at this conference we turned our attention to funding
community services for this population at the `front door' through diversion
programs before people enter the criminal justice system, and at the `back
door,' when they leave the system and re-enter the community."
Critical to persuading local policymakers about the justice and
effectiveness of treatment rather than incarceration are long-term follow-up
data from communities that have diversion programs in place.
Henry J. Steadman, Ph.D., director of the TAPA Center for Jail Diversion,
told psychiatrists that existing data indicate that, in the short term,
treatment in the community is liable to be as, or even more, expensive than
incarceration and that savings may not accrue until as long as 18 months later
when patients have been stabilized.
"The current thinking is equivocal about the cost savings, in the
short term, from jail diversion programs," Steadman told Psychiatric
News. "When you provide appropriate and comprehensive
community-based services for people who are diverted from the criminal justice
system, costs over the first year are about the same as if they had stayed in
the criminal justice system.
"But as you get into the 14- to 18-month period, you begin to see
cost savings," he continued. He referred to research using simulation
models comparing costs of treatment in the community with those of
incarceration. "This is not surprising, given the chronic nature of the
illnesses in this population."
But Steadman said that all of the real-world research from communities with
existing programs has consisted of one-year follow-up studies.
"The major cost savings on the criminal justice side are the saved
jail days," Steadman explained. "All the research in the field has
shown that people who are diverted spend fewer days in jail, and you are
saving expensive jail days because these are people who require high levels of
security and have pharmacy needs in excess of the average person in jail.
"But when you divert to the community, they need medications, and
many of these people need assertive community treatment teams," Steadman
said. "They need housing, in many instances, and if you also provide
supported employment programs to make them employable, and child care for
women so they can participate in treatment and be re-employed, you are talking
about intensive services, and the savings on the criminal side are shifted to
the mental health side."
Steadman said a key to making treatment in the community work is enrollment
of diverted patients into Medicaid, SSI, and SSDI programs. This is especially
true for those individuals who are in jail and due to return to the community;
in those cases, a process of enrollment needs to begin before they are
released and on the streets, Steadman said.
The TAPA Center is a nonprofit agency whose headquarters is at Policy
Research Associates Inc. in Delmar, N.Y. TAPA was funded by CMHS, an agency of
the Substance Abuse and Mental Health Services Administration, to provide
technical assistance and policy analysis for communities seeking to develop
programs for diverting people with mental illness from jail into
community-based treatment and supports.
The DBs represented at the conference included the Illinois Psychiatric
Society, Massachusetts Psychiatric Society, New Jersey Psychiatric
Association, New York State Psychiatric Association, Northern California
Psychiatric Society, Ohio Psychiatric Society, Pennsylvania Psychiatric
Society, and Southern California Psychiatric Society. A representative from
the Washington Psychiatric Society attended the conference on behalf of the
D.C. and Virginia DBs.
Toward the end of the conference, the DBs were divided up to"
brainstorm" about what next steps may be necessary in each of
their states or regions, with a report back to the larger group.
"Some reported they needed to do more homework about the needed
coalitions in their district, and others had different ideas," Goin
said. "We will be following up on their progress and hope this is the
first of future programs with increased ability for outreach."
APA's Fact Sheet on Criminalization of People With Mental Illness
and Jail Diversion is posted online at<www.psych.org/advocacy_policy/leg_issues/CriminalizationofPeoplewithMentalIllnessesandJailDiversion.pdf>.
The proceedings from the February conference are posted at<www.psych.org/edu/other_res/lib_archives/archives/200401.pdf>.▪