Psychiatrists Learn to Argue For Treatment of Offenders

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 point.

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 Center.

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>.▪