Mental Illness: A Condition, Not a Crime

Addressing the Criminalization of Mental Illness by Increasing Sensitivity of First-Responders

According to the Bureau of Justice Statistics, two million adult arrests, or roughly 16.9 percent, in the United States each year involve people with serious mental illness.

And for children, it’s estimated that roughly 70 percent of youth in the juvenile justice system have a mental health condition.

Providing adequate physical care for incarcerated individuals already poses a unique set of challenges and providing appropriate mental health care can seem impossible. Recognizing ways that we can better work to keep these populations out of the criminal justice system in the first place is the first step to addressing the large discrepancies of care these individuals face when seeking help for their mental health needs.

The High Cost of Treating Mental Health Through the Prison System

Roughly 40 percent of individuals who are incarcerated are diagnosed with one or more mental illnesses, with some studies suggesting that number could be as high as 64 percent for local jails, 56 percent for state prisons, and 45 percent for federal prisons. Of these individuals who are incarcerated, approximately half were homeless at the time of arrest, and women who are incarcerated are more likely to have mental health needs than men. 

The financial cost of treating mental health in the prison system is high—costing approximately $50,000 per individual who is incarcerated with psychiatric disorders, or $15 billion a year. Moving these individuals to an inpatient psychiatric placement would cost an average of $5,500 per admission if the individual was uninsured, and preventive care, like an assertive community treatment program, would cost approximately $10,000-$15,000 for the entire year. 

Beyond financial cost, the even more startling cost is the impact on the mental health of individuals who are incarcerated. 

Roughly 75 percent of individuals with a mental illness who are incarcerated receive acute inpatient psychiatric care through the prison system, not through a mental health provider. Suicide rates in prisons are triple what they would be outside the correctional system—with suicide accounting for one-third of all deaths in jails—and those rates are climbing. State prison suicides jumped 30 percent between 2013 and 2014 (the latest number published by the U.S. Bureau of Justice Statistics), and as mass incarceration continues to pack facilities to full-capacity, providing adequate support to lower those numbers is unlikely.

When a Crisis Becomes a Crime

The US local, state, and federal jails and prisons hold 2.3 million individuals—and an estimated 920,000 individuals with mental illness. With the large reduction in inpatient psychiatric beds that began in the 1970s, this means that the prison system is now, by default, the nation’s largest psychiatric hospital. 

But the high rates of mental illness in the prison system do not make mental illness a predictor of crime. Many of the arrests made follow minor incidents such as public urination, sleeping on the street, or public nuisance. Other times, the police respond to a 911 call when someone with a serious mental illness is having a crisis and may be yelling, behaving erratically, or otherwise creating what is perceived as a public nuisance. 

While the petty crimes are what the police were called to address, when an officer shows up without training to help these individuals, the situation can escalate. Mental illnesses can be exacerbated by the stress of interacting with law enforcement, and before long the situation may escalate to the point that the individual is arrested for failure to obey, assault, or something more serious. 

I’m not suggesting that there aren’t incidents where someone has, in a state of psychological distress, done something that warrants arrest. But by and large, additional training can reduce extreme and costly over-precautions when it comes to responding to populations with mental health needs that may contribute to extreme behaviors.  

During my three years as a state Deputy Commissioner and Commissioner for Vermont’s Department of Mental Health, we had four separate incidents where an individual was killed by law enforcement after they responded to a mental health-related call. People with untreated mental illness are as much as 16 times more likely to be killed by law enforcement. In light of current conversations across the United States about excessive police action, particularly in the Black community, we need to expand and invest more in training to help first responders identify and deescalate mental health crises and avoid unnecessary harm.  

A Way Forward: Bringing New Skills to the Scene

Allocating resources to train first responders to identify and address mental illness can help prevent unnecessary incarceration of those with mental health disorders for petty crime or otherwise avoidable escalations of police encounters when no crime has been committed. Better yet, though, allocating resources to develop special crisis response teams that are trained specifically to handle individuals with mental illness can ensure that these individuals are directed to where they’ll get the most appropriate care for their conditions and needs—and often with better outcomes and at a lower cost than a correctional facility. 

Community crisis response and Crisis Intervention Teams use is a growing area of interest for community, city and state leadership in an attempt to mitigate negative police-community interaction. In Washington, for example, the Pierce County Fire Department realized that it was responding to a significant amount of 911 calls for individuals with mental and behavioral health needs. Realizing it was unequipped to effectively address these crises, the department’s paramedics partnered with a local physician network to develop a Mobile Community Intervention Response Team (MCIRT) that was specially-trained to work with mental health patients.  With MCIRT, the county’s EMS services have seen a 47 percent reduction in EMS transport, a 36 percent reduction in ED visits, and a 42 percent reduction in hospital readmissions. 

While the aim of the MCIRT was to address high utilization of EMT and ED services, a similar model could also be used to address the disproportionate arrest rates of those with mental illness and substance use disorder. 

In Vermont, a grant to the Vermont Care Partners combines Department of Mental Health and Department of Public Safety funding to provide training for law enforcement and mental health crisis workers in collaborating together during crisis situations. The reactions to this program have been overwhelmingly positive, and I am optimistic that such programs will ultimately strengthen our ability to care for and respond to individuals with mental health conditions.

Beginning with the End in Mind

In an ideal world, municipalities would have ample resources to fully fund these educational and skill building initiatives. Law enforcement and other first-responders would be thoroughly trained to deescalate psychiatric distress, cities would have fleets of mobile mental health units the way they have fleets of fire engines, and we’d even have psychiatric urgent care/same-day options for those who need walk-in help at a lower acuity level than the ED or psychiatric inpatient admissions. 

Unfortunately, that’s not the case. Working for the state of Vermont, I saw firsthand the difficult discussions surrounding budgets, knowing full-well that hiring social workers, therapists, and others we needed would be challenging to fund. As such, we’re left with a delicate balancing act between needs of individuals in mental health distress, community safety needs in general, and resources being directed toward other types of community prevention options. 

While I don’t have an exact path to get our system from where it is today to a more balanced approach in the use of government, community, and health care resources, the more successful initiatives I have seen in VT and in other states begin with the end in mind— the goal of avoiding arrest and connecting people with supportive resources and necessary treatment. Rather than interacting with individuals simply because of their behavior, we can look for ways to address the person’s needs by connecting them with appropriate mental health resources. Instead of arresting people, we can examine the issues that contribute to the behavior and lead to the interactions with police and try to change the current trajectory. 

Beginning with the end in mind is rarely the easy—or least expensive option—at least in the beginning. But the far-reaching benefits include better health for individuals and communities and contribute to long-term effective use of funding resources and likely even cost savings. 

Related Reading: Implicit Bias and Racial Disparities of Care: Recognizing and Addressing the Role of Implicit Bias in Vulnerable Patient Care

Melissa Bailey is a Senior Fellow at the Center for Health Care Strategies (CHCS) where she promotes programs for individuals with mental and behavioral health needs. Prior to her work at CHCS, she was the Commissioner for the Department of Mental Health at the State of Vermont. She has done significant work for child and family mental health and has a Masters in Mental Health Counseling from Johnson State College. 

This article is provided through a collaborative effort with Collective Medical

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