Shifting the responsibility of untreated mental illness

There is something fundamentally wrong when for some families the only way to get involuntary treatment for the mentally ill family member is to have that person arrested.

As Executive Director of the National Sheriffs' Association (NSA), and also a long-time member of ACA, it is a privilege to have this forum as a "guest editorial" in Corrections Today magazine. My thanks to ACA Executive Director James Gondles for this opportunity.

In December's Corrections Today, ACA Executive Director Gondles spoke of alternatives to incarceration. A serious issue for sheriffs and jail administrators is that of incarceration of the severely mentally ill. Our jails and prisons have also become psychiatric hospitals. According to the U.S. Department of Justice, 16 percent of inmates have severe mental illness. There is a critical need for alternatives as relates to mental illness and the need to shift the responsibility of untreated mental illness out of the criminal justice system. The diversion of people with mental illness from the criminal justice system needs a systems-wide approach/community-wide approach. Early intervention and treatment of the mentally ill is critical to diversion from the criminal justice system and back to mental health professionals. The three largest de facto psychiatric facilities in the United States are now the Los Angeles County Jail, Rikers Island Jail in New York City, and Cook County Jail in Chicago. There are twice as many people in the Miami-Dade County Jail who have mental illness as at the South Florida Evaluation and Treatment Center. In virtually every county in the nation, the county jail holds more people with severe psychiatric illness than any psychiatric facility in that county. The problem continues to escalate - it is a major quality of life issue for inmates with severe mental illnesses who are more likely to be beaten, victimized or commit suicide than those who are not sick. The handling and control of these inmates pose a serious safety threat to staff. It is also a major expense for jail systems - the L.A. County jail spends about $10 million per year on psychiatric medication.

Failure to treat people before they enter the criminal justice system is a major reason for the increase in jail populations. Jail diversion programs and mental health courts are positive steps but don't address the fundamental problem: treating people before problems occur. Today there are nearly five times more mentally ill people in the nation's jails and prisons (nearly 300,000) than there are in all the state psychiatric hospitals (about 60,000). The problem is untreated mental illness. There are 4.5 million Americans with schizophrenia and manic-depressive illness, and at any given time 40%, or 1.8 million people are not receiving adequate treatment. Legal reforms in the 1970's contributed significantly to the criminalization of people with mental illness. Treatment laws were changed to require that an individual be a danger to him/herself or others before they could be treated involuntarily. So what typically happens? A family whose son stops taking medications calls county mental health professionals who tell the family they can't do anything until the son becomes "dangerous." When the son deteriorates to the point where he is dangerous, the mental health professionals are no longer the ones who respond, it becomes sheriffs and police. That means sheriffs' deputies and police officers are the ones on the front line when a person's mental condition deteriorates to the dangerous levels dictated by the law. Law enforcement's role in mental illness crisis response has increased significantly over the years. The most serious issue is that these encounters too often turn deadly. Every year both law enforcement officers and mentally ill subjects are killed in these types of encounters. Just a few months ago, two deputy sheriffs in Prince George's County, Maryland, were shot and killed by a man with paranoid schizophrenia while serving commitment orders. In addition, a 1998 report showed justified homicides by police involving persons with severe and persistent mental illness occurred at a rate four times greater than in the general population.

The most important point to consider is that when people with severe mental illness are being treated, they are no more violent than the rest of the population. But, treatment non-compliance significantly increases the risk of violence. Shifting the responsibility for caring for people in psychiatric crisis to law enforcement and corrections, rather than medical professionals, poses a significant risk to the officers, to the individual, and a significant risk of liability for local government. Untreated mental illness also impacts on law enforcement and our jails in the area of suicides. The National Institute of Mental Health indicates that 72% of people who commit suicide have severe and persistent mental illness. Jails are no place for people with severe mental illnesses. Most local jails do not have resources to provide adequate psychiatric services.

Many of the tragedies both on the street and in jails involving severely mentally ill could be prevented through medication compliance, but the majority of those refusing treatment have impaired awareness of their illness - the illness affects their ability to recognize that they are ill and they, therefore, refuse treatment. The medical reality is confounded by many state laws that require a person become a "danger to self or others" before anything can be done if the person refuses treatment.

NSA actively supports efforts to consider new laws that require treatment based on a "need for treatment" rather than just "dangerousness," and NSA supports laws which will allow a court to order assisted outpatient treatment in the community for individuals who are in need of treatment, but refuse it. A study also showed that long-term assisted outpatient treatment combined with routine outpatient services reduced the predicted probability of violence by 50 percent and reduced arrests by 74 percent. It is likely that reductions in jail admissions would also be effected by assisted outpatient treatment. This has obvious benefits for corrections, law enforcement and the public.

There is something fundamentally wrong when for some families the only way to get involuntary treatment for the mentally ill family member is to have that person arrested, but that is, in fact, happening in many states on a regular basis. It is time to shift the responsibility of caring for the mentally ill back to the professionals who are trained to do so rather than waiting until only law enforcement and corrections can respond.

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