Over fifty years ago there were more than 500,000 people in public psychiatric hospitals around the country. Today there are slightly more than fifty thousand–a reduction of 90 percent. Although one goal has been accomplished–reducing the inpatient incidence of people with serious mental illness, we have not accomplished the overarching goal of enabling people to live successfully in their own community. Instead, we have simply moved many of these people into our prisons and jails.
Research suggests that people with mental illness are overrepresented in the criminal justice system by rates of two to four times the normal population. The last major study on mental health in prisons, conducted by the Bureau of Justice Statistics, found that 64 percent of inmates in state and federal prisons met the criteria for mental illness at the time of their booking or during the twelve months leading up to their arrest. For comparison, the rate of mental disorders among U.S. citizens stands at around 25 percent, according to the NIH. Sixty-nine percent of the country’s prison population was addicted to drugs or alcohol prior to incarceration.
The severity of these illnesses significantly vary, but advocates say that one factor remains steady: with proper treatment, many of these incarcerations could have been avoided. Unfortunately, an estimated 40 percent of people with serious mental illness will come in contact with the criminal justice system at some point in their lives.
Many people with serious mental illness who should be hospitalized or in integrated community based systems, have simply been moved into our prisons and jails as state budgets have slashed programs. In the Los Angeles County Jail, for example, there are 1,400 people with a serious mental illness and substance use disorders, making it the largest mental health facility in the country. Our jails and prisons have become our de facto mental health care system.
Jails and prisons can be terrifying, but for people with a mental illness, this is especially true. Many correctional facilities do not have qualified mental health professionals on their staffs to recognize and respond to the needs of inmates experiencing severe psychiatric symptoms. Even more distressing is that for many people with a mental illness, incarceration leads to further victimization and unspeakable kinds of abuse.
Although a majority of the American public still believes that people with a mental illness are violent, only 25 percent of individuals with a mental illness in our prisons are incarcerated for violent offenses.
Most people with mental illness are incarcerated because of very minor crimes that are preventable–people are homeless for reasons that should not occur, people do not have basic treatment for reasons that should not occur and they get into trouble because of crimes of survival.
High rates of people with a mental illness incarcerated is due to a lack of community mental health services. From 2009 to 2012, $5 billion in funding for mental health services were cut from state budgets across the nation. Because of the cuts, treatment centers have had to trim services and turn away patients.
State hospitals have also been forced to reduce services. There are more people with severe mental illness in prisons and jails than in hospitals.
Once people with mental illness are incarcerated, it becomes a tough cycle to break. Most people are there for minor crimes but then they deteriorate. They cannot follow the rules and so they stay a long time, and they become difficult to release. According to a Bureau of Justice Statistics report, most inmates with mental illness do not receive treatment while in prison.
Corrections employees are not properly taught how to recognize and handle mental illness. There is a lack of training to identify specific issues and how to deal with them. Employees receive a few hours of mental illness training each year and it is not enough. And the expense is high, to be sure. The average inmate in New York State costs the state over $60,000 per year, according to a report by the Vera Insitute of Justice. That figure does not take into account the extra resources that an inmate with a mental illness requires. Experts say that funding mental health services for these inmates would cost less than imprisoning them and could help prevent many incarcerations in the first place.
According to the Bazelon Center, the annual cost of case management for mentally ill people in Michigan is $2,165 per person. A more intensive program, the popular Assertive Community Treatment, costs the state $9,029 per person per year. In contrast, the average Michigan inmate cost the state over $34,000 last year. We are paying criminal justice and other costs and we are investing in those systems but we really should be investing in the services that could prevent that whole trajectory to begin with in the first place.
So far we have talked about adults. Just as alarming or more so, is that each year more than a half million youths enter the juvenile justice system. It is estimated that between two-thirds and three quarters of them have mental health or emotional problems, and of these, 15 percent suffer from a serious mental illness. Only small numbers receive the help they need.
One solution: There are a variety of diversion programs that have proven effective in keeping people out of jails and prisons by redirecting individuals with serious mental illness from jail to community-based treatments and support services. These programs include mental health courts, post-booking programs and crisis intervention mechanisms.
In addition, the Affordable Care Act (ACA) offers new opportunities to increase health coverage among individuals transitioning back into the community from prisons and jails. The ACA established new coverage options by expanding Medicaid eligibility to nearly all adults with incomes at or below 138% FPL ($16,105 for an individual in 2014).
The federal government will cover 100% of the cost of coverage for individuals made newly eligible as a result of this expansion, phasing down to a 90% federal match as of 2020. The ACA also created new Health Insurance Marketplaces with premium tax credits available for moderate income individuals. In addition to these coverage expansions, the ACA also requires all states to implement streamlined, coordinated enrollment processes to connect eligible individuals to health coverage.
Increased coverage among the criminal justice-involved population may lead to improved access to care and broader benefits, including reduced recidivism rates. Individuals transitioning into and out of prisons and jails have significant physical and mental health needs. Upon release from prison and jail, individuals are often uninsured, making it difficult to access stable sources of care in the community to address these needs.
Expanding health insurance to individuals with a mental illness will likely facilitate their ability to access needed care and manage their ongoing conditions. Improved connections to services and better management of mental health conditions may also contribute to reduced rates of recidivism.
We need to keep people with a mental illness in the first place. If they do become incarcerated, let’s make sure they get needed care and never go back again.
Clinical mental health counselors stand ready to provide evidence-based treatments to address the needs of people with a mental illness when they are incarcerated and when they re-enter their communities.