Recommended citation: Major County Sheriffs of America. 2019. Sheriffs Addressing the Mental Health Crisis in the Community and in the Jails. Washington, DC: Office of Community Oriented Policing Services.
Copyright © 2018 by Major County Sheriffs of America. The U.S. Department of Justice reserves a royalty-free, nonexclusive, and irrevocable license to reproduce, publish, or otherwise use and authorize others to use this resource for Federal Government purposes. This resource may be freely distributed and used for noncommercial and educational purposes only.
The major theme of this publication is the effective response of law enforcement agencies to mental illness in their communities. Mental illness is a complex problem that historically has been undetected, unacknowledged, or not treated in a local law enforcement context. Mental illnesses may be more difficult to detect than physical illnesses as the symptoms of mental illness may be misunderstood and may be attributed to personal choices such as substance abuse or nonclinical origins such as poor social skills. When mental illness is suspected or detected by the nonclinical professional, a lack of training and experience on effectively managing patients with mental illnesses may lead to generalization, suboptimal management, and lack of appropriate initial treatment.
In addition to the discomfort and uneasiness the subject arouses in individuals and society, there continues to be much disagreement among mental health experts on even the definition of mental illness (Prins 2010; Williams, Cohen, and Ford 2014; Horwitz 2010). It is no surprise then that professionals in law enforcement, criminal justice, and even general health care continue to debate the precise definition of mental illness. The fluid nature of definitions and treatment is underscored by the continual revision of the Diagnostic and Statistical Manual of Mental Disorders, now in its fifth formal edition (DSM-5). The fact that professionals from a variety of scientific and medical disciplines, including psychology and psychiatry, have difficulty adequately defining mental illness within and across disciplines illustrates the complexity of mental illness and the need to provide working definitions for the purposes of this report. The following working definition should be kept in mind as descriptions of various programs and processes for addressing mental illness and reducing the arrest and incarceration of people with mental illnesses are reviewed and considered for applicability across the criminal justice system.
For the purposes of this project and this report, it was decided to employ a relatively simple and straightforward behavioral description of mental illness. The description (and definition) of mental illness is as follows:
“Any mental illness (AMI) is defined as a mental, behavioral, or emotional disorder. AMI can vary in impact, ranging from no impairment to mild, moderate, and even severe impairment,” the latter describing individuals with serious mental illness (NIMH 2018a).
Unlike AMI, “serious mental illness (SMI) is defined as a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities. The burden of mental illnesses is particularly concentrated among those who experience disability due to SMI” (NIMH 2018a). Further, individuals with SMI represent the vast majority 6 of crisis service calls that require de-escalation and alternative responses by law enforcement. An example of SMI is schizophrenia, a psychotic disorder that includes symptoms such as visual and auditory hallucinations or thought disorders that result in dysfunctional ways of thinking (NIMH 2018b).
Law enforcement, criminal justice, and correctional professionals will quickly recognize the connection between mental illness and disruptions in behavioral, emotional, or relational functioning. While mental or cognitive symptoms are not always clear when an officer approaches a suspect on the street, individuals with serious mental illness always display disruptions of varying severity in one or more of the other categories, which are more clearly recognized and may in fact be the reason law enforcement is involved. It is our hope that the broad and general description will provide context and clarity to the remainder of this report.
Following the description of mental illness, the frequently observed connections among mental illness, substance abuse, and criminal behavior must be recognized, as should the linkages with criminal conduct, which leads to the arrest and incarceration of the person with a mental illness. There are several distinct impacts of co-occurring disorders (COD) in criminal behavior. These can be approached from the perspective of how CODs lead to criminal behavior and how CODs affect those who are involved in criminal behavior.
Particularly in the context of criminal behavior, substance abuse that co-occurs with mental illness must be expected (Minkoff 2007; Goss 2016). The available research on the prevalence of substance use on the part of those who are incarcerated indicates that approximately 85–90 percent of inmates (adolescents and adults) have used alcohol or drugs in their lifetime, and approximately 75 percent report using alcohol or other drugs on a regular basis or meet criteria for substance abuse or addiction (Van Voorhis, Schweitzer, and Hurst 2009; Foster et al. 2010; NIDA 2018).
There is a very clear connection between substance abuse and criminal behavior. In most circumstances, including all situations in which underage individuals are using alcohol or other drugs, substance use (meaning use of alcohol or illicit drugs and misuse or abuse of prescription drugs) is criminal behavior, but it also contributes to an overall attitude and pattern of general or broad criminality (Tripodi and Bender 2011; Neff and Waite 2007). Children and adolescents who use alcohol and drugs are doing so illegally, and yet the specific acts of substance use and related behaviors typically precede and contribute to a general pattern of criminal behavior that is very common among those who abuse or are addicted to alcohol and other drugs.
Researchers have identified eight specific behaviors and circumstances that have been labeled “criminogenic” (Andrews and Bonta 2010; Latessa and Lowenkamp 2005), which means behaviors and circumstances that lead to or contribute to criminal behavior and criminality. Despite substance abuse being specifically identified as one of the criminogenic needs, mental illness has not been so identified and yet can contribute to criminal behavior and criminality. There are a number of specific ways that this can occur, including hallucinations and paranoia, general mental disorganization, mania, and depression.
Auditory hallucinations and paranoia can lead individuals to believe they are in danger and so must harm or kill another person in order to protect themselves or that they will improve their life or circumstance by killing one or more other people. An example of this is James Holmes, the shooter at the Century 16 Movie Theater in Aurora, Colorado. According to court testimony, he believed that he would achieve greater self-esteem and personal power by killing other people and that the more people he killed the greater personal enhancement he would achieve (Denver Post 2016).
General mental disorganization often leads to misdemeanor-level crimes and behavior that is a general public nuisance. Examples include loitering, 7 The Mental Illness Challenge for the Community and Law Enforcement
homelessness, panhandling, trespassing, shoplifting, or other minor theft. The mental disorganization is typically the result of psychotic disorders that do not include paranoid ideation or hallucinations that command the individual to be violent but rather make it difficult for them to accurately perceive reality and effectively solve problems. Tragically, these behaviors often result in people with serious mental illnesses becoming involved in the criminal justice system, where they spend inordinately long periods of time and from which they have difficulty extricating themselves (Bailargeon et al. 2009; Harris and Dagadakis 2004; James and Glaze 2006).
Mania and depression (the two poles of bipolar disorder) can also contribute to criminal behavior. Crimes resulting from mania are often indicative of the poor judgment that is a hallmark of mania and can include theft, excessive speeding, gambling, prostitution, substance abuse, and violence (American Psychiatric Association 2013). Depression is less likely to lead to criminal behavior, but in severe episodes it can contribute to psychoses that result in criminal behavior. Susan Smith, who was convicted of murdering her two young sons in 1995, was believed to be suffering from severe depression that led her to believe she needed to kill them (Chuck 2015).
Effect of mental illness on criminal behavior
Mental illness in almost all cases—and specifically as defined in this document—is manifested in behavioral, emotional, mental/cognitive, and relational disruptions and often a combination of those factors. Mental illness leads to emotional and cognitive disruption of one form or another (Medalia, Revheim, and Casey 2002). This disruption can affect both the individual themselves and others with whom the person is interacting.
The effect of mental illness on a person who is committing or has committed a crime manifests itself in several forms. A lack of self-control has been proposed as the primary cause for criminal behavior (Gottfredson and Hirschi 1990; Buker 2011; Ronel 2011), and when an individual is experiencing an episode of mental illness they are less likely to be able to appropriately control their behavior. It is also true that many people commit crimes in an inappropriate attempt to manage emotions that are less well regulated or managed in the midst of the experience of symptoms of the mental illness (Miller, Vachon, and Aalsma 2012).
When a person is experiencing intensified anger or anxiety as the result of a mental illness, their behavior becomes less controllable and predictable. The anger, anxiety, depression, or panic experienced by people in the midst of an episode of mental illness can contribute to impulsive behavior, which often exacerbates the circumstances and severity of a criminal act. In addition, the mental illness can lead them to experience higher levels of guilt and hopelessness that can become overwhelming following the commission of a crime and subsequent incarceration, leaving them at greater risk of attempting and committing suicide while incarcerated. Finally, the mental illness and accompanying mental confusion can make it more difficult for a person to determine the appropriateness of their behavior or to choose not to commit a crime because their thought processes and judgment are impaired (Torrey et al. 2010).
Mental illness and the related emotional disruption represent a risk to others who interact with the person living with the mental illness. The elevated anger, anxiety or panic, and impaired judgment can lead the person who is in the midst of an episode of mental illness to overreact to perceived slights. They may become aggressive and violent towards those around them and ultimately commit crimes they would not have committed (or that would have been less serious) in absence of the episode of mental illness.
Mental illness and the related emotional disruption represent a risk to others who interact with the person living with the mental illness. The elevated anger, anxiety or panic, and impaired judgment can lead the person who is in the midst of an episode of mental illness to overreact to perceived slights. They may become aggressive and violent towards those around them and ultimately commit crimes they would not have committed (or that would have been less serious) in absence of the episode of mental illness. Individuals who are experiencing mental illness are also less likely to appreciate the 8 impact of their behavior on others and so are more likely to commit crimes that affect others when they are experiencing episodes of mental illness.
There is a complex relationship between mental health problems and crime and the impact of mental health problems on criminal behavior. This complex relationship is made more complicated by the presence of substance abuse as described earlier, which is appropriately conceptualized as a mental health problem and a criminogenic need (Andrews and Bonta 2010; Latessa and Lowenkamp 2005). Mental health problems (including substance abuse) can lead to specific types of crimes that are often directly related to the symptoms of the mental illness, can lead to specific effects on the individuals with mental illness who commit crimes, and can have specific effects on those who are in relationships with or interact with such individuals.
The impact of mental health problems as they relate to crimes can be directly seen in emotional and cognitive processes (judgment, decision-making, problem solving). Emotions are less well regulated and managed during an episode of a mental illness. The impaired cognitive functioning makes it less likely the individual will respond appropriately to the emotional dysregulation, so they often make choices (to commit crimes and harm others) that they would not make in absence of the mental illness.
Mental/Co-Occurring Dependencies (CODs)in the community
The Substance Abuse and Mental Health Services Administration (SAMHSA) collects data on the prevalence of substance use and abuse and mental illness across the United States. The latest year for which data is available is 2014, and it indicates the following:
- Prevalence of illicit drug and alcohol abuse or dependence among those 18 years or older is approximately 8%
- Prevalence of illicit drug or alcohol abuse or dependence among those 18 years or older: 9.5%
- Prevalence of those needing but not receiving treatment for alcohol abuse: 6.5%
- Prevalence of those needing but not receiving treatment for illicit drug use: 2%
- Prevalence of any mental illness among those 18 or older: approximately 19%
- Prevalence of those with co-occurring disorders: approximately 2–3%
SAMHSA does not provide data on the number of people in the United States who need treatment for a mental illness and do not receive it. However, the National Alliance on Mental Illness estimated that in 2009 less than 33 percent of individuals who needed treatment for a mental illness would receive it (Aron et al. 2009).
These data present the scope of the problem as it relates to law enforcement and having to contact or address those with mental illnesses, substance use disorders, or both. A considerable percentage of the population experiences a substance use (alcohol or illicit drug) disorder, a mental illness, or both, and these people are more likely to come into contact with law enforcement than are those in the population with neither substance use disorders nor mental illnesses. It has been estimated that 7 to 10 percent of all law enforcement contacts involve people with mental illnesses (not specifically substance abuse) (Reuland and Margolis 2003). Our survey showed that 24 to 28 percent of persons incarcerated are individuals with mental illness. This figure accounts for those who have self-reported or have been identified through medications prescribed and from incidents observed by correctional staff.
Effect of not providing mental health services in the community
It is well established that the availability of mental health treatment in the community has decreased since the 1980s as a result of cuts in Medicaid reimbursements for mental health care, non-Medicaid cuts in funding for mental health treatment by states and local jurisdictions, and the shuttering of state mental hospitals and other treatment resources (Honberg et al. 2011; Candisky 2011). This reduction in provision of mental health services, which began with deinstitutionalization of people with mental illnesses in the 1960s, has been proposed as a major contributor to what has been called the “criminalization of the mentally ill.” As a result, the current estimated prevalence of people with mental illnesses in jails or prisons is 14 to 31 percent, depending on demographics, community treatment supports, and state statutes (Fellner 2014; James and Glaze 2006; Steadman et al. 2000). Although it is not currently possible to identify a causal relationship between decreased availability of treatment resources and increased calls for service, it is logical to deduce a connection, and various research has identified a correlation (NAMI 2018b). The reality has become, as noted earlier, that law enforcement field officers are regularly encountering those with mental illnesses (and even more regularly encountering those with substance problems), which is contributing to the growing percentages of those with mental illness and CODs being incarcerated.
Negative impacts associated with incarcerating people with mental illnesses
The oft-cited 2006 Bureau of Justice Statistics report (James and Glaze 2006) stated that only one-third of inmates reported receiving mental health treatment in state prisons and a much lower percentage (17.5 percent) of those incarcerated in jails reported having received mental health treatment. In addition, a study done in Michigan found that 65 percent of inmates identified as having a severe mental illness had not received mental health treatment services in the past year (Fries 2010).
A number of other issues and problems have been reported related to the incarceration of people with mental illness. There is disagreement in the professional literature over the frequent claim that inmates with mental illness are incarcerated for longer periods of time than neurotypical inmates. However, the most common findings are somewhat dependent on the type of crimes for which inmates with mental illness serve extended sentences, as compared to those without mental illness (Bailargeion et al. 2009; Harris and Dagadakis 2004; Greenberg and Rosenheck 2014; James and Glaze 2006).
Inmates with mental illness have also been subjected to higher levels of sexual abuse while incarcerated, a higher number of disciplinary infractions than those without mental illness, and higher recidivism rates (Gibbons and Katzenbach 2006; Fellner and Abramsky 2003; National Prison Rape Elimination Commission 2009).
In conclusion, mental illness is a complex problem with many variables, which is difficult for even scientific professionals—even psychologists and psychiatrists—to understand completely. For that reason, arriving at an operational definition of mental illness that provided context was necessary to make this publication and its content clear.
The impact of reduction in treatment resources for people with mental illness, particularly SMI, over the past several decades has certainly contributed to the number of people with mental illness who have been contacted by law enforcement field officers and the corresponding increase in people with mental illnesses who are involved in the criminal justice system and incarcerated. Law enforcement is on the front lines of interacting with people with mental illness (including substance users and those with CODs) and should have resources for diverting those with mental illness and CODs into environments where they can receive the treatment they need. As this occurs, people with mental illness (those whose primary reason for law enforcement contact is the direct effects or sequelae of mental illness) will be able to avoid ongoing involvement and entanglement with the criminal justice system.
Diagnosis and treatment of people with mental illness should not be a primary or even significant portion of the duties of law enforcement field professionals. As is the case with substance abuse and mental health problems (or CODs), crime and mental health problems must be recognized as interrelated but separate problems. Individuals with other mental health problems become addicted to alcohol and drugs and then continue to use those substances addictively because of the nature and effect of the addiction—not solely because of the mental health problems they experience. Similarly, individuals with mental health problems commit crimes for a host of reasons that may be unrelated to the symptoms or effects of mental illness. Criminal behavior has multiple determinants and can be either the direct or indirect result of the symptoms of mental illness. However, criminal activity can also be perpetrated by an individual with a mental illness because of criminal determinants and in the absence of clear symptoms or effects of a mental illness.
This report identifies a number of jurisdictions that are developing, identifying, and implementing specific programs and processes for reducing the involvement of people with mental illnesses in the criminal justice system. It is hoped that other agencies can review these programs, identify elements that are appropriate for them, and implement with the idea of contributing to a national reduction of people with mental illnesses in the criminal justice system and a corresponding increase in proper and effective treatment for those who are among the most vulnerable in our society.
The goal of this project was not only to acknowledge the presence and reality of mental illness in our society as it relates to law enforcement but also to draw attention to the increasing number of individuals with mental illnesses who commit crimes. Another goal is to estimate the scope of the problem of people with mental illnesses encountering the criminal justice system based on information by the MCSA respondents. A final major objective was to describe successful efforts to divert people with mental illnesses from the law enforcement system and assist them in moving toward recovery and reclamation of their lives.
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