Doubl JeopardyPersons with Mental Illnesses in

the Criminal Justice System

A Report to Congressfrom the

Center for Mental Health ServicesSubstance Abuse and Mental Health Services Administration

Public Health ServiceU.S. Department of Health and Human Services

Rockville, MD

February 24, 1995

Acknowledgments

The willingnessofso manypeopleto give generouslyof their timeandexpertiseto readdraftsof thisreportandto committheirreactionsto paperis a majorreasonthatthisreportissocomprehensive,yet incisive.ThestaffsofCMHS andNIMH throughthe IntemalWorkingGroupprovidedtheoriginalimpetus.The 44 membersof the Ad HocWorkingGrouponPersonswithMental IllnessesintheCriminalJusticeSystemprovidedawide rangeof ideasandviewsthat heavilyshapedthe finalproduct.Throughthem,consumerandfamilyperspectiveswere vigorouslypresentedalongwiththeviewsof mentalhealthandcriminaljusticeprofessionalsthatoftenare the only onesconsideredon theseissues.

Muchof theorganizationandwritingof thisreportwasdoneby BonitaM.Veysey,Ph.D.,andHenryJ. Steadman,Ph.D., of PolicyResearchAssociates,Inc.,and SusanSalasinofCMHS. SusanMilstreyWellseditedand formatted the final draft.

Table of Contents

ExecutiveSummary ...................................................................................i

Preface.........................................................................................................1

Background......................................................................................1The Scope of the Report...................................................................2

CHAPTER 1: The Human Face of the Problem ........................................4

PeopleWho Have BeenThere .........................................................4Two Complex Systems.....................................................................7

CHAPTER 2: The Changing Context of Care ............................................8

Background......................................................................................8ShiftingResponsibilitiesfor Mental HealthServices .........................8The Changing Criminal Justice System..........................................10The Recent Impact of the Advocacy Movement .............................11ProfessionalGuidelines..................................................................14The Legal Context ..........................................................................15A Diverse Population......................................................................16

CHAPTER 3: The Nature of the Population ............................................17

A Diverse Group .............................................................................17Most Persons with Mental IllnessesAre Not Violent .......................18ConsensusStatement on Violence and Mental Disorder:Public Perceptionsvs. Research Findings......................................20Persons with Special Needs...........................................................21NeededServices ............................................................................25

CHAPTER 4: Definingthe Needs of Persons with Mental Illnessesin the Criminal Justice System................................................................26

Background....................................................................................26Policeas FrontlineMentalHealthDecisionMakers........................28LockupsandJailsas CommunityInstitutions.................................31Prisonsas ContainedCommunities................................................34ProbationandParole:UnchartedTerritory.....................................38Diversionto CommunityServices...................................................41PlanningCooperativeEfforts..........................................................42

CHAPTER 5: Solutions That Work ..........................................................43

Bardersto ProvidingCare...............................................................43Core PlanningPdnciples................................................................43EffectivePolice/MentalHealthInteractions.....................................46

NotableProgram:MontgomeryCounty,Pa.,EmergencyServiceProgram..............................................50

MentalHealthInterventionsinJailsand Lockups...........................52NotableProgram:SummitCounty,Ohio,JailADAPT Program.................................................................56

MentalHealthInterventionsinPrisons............................................58NotableProgram:NewYorkState PrisonMentalHealth Program..................................................................63

MentalHealthInterventionsfor Personson Probationand Parole.....................................................................................65

NotableProgram:OregonSpecialNeedsReleasePlanningProgram...............................................................70

Diversionto MentalHealthProgramsintheCommunity.................72NotableProgram:HonoluluJailDiversionProgram............73

References................................................................................................75

APPENDIX: CMHS Ad-HocWorkingGroupfor MentalHealthandCriminalJusticeSystems

Executive Summary

On October 1, 1992, the Center for MentalHealthSen/ices (CMHS) wasestablishedas part of the ADAMHA ReorganizationAct (42 U.S.C.290bb-31). This law requiresCMHS to produce a report to Congressconceming

"...the most effective methodsfor providingmental health servicesto individualswho come into contact with the criminal justicesystem, includingthose individualsincarcerated in correctionalfacilities (including localjails and detention facilities),and theobstaclesto providingsuch services."

Current Status Personswith mental illnesseswhocome intothe contactwith the criminaljusticesystemare particularlyvulnerable.Theybeara doubleburden:thestigmaassociatedwiththeirmentalillnessandthestressof potentialarrestand confinement.Involvementwiththecriminaljusticesystemmayexacerbatethe isolationanddistrustoftenassociatedwithmentalillnesses.

At thesametime, individualswithmentalillnessespresentspecialproblemsto the criminaljusticesystem.Lackofknowledgeaboutmentalillnesseson thepartof lawenforcementandcorrectionsstaff,andashortage of appropriatementalhealth sewices, may mean that theseindividualsare left untreatedwith symptoms that may worsen.Although it isin the best interestof all concemedto provide effective mental healthtreatment for persons in the criminaljustice system, many obstacles standin the way of providingappropriatecare, including:

• lackof knowledgeon the partof law enforcementand correctionspersonnelabouteffectivementalhealthprogramsandhowto accessthem;

• lackofunderstandingonthepartof thementalhealthsystemaboutthedemandsandconstraintsof the criminaljusticesystemand anunwillingnesstoworkwithclientswithcriminalchargesorrecords;

• lackofcross-trainingamongcorrections,lawenforcement,and mentalhealthpersonnel;and

• lackofcoordinationamongthecriminaljustice,mentalhealth,andsocialservicesystems.

Inadequateor inappropriateinformationand fragmentedservicescan resultin persons with mental illnesses receiving no services at all or receivinginappropriatetreatment, includingarrest and jail, becauseworkingaltemativesdo not exist in the community.To address the unmetneeds ofpersonswithmental illnesses in the criminal justice system, the Center forMental HealthServices, a component of the Substance Abuse and MentalHealthServices Administration,one of the eight Public HealthServiceagenciesin the U.S. Departmentof Healthand Human Services, waschargedwith the responsibilityfor preparing this report.

The Changing Dramaticchanges inthementalhealthservicedeliverysystemin thiscountryhaveoccurredoverthe last 30 years. Promptedby the

Context of Care developmentof new medications,changingtreatmentphilosophies,theactivismof thecivilrightsmovement,andsignificantnew Federalfundingfora nationwidenetworkof communitymentalhealthcenters,thenumberof patientsinState hospitalsdeclinedfrom560,000 in 1955 to 100,000in1989 (NationalInstituteof MentalHealth,1991).

These changescaused the loss of State-operatedinpatientbedsandresulted in a blurtingof fiscal and administrativeresponsibilitiesfor the careof personswith severe mental illnesses,as well as a growing fragmentationin service provisionas the number and breadth of service providers,bothinpatientand outpatient, increased.

In 1992, the FederalTask Forceon Homelessnessand Severe MentalIllness reportedthat, in many communities,services to personswith mentalillnesses aredeliveredby an often complex and disconnectedset ofbureaucraciesthat are difficult for individuals and their caregiverstonegotiate. Housingis a particular problemfor this population. In 1992,about5 percentof the nearly4 million personswith severe mental illnessesin the U.S. were estimatedto be homeless at any given time.

At the sametime, the criminaljustice system has also undergonemajorchanges. In 1993, the Bureau of Justice Statistics reported that in the lastdecade, the U.S.jail populationon any day increasedfrom 158,394to444,584.Similarly, the prison population increasedfrom 329,000 to824,133 in the same period.Fully 2.3 percent of the U.S. adult population isin jail, in prison,or on paroleon any day, giving the U.S. the world's highestincarcerationrate.

Burgeoning U.S. correctionspopulationsare due to several policy changes,includingthe generallyharshersanctionsresultingfrom the policyof"gettingtoughoncrime"andthemorerecent"war on drugs."Inaddition,stifferpenaltieshavebeenimposedthroughsentencingreformlegislation.

Asjail and prisonpopulationsincreased,andthenumberof personswithmentalillnesseslivingat the fringeof theircommunitiesrose,theabsolutenumbersof personswithmentalillnessesinjailsand prisonsalsoincreased.Exacerbatingtheproblemisa highdegreeof co-morbidityofseverementalillnessesandsubstanceusedisordersamongjail and prisoninmates.

In its1992 report,Crimina/izingthe SeriouslyMentally I/1:TheAbuse ofJails as Mental Hosp#a/s,theNationalAlliancefortheMentallyIII (NAMI)foundthat:

. 29 percentof jailsthatrespondedto a NAMIsurveyholdpersonswithseverementalillnesseswithoutanycriminalcharges;

. 20 percentofjailsthatrespondedhavenomentalhealthservices;and

. 46 percentof jailsthatrespondeddo notknowwhetherpersonswithmentalillnessesreleasedfromjailreceiveoutpatientmentalhealthservicesuponrelease.

As thenumberof jail detaineesand prisoninmatescontinuesto growat analarmingrate,an enormousstrainis placedon theresourcesof theseinstitutions.There hasneverbeena greaterneedfor resourcesdevotedtomentalhealthcare inthesefacilities.

A Heterogeneous Personswithmentalillnessesare a heterogeneousgroup.They are menandwomenof differentages,culturalandethnicbackgrounds,and sexualGroup preferences.The effectsof theirmentalillnessesrangefrompsychosis,to

severedisruptionsinemotions,andfunctionalimpairmentintheirabilitytorelateto othersor sustainwork.Allof thesefactorsmustbe consideredwhendevelopingmentalhealthprogramsinthecommunityand inthecriminaljusticesystem.

One prevalentmythaboutpersonswithmentalillnessesis thattheyareproneto violence.The fact isthatmostpersonswithmentalillnessesareno morelikelythanthegeneralpopulationto commitviolentacts.

Allpersonswith mentalillnesseswhocome into contactwith the criminaljustice system havespecial needs.Yet special populationswithin thisgroup, including people withco-occurringsubstance use disorders,women,ethnic and racial minorities, homelesspersons, persons with HIV/AIDS, andyouth, warrant particular attention.

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Needed Services Servicesfor personswithmentalillnesseswhocome intocontactwiththecriminaljusticesystemare criticalandcan be developedwithoutsubstantialnew funding.Muchof whatis requiredisrethinkinghowto addresstheseproblems.Thedevelopmentof specificservicesto personswhocome intocontactwithpolice,whoare incarceratedinjailsor prisons,orwhoaresupervisedinthecommunitybyprobationor paroledepartments,canbehelpedgreatlybytheadoptionof coreplanningprinciples.

Many recentanalysesof mentalhealthservicesforunderservedpopulationsappropriatelyhaveemphasizedtheneedfor collaborationbetweenprivateandpublicsectorsand, intum,amongthe local,State, andFederallevelsofgovemment.The coreplanningprinciplesemphasizetheneed forcomprehensiveand integratedservicesat theclientandsystemlevels,withparticularfocuson theneedfor communitycollaboration.

The criminaljusticesystemhasdifferingresponsibilitiesfor individualswithmentalillnessesat keycontactpoints.Lawenforcementofficersmustdecidewhethertoarrestan individualwhois incrisisoris creatingadisturbanceor totransporthimor herto a mentalhealthfacilityfortreatment.Servicesthatmakethispossibleinclude24-houremergencymentalhealthtreatmentfacilities,mobilecrisisteamsthatcan assistintheresolutionof the incident,transportation,and staffwhocan waltwithanindividualfor an evaluation.

At Iockupsand jails,thesafetyof thedetainee,otherinmates,andcustodialstaffisthekey issue.Half ofalljail inmatesleavewithin24 hours.Keyservicesat thispointincludeidentificationof personswith mentalillnessesthroughroutinescreeningandfollow-upevaluations,and stabilizationof theindividualthroughcrisisinterventionservices.Inaddition,to facilitatethemovementof personswithmentalillnessesbackintothe communityorto aprisonsetting,dischargeplanningand case managementservicesareimportant.

Prisonsarecontainedcommunities;inmateswithmentalillnesseshave therightto treatmentto improvethe qualityof theirlivesandto allowthemtoserve theirtimehumanely.The optimumlevelof availableservicesshouldduplicatethebestthatis availableinthecommunity,witha fullrangeofinpatientand outpatienttreatmentsandmodalitiesavailableto allinmates.

Personsundercommunitysupervision(i.e.,probationor parole)also needa fullrangeof mentalhealthservices.Theseservicesshouldhelpmaintainpersonswithmentalillnessesinthecommunity,keepsymptomatologyto aminimum,and reducethe risksof recidivism.

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Diversionprogramshave been hailed as an importantservice forindividualswith mental illnesseswho do not belong in jail. Such individualsneed to be diverted from jail, either before arrest or after booking, to acontinuumof mental health and other community supportservices thatincludesoutreach,case management,crisis intervention,housing,vocational training, and family support.

A Place to Begin The problemsdiscussedin this reportarecomplexand multifaceted.Nosinglesolutionor programwilladdresstheneedsof allpersonswithmentalillnessesinthecriminaljusticesystem.However,thematerialcompiledprovidesa placefor Federal,State,andlocalofficials,policymakers,mentalhealthand correctionspersonnel,researchers,andadvocatesto begintalkingabout,and planningactionto achieve,effectivesolutions.

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Preface

Background On October 1, 1992, the Centerfor Mental HealthServices(CMHS) wasestablishedas part of the ADAMHA ReorganizationAct (42 U.S.C.290bb-31).This law requiresCMHS to producea report to Congressconcerning "the most effectivemethods for providingmental health servicesto individualswho come into contact with the criminal justice system,includingthose individualsincarcerated in correctional facilities (includinglocal jails and detentionfacilities),and the obstacles to providingsuchservices."

To define the objectivesassociatedwith this goal, an intemal CMHSworkinggroup identifiedfour primaryareas of attentionas suggestedby thelanguageof the ReorganizationAct. They are:

• (Identifyingthe) ... most effective methods for providing mental healthserv/ces. Individualswithmentalillnesseswhocomeintocontactwiththecriminaljusticesystemmaybe divertedintothementalhealthsystemortreatedwithinthecriminaljusticesystem.InforrnatJonmustbeavailableonthe rangeandtypeofmentalhealthservicesneededbyindividualsbothinthecommunityandinthecdminaljusticesystem,thehumanandfiscalresourcesneededto supporttheseservices,and theanticipatedoutcomesof anyinterventionforthecdminaljusticesystemandforthe individualsinvolved.Lawenforcementagenciesand localjailsmustbeseenas anintegralpartofcommunity-basedcareforthispopulation.

• (Providingtheseservices)... to individuals who come into contact withthe criminal justice system. Personswithmentalillnesseswhocomeintocontactwiththecriminaljusticesystemarea heterogeneousgroup.Tounderstandtheirneeds,a completediscussionofthisissuemustfocusonthespecificcharacteristicsof thispopulation,includingthedegreeofsevedtyof mentalillness,typesof crimescommitted,typicalprecipitatingevents,andthespecialneedsof subgroupswithinthepopulation,suchaswomen,homelesspersons,andpersonswithco-occurringsubstanceusedisorders.

• ...including those individuals incarceratedin correctional facilities(including local jails and detention facilities). Thereare manypointsthroughoutthecriminaljusticesystemwherepersonswithmentalillnesseswill beidentified,includingpolicecontacts,locallyoperatedIockupsandjails,prisons,andcommunitysupervision(probationand parole).Theresponsibilitiesof the criminaljusticesystemfor persons withmentalillnesses,and the needsof such individuals,will vary at each pointthroughoutthe system.Thesemustbe identifiedand clearlyunderstoodbyprovidersin both the mentalhealthand criminaljustice systems.

• (andidentifying)... the obstacles to providing such services. Obstaclesto providingappropriatecare for personswith mental illnessesin thecriminaljustice systemincludehumanand fiscalconstraints,organizationalownership(turf) issues,lackof knowledgeon the part of the cdminaljusticesystem abouteffectivementalhealthprogramsand how to implementthem, and lackof understandingon the partof the mental healthservicessystemaboutthe demandsand constraintsof the criminaljustice system.These barriersmust be identifiedand ways to overcomethese barriershighlighted.

To insure that this report representsthe rangeof issues and concems ofthe manyconstituents involved, CMHS convenedthe Ad Hoc WorkingGroup for Mental Healthand CriminalJustice Systems consistingofconsumers,family members,mentalhealth providersto jails and prisons,law enforcementand correctionsadministrators,Federal and State criminaljustice and mental health agency representatives,and a number ofnationally knownconsultants (see the Appendixfor a list of participants).The Ad HocWorking Groupmet in July 1993 to discuss the major issuesrelatingto the report and to recommendmethods to implement modelservice programs.The group alsorevieweddrafts of this report and offeredmany suggestedchanges that are reflected herein.

The Scope of Thisreportcontainsfivechapters.ChapterOne, 'q'heHuman Face of theProblem,"presentsan overviewof the issues.ChapterTwo,"The Changingthe Report Context of Care," providesa briefhistoryof policyinthisarea, including

discussionsof theorganizationof mentalhealthservicesinthiscountryandchangesinthe criminaljusticesystemthatimpactpersonswhohavementalillnesses.The characteristicsof personswithmentalillnesseswhocomeintocontactwiththecriminaljusticesystem,includingseveralsubgroupswithspecialneeds,are discussedinChapterThree, 'q'heNatureof thePopulation."

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Chapter Four,"Definingthe Needs of Personswith Mental Illnessesin theCriminal Justice System,"discussesthe needs of persons with mentalillnesses at each stage of the criminaljustice system, including policecontacts, jails, prisons,and probation and parole, and outlines theresponsibilitiesof, and challengesto, the criminaljustice system at eachcontact point.Finally,coordinatingessential mental health servicesforpersonswith mental illnessesin the criminaljustice system, includingexamples of successful programs,are presentedin Chapter Five,"SolutionsThat Work."

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CHAPTER 1The Human Face ofthe Problem

People Who Statisticsalonecan neveradequatelyrepresentthe concemsof personswithmentalillnessesinthecriminaljusticesystem.UstentothestoriesofHave Been thosewhohavebeenthere.

ThereJamesJames had been in an Ohio cityjail for six months. During that time, he wastreated for depressionand stabilizedwell. He had little family support in thecommunity,and he wassomewhat uncomfortableabout his prospectswhen the time came for his release.Because of this, mental health staffwithinthejail made concrete releaseplans withhim.

Thestaff madean appointment for him at the localmental health centerthat was withina few hours of his scheduled release time. He did not,however, receive a supply of, or a prescriptionfor, the antidepressantmedicationhe was treated withduring incarceration.

James kept his appointmentat the mental health center. However, he wastold that he could not get medication for at least two weeksbecause thepsychiatrist'sschedule was full until then. Whenhe asked about housing,he was told to come back the next day.

Thatnight,James committedsuicide.

MichaelThefamily of a youngman from a rural county in upstate New York calledthe police to assist their son. Michael wasacting strangelyand refused togo to the hospital. Whena State trooper respondedto the call,Michaelgrabbed the officers weaponand attempted to shoot him with it. Thetroopersubdued Michael and arrested him. He wascharged with attemptedmurder and taken tojail.

Theforensicmanta/health coordinatorevaluatedMichael upon entry intothe facility.At the time, he wasexperiencingpsychotic symptoms. He had aprevious diagnosis of schizophreniabut had not been taking his prescribedmedication.He had also been using some marijuana and was hearingvoices tellinghim to kill.

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Michael was transferred within24 hours to an inpatientpsychiatrichospitalwith whichthe county contracted for services. He spent three months there.Whenhe was retumed to thejail, the forensiccoordinatorhad negotiatedwith the districtattorney,Michael'spublic defender,and the countyjudge toreduce the sentence, in considerationof a plan for mentalhealth treatmentand communitysupervision.

Michael was sentencedto 6 months injail and 5 years of probation, whichrequired him to continue to receive mental health treatment.For goodbehavior and the timehe spent in the forensichospital,Michael served onemonth in the countyjail.

Whilehe was in jail, Michael continued to receive mental health treatment,and plans weremade for his discharge.He wasassigned an intensive casemanager who met withhim and coordinatedhis service needs beforerelease.Close communicationbetweencommunitymental health staffandthe probationofficer guaranteedcontinuity of care for Michael and helpedincrease the likelihood that he wouldbe able to function in the community.

Michael has required two brief hospitalizationsin the last 5 years, but hehas not had any further.contact with the police. He recentlymoved out ofhis family's home into supportedhousingand is employedby a shelteredworkshop.

GraceGrace is a 60-year-oldwidow who lives alone in a suburbanPennsyivaniatown. For severalyears she has been calling the local police to tell themthat people werebreaking into her house and that someone was harassingher. Recently thepolice began to receive complaints from Grace'sneighbors. Thelast time, Grace had apparently gone to a neighbor's houseand threatenedtheir children,even grabbingone and twistinghis arm.

Whenthe police were called for this incident, they felt they had to arrestGrace. Before doing this, however, they calleda mobile mental health crisisteam. Theoutreach workerswho respondedmet withGrace, the police,and the neighbors. Theyalso contactedAging and Adult Services andlocated a relative.

The crisis team consideredhaving Grace committed to an inpatient facility.She waspsychotic, her home was filthyand in disarray,and she was verysuspicious of the team. However, the mental health outreach team andAging and Adult Services agreed to work with Grace.

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Over the next few weeks, the outreachteam visited Grace several times.She came to trust the workersand disclosedthat she had beenhospitalizedin the past and that she had had a drinkingproblem. With thecoordinatedeffortsof the mental health team and Aging and Adult Servicesprovidingher withsupportand homecare assistance, Gracestabilized, andher home is in orderagain. Therehavebeen no calls to the police and nocomplaints from the neighbors.

StevenTwoyears ago, a young male veteranarrived in Honolulu from Californiaestranged from his familyand broke. He had a diagnosis of paranoidschizophrenia. Withinthree months,he had amassed 11arrests for minormisdemeanorcharges.

Each time Steven wasarrested, he wasseen by thejail diversionprogram,which attempted to connecthim to the VeteransAdministration (VA) office.However, Stevenproved to be very resistant to treatment.On his eleventharrest, thejail diversionprogramdirectorconfronted Steven, tellinghim hemightbe facing lengthyjail time if this situation continued.

WithSteven'spermission, theprogram directorcontacted Steven's father,who admitted he was reluctantto have his son return home becauseherefused treatmentand caused such disorder in the family's life. However,given his failuresto function in Honolulu, the father agreed to work with theprogram director to developa plan for Steven's retum home.

Theprogram directorcontactedthe local VAprogram in Steven'shometown, whichagreed to takehis case and to be with the father at theairport when his son arrived.Theprosecutor and the program directoragreed that chargesshould be dropped,and the program director appearedin court on Steven's behalf to explain the situation. Thejudge dismissedallcharges withprejudice,which means that the charges will remaindismissedas long as Steven does not return to Honolulu.

One of the stipulationstheprogram director made was that he had to hearfrom Steven or his father at two month intervalsuntil further notice. Thefather was reliableaboutchecking in, and the notificationperiod wasextendedto six months.

After Steven wasback in California, the father called the program directorto thankhim. "ThankGod for the diversionteam," the father said. "Not onlydid my son come home,but he is in treatment right now. He is doingjustfine." That was twoyears ago, and Steven is still doing well.

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Two Complex Thestoriesof James, Michael, Grace, andSteven are compellingevidenceof the need for communicationbetween the mental health and criminalSystems justice systemsand forcollaborationto meetthe needsof personswith

mentalillnesses.Suchcollaborationcontributesto thesmoothoperationofthecriminaljusticesystemandpromotescontinuityof care for personswithmentalillnesses.Michael,Grace,andStevenbenefitedfromsuchcollaborativeefforts;James'suicidewas a catalystfor increasedcommunicationand cooperationbetweenjail andmentalhealthstaff.

To betterunderstandtheproblemsthatexistatthe intersectionof thesetwocomplexservicesystems,ChapterTwolooksat thechangingorganizationof mentalhealthservicesinthiscountryand atthedevelopmentof policyconcerningthe responsibilitiesof the criminaljusticesystemwithregardtopersonswhohavementalillnesses.

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CHAPTER 2The Changing Contextof Care

Background The Governorof Virginiaexpresseddismaythathe was "forced toauthorizetheconfinementof [personswithmentalillnesses]in theWilliamsburgjail,againstbothhisconscienceandthe law"becauseof lackof appropriateservices.Thisoccurredin 1773 (Deutsch,1937).

Morethan200 hundredyearslater,we arestillfacedwiththesameproblem.The languagehaschanged,butthe issuesremain.TheyexistedincolonialVirginia;in19thcenturyNewYork,wherethe 1894 LunacyCommissionconcludedthatthe presenceof personsconvictedof cdminaloffensesincivilhospitals"wasvery objectionableto theordinaryinmates"and, therefore,a maximumsecurityhospitalforthecriminallyinsaneshouldbebuilt(SteadmanandCocozza,1974);andtodayinFlatheadCounty,Montana,wherethe localjail routinelyacceptspsychiatricemergencyadmissionsintheabsenceof anycriminalcharges(Torrey,et el., 1992).

Overtheyears,variousmovementsand reformshaveattemptedto solvetheproblem,butperiodicallythe issueof personswithmentalillnessesinournation'sprisonsandjailsworsens.Policychangesoverthe last30yearsin boththementalhealthandcriminaljusticesystemshavecreatedconditionsthathaveexacerbatedtheproblemof personswith mentalillnessesinthe criminaljusticesystem.

Shifting Over the last30 years therehavebeendramaticchangesinthe mentalhealthservicedeliverysystem.These includethedeclineof theStateResponsibilities hospital,thegrowthof communitymentalhealthcenters,theexpansionoffor Mental the use of psychiatricservicesingeneralhospitals,the transferof large

numbersof personswithseverementalillnessesto nursinghomesandHealth Services boardandcarefacilities,anda dramaticrise inthenumbersof personswith

mentalillnesseswhoare incarceratedor homeless.

Inthe past,a personwithseverementalillnesscouldexpectto spendmostof hisor her lifeina State-operatedpsychiatricfacility.Now,personswithmentalillnessescan liveinthecommunitywithmentalhealthsupports.Withthe locusofcareshiftingaway frominpatientservices,personswithmentalillnesseshaveaccessto a largernumberof mentalhealthservicesandprovidersanda widerrangeof programs.

These changeshave notalwaysproducedpositiveoutcomes.The reformeffort knownas deinstitutionalizationwas begun in the late 1950sand early1960s,spurred in part by the advent of effective psychotropicmedicationsand by changes in treatment philosophies.

During this time many long-term inpatientswere released from psychiatricfacilitiesto community-basedcare and living situations.At the same time, arelated policyof diversionwas begun that discouragedhospitalizationandencouragedaltematives to inpatientcare. The Federal Govemment,through the Community Mental Health CentersAct of 1963, reinforcedthese generalpolicies by fundingthe development of comprehensivecommunity-basedmental health services.

In addition, the creation of the Medicaidprogram further promoted the shiftof care from State psychiatriccentersto the community, most importantly tonursinghomes and general hospitals. Further, the SupplementalSecurityIncome (SSI) and Social Security Disability Insurance(SSDI) programsprovideddirect assistanceto personswith severe mental illnessesliving inthe community.

One outcome of these policieswas a reductionacross the nation of theState hospital inpatientcensusfrom 560,000in 1955 to 100,000in 1989(National Instituteof Mental Health, 1991). But these changes resulted inmore than simply the loss of State-operated inpatientbeds.They alsoresulted in a blurringof fiscal and administrativeresponsibilitiesfor the careof personswith severe mental illnessesand a growing fragmentation inservice provisionas the number and breadth of service providers, bothinpatientand outpatient, increased.

Several Federally sponsored partnershipshave been developedto addressthe fragmentation and lackof coordinationamongservice providersandfunders, includingthe National Instituteof Mental Health CommunitySupportProgram, begun in 1978,that establisheda single point ofresponsibilitywithin each State for the coordinationand care of personswith severe mental illnesses.The Mental HealthSystems Act of 1980outlined the need for the creation of FederaVState/Iocaialliancesto developcomprehensiveand coordinatedcommunity-basedcare for persons withsevere mental illnesses.

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Fundingcutbacksduringthe past decadehave resultedin systems-levelchanges in the provisionof mental health services. In many communities,that hasmeantthe net redu_on of servicessuch asemergencymentalhealthcare. Certainly,inadequatefundingisone factorassociatedwith the increasednumbersofpersonswithmentalillnessesinthe criminaljusticesystem.Butequally, if not more,importantisthe lackof appropriatesewices, and theunwillingnessof manycommunityprovidersto targetservicesto thoseindividualswiththe mostserious mentalillnesses,includingthoseinvolvedwiththe criminaljusUcesystem(Torreyet al., 1992).

One of the consequencesof the loss of 24-hour mental health emergencyservices is the arrest and incarcerationof personswith mental illnesses incrisis. In communitieswith few mental health resources,jails often havebecome the default psychiatricfacilities (Torrey,et al., 1992).Jails are open24 hours a day, and a personwho is charged with a crime cannot berefused admission regardlessof his or her mental or physicalcondition.

While the mentalhealth servicesystem is strugglingto developacost-effectivemodelthat providescare to all persons with mental illnesses,that is easy to access and negotiate,and that is accountable, bridgestoother systems are also being built. Like the mental health system, thecriminal justice system has also undergonemajor changes in recentyears.

The Changing In the last decade,the U.S. jail populationon any given day has increasedfrom 158,394to 444,584 (U.S. Department of Justice, 1993). Similarly, the

Criminal Justice prison population in the same period has increasedfrom 329,000to

System 824,133 (Bureau of Justice Statistics, 1993). Fully 2.3 percentof the U.S.adult populationis in jail, in prisonor on paroleon any given day, giving theU.S. the world's highest incarcerationrate.

Burgeoningcorrectionspopulationsare a product of several policy changesin the U.S., includingthe generallyharsher sanctions resulting from thepolicy of "gettingtough on cdme" and the more recent "war on drugs." Inaddition,stiffer penaltieshave been imposed through sentencing reformlegislation.

Changing philosophiesregardingthe purpose and goals of punishmenthave led manyStates toward presumptivesentencing--"an offense-basedsentencingsystem with clearlydefined punishments for specific illegalactivities"(Clear et al., 1993).These statutes take much of the discretionarypower out of the handsof judges and place it the hands of the legislatures.

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Presumptivesentencingstatuteshave beenpassedin20 States (Byme,1992). The prisonpopulationhasdoubledinthe lastdecadein largepartbecauseof reformsthat requiremandatorysentencingfor drug,sex anddrivingwhileintoxicatedoffenses.

In addition,presumptivesentencingaffectsparolereleasedecisionsbyestablishingmandatoryminimumlengthsof incarcerationfor all offenses.Stateswiththesestatutesmustreleaseindividualswhentheyhaveservedtheirminimumtermminustimefor goodbehavior.Thesepersonsaredischargedto communitysupervision.In 1977,only6 percentof the totalreleasesto thecommunitywere supervisedmandatoryreleases,butby1990 thisfigurehadgrownto nearly30 percent.At thesametime,traditionaldiscretionaryparolereleasesdroppedby31 percent(BureauofJusticeStatistics,1991).

Clearly,thenumberof jail detaineesand prisoninmatescontinuesto growat an alarmingrate.Thisgrowthplacesan enormousstrainon theresourcesof theseinstitutions.At thesametime,therehas neverbeen asgreata needfor resourcesto be devotedto mentalhealthcare inthesefacilities.Ukewise,paroleand probationpopulationsare alsoincreasing,requiringaccessto coordinatedmentalhealthcare deliveredbycommunityproviders.

The Recent Patients' rightsadvocates, includingconsumerand familygroups,havebeeninstrumentalinthe developmentofa nationalagendato addressthe

Impact of the needsof personswithmentalillnessesinthe criminaljusticesystem.Advocacv Severalof theseeffortsare discussedbelow.

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MovementPatients' Rights Litigation and the ConsumerMovementThe mentalpatients' rights litigationand the consumer advocacymovementhave their roots in the civil rights movement of the 1950s and 1960s.Thepoliticalactivism aroundthe civil rights,antiwar,and women's movementswas also highlycritical of the role of psychiatryin preservingthe status quo(Brown, 1985).The general distrustof psychiatrydue to its affiliation withthe "establishment"was focusedand targeted by consumers/survivors.Liberationgroupsin the 1960s and 1970s pointedto abuses of the systemexemplifiedby the warehousing of individuals,the excessiveuse ofseclusionand restraints,and forced medicationin State psychiatrichospitals.

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Key issuesinmentalhealthadvocacylitigationwerethe rightto treatment(e.g.,Rouse v. Cameron, Wyatt v. Stickney),the rightto refusetreatment(e.g.,Kaimowitz v. Department of Mental Health, Rogers v. Okin),safeguardson commitmentproceedings(e.g., Donaldsonv. O'Connor),and patientlabor(e.g.,Souders v. Brennan).Thesecases,amongothers,establishedtheconstitutionalrightsof personswithmentalillnesses.

Consumergroupshavegrownin recentyearsandnowplaya criticalroleinadvocacyandpolicy.Consumersnowparticipateintheprovisionofservices,includingoperatingself-helpgroups,actingas protectionandadvocacystaff,and providingdirectservicesas case managersandtherapists.In addition,consumergroupsare increasinglyinvolvedinthepolicyarena,conductingresearchandlobbying.The mentalhealthservicessystems,fromthe Federalto the locallevels,havebegunto see theimportanceof havingconsumerconsultantswhendesigningservices,researchandpolicy.Consumergroupshavea uniqueperspectiveonmentalhealthservicesandwill continueto havean impactonissuesrelatingto personswithmentalillnesses.

Family Member Advocacy GroupsTwo nationaladvocacyorganizationshavehada distinctimpacton personswithmentalillnessesinthe criminaljusticesystem:theNationalAllianceforthe MentallyIII(NAMI) and theNationalCoalitionfortheMentally IIIintheCriminalJusticeSystem(theCoalition).

Foundedin1979,NAMI isa nationalgrassrootssupportand advocacyorganizationforthe familiesandfriendsof personswith mentalillnesses.Thisorganizationcurrentlyhasmorethan140,000 membersand over1,000affiliategroupsrepresentingall 50 States.At thenationallevel,NAMIprovidespubliceducationand advocacyandoperatesa toll-freeHELPLINE.In addition,NAMI hasa ForensicNetworkthat advocatesonbehalfof personswithmentalillnesseswhocomeintocontactwith thecriminaljusticesystem.Specifically,theForensicNetworkprovidestechnicalassistanceto familiesand professionalsand lobbieson legislativeissueson boththeStateandnationallevels.

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NAMI,withthe PublicCitizen'sHealthResearchGroup,hassponsoredaseriesof studiesandreportson issuesaffectingpersonswithseverementalillnesses,includingWashington'sGrateSociety: Schizophrenics inthe Sheltersand on the Streets (1985), FiscalMisappropriations inPrograms for the Mentally II1:A Report on Illegality and Failure of theFederal ConstructionGrantProgram for CommunityMental Health Centers(1990), Careof the Seriously Mentally II1:A Rating of State Programs(1986, 1988, 1990),and Cnmina/izingthe Seriously Mentally II1:TheAbuseof Jails as Mental Hospitals(1992).

Thewidedistributionand prominenceof thislatterreport,Crimina/izingtheSeriouslyMentally/11,hasprobablydonemoreto focusattentionon thisproblemthananyothersingledocument.The impetusforthis reportcamefromNAMImemberswhoexpressedfrustrationoverthe circumstancesthatledto the incarcerationof familymembersandtheabusesexperiencedby individualswithmentalillnesseswhileinjail. The reportis basedoninformationsystematicallygatheredfrommentallyillindividualswho havebeen injail andtheirfamilies,anda mallsurveysentto all U.S. countyandmunicipaljails.Amongitsmostnotablefindingsare:

• 29 percentof jailsthat respondedholdpersonswithseverementalillnesseswithoutany criminalcharges;

• 20 percentof jailsthat respondedhavenomentalhealthservices;and

• 46 percentof jailsthatrespondeddo notknowwhetherpersonswithmentalillnessesreleasedfromjail receiveoutpatientmentalhealthservicesuponrelease.

The NationalCoalitionof the MentallyIIIintheCriminalJusticeSystemisanonprofitorganizationfoundedin 1989to dealwiththe growingnationalcrisisof increasingnumbersof individualswithmental illnessesordualdiagnoseswhoare inthecustodyof criminaljusticeagencies.WithmajorsupportfromtheCenterfor SubstanceAbuseTreatmentof SAMHSA,theCoalitionhasdevelopeda nationalagendato developeffectivemodelsforscreening,diverting,andtreatingthese individualsandto establishcomprehensivecommunity-basedsystemsof caretofacilitatetheirrehabilitation.

Throughtheuseof innovativenationalforumson jails,prisonsand thejuvenilejusticesystem,theCoalitionhas soughtto buildconsensusand todesignstrategicsolutionsto theproblemsitaddresses.Participantsintheseforumsarecorrectionsprofessionals,judgesandcourtadministrators,mentalhealthtreatmentproviders,legislativeleadersandpolicymakers,families,researchers,andrepresentativesof Federalagenciesthathave responsibilityfor thecareof these individuals.

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In additionto developinga knowledgebase, the Coalitiondisseminatestheinformation it gathers to those who can best use it. The Coalition hasdevelopedtwo reports of importanceto this field, Respondingto the MentalHealth Needs of Youth in the Juvenile Justice System (1992), and MentalIllness in America's Prisons. (1993).Both of these reportspresentinformationon state-of-the-artinterventionsto effectivelytreat or divertpersonswith mental illnesseswho come into contact with the criminaijustice system.

Professional The movementto improveconditionsinjailsand prisonshas beenaccompaniedby a commitmentto the improvementof healthand mental

Guidelines health care. The genesisfor the developmentof standardsof care camenotfromadministratorsnorfromStateor Federalgovemment,butratherfromprofessionalorganizations.The firstorganizationto publishstandardsof careforjailsandprisonswas theAmericanPublicHealthAssociation(APHA).

In 1976,APHA publishedStandards for Health Servicesin CorrectionalInstitutions.Whiledevotedprimarilyto generalmedicalcare, thestandardscontainedsixprinciplesfor adequatementalhealthcare,and representedan importantfirststeptowardthedevelopmentof comprehensivementalhealthstandards.The AmericanMedicalAssociation(AMA)publishedstandardsforhealthsewicesfor prisonsin1979 andforjails in 1981.Aseparatedraftof mentalhealthstandardswas alsodevelopedat thistime,butwas notpromulgated.

The firstcomprehensivestandardsfor mentalhealthcare incorrectionalsettingswere developedby theNationalCommissionon CorrectionalHealthCare.The Commissionwascomposedof 28 professionalorganizations,includingtheAMA, the AmericanBarAssociation,theAmericanPsychiatricAssociation(APA),and the NationalSheriffsAssociation.In 1987, theCommissionupdatedtheAMAstandards.Thisorganization'sprimarypurposeisto accreditprisonandjailservices,andthegroupalsofocuseson education,training,andresearch.

In 1982, theAPA createda Task Forceon PsychiatricServicesinCorrectionalFacilitiesto addressthespecificneedformentalhealthstandards.In 1989, the APA publishedthemostcomprehensiveset ofmentalhealthstandardsforjailsandprisonsthatcurrentlyexists.Manyofthe coreprinciplesandessentialservicesdiscussedthroughoutthis reportcomedirectlyfromtheAPA guidelines.

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The Legal Providingmentalhealthcareto personsinthe criminaljusticesystemmakessensefroma humanitarian,as wellas froma correctionalContext managementperspective.However,evenintheabsenceofthese

necessities,jailsandprisonshavea substantialconstitutionalobligationtoprovidea minimumstandardof care.The followingdiscussiondrawsheavilyon a reviewof case lawbyCohenand Dvoskin(1992).

While theconstitutionalgroundsfor the rightsof individualsdiffer forconvicted inmatesand unconvicteddetainees,what constitutes adequatecare is essentiallythe same. Thus, while the protectionof vulnerableinmatesand the proactive treatment of an identifiedserious psychiatricdisorder are required under Federal law, other issues such as staff training,who provides the serviceand where, the treatment modality, administrationof the jail and treatment staff, and reimbursementor payment methods arelocaland State decisions.

Cohen and Dvoskin (1992)state, "While the legal source of the right totreatment for inmatesand detaineesdiffers(cruel and unusual punishmentv. due process),the case lawmakes no substantivedistinctions in terms ofwhat must be provided. Obviously,there are differencesin service deliverysystems; for example,jails experiencemore short-termcrises and suicides,and fiscal and administrativerelationshipsmay vary. However, when thecourts addresswhat types of conditionsentitle which persons inconfinementto what type of medicalor psychiatriccare, the substantiveentitlementsare essentially the same."

Custodial facilities have both the duty to protectand the duty to treat aserious medical or psychiatriccondition.Case law in this area has definedthe extent of these duties as they affect personswith mental illnesses.

Duty to protect requiresa facility to providesafeguards so that theinmate/detaineeis no worse off in custodythan he or she was upon arrival.In addition to protectionfrom physicaland sexual assault, this also requiresthat the facilityprotect the individual from himself or herself.This includessuicide prevention and early identificationand crisis intervention services tokeep the individual'sconditionfromdeteriorating.

In addition, the duty to treat requiresthat the custodial facility attempt toalleviate knownsuffering. Once an individual is knownto be suffering froma severe mental illness, the facility is requiredto intervenethroughappropriatestaff and treatmentsas determined by general professionalstandards.

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A case in NewYork, Langleyv. Coughlin,actuallyprovidesa list of thespecificclaimsthat would indicateinadequate mental health care, and, inconjunctionwith deliberate indifference,could justifya conclusion that anindividual's rightswere violated under the Eighth and FourteenthAmendments(Cohenand Dvoskin, 1992):

• Failureto take a completemedical(or psychiatric)record.

• Failureto keepadequaterecords.

• Failureto respondtoinmates'psychiatrichistory.

• Failureto at leastobserveinmatessufferinga mentalhealthcrisis.

• Failureto properlydiagnosementalconditions.

• Failureto properlyprescribemedications.

• Failureto providemeaningfultrealmentotherthandrugs.

• Failuretoexplaintreatmentrefusal,diagnosis,andendingoftreatment.

• Seeminglycavalierrefusalsto considerbizarrebehavioras mentalillnessevenwhena priordiagnosisexisted.

• Personneldoingthingsfor whichtheyare nottrained.

Clearly,caselawindicatesthat the provisionof mentalhealthservicestopersonswithmentalillnesseswhocome intocontactwiththecriminaljusticesystemisnota luxury,buta constitutionalnecessity.

A Diverse Furthercomplicatingthe provisionof mental healthservicesto personsinthe criminaljusticesystemis theheterogeneousnatureof thepopulation

Population and the needsof such special groupsas women,persons of color,youth,and personswith HIV/AIDS or other dual disorders. The characteristicsofindividualswith mental illnesseswho come into contact with the criminaljustice system,and a discussionof their special needs, are discussed inChapter Three.

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CHAPTER 3The Nature of thePopulation

A Diverse Group Peoplecome intocontactwiththe criminaljusticesystemfor manyreasons.Onlya smallportionof themhaveacutementaldisorders,butthisgroupdemandsdisproportionateattention,bothbecauseof theirspecialneedsandbecauseof theproblemstheypose for lawenforcementandcorrectionspersonneland fortheproperadministrationof thecriminaljusticesystem.

Personswithmentaldisordersare a heterogeneousgroup.The effectsoftheirmentalillnessesrangefrompsychosis,to severedisruptionsinemotions,to functionalimpairmentsinthe abilityto relateto othersorsustainwork.They representdifferentages, gender,culturalandethnicbackgrounds,andsexualpreferences.They havea wide rangeofexperiencesandabilities,andthey liveinmetropolitan,suburbanand ruralareas.A few havebeenviolent;mosthavenot.Allof thesefactors mustbeconsideredwhendevelopingmentalhealthprogramsinthecommunityandinthecriminaljusticesystem.

Clearly,thereis anoverrepresentationof menand personsof color,particularlyAfricanAmericans,incorrectionalfacilities.Men represent morethan 90 percentof the jail and prison populationsin the UnitedStates.Further,nearlyhalf of all persons in U.S.jails and prisons are AfricanAmerican,while persons of Hispanicdescent represent 14 percentand 17percent of jail and prisonpopulations, respectively(Bureau of JusticeStatistics, 1993).

The magnitudeof this overrepresentationis clear when one considers thatonly 11 percent of the U.S. population in 1989 was African American,andall other non-White,non-Europeanethnic/racialgroups composed3percent of the U.S. population(U.S. Departmentof Healthand HumanServices, 1993).This fact, alone, has implications for mental healthservices provisionwithin the criminaljustice system in regardto suchfundamentalissues as languageand cultural diversity. In addition,somegroups,such aswomen and personswith HIV/AIDS,though representingonly a small percentageof the whole population,will require adisproportionateamountof attentionto their special needs.

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The currentdiagnosticmanualof theAmericanPsychiatricAssociation,The Diagnosticand StatisticalManual of Mental Disorders, Third Edition -Revised (DSM-III-R),listsapproximately300 identifiabledisorders.Thesedisordersvarygreatlyaccordingto the degreeof functionalimpairment,etiology,symptomatology,prognosisandassociatedtreatmentinterventions.The degreeof distressandtheabilityto adaptto situationswilldifferdependingon boththetype andseverityof thementaldisorder.

Thisreportfocuseson adults withmentaldisordersdefinedbyCMHS as:

someonewhocurrentlyorat anytimeduringthepastyear [has]hada diagnosablemental,behavioralor emotionaldisorderofsufficientdurationto meetdiagnosticcriteriaspecifiedwithinDSM-III-R, that resultedinfunctionalimpairmentswhichsubstantiallyinterfereswithorlimitsoneor moremajorlifeactivities(MentalHealthReport,June3, 1993).

Manymentalillnessesfollowa cyclicalcourse,allowingindividualstoachieveor returnto extremelyhighlevelsof functioningduringperiodsofremission.Withtreatmentandsupportsprovidedon a regularbasis,mostpersonswithmentalillnessescan functionwell incommunitysettings.

Most Persons The belief ina stronglinkbetweenviolenceandmentalillnessisfirmlyrootedinthemindsof manyU.S. citizens.It is importantto evaluatethis

with Mental belief objectivelybecausebeliefsdrivebothformalpoliciesand lawsandIllnesses Are behaviortowardpersonswithmentalillnesses,and, if sucha linkdoesexist

and canbe specified,programmodelsand interventionscan be designedNot Violent and implemented.

In fact, most peoplewithmentalillnessesare no morelikelyto beviolentthananyothermemberof the community.However,some individuals,as aresultof theirmentalillnessesat certaintimes,do presenta greaterrisk.Researchershave foundthatviolentbehaviorisdirectlylinkedto psychoticsymptomsregardlessof whetherthe individualhaseverreceivedmentalhealthservices(Link,1992),andthat personscurrentlyexperiencingpsychoticsymptomsmay beat increasedriskofviolence(Monahan,1993).

The recentNationalInstituteof MentalHealthEpidemiologicalCatchmentArea studyrevealedthat90 percentof personswithcurrentmentalillnessesarenotviolent.Thisfactalonerefutesthedominantmediarepresentationof mostpersonswithmentalillnesses.In fact, violentbehaviorof personswithmentalillnessesrepresentsonlya minorcontributionto all violentcrimes.Monahan(1992)statesthat:

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"comparedwiththe magnitudeof riskassociatedwith thecombinationof male gender,young age, and lowersocioeconomicstatus, for example,the risk of violence presentedby mental disorder is modest.Compared with the magnitude ofrisk associatedwith alcoholismand other drug abuse, the riskassociatedwith major mental disorderssuch as schizophreniaand affectivedisorder is modest indeed.Clearly, mental healthstatus makes at best a trivialcontributionto the overall level ofviolence in society."

For those who might become violentduring acute episodesof mentalillness,several altemativesare possible.For example,such approachesasconditional releaseand outpatientcommitmentshould be considered as away to compel cooperationwith a serviceplan for those persons who mightbecome violentwhen they do not complywith treatment.

In addition, IntensiveCase Managementprograms have shownconsiderablepromisefor helping this population(Dvoskin and Steadman,1994),and brief inpatient treatment or crisis stabilizationservices may alsobe warranted(Task Force on Homelessnessand Severe Mental Illness,1992).Clearly appropriate legal protectionsfor persons receivingvariousforms of community supervisionare necessaryso that individuals' rightsareproperly balancedwith the community'sright to protection.

To the degree that theseservices are available,persons with mentalillnesses pose no greater threat to the communitythan other individuals. Ifthese elementsare not in place, some personswith mental illnesses maycommit violent acts that could lead to their arrest.

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Consensus This statement was drafted by the John D. and Catherine T.MacArthur Foundation Research Network on Mental Health and the

Statement on Law, under the direction of John Monahan, Ph.D., in collaborationViolence and with the National Stigma Clearinghouse.

Mental Disorder: "Mentaldisorder"and violenceare closely linked in thepublic mind.A

Public combinationof factorspromotes this perception: sensationalizedreportingby the media whenevera violentact is committedby a "formermental

Perceptions patient,"popular misuse of psychiatric terms (such as "psychotic"and"psychopathic"),and exploitationof stock formulas and narrow stereotypes

vs. Research bythe entertainmentindustry. Thepublic justifies its fear and rejectionofFindings people labeled "mentallyill,"and attempts to segregate them in the

community,by this assumptionof "dangerousness."

The experienceof people withpsychiatricconditionsand of their familymemberspaints a picture dramaticallydifferent from the stereotype. Theresults of several recent large-scale researchprojects conclude that only aweakassociationbetweenmental disorders and violenceexists in thecommunity.Serious violenceby people with majormental disordersappearsconcentratedin a small fraction of the totalnumber, and especiallythose whouse alcoholand other drugs. Mental disorders---insharpcontrast to alcoholand drug abuse--account for a minisculeportion of theviolence that afflictsAmerican society.

Theconclusionsof those who use mental health services and of their familymembers,and the observationsof researchers,suggest that the way toreduce whateverrelationshipexists between violence and mental disorderis to make accessiblea range of quality treatmentsincluding peer-basedprograms,and to eliminatethe stigma and discriminationthat discourage,sometimesprovoke, andpenalize those whoseek and receive help fordisablingmental health conditions.

May 31, 1994

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Persons with Personswithmental illnesseswho come intocontactwith thecriminaljusticesystemhavespecialneeds,as comparedto otherdetainees.Yet

Special Needs even within this group of personswithmentalillnesses,therearesubgroupsthatwarrantparticularattention.These includepersonswithco-occurringsubstanceusedisorders,women,ethnicand racialminorities,homelesspersons,personswithHIV/AIDS,andyouth.The needsof eachof thesespecialgroupsare describedinbriefbelow.

Persons with Co-occurring Substance Use DisordersIt is well known thatthereisa highincidenceofsubstanceusedisordersamonginmatesinU.S. jailsand prisons.Between60 and 70 percentofU.S.jail detaineeshavea historyof substanceabuse(AmericanJailAssociation,1992).A 1991 Departmentof Justicereportfoundthat78percentof thesurveyedinmatesreportedhavingusedsubstancesofsomekind,excludingalcohol.And56 percentwereunderthe influenceof drugsor alcoholat the timeof theirarrest.

AbramsandTeplin(1991)demonstrateda highprevalenceof co-occurringdisorders,as well. Ina randomsampleof malejaildetaineesinCookCounty,IL,the lifetimeprevalencerateof co-occurringseverementalillness(includingschizophrenia,mania,or majordepression)andalcoholordrug abuseordependencedisorderswas72 percent.

Personswithco-occurringdisordershavespecialtreatmentneeds.Forexample,suchindividualsmayneedto takepsychotropicmedicationstocontrolpsychiatricsymptoms,whilemanysubstanceabuseinterventionsrequireabstinencefromall drugs.Inaddition,symptomsof mentalillnessesandof substancetoxicityoftenappearsimilar,makingit difficultforindividualsto receiveaccuratediagnosesand treatmentplans.

There are fewtreatmentprogramsfor individualswithdualdiagnosesinlocalcommunitiesorwithinState andFederalcorrectionalsystems.InmostStateprisonsystems,for example,personsreceiveservicesfromeithermentalhealthorsubstanceabuseprograms.Insomecommunities,thereisan increasingemphasisondevelopingintegratedmentalhealthandsubstanceabusetreatmentmodelsforpersonswithdualdisorders(CMHS,1993).Suchprogramsneedto includea focusonstafftrainingto helpprovidersinthe mentalhealth,substanceabuse,andcriminaljusticesystemsaccuratelyrecognizeandtreatpersonswithdualdisorders.

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WomenAlthoughwomen representonlya smallpercentageof jailandprisoninmates,between5 and 10 percent,studiesshowtheyare morelikelythanincarceratedmen tohaveseverementalillnesses(Teplin,unpublished;RiceandHarris, 1993).They are also morelikelythan men to bediagnosedwith an affectivedisorder,which is easier to overlook since it isless often associatedwith disruptive behavior.

Compoundingthe problemsof women with mental illnesses in the criminaljustice systemare issuesthat are not common or are non-existentamongmen. Amongthese concems that may require special attention arepregnancy and primaryresponsibilityfor minorchildren,a history ofdomesticviolence and early childhoodphysicalor sexual abuse, andinadequate mentalhealth treatment and housing in jails and prisons.

In 1991,67 percentof women in prisonshad one or more children under18, and 6 percentof all women who entered prisonthat year werepregnant.This represents56,000minor children for the 38,462womenincarceratedin U.S. prisons.Approximately70 percent of these womenlivedwith their minorchildren priorto beingincarcerated (Bureau of JusticeStatistics, 1993).

Some women who are pregnant or who have minor childrenwill also havemental illnesses,and women separatedfrom childrenor who are pregnantare under increasedstress and may require mentalhealth servicestargeted specificallyto these issues.These additionalstresses often can bereducedby policies in jails and prisonsthat allow children to visit andprograms that offer parentingcourses.

Mental healthand substanceabuse treatment programs that are offered towomen in jails and prisons may need to assess and provide additionalservices to women withhistoriesof physicalor sexual abuse. Amongpersons withmental illnessesin general,women are more likely than mento be victims of abuse,particularlysexualabuse (Carmen, Rieker, andMills, 1984;Jacobsonand Richardson,1987).

In addition,historiesof abuse are common among incarceratedwomen.Rann (1993) found that 50 percentof female Michiganjail detainees hadbeen victimsof physicalor sexualabuse at some point in their lives. Morethan 70 percentof women withdrug or alcohol abuse problems werevictims of violence, includingdomestic assault by adult partners, rape andincest (NationalCouncilon Alcoholism, 1990).

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Becausewomen representa smallproportionof jailand prisonpopulations,manyfacilitiesdo notprovidea fullrangeof mentalhealthservices,orappropriatehousingoptions,for femaleinmates/detainees.Further,servicesthatare offeredareoftenbasedonthe needsof men.

Ethnic and Racial MinoritiesEthnicand racial minorities,particularlyAfrican-Americanand Hispanicindividuals,areoverrepresentedinU.S. jailsandprisons,comprising57percentof jail populationsand65 percentofprisoninmates(BureauofJusticeStatistics,1993).Mentalhealthprogramsforsuchindividualsmustbedesignedandimplementedbasedon theculturalexperiencesof thepersonstheyare meantto serve.Mentalhealthandcorrectionalstaffshouldbe trainedto besensitiveto culturalissuesand,to theextentpossible,shouldreflectthedemographicmixof thepopulation.

Persons Who Are HomelessPersonswith mental illnesseswhoarehomelessare amongthe mostlikelyindividualsto bearrested,and incarceration,ratherthan releaseon bond,increasestheprobabilitythatpersonswithmentalillnesseswill behomelessuponrelease(DennisandSteadman,1991).

Arrestratesfor homelesspersonswithmentalillnessesrangefrom20 to 75percent,andthemajorityof these individualsare arrestedfor"trivial,victimless,andnon-violentoffenses"(DennisandSteadman,1991). Manyhomelesspeoplewhocommitminorcrimesdo so inorderto obtainbasicnecessities,suchas shelter,foodandmedicalcare.

Teplin(1987) notesthatarrestisoftenthe onlydispositionavailabletopoliceinsituationswhere personsare notsufficientlydisturbedto warranthospitalization,buttooillto be ignored.Releaseon one'sownrecognizanceor lowbailis lesslikelyifthedetaineeisknownto beundomiciled.

Typically,neitherthementalhealthorcriminaljusticesystemsare preparedto meet thefullrangeof mentalhealth,housing,andsupportneedsofpersonswith mentalillnesseswhoarehomeless.Gelbergandcolleagues(1988) recommendthatmentalhealth,drugand alcoholtreatment,housingprograms,and socialservicesbeprovidedin a sing_e,coordinatedsettingfor homelesspersonswithmentalillnesseswhohavecommittedminoroffenses.

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Persons with HIV/AIDSIn 1991,51 percentof StateandFederalprisoninmateshadbeentestedfor thehumanimmunodeficiencyvirus(HIV). Overall,2.2 percentwerefoundto be HIV positive,withwomen,African-American,and HispanicinmatesmorelikelythanCaucasianmento carrythevirusthatcausesAIDS.

Personswithmentalillnessesmaybe particularlyvulnerableto HIV/AIDS,and individualswithadvancedcasesof AIDS mayexperienceorganicallybasedpsychiatricdisorders(EvansandPerkins,1990). Inadditionto thedementiaaccompanyingthediseaseprocessitself,suicideandsuicidalideation,depression,andanxietymayalsooccur.

Clearly,inmateswith HIV/AIDSmusthave access to a fullrangeof healthand mentalhealthcare, includingpsychosocialandpharmacologicalinterventionsandAIDS-specificcounselingandsupportservices.Suchspecializedservicesare helpfulnotonlyto personscopingwith the disease,butalsoinpromotingHIV riskreductionfor uninfectedpersons(NationalInstituteofJustice,1993).

Whilemanycorrectionalsystemsofferspecialcounseling,housingandservicesto inmateswith HIV/AIDS,these programsareoftenunderstaffed,sharingmentalhealthprofessionalswithmoregenericcaseloads.To meetthementalhealthneedsof inmateswithAIDS, morethan halfof StateandFederalprisonfacilitiessponsorpeercounselingandsupportprograms.Theyalso reportusingcommunityAIDS serviceorganizationsto provideindividualizedcounselingand supportwithintheirfacilitiesandto helpparoleesandotherscomingoutof prisonobtainneededservices.

YouthThe juvenilejustice system is a completelyseparatenetworkofcourts,facilities,andserviceagenciesfromthe adultsystem.Theneedsofjuvenileswithmentalillnessesinthe juvenilejusticesystemareextremelyimportant,andcannotbecoveredadequatelyinthescopeof this report,whichfocusesonadults.However,oneissuethatdoesmeritmentionis thetreatmentofyouthwhoarewaived intoadultcourts.

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In 1991, 1 percentof inmatesinState correctionalfacilitieswere 17 yearsoldoryounger(Bureauof JusticeStatistics,1993). Youthinthe criminaljusticesystemhavehigherratesof mentalillnessthanyouthinthegeneralpopulation(Ottoet al., 1992).Theyaremorelikelyto haveconduct,attentiondeficit,anxiety,andaffectivedisordersthanpsychoticdisorders,withconductdisordersanddepressionmorecommonamongadolescents,andanxietydisordersmoreprevalentamongyoungerchildren(Costello,1989).

Youngpersonswithmentalillnessesboundoverinadultfacilitiespresentseveralmentalhealthissuesto adultcorrectionalfacilities.Becauseof theiryouthand theirmentaldisabilities,theyareat increasedriskof sexualandphysicalabusebyotherinmates.Programsforyouthinadultfacilitiesshouldattendtothe kindsof mentaldisorderscommonamongyouth,betailoredto the interestsandproblemsofadolescents,andaddressthespecialproblemsof victimization.Comprehensiveand integratedfamily-orientedservicesinthecommunitycanhelpdivertyouthfrom thecriminaljusticesystem.

Needed Services Just as personswith mental illnesseshave diverse needs,so too will thoseneeds vary dependingon the point at which they come intocontact with thecriminal justice system.A personwhose acute psychiatric crisis brings himor her to the attentionof the police may need immediatestabilization,whilea prison inmatewith severe mental illnesswill likely require ongoingtreatment and support.

And the responsibilitiesof the criminal justice system for persons withmental illnesseswill differ at eachstage, as well. An individualmay bedetained injail for a short periodof time, so that jail staff may focusprimarily onmaintainingcontinuityof anycommunity-basedservicestheperson is receiving.Personnel responsiblefor individualswith mentalillnesses on probationor parole in the community may act as casemanagers to brokera full range of health, mental health, housing,andsocial servicesfor their clients.

These distinctions-- the varying needs of personswith mental illnesses atdifferentstages of the criminal justice system, and the differingresponsibilitiesof the criminaljustice system for persons with mentalillnesses in their charge-- are explained in Chapter Four.

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CHAPTER 4Defining the Needs of Personswith Mental Illnesses in theCriminal Justice System

Racknrountl There are numerouspointsat which individualswithmental illnessesmaycome intocontact with the criminal justice system. They may be arrested bythe police,heldfor a short periodof time in a Iockupor local jail, serveasentence in prison, or be supervised on probationor parole in thecommunityafter detention in jails or prisons. Eachof these points in thesystemwill be described in this chapter,with special emphasis on theneeds of personswith mental illnesses at each point and theresponsibilitiesof the criminaljustice system for the individuals in their care.Special challengesat each stage will be highlighted.

Table4.1 displays the pointsof contact in the criminal justice system, theprimary relatedmental healthtreatment issues, and the key services thatideally should be available at each level.As indicatedin Table 4.1, theprimary decisionfor law enforcementofficers is to arrest or to transport anindividual to a mental health facilityand attempt to get him or her intotreatment.Services that make this choice possible includethe availabilityand accessibilityof 24-hour emergency mental health treatment,mobilecrisis teams that can assist in the resolutionof the incident, transportation,and staff who can waitwith an individual for an evaluation.

The primary issue in both Iockupsand jails is the safety of the detainee,other inmatesand custodialstaff. Inmates are briefly held pre-arraignment,after not meetingbail, or while serving sentencesof less than one year.Half of all inmates leave within 24 hours.Key services at this point includeidentificationof personswith mental illnesses through routinescreening andfollow-upevaluations,and stabilization of the individual through crisisinterventionservices. In addition, to facilitate the movement of persons withmental illnesses back into the community or to a prisonsetting, dischargeplanningand case managementservices are important.

Prisonsare containedcommunities,where inmatesspend a considerableamount of time. Inmateswith mental illnesses, like persons with mentalillnesses in the general community, have the right to treatment to improvethe quality of their livesand to allow them to serve their time humanely.Theoptimum level of availableservices should duplicatethe best that isavailable in the community;there should be a full range of inpatient andoutpatienttreatments and modalitiesavailable to all inmates.

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TABLE 4.1

Points of Criminal Justice Contact andPrimary Mental Health Treatment Goals

Location Main Treatment Issues Key Mental Health Services

Police Arrest or diversion to mental Emergency MH serviceshealth treatment Mobile crisis teams

Transportation

Lookup Safety of detainee, other Screeninginmates and staff Evaluation

Crisis intervention

Jail Safety of detainee, other Screeninginmates and staff Evaluation

Crisis intervention

Discharge/transfer planning

Prison Do sentence time humanely ScreeningMaximize participation in Evaluation

prison programs and Crisis interventioncommunity Long-term treatment

Special non-medical housingDischarge/transfer planning

Community Supervision Maintain individual in the Access to a full range of(1) Probation community community-based mental(2) Parole Protect the community health services

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Similarto the prison,personsundercommunitysupervision(i.e.,probationor parole)need a full range of mental healthservices available for their use.Theseservices should help to maintainpersonswith mental illnesses in thecommunityand, to the degree that symptomatologyis kept to a minimumand that the mental disorderwas linkedto criminal behavior in the past, toreduce the risks of recidivism.

An issuethat often surfacesin discussionsof mental health services in

correctionalsettings is the conflict between treatment and security, ortherapyversus custody.Often it is taken as a given that the respectiveideologiesof the criminai justice and mental healthsystems are inherently -contradictoryand will produceconflictswherever the two intersect(seeSteadmanet el., 1985 for a reviewof the literature).

However, Steadmanand colleagues (1985), in a study of 43 U.S. jailmental health programs,found that fundamental conflictsbetween mentalhealth and correctionsstaff were not frequent. In providing for the safety ofdetaineesand inmateswith mental illnesses,other detaineesand inmates,and custodial staff, the goals of mental health treatment and correctionsactuallyconverge. Accordingly,correctionsstaff believethat appropriatemental health interventionscan help them to do their job better.

Police as Lawenforcementofficersare frequently the first providersinthe cdminaljusticesystemto havecontactwitha personwithmentalillness.In addition

Frontline Mental totheirroleas peacekeepersandcrimefighters,policespendaHealth Decision considerableamountof timeassistingcitizensand mediatingdisputes.The

policeofficerhasbeen describedinthe literatureas "philosopher,guideMakers and friend"and "amateursocialworker"(Cumminget el., 1966),

"streetcomerpsychiatrist"(TeplinandPnJett,1992),and "psychiatristinblue"(Menzies,1987).

There are severalwaysthatpersonswithmentalillnessescometo theattentionof policeofficers.Theymaybe the objectof a callinvolvingacitizenorbusinesscomplaint,an officermay observethem actingin aninappropriate,bizarre,orcriminalmanner,or policemay havea courtorderorwarrantforan emergencypsychiatricapprehension.In addition,policereceivecallsfrompersonswithmentalillnessesrequestingassistance.

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In a study of mentalhealthcallsto police in a Denver suburb, 50 percent ofcontactswere callsfrom friends or relativesrequesting police assistancefornoncriminalactivity,30 percentwere calls from personswith mentalillnesses, 17 percentwere calls from community members who did notknow the individualpersonally,and 3 percentwere policeobservation(Pogrebin,1986-87).Anotherstudy revealedthat of all policecontacts withcitizens,excludingtraffic violations,4 percent involved personswithsuspectedmental illnesses.Of these, 65 percentwere noncriminal and 35percentwere suspects in a crime (Teplin and Pruett, 1992).

Making Difficult DecisionsDespite thesmallpercentagesofcomplaintsthat involvepersonswithmental illnesses,these can be difficult cases for police to handle. There hasalwaysbeen an inherentconflict for officers in how to best serve the needsof the communityand the needs of the individualwith mental illness. Lawenforcementofficers are often not sure how best to help.

In general,policeofficers feel competent to determinewhether an individualmeets the legal criteriafor emergency psychiatricdetention (Gillig et al.,1990). Nonetheless,while officersmay feel confident they can identifysevere psychoticdisorders, it is not clear that they are well trained toidentifyother serious disorders,such as bi-polaror major depression.

Police may be unfamiliarwith what mental health services and facilities areavailablein the communityand how to contact them. Some communitieslack neededmental healthfacilities, while existing agencies often havelimitedspace for police referrals, restrictiveadmission criteria, complicatedadmissions procedures,and prohibitivefinancial requirements. In addition,the needfor a mental healthagency to restrict confidential informationabout a clientmay conflict with the law enforcement officer's job of trying todecide on the best dispositionfor a particular individual.

While emergencystabilizationof an individual may be a high priority, somecommunitiesdo not have 24-hour services or mobile crisis teams. Oftentheonly options availableto police in lieu of arrest are transportation to acommunity mental healthcenter during the hours it operates or to a generalhospitalemergency roomthat may be reluctant to take problem cases(Steadman,1990).Transportationof personswith mental illnesses can takea considerableamount of an officer's time, and if the facility will not orcannot take the individualdue to commitment laws or the unavailabilityofbeds,the problemremains unsolved. The officer must then decide whetherto arrestor releasethe individual.

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Today,as inthe past, policeare reluctantto arrestpersonswithmentalillnesseswhocommitminorcrimesor arecreatinga disturbance.They alsoare reluctantto havethe individualhospitalized,if informaloptionsareavailable,suchas transportationtothe individual'sfamily(Cumminget al,1966).

Whilea psychiatrichospitalizationispreferredto arrest,manyofficerswillgeta signedcomplaintsothat,if the facilityrefusesto admittheperson,anarrestcanbe made.Arrestisthesolutionof last resort.'q'he policewillarrestrather thanhospitalizethe majorityof mentallydisorderedpersonswho commit misdemeanorswhen they have priorknowledge that thepersonwill be releasedin a very short periodof time due to the shortageofbeds at the medical facility,or that the person's behaviorwill probably notsatisfy commitmentcriteria. In these instances,policewill put the person injail where they knowthey will be removedfrom the community" (Pogrebin,1986-87:68).

Further,dispositiondecisions are often based on how long each altemativewill take. Psychiatrichospitalizationbecomesa less attractivealternative inplaces that have lengthy waits for evaluation.

Officers are clear regarding what assistancethey want from the mentalhealthsystem in order to perform their duties. Once a problemhas beenidentified,proper resolutionrequires information and, sometimes,assistance.Officers state that the most helpful informationthey can have intheir encounterswith personswith mental illnesses is knowledge of anypdor history of psychiatricand substance abuse problems, including thepotential for dangerousnessor suicide, and information aboutcurrentpsychiatricstatus, includingwhether individuals are currently in treatmentand where (Gilliget al. 1990).

In addition,consultationwith community mental health professionalsandavailabilityof mobile mental health crisis teams that can respond within 15minutes of a request have also been noted as important services (Gilligetal. 1990). Open linesof communicationbetween the police and the mentalhealthsystem and formal avenues for response will help law enforcementofficialsmeet their twin goals of protecting the public and helping personswith mental illnesses they are called on to aid.

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Lockupsand After an arrest is made, an individualwill be held in a Iockupand possiblyajail. A Iockupis "usuallya holdingfacility operated by police or other law

Jailsas enforcementagencieswhere arresteesare heldwhile bookingandotherCommunity prearraignmentprocesses are beingcompleted"(Reed1987). They rarelyInstitutions keep detaineesbeyond24 hoursexceptoverweekends.

JailsdifferfromIockupsinthattheyare placeswherepostarraignmentinmatesare detained,and are usuallyoperatedbythesheriff'sofficeor themunicipalcorrectionalagency.The U.S. Departmentof Justice(1980)definesa jailas "a locallyadministeredconfinementfacilitywithauthorizationto holdpersonsawaitingadjudicationand/orthosecommittedafter adjudicationto servesentencesofoneyearorless."

In 1991, therewereapproximately3,353 jailsintheU.S., ranginginsizefrom50 inmatesorless(59 percentofall jailsinthe U.S.) to 1,000or moreinmates.Jailswithratedcapacitiesof 250 or more(10 percentof all U.S.jails)house63 percentof alljaildetainees(UnitedStatesDepartmentofJustice,1990).

Most jailinmatesare men (91percent),and 57 percentareAfrican-American,Hispanic,ormembersofotherracialandethnicgroups.Fifty-onepercentofjail inmatesare unconvicted(UnitedStatesDepartmentof Justice,1991).

Jailovercrowdingisat epidemicproportionsthroughouttheU.S. Notonlyare largenumbersofjailsantiquatedandbarelyable to meet minimalstandardsofcare, butalsojailpopulationsare exploding.

From1980to 1992, thenumberof personsinjailon any givenday intheUnitedStatesincreasedfrom 158,394to 444,584 (Bureauof JusticeStatistics,1993).In 1990, jailswere functioningat 111 percentcapacityoverall.And142 jurisdictions(28 percentof alljurisdictionscontainingjailswith100 or morecapacity)hadat leastonejail undercourtorderto reduceinmatepopulation(UnitedStatesDepartmentofJustice,1992).

AmongtheburgeoningpopulationsinU.S. jailsare largenumbersofpersonswithmentalillnesses(seeTable4.2). A recentsurveyof a randomsampleof malejailadmissionsinCookCounty,IL, foundthat6 percenthada currentpsychoticillnessandwere inneedof treatmentservices(Teplin,1994). AmongfemaleCookCountydetainees,the estimatesof mentalillnesswereevenhigher.Fully15 percentof the female detaineeshadadiagnosisof schizophreniaoraffectivedisorderandhadan acuteepisodewithinsixmonthspriorto arrest(Teplinetal., unpublished).

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TABLE 4.2

Prevalence of Severe Mental DisorderAmong the General Population and Jail Detainees

Major Any SevereDepression Schizophrenia Mania Disorder

GeneralPopulation* 1.1% 0.9 % 0.1% 1.8%

Male Jail Detainees** 3.4% 3.0% 1.2% 6.1%

FemaleJailDetainees*** 13.7% 1.8% 2.2% 15.0%

* From Teplin, L.A. 1990. "ThePrevalence of Severe Mental Disorder Among Male UrbanJailDetainees." American Journal of Public Health, 80:663-669.

** Updated from Teplin, L.A. 1994. "Psychiatric and Substance Abuse Disorders Among MaleUrban Jail Detainees." American Journal of Public Health, 84(2):290-293.

*** Teplin, L.A., Abram, K.M. and McClelland, G.M. 1995. "The Prevalence of PsychiatricDisorder Among Incarcerated Women: I. Pretrial Jail Detainees." Unpublished.

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On a nationallevel,thiswouldindicatethat annually,approximately700,000 admissionsto U.S.jails are individuals with acute and severemental illnesses.An additional 10 to 15 percentof inmates have mentalhealth problemsthat put them at risk due to the nature and stress of theenvironment.

Mental Health Services in JailsOn the average, individualsspendveryshortperiodsof timeinjail. Duringthistime,thejailisattemptingto performitscustodialfunctionof safepretrialdetentionwhileaddressingthe mentalhealthproblemsofindividualswhoseaccessto care ishighlyrestricted.

Often,when a personisdetained,heor sheis notevaluatedformentalhealthproblems,ortheseproblemsare maskedby drugoralcoholintoxication.Thiscan resultinan interruptionof servicesthatthedetaineemayhavebeenreceivingin the communityand leadto an exacerbationofhisor hersymptoms.Inthesameway,afteran inmateis stabilizedinthejail,lackofdischargeplanning,includingreferralto mentalhealthtreatment,socialservicesandhousing,will leavethe inmate,again,withoutnecessarysupports.

To establishappropriateservicesforpersonswithmentalillnesseswhoaredetainedrequiresthatthejail beseenas butoneagencyina continuumofcommunityservices(Steadmanet ai., 1990).Althoughthejail existsas aseparateentity, itsprimaryfunctionis "processingpeople,"andit is bestcharacterizedbyitsinteractionwithotherrelevantcriminaljusticeagencies,includingthepolice,thecourts,the legalcommunity(defenseanddistrictattomeys),and,ultimately,communityservices.It is importantto highlightthis"systemic"aspectof thejailandto approachmentalhealthservicesissuesinsucha fashion.

Exceptforthe largestjails,it is impracticalto considerdevelopingacomprehensiveset ofmentalhealthserviceswithina jail. Thisis warrantedneitheron the basisof neednorintermsof thedollarsor physicalspaceavailable.It isfar morepracticalforthe jail to makeeffectiveuseof suchlocalservicesas communitymentalhealthcenters,psychiatricunitsofgeneralhospitals,privatepractitioners,universitydepartmentsofpsychology,medicine,and social work, and State mental hospitals."Effective use"doesnot necessarilymean actuallytransferring inmates, butdoes mean capitalizingon the expertiseof the staffs of these programs andplanningservices inways that share program resources.

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Over the pastdecade, directgovemmentalexpendituresfor correctionshaveincreasedby216 percent(UnitedStatesDepartmentof Justice,1991). Despitethisincreaseinexpendituresandtheexpansionof physicalplants,at theendof 1990,Stateprisonswereoperatingat 18 to 29 percentovercapacity,whileFederalinstitutionswere51 percentovercapacity.

In 1991,95 percentof the U.S. prisonpopulationwas male,and32 percentwas overtheage of 35. Eventhoughonlya smallminorityof inmatesarefemale, theproportionof womencontinuesto grow.Sixty-f'_epercentof thepopulationisAfrican-American,Hispanic,or otherracialand ethnicgroups.

Of themostseriouscharges,47 percentof U.S. prisoninmateswereservingtimefor a violentoffense,25 percentfor propertyoffenses,21percentfordrugoffensesand7 percentfor publicorderorotherminoroffenses(Bureauof JusticeStatistics,1993).

Level of MentalHealthServiceNeedClearly, the prison population is differentfromthe jailpopulationintermsofseriousnessof offenseand lengthof confinement.However,likejails,asizableportionof prisoninmateshave mentalillnesses.Estimatesof severementaldisordersamongprisoninmatesgenerallyrangefrom 6 to 15percent(MonahanandSteadman,1983;SteadmanandCocozza,1993).

Inaddition,co-morbidityisan importantfactorinthemanagementofpersonswithmentalillnessesin prison.Whilearrestsforall crimeshaveincreasedby28 percentoverthepastdecade,arrests fordrug relatedcrimeshave increasedby126 percent(UnitedStatesDepartmentofJustice,1991).Asof 1991,45 percentof U.S. prisoninmateswereservingtimefordrugoffenses.Further,79 percentstated thattheyhad useddrugs,excludingalcohol,inthepast,and62 percentsaidtheyuseddrugson aregularbasis

The increaseinthenumberof drugarrestshasexacerbatedtheproblemofprisonovercrowdingandcontributedto an increaseinthenumberofinmateswithcommunicablediseases,includingHIV/AIDS,tuberculosis,andhepatitis.These factors,combinedwithinsufficientprogramsto treatsubstanceabuse,complicatetheprovisionof mentalhealthservicestoprisoninmates.Healthandmentalhealthinterventionsmustfocusontreatingindividualswith multipleproblems.

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"Community Mental Health" in PrisonsThe prison is its own full-fledgedcommunity,albeita containedone.Peopleeat, sleepandworkthere24 hoursa day.It hasitsownsocialnetworksandsubgroups,itsownreligiouscommunities,and itsowneducationalsystems.

Forthisreason,it is usefulto conceiveof prisonmentalhealthinthecontextof providinga "communitymentalhealthsystemforeach prison"(CohenandDvoskin,1992).Thisconceptualizationis crucialto theplanningof appropriate,cost-effectivementalhealthservicesforprisoninmates.

The mentalhealthissuesofprisoninmates,infact, closelyparallelthoseofpersonsinthecommunity.Sincemostinmateshavebeeninthecriminaljusticesystemforsometimepriorto transferto prison,acutepsychiatricproblemsare notusuallythepredominantconcern.

Prisoninmateswithmentalillnessesneed intermediateand long-termcare.Becauseseverementalillnessestendto be cyclicalandepisodicinnature,the needsofinmateswiththesedisorderswillvarygreatlyoverthe timetheyare incarcerated.Reflectingthecommunitymentalhealthmodel,theAmericanPsychiatricAssociation(1989)contendsthatessentialprisonmentalhealthservicesincludementalhealthscreening,evaluation,crisisintervention,treatment,anddischarge/transferplanning.

In reviewingmentalhealthservicesuseby inmatesinState adultcorrectionalfacilities,a 1988 CenterforMentalHealthServices reportfoundthat2.5 percentwere receiving24-hourpsychiatricinpatienttreatmentor residentialserviceswithin the p_son setting, 10 pementwerereceivingcounselingor psychotherapyfroma mentalhealthprofessional,5percentwerereceivingpsychotropicmedications,and4 percenthadapsychiatricassessmentor evaluationcompletedduringthestudymonth(thesepercentagesreflecta duplicatedcount).

Of course,notall inmateswithmentalhealthneedsare receivingservices(GeneralAccountingOffice,1991).More than halfofthe Federalfacilitiessurveyedstatedthattheyhadsomeinmateswhosementalhealthhadnotbeendiagnosed.

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The failuretodiagnoseinmateswith mentalhealthserviceneedswas dueto inpartto inmates'abilityto successfullyfunctioninthegeneralprisonpopulation,andto inadequatescreeningproceduresallowingsomeindividualswithmentalillnessesto go unrecognized.Further,manyinmatesdiagnosedas beinginneed of treatmentwere notreceivingany becausetheyrefusedservicesortherewas a lackofavailablementalhealthresources.Betterandmoreuniformmethodsof identifyingpersonswithmentalhealthneedsandthe furtherdevelopmentof mentalhealthservicescanhelpinsurethatall prisoninmateswhoneed andwantsuchservicesreceivethem.

Clearly,personswithmentalillnesses,regardlessof whethertheyareprisonersornot,sometimesrequireinpatientcare. The provisionof bothinpatientandoutpatientserviceswithintheprisonsettingfacilitatestheintegrationof inmateswithmentalillnessesinthegeneralprisonpopulation.

Probation and Afterjailor in lieuof jail, personsmay besupervisedbyprobationdepartments.Similarly,communitysupervisionbyparoledepartmentsoften

Parole: followsreleasefromprison.

Uncharted Likejail and pnson populations,the number of personswhoare under

Territory supervisionby probationand paroledepartmentshas increaseddramaticallyinthepastdecade.As of December31, 1990, therewere2,670,234 personssupervisedbyprobationdepartmentsand531,406individualssupervisedby paroledepartments,representingone-yearincreasesinthosepopulationsof 5.9 percentand 16.3 percent,respectively(BureauofJusticeStatistics,1993).Overallan estimated3 millionadultsor1.7 percentof theadultpopulationinon probationorparole.

The percentof personsundercommunitysupervisionthroughprobationorparolewho havementalillnessesis unknown.However,based onprevalenceratesof mentaldisordersforjail admissionsand dataon prisoninmates,itcan be assumedthatthe rateof mentaldisordersamongparoleesandprobationersistwoto threetimeshigherthan thatof thegeneralpopulation.Giventhe prevalenceof mentalillnessesinjails andprisonsandthefactthatmanyseriousdisordersare undertreatedoruntreated,it isclearthata significantproportionof paroleesandprobationersrequirea rangeof mentalhealthservicesinthe community.

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ProbationCriminal defendantswhoreachthesentencingstageinadjudicationhavepleadorbeenfoundguiltyof a crime.Sentencesmaytake severalforms,includingincarcerationina jail or prison,finesorcommunityservice,andprobation.TheAmedcanBarAssociation(1970)definesprobationas "... asentencenotinvolvingconfinementwhichimposesconditionsandretainsauthorityinthesentencingcourtto modifytheconditionsof sentenceortoresentencetheoffenderifhe violatestheconditions.A sentencetoprobationshouldbe treatedas a finaljudgementforpurposesof appealand similarproceduralpurposes."

Probationsentences can be applied to felonies, as well as misdemeanors.Individualsmay be sentencedto probationonly, or probation may be onepart of a sentence that also includes incarceration.About 40 percent ofprobationcases are split sentences, with 75 percent involvinga median6-monthjail term, followed by three years of probation, and 25 percententailinga medianfour-yearjail term, followed by three years of probation(Dawson, 1990).

There are three types of conditions that can be applied to a probationsentence: (1) standardconditionsapplied to all probationers,such asreporting regularlyand notifyingthe probation office of a change of address;(2) punitiveconditions, including paying fines or performingcommunityservice;and (3) treatment conditionsthat are imposed to address specialneeds of the individual,such as substance abuse or mental healthtreatment.

In the past 20 years, the focus of probation has changed from rehabilitationwithin a medical/socialwork modelto risk managementand brokering ofservices.The earliermodel stressed that probation officers provide directservices such as counseling,much like a social worker. More recently, therole of the probationofficer is much more that of a corrections officer.Specialservices are brokered through the officer, but not provided by himor her.

Typically,the probationofficerrefersindividualsto specializedcommunityservices,such as mentalhealth and substance abuse treatment, that areavailableto all membersof the community. The probationofficer's role asbroker is critical, becausecommunity programs are often reluctanttoaccept personswho are involvedwith the criminal justice system and whomay be participatinginvoluntarily.

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In additionto brokeringservices,someprobationdepartmentshaveprovided treatment programs through the probationagency itself. Whilepersons receivingservices from genericcommunity agencies tend to havehigher rates of technicalviolations of their conditionsof probation due totheir unwillingnessto participate in treatment programsagainst their will(Wilson, 1978), personsinvolved in programsoperated by the probationagency have reducedrecidivismfor certain types of offenses (Gottfredson,et al., 1977).

ParoleUsually,parole is a termthat describes both a releasemechanism fromincarcerationand a form of communitysupervision.Consistentwith thisconcept, parole is defined as"the conditional releaseof an inmate fromincarcerationunder supervisionafter a portionof the prisonsentence hasbeen served"(Clear and Cole, 1990).Recent changes in sentencing towarddeterminatesentences and mandatoryrelease has eliminatedthediscretionarypower of parole boards,but has not superseded the need forcommunitysupervisionof releasedfelons.

Duties of the paroleofficer are virtually the same as those of the probationofficer.Paroleofficersoften act as intensivecasemanagers,monitoringanindividual'sprogress and helpingto connect himor her to needed servicesin the community.

Communication and collaboration betweencorrectionalstaff andcommunity service providersis essentialto help personswith mentalillnesses functionwell in the community and successfully complete theterms of their probation or parole. Further,education of probationandparole officers in some of the uniqueproblems that personswith mentalillnessesface in the communitycan help the officersaccommodate thesometimes unusual,but not criminal, behaviorof those under theirsupervision.

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Diversionto Some individualswithmental illnessesdo not belong in jail. In its 1988reportExemplaryCounty Mental Health Programs, theNationalAssociation

Cornm u n ity of countiesnoted"jailis inappropriatetreatmentfor peoplewithmentalServices illnesswhocommitmisdemeanorsorno crimeat all. Suchindividualsneed

to bedivertedfromjailto a continuumof serviceswhichincludecrisisintervention,outreach,residential,vocationaltraining,familysupport,casemanagement,andothercommunitysupportservices"(Adams,1988).However,it isequallyclearpersonswithmentalillnesseswhocommit

..sedousoffenses"warrantcorrectionaldetentionto accommodatecriminaljusticeprocessingand communitysafety concerns"(Steadman,1990).Theseindividualsarenotcandidatesfor diversion,but requirepsychiatricattention.Whenindividualswithmentalillnessescan be appropriatelydivertedfromthecriminaljusticesystem,ithelpsreducejailovercrowdingand promotethesmoothoperationof jailprograms(NationalAssociationofCounties,1988).

Individualswithmentalillnessesmaybe identifiedfor diversionfrom thecriminaljusticesystemat anypoint,includingpre-bookinginterventions(beforeformalchargesare brought)and post-bookinginterventions(afterthe individualhasbeenarrestedandjailed).Post-bookingdiversioneffortscan takeplaceinthejailorthroughthecourtsystem.

Regardlessof itstype or location,a diversionprogramis onethat screensindividualsforthepresenceof mentaldisorders,evaluates thosepersonsdeterminedto be inneedof mentalhealthtreatment,andnegotiateswithprosecutors,defenseattomeys,community-basedmentalhealthproviders,andthecourtsto producea dispositionoutsidethe jail in lieuof prosecutionor as a conditionofa reductionincharges(whetheror nota formalconvictionoccurs).

Thisdefinitionincludesprogramsthatallowindividualsto awaittrialinthecommunity,ratherthanjail. In addition,althoughit is notacknowledgedasa formaldiversionprogram,thepleabargainis oftenusedto keepdefendantswithmentalillnessesoutof jail. Courtdecisionsmay rangefromdroppingchargesaltogetherto requiringmentalhealthtreatmentas aconditionof probation.

Diversionprogramsmaybeprimarilyoperatedbya mentalhealthserviceprovideror bya componentof thecriminaljusticesystem,includingthepolicedepartment,jail,orcourts.However,to be trulyeffective,diversionprogramsmustinvolvetheclosecollaborationof all relevantstakeholders.The benefitsofsuchcollaborationare substantial.

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In additionto reducingthe numberof peopleheld unnecessarilyinjail,diversionprograms help personswith mental illnesses become connectedto appropriatecommunity-basedservices,insuringcontinuity of care. Thisleads to minimumdisruptionin both the individual'slife and the jail'sprogrammingand security.Another importantbenefit is that diversionprograms can be developedwithout significantadditionalcosts. Theprimary resourcesare spent in the developmentof working relationshipsamongthe key players, includingpolice, courts, probation,jail staff, mentalhealth programs,and other community resources.

Ultimately,for diversionto be successful, a wide array of community mentalhealth and other support servicesmust be availableand accessible. Manyindividualswith mental illnesseshave a range of needs, includingmedicationmanagement,housing,drugand alcohol abuse treatment,social services, and other supports.

Plannino Coordinatingthe effortsof the mental healthand criminaljusticesystemstoII l _ meettheneedsof personswithmentalillnessesis criticalto insuretheCooperative proper functioningofthecriminaljusticesystemand to guaranteetheEfforts provisionof appropriatecarefor individualswith mentalhealth needs.

Therearea numberof barriersto thistype ofcooperation,however,includinginsufficienthumanandfiscalresourcesanda lackofunderstandingof therolesthat personnelineach systemcan, andmust,perform.Waysto overcomethesebarriersandimplementjointprogramsthatserve theneedsof all involvedare highlightedinChapterFive.

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CHAPTER 5Solutions That Work

Barriers to There are numerousobstaclesto providingappropriatecare to personswith mental illnessesin the criminaljustice system, including:

Providing Care. lackof knowledgeon thepartoflawenforcementandcorrections

personnelabouteffectivementalhealthprogramsandhowto accessthem;

• lackof understandingonthepartofthementalhealthsystemaboutthedemandsandconstraintsofthe criminaljusticesystemandanunwillingnesstoworkwithitsclients;

• lackof cross-trainingforcorrec'dons,lawenforcement,and mentalhealthstaff;and

• lack of coordinationbetweenthe criminaljustice, mentalhealth, and socialservicesystems.

As was apparentin the vignettes in Chapter 1, inadequateor inappropriateinformation and fragmentedservices can result in persons with mentalillnesses receivingno services at all, or receiving inappropriatetreatment,including arrest and jail, becauseworking altematives do not exist in thecommunity. Informationsharingand coordinatedplanningamong lawenforcement and correctionalpersonnel,mental healthagencies, and socialservice providers--including housing, income support, and substanceabuse programs-- can help meet the needsof all parties involved.

This chapterhighlightsways to coordinate care for persons with mentalillnessesat key points in the criminal justice system, including examples ofsuccessful programs.

Core Planning Servicesfor personswith mentalillnesseswho come intocontactwith thecriminaljusticesystemarecriticalandcan be developedwithoutsubstantialilml= _l I__l

i-,rlnclples new funding.Muchof whatis requiredis rethinkinghowto addresstheseproblems.Comprehensiveand integratedservicesat theclientand systemlevels,withparticularemphasison communitycollaboration,areneeded.

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Many recentanalyses of mentalhealthservicesfor underservedpopulationsappropriatelyhaveemphasizedtheneedfor collaborationbetweenprivateandpublicsectorsand, inturn,amongthe local,State,andFederallevelsof govemment.A majorrecommendationof the FederalTask Forceon HomelessnessandSevere MentalIllnessstated,"Thereisgrowingconsensusthata trulyintegratedsystemof care...requiresintegratingbasiclifesupportswithspecializedservices;linkingservicesattheclientandsystemlevels;coordinatingFederal,State,and localresources;andprovidinga cleardelineationof authorityand of clinical,fiscal,andadministrativeresponsibility"(p,xiv).

At theheartofwhatneedsto happentosignificantlyimprovethe livesofpersonswithmentalillnesseswhocomeintocontactwiththe criminaljusticesystemare severalcore planningprinciples.Howeachof theseplaysout ina specificjurisdictionfor a particularsetof problemswillvarygreatly.However,adherencetotheseprincipleswillgreatlyincreasethelikelihoodof solutionsthatbenefitindividuals,theirfamilies,criminaljusticeprofessionalsandthecommunityat large.

Thesecore principlesare:

• Coordinatedandintegratedprogramsclearlyincreasethe likelihoodofuninterruptedcare, betterpsychiatricoutcomes,andlowerrecidivism.Especiallycrucialincriminaljusticecontexts, fullyintegratedsystemsofcare should includementalhealth,substanceabuseand other healthservices,housing,assistanceobtainingfinancialentitlements,andeducationaland vocationalprograms.

• Accessto targeted, appropriate and flexible mentalhealthservicesshould be availableto all personswith mental illnesses,regardlessofwhetherthese individualsare women,people of color,youth,or personswith specialtreatmentneeds.

• Interagencyworkinggroupsor planningteamscan greatlyenhancethesuccessof integratedservicesfor personswithmentalillnesses.Theseinteragencyworkinggroupsare importantacross all levelsof govemment:Federal,State,and local.At the Federallevel, this groupwould be abletotargetand coordinateeffortsbetweenall relevantdepartmentsto facilitatethe improvementof mentalhealthservicesto this population.At the locallevel,the groupshould havethe authorityto planand implementa fullarrayof integratedservices.

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• Representativesfrom key constituencies,includingmentalhealthadministrators,criminaljusUceoffidals,substanceabuseandotherrelevantserviceproviders,and familyand consumeradvocatesshouldbeinvolvedintheplanning,implementation,andevaluationof mentalhealthservicesforpersonsincontactwiththecriminaljusticesystem.

• Creativeuseof existingresourcescanaccomplishmanyof theneededchangesto thecriminaljusticeandmentalhealthsystemsinthedevelopmentofaccessto essentialmentalhealthservices,withouttheneedfora massiveinfusionof newresources.

• Mentalhealthservices targetingthe co.-morbidityof severementalillnesseswithalcoholanddruguse disordersshouldbe a priority.Mentalhealthserviceprovision,whethercommunity-basedor facility-based,shouldacknowledgetheneedto developinterventionsandworkingrelaUonshipsforpersonswithdualdiagnoses.

• Cross-trainingof mentalhealth,lawenforcementand correctionspersonneliscrucial.Regardlessofwhetherwe discusspolice,jails,prisons,orcommunitysupervision,thedominantthemeisthe needforbothmentalhealthandcriminaljus,ce personnelto betterunderstandthedemands,operations,andcontextof theothersystem.

• The identificationof needandtheprovisionofmentalhealthservicesshouldtake culturaldifferencesinto account. Becausethe personsinvolvedwiththeU.S. criminaljusticesystem,and,therefore,inmentalhealthtreatmentservicesinthesesystems,aredisproportionatelyAfrican-American,Hispanicandotherminorities,servicesshouldbeprovidedthatareculturallysensitiveand thataregearedto an individual'suniquecircumstancesandneeds.

• The disseminationof existing knowledgeandthe generationof newinformationtosupporttheinformationneedsofStatesand localcommunitiescouldgreatlyimproveserviceswithoutsubstantiallyincreasedcosts.Thisreporthascollectedsomeof thebestideasavailableacrosstheU.S. regardingtheprovisionof mentalhealthservicesto personswhocomeintocontactwiththecriminaljusticesystem.However,thisinformationmustfirstbe availableto communitiesif it isto haveany effect.Theestablishmentofa comprehensiveinformationgatheringandknowledgedisseminationplanshouldbe consideredto providethenecessaryinformationandtechnicalassistanceto implementorenhanceservices.

Effective Effectivepoliceresponseto citizenswithmentalillnessesrequirescooperationandtheexchangeof knowledge,resourcesandservices

Police/Mental betweenlawenforcement,mentalhealth,andsocialserviceagencies.Health Without such cooperation,police may resortto the inappropriateuseof

Interactions arrest or of emergencypsychiatrichospitalization.What officersmostwant andneedintheirinteractionswithpersonssuspectedof havinga mentaldisorderisinformationandaccesstoconsultationandassistance.There are a numberof wayscommunitieshavemet theseneeds,includingtheuseof designatedmentalhealthprofessionals,specialrecognitionfor policeofficershandlingmentalhealthcases,emergencyhotlinesand24-hourmobilecrisisteams,cross-trainingof lawenforcementandmentalhealthpersonnel,andcommunityplanning.In allof thesestrategies,itis importantto balancecarefullycitizens'rightsto privacywithlawenforcementofficers'needfor information.Eachof thesestrategiesis outlinedbelow.

Designated Mental Health PersonnelSome policedepartmentsdesignatea mentalhealthprofessionalto handlecasesinvolvingpersonswithmentalillnesses.Dependingonthecharacteristicsof the localityandthesizeof thedepartment,thisindividualmightbe a policeofficerwhoistrainedinmentalhealthissues,a civilianmentalhealthprofessionalwhoworksoutof thepolicedepartment,oramentalhealthprofessionalfroma communityagencywhocontractswiththepolicedepartmentto providecrisisconsultationand intervention.

Theseprofessionalsare available24 hoursa dayto respondto callsforassistancefromofficersinthe field.Theymayofferadviceoverthetelephone,go to thesiteto assist,orconductevaluationsintheoffice.

There are manyadvantagesto allpartiesinvolvedof havingdesignatedmentalhealthpersonnelrespondto personswithmentalillnesses.Thesestaffmeanthatpoliceofficershavea readilyavailablesourceof expertiseandsomeonewhois responsiblefor screening,transportation,waitingforan evaluation,andfollow-up.

Mentalhealthagenciesaremorelikelyto receiveappropriatereferralsfromsuchindividuals,whocan successfullynegotiateforcrisisinterventionandotheroutpatientmentalhealthservices.And personswithmentalillnessesare lesslikelyto be arrestedon minorchargesorto beinappropriatelyhospitalized.

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Recognition for Handling Mental Health CasesPolice interactionswithpersonswithmentalillnesseswillbe enhancedifofficersbelievethattheirroleindeterminingtheappropriatedispositionisvalued.Thiscan involvenotifyingtheofficerof theresultsof a referral,allowingextratimeforthedispositionof suchcases,andevaluatingthemanagementof a mentalhealthcasein muchthesameway as an arrest.Knowingthat heorshewillbe rewardedfordealingeffectivelywithpersonswithmentalillnessesisan incentivefor the frontlineofficerto makeappropriatedecisionsregardingtheirtreatment.

Emergency Hotlines and 24-Hour Mobile Crisis TeamsMany policeencounterswithpersonswithmentalillnessesoccurwhenmentalhealthfacilitiesareclosed.The availabilityof mentalhealthservicesafter hourscan be critical.Of particularimportanceare telephoneconsultation,on-siteassistancein the form of mobile crisis intervention,andthe availability for emergencyhospitalization.

Some communitieshave found that emergency hotlines(both police andmental health)help solveproblems that arise between the systems.Agreementsof mutualsupport, often written and formal, mean that mentalhealth professionalsprovideconsultationand/or on-site handlingof adifficultsituation and police respondto a call for assistancewhen someonebecomesviolent in a mental health residence/facility(Finn and Sullivan,National Instituteof Justice, 1987).

In addition,a special liaison (a management-levelpersonfrom the policedepartmentand from the communitymental healthcenter) can helpalleviate problemsas they occur.The liaison has the authority to overcomestaff resistanceand program-levelbarriers.

Other communitieshave established24-hour mobile crisis teams that canrespondquickly to policecalls for assistance.These teams take charge ofthe situationupon arrival (if the incident is not criminal),and screen,evaluate,and transportthe individualto an appropriate treatment setting.Some communitieshavecontracted with taxi services to transportindividualshome,when this is an option.These simple solutions save anofficer a substantialamountof time, allowinghim or her to retum to patrolwork.

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In addition,around-the-clockavailabilityof hospitalor community-basedpsychiatricevaluation,and specificguidelinesfor inpatientadmissions, canhelp policeofficers makeappropriate referrals.Cooperative agreementsbetweenpolice and screening facilities may be developedsuch that apsychiatricfacilitywill identifyavailabletreatment slots elsewhere in thesystem if there is no space within that facility.

Cross-TrainingCross-training is probably the most important factor in cooperativeworkingarrangements between the mentalhealth and criminal justice systems.Policetraining generally focuses on characteristicsand diagnostic issuesrelated to mental illness,but hasfailed to address such issues as whatservicesare available in the localarea, how to make appropriate referrals,understandingconfidentialitystatutesand mental health law, and the goalsand outcomes of treatment. Ukewise,mental health professionalsarerarelyeducated about the criminal justice system and the specific demandsand proceduresof policework.

In particular, it is essentialthat both policeand mental health staff have aclear understandingaboutwhat informationcan be sharedabout individualsand of the rationale,both ethicaland legal, for the policies.Access toinformation is a very sensitive matterthat requiresa careful balancing ofindividual rightsto privacy with the community's right to protection.

Where police departmentshave a designatedmental health unit,informationmaintainedon contactswith persons with mental illnesseswillbe availableto officers without involvinga breachof confidentiality. If thedepartment contractsfor crisis interventionservices, the crisis team maynot be allowed to share confidentialinformationwith the police, but teammembersmay usetheir knowledgeto resolve a problem themselvesor tosuggest methods for resolutionto the officeron site.

In addition to classroom or in-servicetraining, cross-training may involveworking in the environment, i.e., mental healthworkers ridingin a patrol car,or police observing in a psychiatricfacility.

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Community PlanningPeoplewho comeintocontactwiththepolice,particularlythosewithmentalillnesses,havea highincidenceof co-occurringsubstanceabuseandphysicalhealthproblems.Inaddition,theyare likelyto be poorand inneedof housingorothersocialservices.Helpingindividualswithmultipleproblemsoftenrequiressystems-levelintegration,whichultimatelysupportsandenhancestheeffortsof frontlinelawenforcementandmentalhealthpersonnel.

Ata minimum,communitiesmay wantto considerthe developmentof astandingmentalhealth/lawenforcementplanningcommittee,whoseprimaryresponsibilityisto clarifytheresponsibilitiesof each of theagenciesinvolved.Sucha groupshouldrepresentmentalhealthcliniciansandadministrators,lawenforcementand correctionsofficials,electedofficials,andotherrelevantcommunityserviceproviders.The groupmaybesupportedbya formalmemorandumof understandingand shouldhavetheauthorityto planandimplementa fullarray of integratedservicesto meettheneedsof thispopulation.

Inparticular,a jointplanninggroupcoulddevelopstreamlinedproceduresto facilitateappropriateinpatientandoutpatientmentalhealthtreatment.Inaddition,suchservicesas housing,alcoholanddrugtreatment,entitlementassistance,andeducationandvocationaltrainingprogramsshouldbeavailableandaccessible.

Making Maximum Use of ResourcesTheseapproachesto effectivepolice/mentalhealthcollaborationusuallycan be accomplishedwithlittleor noadditionalfunding.Makingmaximumuseof existingresources,insomecases byjointlyfundingcooperativeefforts,can resolvea majorityof the issuespresentedherein.Someovertimepayfortrainersand trainees,with occasionalsupportforoutsideconsultants,areoftentheonlyaddedcosts.

Selection of Notable ProgramsThe NotableProgramsincludedinthisreportwere selectedbasedoninformationfrom a number of sources.The selectionof these programsrepresentsthe combined resourcesof the most current research, theopinionsof programdirectors, and the expert advice of the 60-person AdHocWorking Group.Based on these experiences and information,programs were selectedthat were deemed especiallynoteworthy bothbecauseof the quality of what was being done and becauseof thetransferability of their initiativesto other sites throughoutthe U.S.

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Notable Program

Montnome The MontgomeryCounty, Pennsylvania,EmergencyService (MCES)program wasdevelopedin 1974as a response to the legal mandate to

_-- ""II_uU nl[y_ Pa.y provide 24-hour emergency mental health care and to meet the need for

Emergency readily accessible drugand alcohol emergency services,particularly forpersons who come into contact with the criminaljustice system. ThroughService close cooperation with local law enforcementand jail, MCES provides a

P rog ram range of services, includinginpatient treatment,training topolice, crisisintervention withpersons withmental illnessesin the community andmental health services tojail detainees.

Montgomery County EmergencyService is a nonprofit hospital. Its annualinpatient budget is approximately$7 million. Inpatientservices are paidprimarilyby Medicaid,Medicare, and third-party insurance. The hospitalalso receives direct fundingfrom the countymental health department. Inaddition, approximately$500,000is budgeted for all other services and ispaid for by county dollars,and services are billed to entitlementprogramsor privateinsurers as appropriate.

Police officers in Montgomery County receive training on how to identifyand communicate withpersons withmental illnesses who are experiencingcrises. The officers carry a "copcard" with instructions for what to do whendealing witha person who has acute symptoms. In addition,police cantelephone MCES at its 24-hourhot line to consult witha mental healthprofessional. MCES may instruct the officerto bring the person in forevaluation or may send out an ambulance to pick up the individual.

MCES also operatesa community outreachprogram in which crisisinterventionprofessionalsconduct a follow-up to further evaluate a situationthat may be unresolved.Finally, for persons withmental illnesses already injail, MCES has a forensiccaseworker who develops treatment plans in thejail setting and provides linkage to services after release.

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A major reason for the success of thisprogram is its comprehensiveness.MCES providesaccess to inpatientcare, follow-upservices guaranteeingproperaftercare,emergencyand crisisinterventionservices,in-jailservices,and cross trainingof mental health, law enforcement,correctionsand courtpersonnel. Of primary importanceis the Forensic TaskForce. Thisgroup ofindividuals includesrepresentatives from emergency, outpatientandinpatientmental health programs,police,jail, probation and parole,defenders and prosecutors offices, and consumerand famity advocacygroups. Thegroup has the authority to implementchanges in the systemsand functionas a watchdogorganization.

Contact: Robert Bond, Director of CrisisServicesPhone: (215)279-6100

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Mental Health Individualswith mental illnessespresentspecialproblemsto thejailadministrator.Lackof knowledgeaboutmentalillnesseson thepartofjail

Interventions in staff andotherinmatesmeansthatpersonswithunusualbehaviorareJails and treated eitherwith fear orwithpunitivesanctions.Equallyas problematic,

personswithseveredepressionmaygo virtuallyunnoticedbecausetheyLockups do notcreatedisturbances.When thishappens,they are left untreatedand

theirsymptomsmayworsen.

Becausejailshavea constitutionaldutyto providementalhealthtreatmentto individualswho requireit,and a responsibilityto providea safe andsecureenvironmentfor bothstaffand inmates,it isinthe bestinterestof allconcernedto stabilizepersonswhohavementalillnesses.Effectivementalhealthservicescan reducesecurityrisksbyhelpingpersonswithmentalillnessescontroltheirpsychiatricsymptomsand byeducatingstafftointeractina morepositivewaywiththese individuals.

Screeningand evaluationare the firststepsto identifyingpersonswithmentalillnesseswho requireintervention.This isthepointat whichindividualswilleitherbe diverteddirectlyintomentalhealthtreatment(inpatientoroutpatient)oridentifiedfor in-jailservices.Thus,jailsshouldhavebothpre-detentiondiversionoptionsandprovideorhaveaccess to afull rangeof mentalhealthanddischargeplanningservices.

Manyexpertsstressthe need to usecommunitymentalhealthresources,ratherthandevelopingmentalhealthtreatmentprogramsinjails.Thecreationand supportof a fullarrayof in-jailmentalhealthservicesnotonlyduplicateswhatmaybe availableinthecommunity,butalsomightcreatean incentivefor criminaljusticepersonnelto incarceratepersonswithmentalillnessesas a treatmentaltemative(Steadmanet al., 1989).Thedevelopmentof workingagreementsto purchaseservicesfromcommunitymentalhealthagenciesandto transferindividualsto inpatientcarewhennecessaryiscost effective,allowsforcontinuityof care, andsupportsdevelopmentof thecommunityservicesystem.

Realistically,however,therewillalwaysbe theneed fora minimumnumberofservicesto be providedinjails,particularlywheresuchservicesare notreadilyavailableinthe localcommunity.Amongtheseservicesare inpatientbedseitherinjailor ina localhospitalorpsychiatricfacility,around-the-clockmentalhealthandnursingcoverage,treatmentplanning,andtheavailabilityof psychotropicmedications.Inaddition,opportunitiesfor individualandgroupcounselingandbehaviormanagementmay proveuseful.

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Jailsthat do not providea full rangeof servicesshould,at a minimum,provide screeningand evaluation, crisis interventionand short-termtreatment with the availabilityof psychotropicmedications,anddischarge_transferplanning.

Screening and EvaluationScreeninginvolvescontinuingassessmentsof thementalhealthstatus,medicationneeds,andsuicideriskof individualsbeingdetained.It may bedoneformallybypersonneltrainedinthe identificationof psychiatricproblemsusingstandardizedinstruments.Morecommonly,screeningisaccomplishedinformallybyobservationof an individual'sbehavior,appearance,andspeech.Screeningistheresponsibilityof all staff,includingarrestingandbookingofficers,supervisors,andothercorrectionspersonnel.

InIockups,thepurposeof screeningisto determinewhetherthepersonbeingdetainedisdangerousto himorherselforto othersdueto symptomsof mentalillnessor issodisabledas to requirethe immediateassistanceofa mentalhealthprofessional.Evaluationsof thisnaturemustbeaccomplishedina timelymannerduetheacutenatureof theproblem.

Screeningandevaluationinjailstendsto be morecomplexandcan beseenas a three-stepprocess:routinementalhealthscreeningat intake,morein-depthmentalhealthscreeningwithinthe first24 hoursofadmission,andfollow-upmentalhealthevaluationwhen deemednecessan].

Persons who are identifiedthrough these screeningprocedures as needinga full mentalhealthevaluation should haveone immediately incrisissituations or within 24 hours of a referral.Such evaluationswill determinethe level of each inmate'sneed for special housing and mental healthtreatment.

The critical importanceof screeningbecomesapparent in the case of asuicidal inmate. Individualsin detention are ninetimes more likely thanthose in the generalpopulationto commit suicide, and most suicides occurin the first 24 hoursafter arrest (Jail Suicide Prevention InformationTaskForce, 1988). In 1986,97 percent of persons who committedsuicide inIockupsand 89 percentof all suicide victims in jails had not been screened.

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Personswhocommitsuicidewhile indetentionare mostlikely to be male,white,arrestedfora non-violentoffense,and intoxicatedat the timeofincarceration(JailSuicidePreventionInformationTask Force,1988).Thereis alsosomeevidencelinkingtheprobabilityofsuicidewiththe presenceofseverementaldisorders.Whilementalillnessmay increasethe riskofsuicide,screeningandevaluationshouldbeseen as a preventivemeasurefor allpersonsdetainedin Iockupsandjails.

Crisis Intervention and Short-Term TreatmentCrisisinterventionandshort-termtreatment arenecessary in responsetoan acute,psychiatricconditionthatpresentsthe possibilityan individualwillbe of imminentdangerto himor herselforto others. In Iockups,crisisinterventionmayinvolveanimmediatetransferof the individualto anappropriatementalhealthfacility.Specialprecautionsincludingcloseandcontinualobservationuntiltransferare usuallyrequiredduringa crisissituation.

Crisisinterventioninjailsmayinvolvetheprovisionof moreextensiveservices,includinga briefmentalhealthevaluationto identifythe problemathand,andemergencytreatmentwherewarranted.Suchshort-termtreatmentmayincludetransferto the in-jailinpatientor medicalunitortoanotherinpatientfacility,includingState, countyor generalhospitalsettings.Othershort-termtreatmentinterventionsincludepsychotropicmedications,specialobservation,andsomeverbaltherapies.

Effectivecrisisinterventionandshort-termtreatmentservicesrequirethatstaffare trainedto recognizeacutedistress,thatmentalhealthprofessionalsare accessibleon a 24-hourbasisto assistwithevaluations,medications,andemergencyplacementsincommunityfacilities,andthatspecialhousingunitsareavailablefor inmateswho requirecloseobservationorextramedicalsupervisioninjail. Formaland informalworkingagreementsbetweenjailsandcommunitymentalhealthprovidersinsurethatindividualsincrisisreceiveappropriatecareand jailoperationsare notdisrupted.

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Discharge/Transfer PlanningDischargeortransferplanninghelpsindividualsbeingreleasedto thecommunityor beingsent to pdsonconnectwithappropriatementalhealthservices.Ina recentstudyof all U.S. jails,only26 percentreportedofferingdischargeplanningservices(Morriset al., 1994).

DischargeplanninginIockupsis generallyrestrictedto communicatingwiththeappropriatereceivingfacility,includingthecourtandjail,to insurecontinuityof care. Aspart ofa jailmentalhealthprogram,dischargeplanningisusuallythe responsibilityof a case managerwho is a mentalhealth professional.

Typically, this individual makes referralsor appointments with mental healthagencies for continuing mental health treatment after release, and notifiesState prisonofficials for those being transferred. In addition,case managerscan facilitate an individual's releaseby helping with arrangementsforhousing,social services, and other supports. Medication managementandindependent living skills training may be especially important.

Principlesfor effective dischargeplanning include the following(Griffin,1990):

• Dischargeplanningmust be a clearlyarticulatedgoal of the jailmental healthprogram.Makingita pdodtyhelpstojustifytheallocationof resourcestowardthisimportanttask.

• Close collaboration between the criminal justice and mental healthsystems is essential. Whether the relationshipsareformal or informal,itis importantthat all key playersparticipateto insurecomprehensiveandcontinuousservicesto personswith mental illnessespreparingfor release.

• Discharge planningmust begin in advanceof releasefrom jail.Becauseindividualstypicallyspenda veryshorttimeinjail,sucheffortsshouldbe integratedintothe ongoingevaluationandtreatmentprocess.

• Continuityof careshould be insured bydeterminingthatallindividualsleavingjailhavereferralsforaftercareand thattheyareencouragedtoparlJcipateinmentalhealthservices.Case managersmayneedtofacilitatesuchongoingcare byworkingdirectlywithindividualsand byexpandingtheirnetworkof communityresources.

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Notable Program

Summit County, TheSummit CountyJail Unit inAkron, Ohio, was renamed the Alcohol,Ohio, Jail o_ug Abuse and PsychotherapyTeam (ADAPT)in 1992. Itsprimaryresponsibilitiesare: psychosociaiassessments, crisisintervention,ADAPT Program management of acute psychotic episodes,monitoring of detoxification,

suicide prevention,prevention of psychological deterioration whileincarcerated,chemical dependencytreatment,education focused onindividualneeds, elective therapyservices including individual and group,and, administrativeassessmentand planning for continuing services.Theseservices are available to all inmates of the Summit CountyJail (ratedcapacity 402) at no cost to the individualinmate. Referralsare made tocommunityagencies for follow-upservices.

In addition to the use of traditionalmental healthproviders, the SummitCountyJail createda Crisis InterventionSpecialistposition to address thecriticalneed to respond to crises quicklyand professionally. Thisstaffmember enables thejail to speed up the classificationprocess for personswithmental illnessesand to more effectivelybring individuals' mental healthneeds to the attention of mental healthstaff.

Inmates whoare at high risk may be housed in the mental health housingunits Wheretheyare more closelyobserved and monitored by professionalADAPT staff and deputies.These inmatesmay include those who areactivelypsychotic, suicidal,or in withdrawal.Correctionsstaff for the mentalhealth unit are selectedjointly by the ADAPT director and correctionalsecurity supervisors. Thesedeputieswork only on the mental health unit.

Jail mental health servicesare enhancedby the use of a computerizedinformation trackingsystem. Thissystem is used to track all inmates whohave receiveda mental health evaluation. Theinformation contained in thesystem includes demographics,diagnosis, staff time, and the number ofinmatesusing each typeof service.

Trainingfor staffof the Summit CountyJail is also provided and includessuch topicsas: recognitionof signs and symptoms of intoxication,withdrawaland mental illness, suicideprevention, crisis intervention, andstress management.

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ADAPT does not provide follow-upservices in the community, feeling thatthe communityresourcesare appropriate for such services. They doprovide referral to community resourcesin attempts to provide for continuityof care.

TheSummit Countyjail employs a uniqueblending of resources to fund itsmental healthservices staff. Self-employed contractors make up the bulk ofthis staff. Activelyseeldnggrants to supplement the county's budget hasenabled the mental health coordinator to retain additionalmental healthpersonnel. Currently there are two funding streams through mental healthservices areprovided: positions for thejail staff are financedby the county,whilethe self-employed contractorsare compensated with resourcesobtained from variousgrants.

Contact: Rebecca Titus, Mental Health CoordinatorPhone: (216) 643-2145

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Mental Health Consistentwith the conceptofa "communitymentalhealthsystem,"prisonsshouldprovidea fullarrayof mentalhealthservices,beginningwith

Interventions in screeningand evaluationandcrisisinterventionat the "frontdoor,"throughPrisons psychotropicmedicationandmonitoring,individualandgrouptherapy,case

management,andspecializedhousinginprison,to dischargeplanningandreferralat the "backdoor."Innon-prisoncommunities,the useof outpatientservicescansignificantlyenhancean individual'sabilityto liveand functioninthecommunity;thus,withsimilarhelp,inmateswithmentalillnessescanloamto functioninthe prisongeneralpopulation.

Lackof financialresourcesandprisonovercrowdinghavecreatedsignificantbarriersto the provisionof qualitymentalhealthservicesinprisons.Inaddition,mentalhealthservicescan be providedunderdifferentauspices,typicallybythe Statedepartmentof mentalhealthor theStatedepartmentof corrections.InsomeStates,mentalhealthbudgetsare beingdrasticallyreducedand correctionsbudgetsare continuingto expand.Clearly,eachStatewilldifferinitsresourceallocationand mustdecideindependentlyonthe bestway tosupportprisonmentalhealthservices,bothfiscallyand administratively(Cohenand Dvoskin,1992).

The informationinthe followingsectionsdrawsheavilyfromtheworkof theNationalCoalitionfortheMentallyIIIintheCriminalJusticeSystem.Thegroup's recentmonograph,Mental Illnessin America's Prisons, representscurrentthinkingabouthowto designanddelivermentalhealthservicestoprisoninmates.

Screening and EvaluationOne of themajorreasonswhyprisoninmateswith mentalillnessesdo notreceiveservicesisthattheyare inadequatelyscreened.Ogloffandcolleagues(1993) recommendthatscreeningbe a two-stageprocess:abriefmentalhealthscreeningfor everyinmateuponadmissionto theprison,and a morein-depthmentalhealthassessmentforthosewho areidentifiedduringthescreeningprocessas needingfurtherevaluation.

Theseearlyassessmentshelppdsonstaff:(1) identifyinmateswhoareatriskof injuringthemselvesorothers;(2) determinewhetheran inmateissodisabledthat he orshecannotfunctioninthegeneralpopulation;(3)assesstheneedto transferthe inmateto a mentalhealthfacilityoutsidetheprison;and (4) decidewhetherthe inmatewill benefitfrommentalhealthservices.

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American PsychiatricAssociationstandardssuggestthat a mental healthprofessionalor trained correctionsofficerscreen all inmates immediatelyonadmissionto the prison, using a standardizedset of instrumentswith alow-thresholddesigned to detect any evidence of mental health problems.Further screeningshould be part of a standard medicalworkup conductedby health care personnel. Recordsaccompanyingan inmate may beinadequate,making carefulassessments particularlyimportant.When theyare screened, inmatesshould be provided with informationabout mentalhealth servicesavailable in the prison.

In addition to the formal screeningprocedures,corrections and mentalhealth staff must continuouslyobserve inmates for changes in behavior thatmight indicate a worsening mental healthcondition. Some inmatesmaydevelopmental health problemswhile in prison, and the mental healthstatus of others may change during the time they are incarcerated.Although correctionsofficers are likelyto be the ones who have the mostday-to-daycontact with inmates,additional personnel, including teachers,librarians,nurses, and other supportstaff, should be trained to recognizemental health problems (Ogloff,et al., 1993).

This training should include recognitionof so-called positive symptoms,such as hallucinationsor delusions,and of negativesymptoms, includingwithdrawal. Often, non-disruptiveinmatesdo not come to the attention ofthe mental health staff even thoughthey may be inacute need of services.

Clearly, diagnosis of mental health problemsis an important feature ofscreening and evaluation. However,as Ogloff and colleagues (1993)caution, diagnosisis not equivalentto impairedfunctioning. "Very oftenmentally ill inmatesare not disruptiveand will not harm themselves,whilemany disruptiveinmatesare not mentally ill. Therefore, rather than justfocusing on identifyingmental illness, it is important to consider inmates'psychosocialfunctioning."Giventhe stigma associatedwith mental illness,it may not benefitan inmate to be designated mentally ill if he or she canfunction well within the prisoncommunity and/or if there are no appropriatemental healthservices or programs availableto meet his or her specificneeds.

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Crisis ServicesRegardlessof the effectivenessandthoroughnessof thescreeningprocess,mentalhealthcrisescan occuratany time.Crisisservicesmustbe availableto allinmateson a 24-hourbasis;a timelyresponseis criticaltostabilizethe inmateandpreventfurtherdisruptiontothe individualandtotheprison.Effectivecrisisinterventionprogramsshouldincludestepstoreducetheprobabilitythat a crisiswillrecur(CohenandDvoskin,1992).

Crisisservicesgenerallyinvolvea mentalhealthevaluationto determinethenatureof the problem,followedbyemergencytreatment.Suchtreatmentmayincludetransferto inpatienttreatment(eitherwithintheprisonor outside)or tospecialmedical/psychiatrichousingunits,theuseofemergencypsychotropicmedications,andtheuse ofspecialobservation.Emergencytreatmentservicesgenerallywill notexceed 72 hours,afterwhich the services the inmate receivesbecome part of his or her on-goingtreatment plan.

For theseservices to be effective, all correctionsstaff must be trained torecognizewhen an inmate is in crisis. It is important to underscorethatattentionmust be given to both the "positive"and "negative"signs of mentalillness, that is, withdrawaland loss of appetite should be given as high apriorityas hallucinationsand delusions. In addition, mental health andmedicalpersonnel must be available on a 24-hour basis.

When a crisis occurs it may be necessaryto removethe inmate from thegeneralpopulation. Inpatienthospitalizationcan often be avoided throughthe useof short-termcrisis beds within the prison setting (Cohen andDvoskin, 1992).

Mental Health Treatment ServicesOne ofthe primaryissuesinreviewingmentalhealthtreatmentforprisonershastypicallybeenthe lackofdiscussionregardingwhat typesofservicesandmodalitiesareeffective.Certainly,thereissupportfortheeffectivenessof psychotropicmedication.However,medicationdoesnotworkforallpeopleand,giventhesometimessevereside-effects,mayberefused.Norwouldmentalhealthprofessionalsgenerallyrecommendmedicationaloneas an appropriateintervention.

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Thus, mentalhealthservicesin prisonmustincludea wide array ofapproaches.Riceand Harris (1993)cite support for the useof behavioralinterventionswith this population.They suggest a two-pronged approachdesigned to reinforceappropriatebehaviorsand to address specific deficitswith skills training. Such techniques have been usedsuccessfully inCanadianprisons.

Assertiveoutreachand case managementare key components of effectivemental healthservices within the prisonsetting (Cohen and Dvoskin, 1992).This is especiallytrue for groupswith special needs,such as combatveterans, adult survivorsof childhood physicalor sexual abuse, victims ofphysicalor sexual assault in prison,or inmateshoused for long periods indisciplinary segregation.

Special HousingTo meet the needs of inmateswith mental illnessesoverlongperiodsoftime,a continuumof housingoptionsmustbeavailablewithintheprisonsetting.Inadditionto crisisbedsandaccessto inpatienttreatment,longtermresidentialtreatmentunits(RTUs)complementtheneedsof inmateswithmentalillnesses.

Inmateswithseverementalillnessesoftenhavetroubledealingwiththestressesof prisonlifeandare particularlyvulnerableto abusefromstaffandotherinmates.RTUs,whichfeatureseparatehousingandtherapeuticinterventions,can dramaticallyimprovean inmate'squalityof lifewhileprovidinga saferenvironment.Theseservicescan betransitionalin natureor be a permanenthousingoptionfor thosewho need it.

Specialized residentialunits do not necessarily require24-hour a daymedical coverageand can be a cost-effectivealtemative to psychiatricinpatient treatmentwithout compromisingthe inmate's mental health care.In a study of New York State prisons,Condelli and colleagues (in press)found that such programs reducepsychiatriccrises, disciplinaryviolations,suicide attempts,and hospital transfers.

Inpatient ServicesPsychiatricinpatientservices are a necessary component in the continuumof care, but are not required to be operated by the prison. If the otheraspects of the continuumof care notedherein are present, the number ofinpatientstays can be minimaland the averagelength of stay typically short(under 60 days).

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If the prisonor prisonsystemdoeshave a psychiatricinpatientfacility,these units may want to seek accreditationby the Joint Commissionon theAccreditationof Health Care Organizations(JCAHO).While there is nomandatefor prison psychiatric inpatientfacilities to be accredited, suchaccreditationof civil facilities presumesa minimum of constitutionallyadequatecare (Woe v. Cuomo).

Discharge Planning and ReferralDischargeplanninghelpsinsurecontinuityof care for inmates,butthisismorecomplicatedintheprisonsettingthan in jailsbecauseprisonsare nottypicallylocatedinthecommunitiesto whichinmatesare released.Formalor informallinkagesbetweenStatefacilitiesand localprovidersare seldomdeveloped.

Typically,transfersto otherStateprisonsorto psychiatricfacilitiesarerelativelyeasyto facilitate.Butthereisoftenlittlethata dischargecasemanagercan do to guaranteethatsomeonereleaseduponcompletionof asentencewill receiveneededmental healthservicesin hisor her owncommunity. Resourcedevelopmentis neededto enhancethe connectionsbetween the criminal justice and mental healthsystems at the State andlocal levels.

A strong working relationshipbetween prison-basedcounselorsand Stateparole agenciescan be an important indirect mechanismfor insuringcontinuity of care for persons releasedon parole. Parolesupervisioncanrequire participationin mentalhealth treatment programs.While paroleboards are often reluctantto release inmates receivingmental healthtreatment, it is likely that more such individuals would be releasedto theircommunities if formalagreementsfor their care and supervisionweredevelopedamong prison administrators,parole officers,and local mentalhealth providers.

Specific policiesand proceduresgoveming the methodof transfer, theexchange of medical recordsand information,and the means of notifyingthe receivingfacility or agency should be developedat each institution. Inaddition, there should be a designatedmental health professional whoseresponsibilityit is to planfor inmate transfer or discharge.

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Notable Program

NewYork State New YorkStateprovidesmental health services to individuals who havebeen sentencedthrough one psychiatric centerand 11satellite units

Prison Mental throughout the Stateprison system. The Central New YorkPsychiatric

Health Program Center, a 191-bedhospital that operatesunder the auspices of the NewYorkStateOffice of Mental Health (OMH), is a fulty-accreditedpsychiatricinpatient facility.Although its perimeter security and procedures are asstringent as any maximumsecurily prison, within that perimeter the facilityfunctionsas a psychiatric hospitalwith a widerange of environmentsofferingvariouslevels of unrestrictedmovement.

The satellite unitsprovide a range of services to eachprison cluster. Theseinclude screeningand referral;crisisbeds, withan average stay of lessthan 10days; long-term residentialtreatmentunits called intermediatecareprograms; outpatienttreatment,which usuallyincludes medication and_orpsychotherapy,for thoseliving in the generalpopulation;and pre-dischargeplanning servicesfor inmatesabout to be released orparoled.

Screening and ReferralAt New York'sreception correctionsfacilities,satellite units focus onscreening and follow-upevaluationsof incoming inmates to determinethose who are likety to have a highlevel of need for mental health servicesduring their incarceration.

After inmatesare screeneda follow-upreview is conductedto discusswhether the inmate needsor wantsservices and the proposedrequirements.Eachinmate is given a mental health service designation,which determinesto whatinstitutionan inmate is transferred, so that at anygiven time those inmatesmost liketyto need intensive services will behoused in institutionswithsatellite units.

Crisis BedsEach satellite unithas a crisisbed capacity of approximate_ 10beds.Theseare for short-termplacements that allow inmates to receivetreatment aimed at stabi/izingcrisessuch as acute psychoses or suicideattempts. Treatmentinc/udesmedicationsand verbal crisis-orientedtherapy.

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Intermediate Care Programs (Residential Care)For some inmates, the generalprison population can be so stressful thatthey are in a constant state of crisis. New York realizes that this groupneeds a level of service less intensive than crisisbeds or inpatienthospitalcare, but more intensive and supportive than generalpopulation outpatientcare. Theintermediatecareprograms were created to meet this need.

Outpatient ServicesEach satellite unit maintains an outpatient caseload of general populationinmates who receive regular treatment,most often medicationand_orpsychotherapy. This level of treatment is meant to help the inmate live andwork withinthe generalprison community. Satellite unit staff provideconsultationon all aspects of the prisonprogram and security operations tohelp maintaina safe and secure environment for all staff and inmates.

Pre-Discharge Planning ServicesSeveralyears ago, OMH determined that the weakestpart of the servicedeliverysystem wasthe pre-dischargeplanning services for those inmatespreparingfor release or parole. Each satellite unit now has a dischargecoordinator who works closelywith the Divisionof Paroleand the State andlocal mentalhealth service network.Current initiativesinclude negotiationsto developa process of Medicaidreview to enable newly dischargedparolees to avoid long delays in receivingneeded mental health services inthe community;and an IntensiveCase Managersprogram devotedexclusivelyto parolees withmental illness.

Thisprogram is expected to reduce the relianceon crisis-orientedcare andis designed to tailorservices to the client.Specially trainedparole officerswill be assignedto work as a team with several intensive case managers,withprogressive sanctionsaimed at reducing technical violationsby givingparole officersmore choices (as opposed to revocation) for responding toepisodesof treatment failure.

Contact: Dr. Joel Dvoskin,Associate Commissionerfor ForensicsPhone: (518)474-3290

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Mental Health The first monthsarea criticalperiodin thetransitionof an individualfromjail orprisonto communityliving.Forpersonswithmentalillnesses,

Interventions for entitlementbenefitsand stable housingare importantcomponentstoPersons on success.However,thesemaybeespeciallyproblematicfor newlyreleased

Probation and parolees.Priorto 1985,prisoninmateswereeligiblefor Medicaidcoverageduring

Parole their first and last months of incarceration.Currently,prisoninmatesarenoteligibleto receiveFederalentitlementsm includingSupplementalSecurityIncome(SSI),SocialSecurityDisabilityInsurance(SSDI), or Medicaid--whiletheyare inprison.The earlierpracticebothallowedfor diversionofmentallyillindividualsintotreatmentprogramsand facilitatedthereferralofclientsto servicesafterrelease.Medicaidcan be as an incentivetoprovidersto acceptdifficultclientsthattheywouldotherwisereject.

Anotherdifficultyfacingtheseindividualsandtheirprobation/paroleofficersis thereluctanceof manymentalhealthservicesagenciesto providetreatmentto personswitha criminalrecordor to thoseindividualswhoareparticipatinginservicesinvoluntarily.At thesametime,probationandparoleofficersmay finditdifficultto helppersonswithmentalillnessescompletetheirsentencesiftheyare unawareof thebehavioralandsocialproblemstheseindividualsmayexperienceas partof theirdisorders.

Clearly,themostimportantcomponentofeffectivementalhealthserviceprovisionto personson probationor paroleisclosecollaborationbetweenprobation/paroleofficersandcommunitymentalhealthproviders.Cross-trainingofstaffmay be criticaltothe successof thesecollaborativeefforts.

Accessing Community TreatmentIndividualswithmentalillnesseson probationandparole,likeothercommunitymemberswithsimilarproblems,requiretheavailabilityof a fullrangeof mentalhealthservicesthatareaccessible,appropriate,andrelevantto theirneeds.Mentalhealthtreatmentmay be a conditionofprobationor paroleforsomeindividuals;forothers,participationinsuchservicesisvoluntary.

65

Some probationand paroleagencieshave developedstandingcontractswith community providers.These workingagreementssupport the activitiesof both systems and the clients they jointly serve. Communityagencies thatwork with individualson probationand paroletend to be familiar withcorrections practicesand are more receptiveto nonvoluntaryclients (Cole,et al., in press).Such arrangementsmay also allow for parole/probationofficersto intervenein emergenciesthat involve personsunder supervisionat the mental health service providersite.

In addition, probationand paroleofficers may take advantage of mentalhealthintensive case managementprograms,where they exist. Theseprogramstypically provide support for many domainsof living, includinghousing,mental health and other support services, and finances. Theintensityof the services and the funding is flexible. Such programs appearto be effective in reducingthe inappropriateuse of psychiatricservices andthe number of days spent in hospitals and jails by some of the mostdifficult-to-serveindividuals.

While such arrangementsinsure access to treatment for many individualswith mental illnesses,problems may arise when the mental health agencyis not equippedto serve personswithvarying levels of disability, or withdiffering needs and interests. In addition, the highco-occurrenceofsubstance use disordersin this populationmay require the involvementofother serviceproviders.Interagencycollaboration among key organizationsis requiredto make these effortswork. Communityplanningcommitteesthat involveprobationand parolestaff, substance abuse and mental healthproviders,housingprograms,and local social services agencies candevelop a networkof flexible services. Formal agreements and memorandaof understandingmay insure access to treatment for persons with mentalillnesseson probationor parole.

Informationexchangeand mutualsupport betweenparticipatingagencies iscritical. In particular, issuesof client confidentialitymust be explored. Whilecommunity supervisionofficers must be informedof an individual'snon-participationin services when treatment is a condition of release,manymental healthconsumers object to the idea of complete informationexchangebetween the mental health and criminaljustice systems.Discussionswith consumer advocacy groups may allow a clearerunderstandingof the kindsof circumstances under which information maybe exchanged.

66

Staff TrainingStaff trainingis a key componentat alllevelsof cdminaljustice/mentalhealthinteractions.Foreffectivecommunitysupervisionof personswithmentalillnesses,probationandparolestaffandmentalhealthprovidersmustunderstandeachothers'roles.In particular,communitysupervisionstaffneedto understandthe effectsof mental illnesseson dailyfunctioning.

Probationandparoleofficersmayhaveinternalconflictsbetweentheirrolesas facilitators/helpersforpersonsundertheircareandas enforcersofprobationand parolesentences."Oddbehaviorbyclientsmay beinterpretedfromanorganizationalviewpointthatemphasizesclientcompliance,ratherthana clinicalstandpointthatseeksto interpretbehaviorin termsofa needfor intervention.Thiscouldresultinhigherrevocationratesformentallyilloffenders,basednotonlyon the offenders'behavior,butalsoon the inadequatetrainingofparolestaff"(Clear,et al., inpress).

To increasethe likelihoodof success for personswith mental illnesses,allcommunitysupervisionstaffshould be trained to identify the symptoms ofmental illnesses,to understandsome of the unique problems and issuesfacing persons with mental illnesses in the community, and toaccommodatethe sometimes unusual,but not criminal,behavior of thoseunder their supervision.By the same token, community mental healthprovidersneed to be informedabout the demands and nature of thecriminal justice system and the need to work with personswho have mentalillnessesto help them meet the conditionsof their probation and parole.

Special Accommodations for Persons withMental IllnessesPersonswithmentalillnessestendto havehighratesoftechnicalviolationsof theirprobationandparolesentences.To accommodatetheiruniqueneeds,manycommunitysupervisiondepartmentshavedevelopedsomespecializedservicesto helppersonswithmentalillnessesbecomesuccessfullyintegratedintothecommunityandmeettheirconditionsofrelease.

Technicalviolationsoftheconditionsof releasetendto be allor nothingdecisions.Alternativestrategiesallowforcontinuousmonitoring,increasedcommunicationbetweencommunitysupervisionandotherprovideragencies,greaterclientresponsibility,andsanctionsthatallowforsomemistakeswithoutresultinginan immediatereturnto jailor prison.

67

Specialized CaseloadsPersonswithmentalillnesseson probationorparolemaybe assignedto aspecializedcommunitysupervisioncaseload.Suchspecializedcaseloadstenclto be smaller,andtheprobation/paroleofficerinchargeoftheseclientshasspecialskillsandknowledgethatmay facilitatethe integrationofthe individualwith mentalillnessintothecommunity.

Sometimestheseservicesare transitional.Personswithmental illnesseswhoare newlyreleasedfromjail orpdsonmay beassignedto a specializedcaseload.Becausetheseindividualsmay havemoredifficultyadjustingtocommunitylivingafterincarceration,havefewernaturalresources(e.g.,employment,socialsupports,housing),and requiresupervisionofspecialconditionsfor treatment,suchearly,intensivesupervisiontailoredto thespecificneedsof each personcan be important.Once the individualisstabilizedinthecommunity,he or shemaybe transferredto a genericcaseload.

In addition,persons with mental illnesses may require more intensivesupervisionat a later date. It is important that probation and paroledepartments be able to monitorand reassign individualsbased on currentneed.

Relapse PreventionRelapsepreventionisa recentmodelthathas gainedwide support(Palmer,1992).Thisapproachfocuseson thedevelopmentof socialandemotionalsupports that reinforcean individual'sresistanceto furthercriminal behavior.

The key to this effort is the probation/paroleofficer who acts as an intensivecase manager, maintaining up-to-dateinformation on the individual'sprogress in treatment programs and in employment,family, and socialenvironments.Effective monitoringallows the officer to anticipate periods ofincreasedstress, exacerbationof symptoms, and possible criminal activityand to intervene to avoid recidivism.This approachincorporatesandarticulatesthe shared responsibilitiesof the client,community supervisionstaff, and service providersin the overall outcomes.

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Progressive SanctionsProgressivesanctionsfor technicalviolationsis anotherstrategythatmaybe usedaloneorin conjunctionwithothermodelsto reducerecidivismforpersonswithmentalillnesses.Thisapproachrecognizesthe fact thatmanypersonswithmentalillnesseson probationand paroleare ina "catch-22"situation.

Termsof probationandparoleoftenmandatementalhealthtreatmentforindividualswith mentalillnesses,anda client'srefusalto cooperatewiththetreatmentplanmay resultinan increasednumberoftechnicalviolations(Clearand O'Leary,1983).Thepurpose,however,of mentalhealthtreatmentinthiscontextisto increasetheprobabilityof successfulcompletionofprobation/parole.Thus,ifcommunitysupervisionstaffadhereto strictsanctionsfortechnicalviolationsin regardto treatmentcompliance,specialneedsclients,particularlythosewithmentalillnesses,are likelytofail.

To avoidthisproblem,theuseof progressivesanctionsissuggested.Theessentialcomponentof thiseffortisto avoidan Uallornothing"approachtosuccessorfailureintreatment.Forexample,as describedbyClearandcolleagues(in press),Uclientsmightinitiallybe requiredto checkinwiththeirparoleofficerweekly,butafterfailingto showupforseveralpsychiatricclinicappointments,theparoleofficermightincreasethe frequencytoseveraltimesperweek. It isthenatureofseriousmentalillnessto haveperiodicexacerbationsandremissions,andprogressivesanctionsallowthesystemto provideresponsiveincreasesinstructurewithoutnecessarilyreturningthepersonto prison._

Forthisstrategyto be effective,openlinesof communicationandcooperationmustbe maintainedbetweenprobation/paroledepartmentsandcommunitymentalhealthandotherserviceproviders.

69

Notable Program

_._=..nr_nnn Special in June 1992,collaborationbetween the Health Services DivisionandRelease Servicesproduced a pilot program to improve release planning for

Needs Release long-stayinmates withmental health or medical problems who arePlannino retuming to the community. Previously,planning release for persons with

r_::jOro-ram_ mental illnesses or medicalproblems had been a complex, time-consumingand frustratingtask because of their complex needs and the lack ofappropriate resourcesin many communities.

To reduce the problems associated with release to the community, Oregondevelopedthe Special NeedsRelease Planningprogram, funded entirelyby the OregonDepartment of Corrections. Up to six months prior to his orher releasedate, a packet of information, including criminalhistory andpsychiatric evaluations,is sent to the county mental health and countyparole and probation offices. Theseofficessend staff to evaluate theinmate and, then work together to developa communityplan, includinglinkage to mental health services withmedication monitoringand theestablishmentof neededsupports, including housingand entitlementbenefits (particularlya Medicaidcard).

In addition,parolees withmental illnesses who are returned to prison ontechnical violationsare interceptedand sent directly to the SpecialManagement Unitwhere their symptoms are stabilized. Thisshortens theprocess, and inmatesare usually retumed to the community in 60 to 90days.

This initiativehas developedreferral agreementsand protocols withmanyserviceprovider agencies,streamlinedapplicationprocedures for SocialSecurityAdministrationbenefits, establishedworking agreements with fourcounty communitymental healthagencies, and developed a procedure toenable civil commitmentof severely mentally ill inmates to State psychiatriccenters. In addition, the team approachbetween community mental healthand probation_paroleencouragescooperationand reduces the probabilitythat a newly releasedinmate will fall through the cracks. In view of thesuccessof the program, parole boards are increasingly referring inmatesthat could benefit from these special services.

70

In its first 18 months of operation,the Special Needs Release PlanningProgram has servedapproximately 150persons, two-thirdsof whom haddiagnoses of severe mental illnesses. Of these, 80 continue to bemonitored in the communityby the program.

Thisproject has succeededin establishinga single point of referral forreleaseplanning for complex cases,has leveraged resources that had notbeen available to this populationpreviously, has impactedpublic safety andsaved cost associated with recidivism,and has benefited clients whorequire assistance to retum to the community safely.

Contact: Ron Ward, CorrectionsCounselorPhone: (503) 945-2834

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Diversionto The mosteffectivetypesof jailmentalhealthdiversiondo notend when thedetaineeleavesthe jail. In orderforjailandcourtdiversionprogramsto be

Mental Health successful,theymustbe partof a comprehensivearrayof otherjail

Programs in the services including screening,evaluation,short-termtreatment,anddischargeplanning(i.e. linkage)thatare integratedwithcommunity-basedCom ity mental health, substanceabuse, housing,and social services.mUnThe best diversionprogramsdo not simplylook to keep personswithmentalillnessesoutof jail.Theysee themas citizensof the communitywhorequirea broadarrayofcommunity-basedservices.Theyrecognizethatdueto thenatureof mentalillnesses---andwithouttheassistancetoovercomethe barrierscreatedby fragmentedservicesandthe lack ofsocialsupportsandotherresoumes_hese individualsmay returnto jail.

As previouslynoted,jail diversionprogramscanbe dividedintopre-bookingandpost-bookinginterventions.Pre-bookingdiversionoccursatthe pointofcontactwithlawenforcementofficers.If thisisdoneeffectively,asdescribedearlierinthischapterinthesection"EffectivePolice/MentalHealthInteractions,"personswithseriousmentalillnesseswillbe divertedpriorto arrest.

Effectivestrategiesfor post-bookingdiversiondifferfromthosepriortoarrest.Basedon informationrecentlygatheredas partof a NationalInstituteof MentalHealth-fundedstudy(Steadmanand Morris,submitted),the followingsixfactorsrepresentthekey componentsassociatedwitheffectivecourt-andjail-baseddiversionprograms:

. servicesintegratedatthecommunitylevelwithcorrections,mentalhealth,thejudiciary,andsocialservicessuchas housingand entitlements;

• regularmeetingsof keyagencyrepresentalJvesto encouragecoordinationofservicesandsharingof information;

• liaisonsto managethe intera_onsbetweenthecorrectional,mentalhealth,andjudicialsystems;

• a strongleaderwithcommunicationskillsandan understandingof allofthesystemcomponentsandtheinformalnetworks;

• earlyidentificationof detaineeswithmentalhealthtreatmentneedswhomeetthediversionprogram'scriteria;and

• nontraditionalcasemanagementservices,involvingcase managerswhoare familiarwithboththe criminaljusticeandmentalhealthsystemsandwhoareculturallyand raciallysimilartotheclientstheyserve.

72

Notable Program

Honolulu Jail The HonoluluJail Diversionprogram is a court-basedprogram thattransfersmisdemeanantswithmental illnesses from thejail into mental

Diversion health treatment.TheJail DiversionProgram was begun in 1988 with

Program Robert WoodJohnson Foundationfunds. SinceJuly 1991, the program'sfunding has come from the State'sgeneral fund, administered by AdultMental HealthServices, Department of Health.

Potentialparticipantsare identified through the followingprocedure. Duringthe prearraignmentinterview, non-mentalhealth staff screen all detaineesand flag those whoappear to have acute mental illnesses. Arrestees aremoved at 6 a.m. every morningfrom the Honolulu Police Department to theArraignment Court. Diversionstaff interview the identified detainees todetermine whetherthey are appropriate for diversion.

Theprogram is entirely voluntary. Individuals who choose to participate inthe program are asked to sign a release of information form allowingprogram staff access to their medicaland mental health records. By thetime of arraignmentat 8:30 a.m., the Diversion Program's CaseCoordinator has arrangedfor mental health services and negotiated theacceptance of the diversionplan with the district attorney's office, the publicdefender, and thejudge.

If the detaineeagrees to participate in the recommendedmental healthservices, he or she is releasedon his or her own recognizance by theArraignment Courtafter a court date is set. TheJail Diversionprogram staffarrange for a same day appointmentat the CMHC, VA outpatient clinic, orother appropriatecommunity-basedmental health program. Program staffdrive the client to the appointmentand wait while the client is seen.

Much of the successof the program is due to the program's ability torespondquickly,to arrange referralsand to the availability of the CaseCoordinator to transportand wait for clients to be seen. In addition,extensive follow-ushelp to assure a successful outcome. Clientsare calledevery 60 days at a minimum to findout how theyare doing, whether theyare stillparticipatingin services, and whether further assistance is needed.

73

Court docketsprovided by thejudiciary are reviewed each day for the nextday's cases.Any Jail Diversionprogram client scheduledto appear iscalled,and if he or she needs help getting to court, the Case Coordinatorwill provide transportation.Case Coordinatorsaccompany all clients to trialcourt.

TheJail Diversionprogram maintains clientcharts on all participants, ffserviceproviders lose contact witha client, this file canbe used to helplocate and reconnect theperson to services.

Thisprogram diverts misdemeanants fromjail whileawaiting trial,substantially reducingthe time an individual willspend incarceratedregardlessof the outcome of the trial. Using assertivecase management,the probabilitythat clients will miss court dates (avoidingbench warrants)and drop out of treatmentis also decreased.

The keys to the successof this program are: (1) the presence of aneffectiveleader whois familiar withcorrections, the courts and the mentalhealth system in Honolulu; (2) information sharing betweenmental healthand thejail diversionprogram; (3) aggressive case management with samedaymental health clinic visitsand real access to services; and (4)multiculturalstaff who work well with the clients in the program.

Contact: James Miller,Jail DiversionProject SupervisorPhone: (808)586-4683

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APPENDIXCMHS Ad-Hoc Working GroupforMental Healthand CriminalJustice

Systems

Center for Mental Health ServicesAd Hoc Working Group for the Mental Health and

Criminal Justice Systems

John Allen Sue Dickinson

On Our Own Computer Center Chair213 Monroe Street NAMI Forensic NetworkRockville, MD 20850 202 Briarwood Drive(301) 309-8794 Simpsonsville, SC 29681

(803) 967-7583Paul Appelbaum, M.D.University of Massachusetts Mike Gatling

Medical Center Executive AssistantDepartment of Psychiatry American Correctional Association55 Lake Avenue, North 8025 Laurel Lake CourtWorcester, MA 01655 Laurel, MD 20707(508) 856-3983 (301) 206-5100

Pamela Casey, Ph.D. Voncile GowdyInstitute on Mental Disabilities and the Management of Special PopulationsLaw Mentally Disabled OffendersNational Center for State Courts National Institute of Justice300 Newport Avenue 633 Indiana Avenue, NW, Room 842Williamsburg, VA 23187 Washington, DC 20531(804) 253-2000 (202) 307-2951

John Clark, M.D. Ron Honberg, J.D.Chief Medical Officer National Alliance for the Mentally IIILos Angeles County Sheriff's Dept. 2101 Wilson Blvd., Suite 302441 Bauchet Street, Room 6044 Arlington, VA 22201Los Angeles, CA 90012 (703) 524-7600(213) 974-0149

Steve IngleyRay J. Coleman Director of Professional ServicesAssociate Director American Jail Association

King Co. Department of Adult Detention 1000 Day Road, Suite 100500 5th Avenue Hagerstown, MD 21740Seattle, WA 98104 (301) 790-3930(206) 296-1269

Judith Johnson

Ronald Diamond, M.D. Green DoorAssociate Professor of Psychiatry 1623 16th StreetUniversity of Wisconsin Washington, DC 20009600 Highland Avenue (202) 462-4092Madison, Wl 53793(608) 251-2341 Mental Health Center

(608) 263-6098 University of Wisconsin

Charles Meeks Judith Regina, R.N.National Sheriffs Association Woodburn Community Mental1450 Duke Street Health CenterAlexandria, VA 22314 3340 Woodburn Road(703) 836-7827 Annandale, VA 22030

(703) 246-4431Michael O'TooleNational Institute of Corrections Don Richardson

Jail Division 3139 Colby Avenue1960 Industrial Circle, Suite A Los Angeles, CA 90066Longmont, CO 80501 (310) 391-2823

Raymond Patterson, M.D. Susan RotenbergSuperintendent National Coalition for the Mentally III in theClifton T. Perkins Hospital Criminal Justice System450 Dorsey Run Road 2470 Westlake Avenue, N., Suite 101P.O. Box 1000 Seattle, WA 98109-2282

Jessup, MD 20794-1000 (206) 285-7422(41 O) 792-4022

Jayne RussellJohn Petrila, J.D., L.L.M. Program AdministratorUniversity of South Florida Maricopa County Justice and LawDepartment of Law & Mental Health 301 West JeffersonThe Florida Mental Health Institute Phoenix, AZ 8500313301 Bruce B. Downs Blvd. (602) 506-1381

Tampa, FL 33612-3899(813) 974-2011 Matt Russell

Director of Legislative AffairsRobert T. M. Phillips, M.D., Ph.D. National Mental Health AssociationDirector Forensic Services 1021 Prince Street

Department of Mental Health Alexandria, VA 22314Whiting Forensic InstituteP.O. Box 70 Ron SchraiberO'Brien Drive Consumer/Survivor Mental HealthMiddletown, CT 06547 Research and Policy Work Group

24844 Newhall Avenue #3

Walter Y. Quijano, Ph.D. Newhall, CA 91321Psychologist (213) 488-0031Montgomery County Jail2040 Loop 336 West, Suite 105 Lawrence SolomanConroe, TX 77304 Acting Director(409) 549-2226 National Institute of Corrections

500 1st Street, NW, Suite 1002Barbara Rankin Washington, DC 200017002 Harrods LandingProspect, KY 40059(502) 228-2807

James Stephan Federal RepresentativesBureau of Justice Statistics633 Indiana Avenue, NW, Room 1142 Peggy ClarkWashington, DC 20531 Public Health Advisor(202) 616-3289 Community Support Program

Division of Demonstration ProgramsJim Stratoudakis, Ph.D. Center for Mental Health ServicesMental Health Director Substance Abuse and Mental HealthFairfax County Mental Health Services Services Administration3340 Woodburn Avenue 5600 Fishers Lane, Room 11C-26Annandale, VA 22003 Rockville, MD 20857(702) 207-7743 (301) 443-3606

Linda Teplin, Ph.D. Ingrid GoldstromNorthwestern University Medical School Survey and Analysis Branch215 East Chicago Avenue #708 Division of State and CommunityChicago, IL 60611 Systems Development(312) 908-3712 Center for Mental Health Services

5600 Fishers LaneRebecca Titus, M.S.W. Rockville, MD 20857Mental Health Coordinator (301) 443-3343Summit County Jail205 East Crosier Street Dawn JahnAkron, OH 44311 Center for Mental Health Services(216) 643-2145 Substance Abuse and Mental Health

Services Administration

Mary K. Vaughn 5600 Fishers Lane, Room 15-105Acting City Manager Rockville, MD 20857City Hall, 29th Floor (301) 443-0001414 East 12th StreetKansas City, MO 64106 G. Bryan Jones, Ph.D.(816) 274-2474 Refugee Mental Health Branch

Center for Mental Health ServicesRon Waters Parklawn Building, Room 18-49Consumer Self-Help Center 5600 Fishers Lane2195 Lejano Way Rockville, MD 20857Sacramento, CA 95833 (301) 443-2130(916) 737-7100

Ronald W. Manderscheid, Ph.DoMarthagem Whitlock, Ph.D. Survey and Analysis BranchDepartment of Special Services Division of State and CommunityDepartment of Mental Health and Systems Development

Mental Retardation Center for Mental Health Services706 Church Street 5600 Fishers LaneNashville, TN 37219 Rockviile, MD 20857(615) 741-2517 (301) 443-3343

Harriet McCombs, Ph.D.Program Development and SpecialPopulationsCenter for Mental Health Services5600 Fishers Lane, Room 13-103Rockville, MD 20857

James Pittman

Acting DirectorDivision of Program Development andSpecial

Populations ProjectsCenter for Mental Health ServicesParklawn Building, Room 7C-1055600 Fishers LaneRockville, MD 20857(301) 443-2940

Susan SalasinDirectorMental Health and Criminal Justice

ProgramDivision of Program Development and

Special PopulationsCenter for Mental Health Services5600 Fishers Lane, Room 13-103Rockville, MD 20857(301) 443-7790

Henry J. Steadman, Ph.D.PresidentPolicy Research Associates, Inc.262 Delaware AvenueDelmar, NY 12054(518) 439-7415

Bonita M. Veysey, Ph.D.Policy Research Associates, Inc.262 Delaware AvenueDelmar, NY 12054(518) 439-7415