By Sue Abderholden, Executive Director of NAMI Minnesota
Sue Abderholden, MPHA, has devoted her career to changing laws and attitudes that affect people with disabilities and their families. She is currently the executive director for the National Alliance on Mental Illness of Minnesota and has held positions with Arc of Minnesota, U.S. Senator Paul D. Wellstone and PACER Center.
Today, people often refer to the “broken mental health system.” This infers that of course that there was a system at one time. A statement on a 1980’s flyer produced by NAMI sums it up best: “People who suffer from mental illness: we used to lock them up and throw away the key. Now we just drop them off on the street.”
In 1957 across our nation, there were about 565,000 people with mental illnesses in psychiatric hospitals or institutions. It’s important to acknowledge that institutions themselves are not a mental health system. For the most part, institutions were closing at that time because of lack of treatment and substandard conditions.
Today, the number of people with mental illnesses living in hospitals or institutions is well under 40,000. This significant reduction reflects the change in the way our society generally views mental illnesses and other disabilities; that people belong in communities and not institutions.
The community movement began in 1946 with the passage of the National Mental Health Act which created the National Institute of Mental Health (NIMH) and charged the organization with three broad functions:
During the 1950’s antipsychotic medications were introduced which also offered hope for recovery and a life in the community. This was followed by passage of several pieces of legislation, including one in 1963 that created Community Mental Health Centers. President Kennedy held out the promise for a life in the community in a 1963 speech stating that “If we launch a broad new mental health program now, it will be possible within a decade or two to reduce the number of patients under custodial care…reliance on the cold mercy of custodial isolation will be supplanted by the open warmth of community concern and capability.”
Minnesota’s experience reflected what was happening across the country. We went from having 9,000 people in the institution in 1963 to just 1,500 in 1978 and to just a few hundred today. While the Minnesota legislature did, like other states, increase its funding for mental health services, it never came close to meeting the needs of people who were being discharged from the institutions. According to an old NAMI (then called the Mental Health Advocates Coalition of Minnesota) newsletter, “the community programs that would have smoothed the way for ‘de-institutionalized’ patients trying to make it outside the hospital wards simply did not exist.”
The promise for a life in the community could only be realized if there was access to and coordination between treatment, medications, employment, housing, peer supports and other community services. But the promise has never been fully funded or coordinated. This broken promise was recognized as early as 1968, when the National Institute of Mental Health released data demonstrating that there was little follow-up care being provided to patients who were discharged from the institutions. The media also followed this issue closely, exemplified by an airing of a public television documentary in 1980 entitled “Back Wards to Back Streets.”
There is a great deal of stigma associated with mental illness. The Surgeon General’s report on mental health identified stigma as one of the major barriers that discourage adults from seeking treatment. One study found that people live with their symptoms for ten years before seeking treatment.
How our society views mental illness impacts recovery. If people believe that mental illness is the fault of an individual or their family, few people will readily come forward to acknowledge the illness or obtain treatment. Negative or stereotypical views of mental illness compound this problem. Kathy Cronkite, who has lived with depression states in her book that when we talk about mental illness we conjure up “images of bedlam, of maniacs running uncontrolled or lunatics gibbering on the sidewalk.”
A 1996 survey found that 71% of people believed that mental illness was due to emotional weakness, 65% thought it was caused by bad parenting, 45% believed it was the person’s fault and 35% believed it was the consequence of sinful behavior. Only 10% thought it had a biological basis. Clearly these attitudes increase the difficulty of people’s willingness to obtain the treatment, services and supports needed for recovery.
African Americans face additional barriers seeking and receiving appropriate treatment for mental illnesses. The first barrier is additional stigma. Dr. Anelle Primm, of the American Psychiatric Society Association stated, “We are not supposed to seek help for our mental illnesses. … Being African American in this society and culture carries a certain stigma with it. Then to admit to having a mental illness - that adds additional stigma.” Add to this a lack of African American mental health professionals, and is it not surprising that the Surgeon General’s report on mental illness found that, “…the percentage of African Americans receiving treatment from any source was only about half of that of whites.”
The Wilder Research report entitled, “Racial and Ethnic Disparities in Children’s Mental Health,” addresses the elevated level of stigma regarding mental illness in the African American community. The report states that, “Several factors can contribute to increased perceptions of stigma, including a greater tendency to assume that mental illness is due to personal failure.” Additionally, the report asserts that parents fear the consequences of a mental health diagnosis. They fear that their child will be labeled and removed from the regular classroom or removed from their home and placed in a residential program.
Stigma also served to prevent people with mental illnesses from being welcomed back to their communities when the institutions closed. In nearly every community across the country neighbors fought to have any residential facilities – including very small ones – from being located in their neighborhood. “NIMBY” known as “not in my back yard” became a common term used by advocates to refer to community opposition.
Impact on the Justice System
The lack of a funded and coordinated mental health system and the prevailing stigma surrounding mental illness has resulted in an increasing reliance on our justice system as the safety net. Some might say our jails and prisons are our largest treatment centers, but it would be incorrect to imply that real treatment – evidence-based and effective – is being – or even can be - truly carried out in correctional facilities.
This is not the first time our jails, for example, have ended up taking in large numbers of people with mental illnesses. E. Fuller Torrey, M.D. has pointed out in numerous papers that this also happened in the 1820’s. Massachusetts actually created the first mental hospital in response to the large numbers of people with mental illnesses who were in their local jails. Dorothy Dix’s work to build psychiatric hospitals began when she came upon people with mental illnesses in the jails whose treatment and care was horrific.
What can be learned from the experiences of the 1800’s is that when alternatives were provided, fewer people with mental illnesses ended up in jail. It is not surprising then that when the alternative at the time – state institutions – were taken away, people with mental illnesses again began filling up our jails and prisons. An English researcher in the 1930’s named Penrose actually promoted a theory that there is a stable number of people who need “confinement” for a period of time and that there is an inverse relationship between prison and psychiatric hospitals.
There have been numerous reports and articles, particularly during the last 30 years, detailing the increasing numbers of people with mental illnesses in our criminal justice system. In 1976 there was an article in the American Journal of Psychiatry entitled “Occurrence of psychiatric disorders in a county jail population” followed by “From the Hospital to the prison: a step forward in deinstitutionalization?” in a 1979 publication of Hospital and Community Psychiatry.
A City Pages article published in 1993 quoted Department of Corrections' staff stating that only 2 to 4% of inmates had a mental illness. Others knew, however, that this had to be a very low estimate but the ranges varied greatly across the country with some research stating it was between 6 to 8% and others that it was closer to 15 to 20%. By 1999 the U.S. Department of Justice was reporting that about 16% of the people in prisons or jails had a serious mental illness. The release of a study by the U.S. Department of Justice’s Bureau of Justice Statistics (BJS) in 2006 showed that 64% of local jail inmates, 56% of state prisoners and 45% of federal prisoners had symptoms of serious mental illnesses. As in other data from the criminal justice system, African Americans are overrepresented.
It should be noted that the numbers of young people with a mental illness in the juvenile justice system are even higher. Young people who come into this system are more likely to have a mental illness, live in poverty, be uninsured and be a minority. Most of the studies put the prevalence rate around 70%. The Minnesota Council of Child Caring Agencies found that Caucasian youth were more likely to be placed in residential treatment and group homes while youth of color were more likely to be placed in corrections or foster care.
The increasing numbers of people with serious mental illnesses in our criminal justice system has seriously strained the resources and staff. Police and sheriffs often cite their frustrations with having to respond to people with mental illnesses, often for public nuisance crimes but other times for a psychiatric crisis. Judges are overwhelmed with the volume of cases, often repeat offenders whose untreated mental illness results in numerous appearances before the court. Jail staff feel particularly lacking in the training and education needed to keep these individuals safe, including those who may be at risk for suicide. Local budgets are strained by the costs of providing medication. Prisons are also not well equipped to address the needs of these inmates.
While our criminal justice system is overwhelmed with these increasing costs and pressures, the money that we do spend is extremely ineffective. People with mental illnesses do not fair well once they come into contact with the criminal justice system. The person who responds to the mental health crisis decides what path a person will take. If it is a police officer, particularly one who has not received any training, the person will most likely end up in jail instead of an emergency room. Some studies find that people with mental illnesses are much more likely to be arrested – perhaps even twice as likely – after coming into contact with police. Sometimes the encounter involves the use of weapons, causing injuries or even death to the individual. If they have benefits, such as Social Security or Medicaid, they lose them once in jail. Reapplying for benefits is not easy and so once released into the community he or she may not have any way to pay for medications, treatment, housing, etc. This leads to a revolving door.
People with mental illnesses are likely to have longer sentences, so they spend more time in prison. Their mental illnesses can make them more vulnerable, increasing the likelihood that they will be assaulted or victimized. Many do not want to take their medications in prison for fear that they will be singled out. Statistics show that someone with a mental illness is more likely to end up in segregation or isolation, which is an extremely detrimental environment for someone with a serious mental illness and can even exacerbate their symptoms.
What was most disturbing about the recent DOJ report was that for many of the current inmates with mental illnesses this was their second or third time being incarcerated. Thus, the very issues that landed them in the criminal justice system were not being effectively addressed and discharge planning at all levels is either nonexistent or inadequate.
In a 1993 article published by the American Correctional Association, the authors stated that “incarcerating mentally ill offenders without case management, rehabilitation services and careful disposition planning is unacceptable from both a financial and a human resource perspective.” Fast forward to the substantive and widely acclaimed Consensus Project report published in 2002. Nearly a decade later similar recommendations are being put forward to address this very important issue.
While it may seem like déjà vu all over again, many advocates believe that there is movement to both change the mental health system and address the increasing criminalization of mental illness.
First there continues to be movement forward in increasing access to mental health services. Minnesota has developed a comprehensive array of mental health services under its Medical Assistance program covering not only basic medications and treatment but also other community supports such as Adult Rehabilitation Mental Health Services (ARMHS), Assertive Community Treatment Teams (ACT), Children’s Therapeutic Services and Supports (CTSS) and Intensive Residential Treatment Programs (IRTS). Community Behavioral Health Hospitals are being developed across the state to replace old institutional beds. Community Support Programs continue to exist and new programs for supported employment and supportive housing are being developed. Crisis teams and crisis homes are also being developed across the state. The 2007 legislative session resulted in over $34 million in new dollars for mental health treatment for both children and adults and in creating a uniform mental health benefit set across Medical Assistance, MinnesotaCare and General Assistance Medical Care.
Second, attitudes towards mental illness are changing. A more recent survey found that 63% believed that mental illness is primarily due to a brain disorder. This is an increase over past years.
Third, some of the recommendations from the Consensus Project report are being implemented in Minnesota. 911 dispatchers in a few communities ascertain if it is a mental health crisis and send out mental health crisis teams. Mental health screenings are now required to be conducted on people going into jails. Some police, particularly in Minneapolis, have received Crisis Intervention Training. County attorneys are more willing to look at pre-trial diversion. There are now two mental health courts in Minnesota, Hennepin and Ramsey. Discharge planning is being done for some people with mental illnesses leaving the prisons, and from a handful of jails.
While this is a hopeful picture, it is not a rosy one. There is still much work to be done before people can access the right services at the right time. The criminal justice system will continue to be overwhelmed and over utilized until there are:
It is, therefore extremely important that the rock solid recommendations of the Consensus Project be implemented in Minnesota. We must look at everything from contact with law enforcement to the courts, to incarceration to reentry. We must look at effective training for all staff and professionals in the criminal justice continuum. The criminal justice system cannot solely rely on an improved mental health system to reduce the numbers of people with serious mental illnesses in its web. It, too, must be committed to decriminalizing mental illness. It will take the two systems, working together, to truly address this issue.
See the Critically Acclaimed Guthrie production of :
The Invisible Children:
Building Community Support for
Children of Incarcerated Parents
7-29-2010 MPR Morning Edition
President Pam Alexander speaks on Minnesota Public Radio about recent legislative actions aimed at reducing crack vs. cocaine sentencing disparities.
Learn about the process to seal a criminal record in Minnesota
Help Crime Victims!
Volunteer as a crime victim advocate on the Council's 24 hour crisis hotline. You can work at home or in our offices. Flexible schedules.
The next Volunteer Crime Victim Hotline Trainings are:
Contact us at 612-353-3045
