Topic: Mental Health

A pivotal moment has come in the long and complex effort to reform the U.S. criminal justice system.  The U.S. Department of Justice (DOJ) has directed officials in Alameda County, California, to fundamentally change the way it deals with people with mental illness.

DOJ did so by issuing a formal “letter of findings“, taking the county to task for failing to meet the needs of people with mental illness and entangling them in the criminal justice system. Policy makers and lawyers are watching the situation closely, and the outcome is likely to have an impact far beyond the Bay Area.

The DOJ letter recognizes that people with serious mental illness can live productive lives in our communities. Many of them do so by receiving services funded by the government, such as mental health treatment, peer supports, and housing. Many others, however, do not get the services they need, and those individuals are disproportionately Black, Indigenous, and people of color. Among those who lack services are people commonly called “frequent fliers.” People with mental illness are repeatedly jailed for low-level offenses such as trespassing, shoplifting, and disorderly conduct. Their mental health care consists of visits to emergency rooms and short hospital stays. They typically lack stable housing. They cycle between jails, hospitals, and the streets.

The Cycle as a Single, Failing System of Care

The DOJ letter is a turning point in remedying the cruel trap that this cycle creates, harming people with mental illness, their families, and their communities. The letter recognizes that, as a practical matter, jails, emergency rooms, and hospitals operate as a single, failing system of care. The letter requires the county to abandon that failed system and instead provide community-based treatment and housing to people who cycle in and out of the criminal justice system. It directs the county to deliver evidence-based mental health services, such as mobile crisis teams, assertive community treatment, intensive case management, peer support, supported employment, and supported housing.

DOJ’s letter shows that the political and legal landscape is changing. The letter is a sign of new priorities, reflecting a changed federal approach to criminal justice reform. And it also reflects a renewed federal commitment to civil rights enforcement. Much of the letter is a legal analysis of why Alameda County’s practices violate the Americans with Disabilities Act, a federal statute, enforced by DOJ, prohibiting discrimination against people with disabilities, including people whose disabilities stem from mental illness.

Assuring that people who cycle in and out of jails get the community-based treatment and housing they need is not “pie-in-the-sky.” It is achievable. The expertise exists. The MacArthur Foundation’s Safety and Justice Challenge, which is helping to reduce jail populations across the country, has provided a blueprint.

First, we must identify the individuals who are trapped in the cycle and work with them to identify better ways of providing them services. Second, we must invest in the community-based services we know are effective.

Fortunately, new federal funding is available through President Biden’s new American Rescue Plan. It increases the federal Medicaid contribution for community mental health services, including an 85% federal Medicaid contribution for the cost of mobile crisis teams. It also provides new federal funding for housing.

Funding can come as well from savings generated by reducing jail populations. When people with mental illness receive needed services, far fewer go to jail. Far fewer people in jail should yield substantial cost savings, which can be reallocated to pay for an expansion of community services.

Third, we must shift responsibility from the criminal justice system to the mental health system. It is not acceptable to rely on the criminal justice system to address what is, at its core, a mental health care problem. Moreover, it is dangerous to have police respond when people with mental illness are in crisis or need services. Far too many people have been killed in such encounters. Fully one-quarter of the people killed in police shootings are people with mental illness.

The current system, which takes lives, also exacts an enormous financial cost. We are squandering millions of dollars on maintaining the trap of cycling. For example, it costs Alameda County in the vicinity of $120,000 per person per year for avoidable jail and hospital stays. For substantially less, it could provide an apartment and quality community-based treatment. It may be that Alameda County could fund the reforms sought by DOJ entirely from the money it spends on practices that consign many people with mental illness to repeated and avoidable stints in jail, hospitals, and the streets.

Taking these steps would dramatically improve, indeed transform, the lives of many people with mental illness. It would recognize them as deserving members of our communities with much to contribute. Taking these steps would also promote greater equity in the health care and criminal justice systems, since those who would benefit are disproportionately Black, Indigenous, and people of color.

No one should be caught in a futile system of harm. DOJ has now joined and given a big boost to the effort to dismantle that system and replace it with effective community-based treatment and housing. It will be a long road, but such systemic reform is within our grasp.

Incarceration is traumatic, and the institutions charged with that function—prisons and jails—often operate in a way that is most traumatic for the people who are incarcerated. But we often overlook the trauma that is also experienced by those who work to staff the jails, and the families of people who are incarcerated.

It’s an opportunity for us to do better, and the scale of the challenge is huge. Every year, people are placed in jails 10.6 million times. On any given day, approximately 2.7 million US children have a parent who is incarcerated, and more than 5 million children have experienced parental incarceration in their lifetime. Approximately 415,000 correctional officers work in our jails and prisons.

Families

Over-policing of Black communities results in a disproportionate number of Black people being sent to jail for low-level offenses. My own father was arrested for marijuana possession when I was growing up in a small town in North Carolina, and he ended up going to jail and then to prison for a couple of years.

As a child, you never forget the experience of police officers hauling your father off. You do not forget having to interact with your father through a piece of glass. They are links in the chain of trauma that lie embedded within a person. And it radiates through communities. Yet, these communities have no pathway to power when it comes to the policies and practices of the institutions responsible for the safety of their loved ones. That must change. There must be a shift in power from correctional leaders to community members when developing and overseeing policies, practices, training, and environmental conditions within these institutions.

Image credit: Chicago Beyond.org

Staff

I ran the jail in Chicago, Illinois, otherwise known as Cook County Jail, as warden, for several years. I was one of the first clinical psychologists in the country to run a correctional institution. My focus was to use my training to instill humanity in the institution, but we don’t talk about how people are traumatized by the experience of incarcerating other people.

The numbers are stark.

When you talk about such trauma the attitude, historically, towards jail and prison staff is, “Suck it up. You signed up for this.” But the problem is that compartmentalizing the trauma just leads it to bleed out in other areas of your life.

A person’s partner might say, “you are snapping much more often.” Or point out that you are not the same person you used to be. It took me a while after I left the job to realize that it is not normal to sleep only two hours a night. It is not normal to be constantly ready for your phone to ring. To feel on the edge of your seat worrying about the next crisis. It takes a significant toll on a person, and it is hard to see the woods for the trees when you are in the thick of it.

People who work in the system are sometimes a little nervous when I bring this stuff up. They do not want to risk opening an emotional Pandora’s box by talking about the trauma they might be suppressing. My response is that the box is already open. The effects are already exerting themselves on you, on your family, and on those you signed up to keep safe.

Interconnected Humanity

At Chicago Beyond, we have started an impactful conversation about all this. In my reflection on my time at Cook County Jail, one of the big things we realized was that if correctional staff treated the people who were confined and their families with humanity, they could also see the humanity in themselves. We partnered with the Cook County Sheriff’s Office to develop family-friendly visitation, because helping people who are incarcerated hug their children for the first time in years is humanizing for everyone. People had strong emotional reactions to working in visitation, and we talked about the implications. We also acted on them at the policy level.

We have produced a report on this at The Square One Project, called Harm Reduction at the Center of Corrections. It includes a first-of-its kind framework for correctional leaders to better support the people detained, staff, and the families of both. It provides recommendations for correctional leaders centering on safety, transparency, agency, asset-based approaches, and interpersonal connections for these three groups to minimize the harm created by jails and prisons.

The project of harm reduction is critical from this perspective. There are many specific measures that can be used in correctional settings to decrease harm, including incarcerating fewer people. But the key ideas center around one core concept: correctional leaders promoting human interaction that instills humanity.

We are talking about imagining a future for justice and public safety that starts from scratch — from square one — instead of tinkering at the edges or cherry-picking cordoned-off areas for reform. To do so, we need to get to the root of the problem: decades of neglect around communities with chronic poverty and the twin crises of ingrained racism. That begins with drastic systemic change. It requires addressing the specific harm we have experienced as people and extending the compassion we give to ourselves to other people – all people.

At the National Center for Victims of Crime, we have come to realize that the majority of the people in our jails and prison are victims of crime themselves.

We hope to shed light on the link between experiencing trauma or victimization and incarceration in our new video series.

We hope this series will encourage cities and counties across the country to develop and provide programs for crime victims who are behind bars  to overcome their traumatic pasts, and live happier, more fulfilling lives.

The series focuses on the experiences of three people: Lisa James, David Garlock, and Richard Smith, all alumni of Just Leadership USA—a national nonprofit dedicated to decarcerating the United States by educating, elevating and empowering the people and communities most impacted by systemic racism. Each of them has a lived history of victimization, trauma, and incarceration. These videos focus on them as survivors, examining their pasts through their own words. We are extremely thankful that Lisa, David, and Richard were willing to share their stories in such an honest, open, and vulnerable way.

The interviewer and narrator, Dr. Justin Ramsdell, Assistant Professor of Psychology at George Mason University, provides us with an introductory video providing background on the series and  guides us through four additional videos on: what makes victimization traumatic; developmental effects of victimization and trauma; connecting victimization and incarceration; and treatment within the criminal justice system

The videos are an effort to break down the false dichotomy between victims and offenders. The videos do not suggest that being a victim necessarily leads a person to involvement with the criminal legal system, later on. But they provide insight as to how these experiences are sometimes connected, and why the trauma experiences of incarcerated individuals need to be addressed. Just as we provide someone who is diabetic in jail with proper treatment, we should provide help to someone with a history of abuse.

One way that cities and counties can begin to address this issue is by reaching out to victim organizations in their communities who may be able to provide assistance to individuals inside the jail and those who are re-entering their communities.

—Renee Williams is the Executive Director of the National Center for Victims of Crime

Over the past year, the COVID-19 pandemic has shed new light on how incarceration threatens public health. Against the backdrop of another national health emergency—the opioid overdose crisis—people who use drugs have long endured the health impacts of punitive enforcement policies. Black, Latinx, Native American, and low-income communities in particular have shouldered these impacts, and jurisdictions across the country have been slow to shift their overdose responses toward a paradigm that prioritizes solutions outside of the criminal legal system. For policymakers and community members, difficulty locating and tracking local data has only complicated efforts to identify and deploy appropriate interventions.

With support from the Safety and Justice Challenge, the Vera Institute of Justice has released a new digital report, Overdose Deaths and Jail Incarceration: Using Data to Confront Two Tragic Legacies of the U.S. War on Drugs, with data tools and county-level case studies that situate trends in jail incarceration, overdose deaths, and racial disparities side-by-side. While the relationship between jail incarceration and overdose deaths is clearly complex, the data shows that an overreliance on enforcement and incarceration rooted in the War on Drugs has amounted to a patently ineffective strategy for reducing overdose deaths, which sharply increased between 2014 and 2018. In fact, evidence suggests that incarceration itself increases the risk of overdose death by reducing tolerance during periods of abstinence, limiting access to medication-assisted treatment and naloxone during incarceration and post-release, and more broadly disrupting healthcare and social supports located in the community. A recent study from North Carolina found that formerly incarcerated people were 40 times more likely to die of an opioid overdose than the general population two weeks post-release. Additionally, overdose is the leading cause of death among people recently released from prisons and the third leading cause of deaths in custody in U.S. jails.

While jail incarceration rates in some cities have plateaued or declined in recent years, small towns and rural areas have seen the opposite trend. Although racial disparities in jail incarceration have declined since 2000, Black, Latinx, and Native American people were still incarcerated at significantly higher rates as of 2015.

Meanwhile, although overdose deaths have come to be widely thought of as a crisis uniquely endangering white Americans, Native American people have seen similarly high rates of overdose death, and from 2013 to 2018, the rate of overdose death among Black people increased by about 120 percent.

As communities of all kinds have confronted the overdose crisis, they have responded with a wide variety of strategies based in community and criminal legal settings. To examine the interplay between these strategies—and how state and local stakeholders shape them—Vera’s report looks at recent responses in Bernalillo and Rio Arriba counties in New Mexico, and Haywood and Durham counties in North Carolina. In each community, Vera spoke with criminal legal and behavioral health practitioners and directly impacted community members about how they assess the impact of their jurisdiction’s emerging strategies, including naloxone distribution, pre-arrest diversion programs, and the delivery of medication-assisted treatment in jails. While each county’s story is different, they all highlight the potential of reforms that deliver health services outside of criminal legal settings while underscoring the utility of data to aid jurisdictions in evaluating new programs and initiatives.

Above all, these case studies reiterate the need for urgent action in order to save lives. Vera’s report offers guidance for jurisdictions responding to the ongoing overdose crisis, including the following recommendations:

• Programmatic and policy responses should account for historical and present-day inequities in our criminal legal and behavioral health systems. New strategies should be designed to actively address racial and ethnic disparities in criminal legal system involvement and access to community-based health and social services.
• Resources and responsibility for handling problematic drug use should shift toward community-based harm reduction and treatment services. In addition to being ineffective, criminal legal responses like arrest and incarceration can be tremendously harmful for people with substance use disorders, and criminalization itself further stigmatizes people who need help and support.
• Until responses to the overdose crisis are moved to community settings, the harms associated with criminal legal system involvement should be minimized by ensuring police use their discretion to divert people with substance use disorders to appropriate services. Jails should facilitate access to medication-assisted treatment for those who need it both while in custody and post-release. Harm reduction services should also be made widely available post-incarceration as well as to those at risk of criminal legal system involvement.

As communities face COVID-related budget cuts and weigh the merits of response strategies on a continuum between community-based harm reduction and jail-based harm by punishment, they must stay vigilant and follow the data.