Council on Crime and Justice’s 50th Anniversary Forum
October 10, 2007, Minneapolis Convention Center
By: Mark Anderson and Lynda Cannova

Mark Anderson, founding Executive Director of the Barbara Schneider Foundation, was Senior Policy Advisor on mental health and related issues for Wellstone’s 12 years in the U.S. Senatae. 1989-1990, Director of Board and Commission Appointments in the Office of Governor Rudy Perpich. He has an MA, in Liberal Studies, HamlineUniversity. Lynda Cannova is the mother of two grown sons with schizophrenia. She has worked with Barbara Schneider Foundation on policy development and outreach for three years. She has an MSW from the University of Minnesota School of Social Work.

In the last 50 years there have been dramatic changes in systems of care for those with mental illness, and in how this care is financed. There have been exciting advances in the science of the brain that helps us understand what mental illness really is and how we can respond to it. But even with all the improvements in what we know and what we do, the lives of those with a mental illness have not improved nearly as much as they could have. We know much more now than we did fifty years ago, but our society’s institutions have not kept up so we continue to fall short. Where our health care systems have failed, our criminal justice system has taken on the burden with problematic consequences.

According to the Surgeon General’s Report on Mental Illness, it is estimated that in an average one-year period, 22 to 23 percent of the U.S. adult population—or 44 million people—have diagnosable mental disorders. About 28 to 30 percent of the population has either a mental or addictive disorder. It is estimated that 9 percent of all U.S. adults have mental disorders experience some significant functional impairment. Five percent of adults are considered to have a “serious” mental illness. About half of those (or 2.6 percent of all adults) were identified as being even more seriously affected, that is, by having “severe and persistent” mental illness. This category includes schizophrenia, bipolar disorder, other severe forms of depression, panic disorder, and obsessive-compulsive disorder. Today, only 60% of severely mentally ill persons receive treatment in a given year, leaving approximately 2.2 million severely mentally ill persons untreated (Torrey, 1997).

In 1957 mental health treatment was typically provided in large state hospitals and other institutions. This was the era when pharmaceutical treatment of mental illness was just beginning and an affordable community based mental health system did not exist. Patients were sent to these institutions for care and often spent many years there. Families could care for their family members in their own home, as had been done since time immemorial but, in an increasingly urbanized society, that style of care was less possible for many. These state run institutions were seen as humane alternatives to incarceration or homelessness.

According to the groundbreaking first Surgeon General’s Report on Mental Health, “In the 1950s, the public viewed mental illness as a stigmatized condition and displayed an unscientific understanding of mental illness. Survey respondents typically were not able to identify individuals as “mentally ill” when presented with vignettes of individuals who would have been said to be mentally ill according to the professional standards of the day. The public was not particularly skilled at distinguishing mental illness from ordinary unhappiness and worry and tended to see only extreme forms of behavior—namely psychosis—as mental illness. Mental illness carried great social stigma, especially linked with fear of unpredictable and violent behavior.”

With the invention of new pharmaceuticals, that made it possible to moderate the extreme behavior of many who lived in these institutions, it was thought that allowing patients to leave and be treated in the community would be more humane.

President John Kennedy supported the Community Mental Health Act of 1963 which provided federal financing to states to develop community mental health centers. These community mental health centers developed as an important part of our mental health system, and formed an important core of a growing community mental health movement. But they were never adequately funded and so were never able to provide community based mental health care for all those who had been deinstitutionalized. Deinstitutionalization reduced the population of state and county mental hospitals from a high of about 560,000 in 1955 to well below 100,000 by the 1990s. De-institutionalization has eliminated over 90% of former state psychiatric hospital beds (Sigurdson, 2000). But an adequate community based mental health system has even today not been created.

On July 30, 1965 Medicare, a federal single payer system for those over 65 and, after 1972 for those with a disability, was created. Its companion program Medicaid was also created to cover long term care for the elderly and others and care for mothers and children who met income guidelines. Unfortunately Medicare, to this day, discriminates against mental health coverage, charging a 50% co-pay for mental health care and a 20% co-pay for medical and surgical care. In addition, there was no Medicare coverage for pharmaceutical care outside the hospital setting for the first 4 decades of the program. And Medicaid is moving to a managed care model that has not worked well with this population.

The development of a wide variety of pharmaceuticals lead to an increased reliance on pharmaceutical care rather than hospital care for mental health as well as medical and surgical care. After the failed 1992 national health care reform effort, managed care became the standard way to organize care including mental health care. This business model of mental health treatment helped further medicalize mental health care by disconnecting it from support services. The rise in reliance on pharmaceutical care, combined with managed care led to a decrease in talk therapy and a failure to provide needed support services to those who were de-institutionalized. In fact it would not be an understatement to say that pharmaceutical companies took on a growing role in defining care options. In mental health this lead to the colloquialism, “off his meds,” to refer to someone who was exhibiting symptoms of psychiatric illness.

In speeches to medical societies in the 1940s and 1950s, Bill W., the founder of Alcoholics Anonymous, noted the important role played by leading psychiatrists in the development of AA. And yet there developed a split between the treatment of mental illness and the treatment of substance abuse and addiction. The varying stigma associated with these two sets of disorders and the public’s and the health care community’s failure to understand their inter-relationship lead to a situation where patients with co-occuring mental illness and substance abuse or addiction we bounced back and forth between these systems because neither system was fully able to treat both disorders. This is now changing due to the new brain science that is clarifying the underlying disease processes at work and making possible the identification of effective dual-diagnosis treatments.

After the Vietnam War, military veterans fought for years to gain the recognition of the diagnosis of post traumatic stress disorder, PTSD, as a diagnosable and treatable mental health disorder. Later it was recognized that other sufferers of trauma, sexual assault, torture, children who witness violence, and others, could also be affected by PTSD. During the current conflicts in Iraq and Afghanistan, it is being recognized that combat and operational stress are treatable disorders and that their immediate treatment can lower rates of PTSD in warriors who experience the stress of life in the combat zone. In addition, military health care providers are seeing the importance of traumatic brain injury, TBI, and this is leading to the recognition of the importance of treatment of this disorder throughout the health care system.

Consumer movements like those that lead to the recognition of PTSD have also grown up with a number of other mental health disorders. Consumer organizations, and organizations of family members of those with mental illness, have played an important role in recent years in raising awareness among policy maker and health care leaders in the need to treat mental illness.

Beginning in the 1960s, the feminist movement helped re-define women’s mental health.

Communities of color pressed for respect for cultural differences in mental health care and began to insist on cultural competence by mental health providers so that providers would have the ability to develop rapport and a healing relationship with their patients and clients.

As society changed its view of mental illness, the courts became more understanding of mental health related issues. Civil commitment proceedings were reformed and criminal mental health courts created.

There was a growing understanding of the relationship between children’s and adult mental health. School districts have become much more aware of the barriers to success in education that mental illnesses create for children. And yet schools are not health care institutions and their failure to adequately respond to the needs of children with a mental illness has contributed to the overwhelming majority of children in our juvenile justice system having a diagnosed mental health disorder.

The American’s with Disabilities Act, ADA, which took effect on July 26, 1992, supported parents and consumers’ insistence on an appropriate response to mental illness in the workplace and public accommodations.

Particularly since 1990, advances in brain science, brain scans, growing understanding in brain biochemistry, advances in psychological therapy, electrical brain stimulation, and the role of the genome in brain development and functioning are bringing important new understandings to health care providers, policy makers and the public.

There is an increased understanding that the mind/body split that 18th century philosophers detailed is a fiction. The brain is a real part of the body and the brain and other organs of the body interact in numerous ways so that a health care system that does not treat the brain with the body is outmoded. This new understanding is reflected in the Mental Health Parity Act of 1996 which broke down some of the discrimination against mental health care. So called full parity between mental health, substance abuse treatment and medical and surgical treatment has been under consideration by congress since the mid 1990s and appears closer than ever to passage this year. And at the state level, 1997 saw passage of uniform mental health benefits in all the major public health care program benefit sets. Mental health parity has already been the law in Minnesota since the 1990s.

Today there is an overwhelming need to update all health care, public safety, criminal justice and social service institutions to utilize the new insights that science provides. These systems, which in many cases are based on models that are centuries old, must be updated based on this new knowledge.

In spite of all the progress made in the mental health system in the last 50 years, our current mental health system reflects a social and political mental health injustice. Mental health care providers report that our capacity for emergency psychiatric care is regressing to a time 40 years ago when providers had to accompany patients to the emergency room and wait with them for care. Criminal justice professionals report that 60-75% of those in some of our jails have a mental illness. There are more persons with mental illness in jails and prisons than in all state hospitals combined. Many have identified this situation as the criminalization of the mentally ill.

Due to the decreasing number of inpatient beds and the lack of needed community based mental health providers, many people struggling with severe mental illness find themselves repeatedly and unnecessarily in mental health crisis. Many of them will end up committing suicide, as crime victims, and encountering the police. Clearly reform is needed. There is a need for comprehensive and effective long-term care environment for this high risk population. People with severe mental illness are frequently turned away from treatment facilities and often wind up in jail or are homeless due to lack of treatment. These individuals often have to go through the criminal justice system to get the treatment they need.

In the current situation a large percentage, estimated at 30%, of the population in the criminal justice system is on psychotropic medications to treat severe mental illness; the historic and continuing decline in inpatient beds in mental health hospitals and hospital psychiatric wards; the lack of community based programs to provide long term support to people with severe mental illness needed to avoid repeated hospitalizations, homelessness, suicide, and the number of people who die each year because of the inadequacy of our prevention systems make this proposal profoundly important. Besides these disastrous results our current view of mental health as a social welfare and public safety issue promotes actual loss of liberty when someone who is mentally ill but untreated commits a crime and ends up incarcerated, often being forced into treatment that could easily have been given on a preventive basis in the community.

Research has proven that mental illness is a biological brain disease and not a lifestyle choice. When someone is sick, whether from disease that can be seen under a microscope or from one that strikes the mind invisibly, treatment is required. Unfortunately the current system for providing treatment for those with psychiatric disorders remains dangerously troubled. There is inequity in laws concerning the mentally ill in that they are not guaranteed the right to high quality treatment given to people with other organic but not behavioral illnesses. To be equitable, the mentally ill should have the same right to get treatment as people with any other debilitating disease or disorder. If mental illnesses are not understood as medical conditions, then equity is not a feature of laws and services. People with severe heart conditions or diabetes and cancer can access treatment by going to a doctor’s office or hospital, while the mentally ill are often turned away from treatment facilities. Appropriate response to this population can help save lives, save law enforcement, court, incarceration and health care costs, reduce homelessness, and improve the lives of people with severe mental illness and the lives of their loved ones.

Since the 1970s police departments across the country have seen a sharp increase in calls involving persons with mental illness (Torrey, 1997). It is estimated that between 7-10% of law enforcement contacts involve persons with mental illness (Bailey 2001, Hails & Borum, 2003). Research also indicates that in police encounters, persons with mental illness are more likely to be arrested than those who are not (Teplin, 2000). This high rate of law enforcement contact with persons with mental illness has led to incidents that have resulted in injury or death for the mentally ill. For example in Los Angeles, over a six-year period confrontations with the mentally ill ended in 25 fatal shootings by police (Bailey 2001). One study in a large law enforcement agency found that “suicide by cop” accounted for 11% of all officer-involved shootings (Lamb, Weinberger, DeCuir, 2002).

Recent strides by science in the understanding brain and biological factors that contribute to mental illnesses make these illnesses diagnosable and successfully treatable. This progress has not been matched by public policy in guiding our response to mental illness. Law enforcement response to mental health crisis involves a great deal of discretion in determining the outcome. Police decisions at a scene often determine whether a person will enter the mental health or the criminal justice system; yet officers often have very little training in identifying and working with persons exhibiting mental illness.

Police officers are called on to respond to mental health crisis situations while ensuring officer safety, public safety and on scene resolution or transport to the mental health system. Police need specialized response programs to respond appropriately and effectively.

Persons with mental illness face many risk factors which impact their chances of encounters with law enforcement and for incarceration, including dual-diagnosis with chemical dependency, homelessness, and treatment non-compliance (Munetz, Grande & Chambers, 2001). It is estimated that between 20-30% of the adult homeless population suffers from a severe mental illness (Sigurdson, 2000). In addition 80-90% of mentally ill offenders are estimated to have co-occuring substance abuse problems (Sigurdson, 2000). Disordered thinking and paranoid delusions can lead to nuisances as perceived by the public and even criminal, sometimes dangerous, behavior.

Along with the reports of increased police involvement, reports of large numbers of mentally ill persons in U.S. jails and prisons began appearing in the 1970s (Lamb & Weinberg 1998, Torrey, 1997). Approximately 685,000 persons with severe mental illness are admitted to U.S. jails every year and between 6-15% of jail inmates have a severe mental illness (Hails & Borum, 2003; Lamb & Weinberg, 1998). The U.S. Department of Justice estimates that in 1998 there were 283,800 mentally ill offenders in U.S. prisons and jails, representing 16% of state prison inmates, 7% of federal inmates, and 16% of those in local jails (Ditton, 1999). The incarceration of persons with mental illness has become so rampant that professionals in the field claim that jails and prisons have become mental health facilities (Faust 2003, Howd 1998, Torrey 1997). This has major implications for criminal justice funding, for the cost of imprisonment often exceeds the cost of appropriate mental health care in the community (Sigurdson 2000). Mentally ill offenders are considered to have the highest rate of recidivism of any group of offenders (Sigurdson 2000).

Law enforcement has a professional responsibility to respond to persons with mental illness who are experiencing crises. There are two common law principles that create the opportunity for police officers to become involved with persons with mental illness. The first is that the police have the authority and responsibility to ensure public safety. Secondly, officers have a parens patriae obligation to protect persons with disabilities who cannot care for themselves (Lamb et al., 2002). Police have the authority to initiate a psychiatric emergency apprehension when a person poses a danger to themselves or others or if unable to provide for his or her own basic physical needs necessary to protect oneself from harm (Teplin, 2000). Police officers are often the first responders to people in crisis, but often lack the training necessary to respond appropriately (Patch & Arrigo, 1999).

Police officers typically have three options when encountering a person with mental illness who is creating a disturbance or is in crisis: 1) resolve the situation informally at the scene; 2) transport the person to a mental hospital; or 3) arrest the person (Teplin, 2000). Law enforcement response to persons who are apparently mentally ill involves a lot of discretion in determining the outcome (Patch & Arrigo, 1999). The decisions that police make at a scene involving a person exhibiting mental illness often determine whether a person will enter the mental health system or the criminal justice system. Depending on other community resources, police officers are often the only responders to situations involving persons with mental illness who are experiencing crisis. This is why police officers are often referred to as “street-corner psychiatrists” (Teplin, 2000) or gatekeepers (Patch & Arrigo, 1999).

This role that police officers take on as “street-corner psychiatrists” can be problematic because they often have very little training in identifying and working with persons exhibiting mental illness. Sometimes police do not have the training necessary to distinguish between whether someone’s behavior is a manifestation of mental illness or it is unlawful behavior (Hails & Borum, 2003). When asked, police officers will often identify that they feel unprepared to respond to such situations (Hails & Borum, 2003) and identify that they would like to receive training in how to recognize mental illness, how to respond to situations, and what community resources are available for persons with mental illness (Lamb et al., 2002). Also, research indicates that police interactions with persons exhibiting mental illness are different from interactions with persons who are not apparently mentally ill. Teplin conducted a study in 1980 in which it was found that persons with mental illness have a 67% greater chance to be arrested than those who apparently were not mentally ill (2000).

There is also a concern regarding the use of excessive force with persons with mental illness. As discussed above, interactions between police and persons with mental illness have unfortunately led to death and injury for both persons with mental illness and involved police officers. Although more research is needed, national data indicates that force is more likely to be used with persons with mental illness. Police training in the use of interpersonal skills for de-escalation, the use of less lethal weapons, such as tasers, and other tactics are all issues that impact the use of force by police officers.

When police officers do try to initiate a psychiatric response, by transporting a person for emergency apprehension, they often face barriers. Due to the cuts in funding experienced by the mental health system, many hospitals have a limited number of psychiatric beds. Some programs also have regulations on whom they will accept, such as not accepting persons who are considered dangerous or if they have a co-occurring substance abuse problem (Teplin, 2000). Sometimes officers will transport a person for hospitalization or psychiatric evaluation, just to have the person back on the streets with in hours–creating a revolving door for criminal justice response. In addition, when officers transport a person to the hospital, they sometimes will face a long wait to transfer the individual, which takes the officer away from their patrol duties. In addition, psychiatric care may be more available in the jails than in the community system. Given the barriers officers often face when trying to initiate a psychiatric hospitalization, sometimes arrest is viewed as a simpler and more reliable way to resolve some situations (Teplin, 2000). This is often referred to as “mercy bookings” and is used both when officers do not feel like they have any other realistic choice and also when they believe that it is in the person‘s best interest, for they will receive shelter and possibly mental health services provided by the system (Sigurdson, 2000; Torrey, 1997).

There is growing evidence that formal collaboration between law enforcement and the mental health system is critical for the best law enforcement response to persons with mental illness (Klein, 2002; Gentz & Goree 2003; Lamb et al 2002; Sigurdson 2000; Steadman, 2000 & 2001; Teplin, 2000; Thompson 2003). Police-based diversion programs, involving collaboration with the mental health system have emerged. As compared to court-based diversion, police-based diversion happens before booking and the filing of charges and involves police making direct referrals to community-based mental health or substance abuse programs as an alternative to arrest and detention (Steadman, et. al. 2000). Diversion programs have been shown to work in both decreasing subsequent hospitalizations and recidivism (Sigurdson, 2000).

The Barbara Schneider Foundation was born out of a tragedy that occurred on June 12, 2000. Local police, called in on a noise complaint, shot Barbara Schneider to death in her own home. Six police officers entered her Minneapolis apartment when she was having a mental health crisis. The police were untrained to deal with this call as a health care intervention and rather than de-escalating the crisis they confronted her with force. She had a deadly weapon and she did not back down, as is not uncommon with individuals in mental health crisis.

The mental health community responded by building a long term dialogue with law enforcement and they partnered to prevent such tragedies from re-occurring. In fact the crisis of Barbara Schneider’s death has lead to training in for those responding to individuals in crisis for police, jailers, paramedics, nurses, mental health professionals and social service providers by Barbara Schneider Foundation and their partners in the community. There is a growing awareness of the need to improve our response to mental illness and to build collaborations across all the institutions that respond to those at risk for mental health crisis. This growing consumer lead movement is challenging all the systems in health care and criminal justice to make urgently needed changes. It is this growing voice of those who themselves struggle with a mental illness that provides hope that fairness for those with mental illness can prevail over the forces of ignorance, denial, discrimination, greed and stigma.