5

Prevention, Intervention, and Treatment

Several systems, particularly mental health services and the justice system, play crucial roles in addressing mental illness and violence. If not established as supportive structures, they can cause harm and trauma and possibly increase the risk of violence. Speakers explored how these systems can protect and heal, by building positive environments and providing treatment and redress.

MENTAL HEALTH SERVICES AND VIOLENCE

Speakers discussed ways in which the provision of mental health services can both prevent and reduce violence. Access to care means appropriate treatment for people with mental illness, particularly for those who might seem disruptive to society and whose actions could result in the involvement of the justice system. Furthermore, early and universal mental health services, including those in schools, have implications for reduced violence prevalence across society by addressing risk factors directly. Speakers also discussed the role of policy and programs in expanding services and increasing access in the United States and Latin America.

Mental Health and Access to Services¹

Stigma around mental health is often exacerbated by a perception of a higher risk of violence among those with mental illness. Colleen Barry cited

___________________

¹ This section summarizes information presented by Colleen Barry, Johns Hopkins Bloomberg School of Public Health.

a study that found 46 percent of those surveyed believe that people with serious mental illness are much more dangerous than those without; 29 percent were willing to work closely with someone with a mental illness, and 33 percent were willing to have a neighbor with a mental illness. These perceptions are also affected by whether the respondents had experience, either directly or through a family member or close friend, with mental illness. This context, Barry argued, is important for considering the connection between public attitudes and broader support for mental health services.

Many people experience mental illness, and seeking care is common; one in five seeks care yearly, and one in three over the lifetime. Broadly speaking, she asserted, treatment history or diagnosis is not a specific or useful predictor of violence. Most people with mental illness do not commit acts of violence, and most violent acts are not committed by people with a diagnosis of mental disorder. Less than 2 percent of the population meets the diagnostic criteria for severe and persistent mental illness, and it is a subgroup of those—adults with conduct disorders in childhood—that has the strongest association with violence. But even among that subgroup, the majority is not violent but instead is more likely to be victims of violence.

Given this background, Barry asked, can access to services impact violence? She described two types of services most often discussed: broad institutionalized care and universal screening. On the first, she observed that there is no clear association between institutionalized care and patterns of violence among people with severe and persistent mental illness. Additionally, there are several civil rights challenges with institutionalization and its history of practice. On universal screening, she pointed out there is both low specificity for screening instruments and a lack of capacity in the system for the additional individuals who might be identified in screening. She concluded that broad approaches are not likely to be effective in reducing violence related to severe mental health disorders.

There is a role, she noted, for targeted interventions that improve access and treatment for adolescents with conduct disorders, particularly interventions that address co-occurring mental health and substance use disorders or that are oriented toward suicide prevention. Yet, many of them have not been well implemented. She emphasized, however, that there are reasons beyond violence to improve behavioral health systems in the United States, such as dealing with undertreatment and inappropriate treatment, quality of care, and even measuring and tracking quality. This has implications for payment and insurance, particularly in the context of performance-based metrics. In contrast to the overall health care system, Medicaid plays a much larger role in covering the costs of care and treatment, while private insurance is limited. Even within insurance schemes, historically, mental health services have been underprovisioned and underfunded. However,

people with severe mental illnesses are uninsured at a much higher rate than people with no mental diagnosis.

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, enacted in 2008, was intended to equalize coverage for mental health and substance use services, as comparable to other health services within an insurance program, including not only coinsurance, but deductibles and copayments, as well. It also required that insurance program designs, including elements such as prior authorization and provider networks, had to be equal. Its impact is significant, especially in providing out-of-pocket financial protection.

The Patient Protection and Affordable Care Act of 2010, designed to expand access to and affordability of all health care services, has also resulted in increased coverage of mental health services. Barry explained that this increase is due to an expansion of public programs, reform and redesign of insurance markets, and delivery system and payment reform. While the state health insurance exchanges account for some of the expansion, the bulk of it is a result of Medicaid expansion, particularly the new Medicaid Health Home option, which allows for different types of services that have not been traditionally financed but are important for coordinating care.

The new health care provisions also have implications for criminal justice. People in prisons have the option to enroll in or maintain Medicaid, which provides continuity of coverage. For those on antipsychotics, for example, this means continued medication access and could result in lowered recidivism. Barry closed with a reflection about stigma and mental health, citing a recent study of her own in which, when presented with information about the recovery and treatment of people with mental illness, survey respondents responded more favorably when asked if they would be willing to work closely with or live next to a person with mental illness. Such vignettes, she observed, could dramatically alter public perception on mental illness and improve mental health services and access.

Role of School Mental Health in Mental Health Promotion and Violence Prevention²

School mental health was defined by Sharon Stephan as a partnership between schools and community health and behavioral health organizations, guided by youth and families. While it includes students in special education, its scope is all students and a full array of services from universal prevention to tertiary care. Of the roughly 96,000 public schools in the United States, approximately 40 percent of them indicated that mental

___________________

² This section summarizes information presented by Sharon Stephan, University of Maryland.

health services were provided by a combination of school employees and community employees. An additional 32 percent indicated services were only provided by school staff, and another 28 percent by outside partners.

The community partnership offers schools the ability to provide a broad continuum of care beyond what school staff provides. Community partners also reduce necessary and expensive services, such as emergency room visits, by facilitating pathways, providing preventive care, and assisting with transition from inpatient psychiatric care back to schools. It is important to note, however, that community partners are building on the school’s existing platform and supplanting staff.

Mental health service provision in schools is based on a few principles:

• Healthy students make better learners, and students who succeed in school are more likely to be healthy.
• Adult mental health has its roots in childhood experiences and mental health, and early treatment yields better prognosis in adulthood.
• About one in five children will experience mild mental health impairment, and one in 10 will experience severe impairment. Many of them do not receive the care they need outside of school (McKay et al., 2005), so schools serve as a de facto mental health system for children.
• Addressing mental health in school versus in the community means less time lost from school or work for students and their parents, respectively.

Stephan stated that promising evidence suggests that there are benefits to in-school mental health services. Around social and emotional learning and universal mental health promotion, there are improvements in student social competency and behavioral and emotional functioning. Additionally, improvements are seen in academic indicators, such as grades, test scores, attendance, and teacher retention. There is also evidence of cost savings to schools and communities.

In looking at violence, Stephan remarked that youth are exposed to violence in a variety of settings, including school and home, and more than 60 percent of them report lifetime exposure to traumatic events (McLaughlin et al., 2013). One in five youth report being physically assaulted by peers; a similar proportion report emotional violence by peers, as well. The school is a common setting for physical intimidation, assault, and emotional violence, with more than half of all incidents occurring in school (Turner et al., 2011). During the 2009 school year, 1 in 10 schools reported a serious violent incident that required the presence of criminal law enforcement (Robers et al., 2012). Moreover, 16 percent of students

report carrying a firearm to school, and 6 percent of students report missing school because of safety concerns (CDC, 2008). This violence has repercussions for educational attainment. For example, in a study in Baltimore, Maryland, increasing violence was associated with reduced reading achievement in elementary school students, while increasing perception of safety was associated with higher achievement (Milam et al., 2010).

A public health approach to violence prevention in schools would have multiple intervention points, including the student, the classroom, the school, and the community. In addition, evidence-based health interventions focus more broadly on safety, rather than on just security, as the research suggests that measures such as security cameras and guards are not effective. The interventions with evidence of success include environmental design, teaching students to be peer mediators, and multifamily group intervention.

Stephan presented further information on one particular intervention, Positive Behavioral Intervention and Supports (PBIS), which is a schoolwide framework targeting school climate. PBIS is currently in about 20,000 schools. Some evidence suggests that PBIS improves perception of safety and reduces aggressive behavior. Elements of the intervention include adapting the environment through natural surveillance, access management (e.g., better signage), physical maintenance, visibility maximization, and order maintenance.

Mental Health in Latin America and the Caribbean³

The Global Burden of Disease shows depression as the second largest cause of disability globally. In Latin America and the Caribbean (LAC), 14 percent of disability-adjusted life years (DALYs) and 35 percent of years lost to disability (YLDs) are related to mental health and neurological disorders. Treatment gaps for mental disorders, such as anxiety, schizophrenia, depression, and alcohol use disorder, in LAC are also higher than global rates (Kohn et al., 2004).

Globally, there is also an insufficiency of mental health resources: the world median percentage of the public health budget dedicated to mental health is less than 3 percent. In LAC, the majority of countries allocate between 1 and 5 percent of the public budget to mental health, with a small number of countries having no allocation whatsoever. Of the monies dedicated to mental health, 88 percent goes to mental hospitals, which leaves only 12 percent (of the less than 5 percent) for community-based services. Dévora Kestel remarked that in LAC, there are on average 2 psychiatrists,

___________________

³ This section summarizes information presented by Dévora Kestel, Pan American Health Organization.

4 psychologists, and 1 social worker per 100,000 people. Additionally, she noted that the majority of these personnel work in psychiatric hospitals or psychiatric units in hospitals; across LAC, less than 40 percent of them work in ambulatory care. Nonpersonnel resources, in particular beds, are also concentrated in the hospitals, with very little community housing. Kestel also commented on the variation and quality of mental health policy; most policies are outdated and would not meet internationally agreed upon standards.

The Pan American Health Organization’s work in the region is focused on two aspects: leadership and governance, and mental health and social care services. Greater investment in both aspects is needed, Kestel felt, because the mental health burden in LAC cannot be addressed solely by mental health professionals, but should be integrated with primary care and community care. And importantly, without a more comprehensive and better funded approach to mental health, there cannot be a system to address violence and care for victims and perpetrators.

Discussion

Several themes raised by the speakers were further explored by audience participants following the presentations. In the absence of a robust community mental health system, and with limited capacity of mental health professionals, prisons in the United States have served the role of mental health care providers—a situation that participants felt was not necessarily one to emulate in other parts of the world. In particular, as children leave school for various mental health or violence issues, many of them end up in prison. Michael Phillips of the Shanghai Mental Health Center noted that in China the transition of mental health care from involuntary commitment to voluntary has resulted in more people with mental illness ending up in prison. He commented that training community health workers in mental health could be one way to address the personnel shortage, while others noted that integrating mental health and general health could address issues in both domains.

INTERFACE WITH THE JUSTICE COMMUNITY AND OPPORTUNITIES FOR INTERVENTION

Gaps in community mental health care have resulted in an increased role for the criminal justice system in addressing mental health needs. At the same time, a disproportionate number of people with mental illness are incarcerated, and the correctional system has an obligation to meet their psychiatric needs. Speakers discussed the ways in which the justice system can serve those needs, as well as how it can be a supportive environment rather than a punitive one.

Encounters with the Justice Community and Opportunities for Intervention⁴

Madelon Baranoski described early mental health linkages to the justice system, noting that, historically, those who could not afford private care often ended up in prisons. In a time when there were no effective treatments for severe mental illness, reformers worked to move people to other facilities where, though they were still isolated from the general public, they would be treated more fairly. These facilities became modern-day asylums, and care deteriorated. With the advent of treatment options for severe mental illness, it was no longer considered humane to isolate people without due process. The U.S. Supreme Court in 1966 declared that dangerousness was a prerequisite for involuntary commitment, and the process of deinstitutionalization began.

However, with the transition of people with severe mental illness from institutions to the community, there was no additional provision for care or treatment. And while Baranoski cautioned that not everyone with a mental illness is violent, a number of them end up in prison for what she termed “nuisance crimes,” such as breach of peace. Baronski went on to note that while the number of people with mental illness in prison is increasing, the increase is not because of violence, but rather because life is becoming more destabilized. Poverty, low education, limited housing and resources, and discrimination contribute to the increased number of people with mental illness in prison. In addition, the public misperception that people with mental illness are more dangerous results in the justice system taking control where it seems the mental health system has failed. Jails and prisons, Baranoski asserted, should be the last step. The interface begins with policing, moves to the courts, and if all else fails, ends up in prison. Box 5-1 describes a few of the issues that arise in this process.

Public Safety and Mental Health⁵

Police play an important and complex role in community mental health services, but, as Sheldon Greenberg noted, there are many areas in need of improvement. Some areas are easier and simpler to address, such as terminology. For example, the Association of Public-Safety Communications Officials International (APCO) uses the code “10-96,” which translates to “mental subject,” rather than “person with mental illness.” This change, he asserted, is a simple one to make, but is still an important one.

___________________

⁴ This section summarizes information presented by Madelon Baranoski, Yale University.

⁵ This section summarizes information presented by Sheldon Greenberg, Johns Hopkins University School of Education.

He further observed that police officers think that their work is misunderstood by researchers and other social service providers. For example, about 70 percent of police work does not involve law enforcement, and much of a police officer’s interaction with the public is not recorded. Many police officers would like to do more to serve people with mental illness, but barriers of time and resources stand in the way (Cooper et al., 2004).

The justice system in the United States is one of the most fragmented professional systems in the country, Greenberg remarked. There are about 18,000 state and local law enforcement agencies in the United States; however, if a department has fewer than 10 officers, it is not required to report within the federal system. Across the world, police agencies are sometimes military or quasi-military operations or they fall under the purview of a national police system. Similarly, the court system is fragmented, and sound data do not exist on numbers because many courts are temporary. Incarceration is not well integrated either: prisons, jails, and lockups are distinct places and fall under different jurisdictions, police departments, sheriff departments, departments of corrections, county jails, and state and federal penitentiaries.

In addition to the fragmentation, Greenberg observed that the conversation around deinstitutionalization and community-based services occurred before the majority of today’s police departments were in service, and there is still miscommunication around mental health issues. Additionally, policing is primarily a reactive profession—that is, police officers respond to calls and attempt to resolve them on the spot. Greenberg stated that, on

average, an officer has approximately 2.5 seconds to react appropriately when deciding if the situation calls for the use of lethal or nonlethal force. However, police officers receive minimal training on mental health—only an average of 2.5 hours, most of which is focused on process and not purpose or ideology. This is within the context of 16 to 24 weeks of academy training, with an additional 8 to 12 weeks of field training. Between minimal training and limited personnel, police face several challenges in providing appropriate services to people with mental illness, several of which are outlined in Box 5-2.

Greenberg raised several additional concerns at the intersection of law enforcement and mental health. There are an estimated 1.2 million people with mental illness currently incarcerated, but it is not clear how many have already been sentenced and how many are in jail awaiting trial. Many of these individuals face a significant amount of bias. Furthermore, there is miscommunication and distrust between the police and the community, which could be improved with some bidirectional learning. He gave the example of working with the National Association for the Deaf to reduce killings of deaf people that occurred at traffic stops because of

misunderstanding. Police were better trained, but it was not until there was outreach in the deaf community that the shootings were reduced.

Greenberg closed by noting that rather than focusing on top-level goals, such as policy, procedure, or funding, interventions primarily should focus on point of entry. He noted two specific groups that could benefit from interventions focused on the point of entry: emergency dispatchers, who gather and disseminate information and thereby create the foundation for potential encounters, and the police, who interact with the affected family or the environment in a direct way. Better training and support for emergency dispatchers and police is particularly crucial.

Education and Treatment as Alternatives for Incarceration⁶

Ray Kotwicki spoke about an intervention used successfully at Emory University. It is a 4-year program for medical students to help people identify patients who have symptoms of mental illness, such as impulsivity and para-suicidality, in primary care clinics and other places. The intervention is designed to divert such people away from the penal justice system and toward treatment. Kotwicki noted that once people agree to treatment, there need to be good treatment options. Skyland Trail, his community treatment facility in Atlanta, Georgia, is one such innovative center.

Health professionals tend to view the mental health field with negativity, argued Kotwicki, and medical students typically are not attracted to psychiatry. This is partially because of misperceptions around mental illness and treatment, as well as a lack of understanding of the biological basis of mental illness. In addition, people who do psychiatry clerkships in facilities where containment, not recovery, is the goal tend to have a less positive experience in working with people with mental illness. Thus, part of the work at Skyland Trail is also educational, to engage health professionals in a more positive way when addressing mental health.

Skyland Trail also incorporates educational programs for law enforcement. Kotwicki and his colleagues studied the impact of a 2-day training for police officers involving mental health professionals, including doctors and nurses. They saw a robust, statistically significant improvement in attitudes and knowledge about how to manage situations involving people with symptoms of mental illness. This finding tracks with other research, in which exposure to an individual with mental illness is one of the best ways to reduce personal stigma.

The same paradigm shift for engaging professionals also applies to treatment for patients’ recovery. Periodic measurement of indicators associated with violence, such as psychosis and impulsivity, and indicators related

___________________

⁶ This section summarizes information presented by Ray Kotwicki, Skyland Trail.

to social relationships and immediate environment, can shed light on how engagement of professionals can positively impact recovery. Using pre- and post-test outcome assessments of these indicators, Skyland Trail has shown statistically significant improvement in people who underwent the program, not just in symptomology but in managing relationships and quality of life to reduce violent behavior. Kotwicki concluded his presentation by emphasizing the importance of access: proper treatment can yield great benefits, but only if people can be directed toward and reach such programs.

Therapeutic Jurisprudence⁷

Therapeutic jurisprudence is a healing approach to the law, with the intention of “rehabilitation, compliance with the law, and helping victims to cope with the impact of crime on their lives,” David Wexler stated. He explained that therapeutic jurisprudence is best known in special problem-solving or solution-focused courts, such as drug treatment court, mental health court, and domestic violence court. The law has an effect on well-being. This effect has been largely ignored in administration of the law, but Wexler argued that it should be studied and factored into law reform. The Hague Institute for Innovation of Law is exploring options to maintain therapeutic jurisprudence, particularly in criminal law and juvenile justice. It is an interdisciplinary approach that involves psychology, criminology, and social work, as well as working with offenders and victims.

While it has mostly been used in specialized courts, the therapeutic jurisprudence approach has broader implications for those who fail to meet the qualifications of those special courts. Attempts to expand the special courts often encounter budget obstacles, so a second option is to apply the skills and insights elsewhere in the criminal justice system, in which people with mental illness or drug or alcohol problems might find themselves. Wexler suggested that there are several elements that could be incorporated with the wider system, such as early diversion, bail hearings, plea negotiations, judicial settlement conferences, non-incarcerative sentences, and conditional release. Wexler noted that his project also examines police interrogation and newer, more humanistic methods of investigative interviewing, even before a person’s entry into the court system. In this way, he remarked, the project looks at both the law in action and the roles of legal actors, including judges, lawyers, and therapists.

In exploring how such elements might be included in criminal justice, Wexler noted that he and his colleagues examined which practices are in place already, which are not, why they are not, and how they could be

___________________

⁷ This section summarizes information presented by David Wexler, International Network of Therapeutic Jurisprudence.

maximized. They also examined what kind of training would be required for legal actors to incorporate therapeutic jurisprudence insights. It is also important, he explained, to note which existing structures allow for adaptability to new processes, and which legal structures might need to be reformed. He gave the example of probation, which is traditionally handed down unilaterally by a judge. Instead, the literature indicates that soliciting offender input, such as asking him or her to personally justify a probationary sentence and conditions, enhances offender compliance and a sense of fair treatment.

At its heart, Wexler remarked, therapeutic jurisprudence is multidisciplinary and draws from insights of different realms. He concluded by citing important research areas: relapse prevention planning, reasoning and rehabilitation, desistance from crime, treatment adherence, behavioral contracting, active listening, and restorative justice.

Behavioral Health Care in Correctional Facilities⁸

Patrick Fox described the shift of population, cost, and burden from community-based and state-hospital-based mental health systems to the correctional system as trans-institutionalization. Since the mid-1970s, the prison population has steadily increased. Currently, there are approximately 2.5 million individuals incarcerated, with another 4.2 million on parole or probation—representing 2.9 percent of the population. The vast majority of those entering the criminal justice system, particularly those with behavioral health disorders, are not being arrested for violent crimes. Yet, among people with behavioral health disorders, there is a 40 percent lifetime prevalence of incarceration. Additionally, there are huge racial disparities, with African American and Hispanic individuals being grossly overrepresented. Fox emphasized that these racial disparities pervade the entire criminal justice system, from death penalty cases to insanity pleas, and even probation and parole decisions (though there is no correlation between the race of the arresting officer and these disproportionate incarceration rates of people of color). The increase in prison populations also trends with a commensurate increase in substance use arrests.

People with behavioral health disorders are also overrepresented in the criminal justice system, especially as mental institutions close. Currently, about half of those within the correctional system experience some form of mental illness. This is a problem because the focus of psychiatric hospitals is on the restoration of health and treatment, whereas correctional facilities are intended to contain and punish. Fox further discussed the differences between mental health facilities and prisons:

___________________

⁸ This section summarizes information presented by Patrick Fox, University of Colorado.

• Treatment versus security. 90 percent of staff at a state psychiatric hospital are mental health professionals or support staff, and security is an ancillary service. In a prison or jail, 90 percent of staff are correctional officers, with security equipment, while therapy is a secondary consideration.
• Crisis intervention. When there is a behavioral health emergency, correctional officers are usually first responders in a correctional facility. However, mental health staff who manage such events in psychiatric hospitals have a greater understanding of trauma-informed care and recovery.
• Standards. The Joint Commission and the Centers for Medicare & Medicaid Services serve as crediting bodies for hospitals, whereas the American Correctional Association and the National Commission on Correctional Health Care work on the correctional side.
• Discharge. Release from a mental health facility is based on recovery, whereas release from prison is conditioned on resolving the criminal offense.

Fox stated that within correctional facilities, prisoners have a right to treatment, as mandated by several court rulings. Ruiz v. Estelle in 1980 laid down six criteria for mental health services:

1. Systematic screening and evaluation
2. Treatment that is not just close observation or seclusion
3. Trained mental health professionals
4. Confidential and complete medical records (separate from the custody record)
5. Safeguards governing the use of psychotropic medications
6. A suicide prevention program

Additional laws, such as the Americans with Disabilities Act (ADA), have also served to improve quality of care. Entities such as the National Commission on Correctional Health Care and the much older American Correctional Association provide standards for 90 percent of jails and prisons in the United States. Because of these laws and standards, mental health treatment has improved. A 2000 report indicated that 95 percent of adult correctional facilities comply with screening requirements, but other quality measures are lower (Beck and Maruschak, 2001).

Mental health treatment varies greatly between jails and prisons because of differences in funding and standards at the local, state, and federal levels. How a community chooses to allocate funds (that could go toward other systems) can constrain or expand treatment services. In particular,

because incarceration is still seen as a punishment, there is resistance to funding and provision of mental health services in jails.

When treatment is available, Fox said, the goal is shifting from preventing poor outcomes to a more proactive approach of developing independent living and social skills. Therapy is now focused on improving mood and functioning, modifying behavior, and developing vocational skills for future employment. Different treatment modalities exist, including group therapy, though their implementation is not always of the highest standard. Standards around the use of medication have also been altered: there is a much narrower mandate for the use of medications, and in all cases except emergencies, informed consent must be obtained. When consent cannot be obtained, there must be a clear rationale for the use of medication, as well as documentation of any side effects.

Another crucial mental health measure is suicide prevention. Thus, current standards require screening and assessment for suicide risk in correctional facilities. Fox noted that suicide is the second leading cause of death in jails and the third leading cause of death in prisons. Half of completed suicides occur within the first week of incarceration. Among the interventions to reduce suicide are reducing means (e.g., no fixtures in cells, cameras, and monitoring for substance withdrawal), reducing distress by allowing contact with family members, and monitoring changes in mood around any court dates.

Administrative segregation, or solitary confinement, is another issue in correctional facilities. Fox referred to it as a dehumanizing environment with pronounced psychological effects. Persons with mental illness are overrepresented in administrative segregation, and there is evidence that it exacerbates pre-existing mental conditions (Metzner, 2002). Fox suggested that the externalizing behaviors of someone with mental illness could be seen as disruptive behavior within a correctional facility and might result in the use of administrative segregation. The increased decompensation and limited access to mental health professionals could result in prolonged confinement, as well.

Despite the challenges and limitations of addressing mental health in the current incarceration system, there are shifts occurring. Fox shared the restorative justice model, an approach that focuses on the needs of the victim and the offender, the prevention of recidivism, and the duty of the community to maintain peace and restore order. Restorative justice programs help individuals take inventory and accountability of actions and understand where the origins of their criminogenic behavior reside. Correctional facilities with these programs would have special management units and treatment facilities for those with mental illness. And perhaps most important are offender re-entry programs, particularly programs that

include outreach by community mental health professionals, that prepare individuals with mental illness to successfully reintegrate into communities.

REFERENCES

This page intentionally left blank.