Criminal Justice Reform Means Reforming the Mental Health System

Events of last year have renewed our country’s awareness of the shortcomings in our criminal justice system. The COVID-19 pandemic has not only shown the cracks in our health care system, it has highlighted existing disparities for people of color and those who are incarcerated.

NAMI has long engaged in the conversation around how to keep people with mental illness out of our nation’s criminal justice system. With this new energy in the public discourse, we are prepared to help mold an innovative model of safety for our communities. In order to reform the criminal justice system, we must reform our nation’s mental health system.

The link between the lack of investment in our nation’s mental health system and the over-reliance on the criminal justice system is undeniable. In the mid-1800s, Dorothea Dix first advocated for the creation of a system of care for people with mental illness after she witnessed deplorable conditions in a Massachusetts jail.

Starting in the 1950s, many of the hospitals championed by Dix began to close, and people with mental illness returned to their communities in a trend known as “deinstitutionalization.” Unfortunately, the promise of a community mental health system did not materialize, and communities again began to rely on jails and prisons to deal with mental illness.

Today, an estimated 44% of people incarcerated in jail and 37% of people incarcerated in prison have a mental health condition. We continue to use the criminal justice system to address mental illness not because people with mental illness are more likely to commit a crime, but because we fail to offer an alternative. So, what should reform look like?

Investing in Crisis Response Systems

To begin, we need to change our expectations of the response to people experiencing a mental health crisis. For many communities, law enforcement is the primary first responder.

A law enforcement response often results in people with mental illness being booked into jail instead of receiving the mental health care they need. Law enforcement’s role in responding to mental health crises has developed over the years for two main reasons:

1. Mental health crises are not confined to business hours, while law enforcement is available to respond 24/7.
2. People who need help might not be able to get it until there is an emergency, because there is a standard that someone must be “a danger to self or others” before they can receive help.

Law enforcement’s role must be reduced in mental health crises. We can do this by investing in robust crisis-response systems, with the goal of connecting individuals to appropriate care and long-term recovery. Robust crisis-response systems include services such as 24/7 crisis hotlines, crisis respite centers, mobile outreach and mobile crisis units.

NAMI’s publication “Divert to What? Community Services That Enhance Diversion” outlines our vision for what a mental health system should look like. It prioritizes care coordination and services that work toward not only diverting people from justice system involvement, but also supporting them to have fulfilling lives in their communities.

Creating Accessible Mental Health Care

In conversations with front-line criminal justice professionals, people often ask, “Why don’t they just get help?” This is usually in reference to individuals who cycle in and out of the criminal justice system due to symptoms of mental illness. For those who are less familiar with the failures of our mental health care system, it can be difficult to understand the number of barriers to care people with mental illness face.

Cost and mental health coverage are two of the most significant barriers. In 2018, over half of people with serious mental illness who felt they had an unmet need for mental health services didn’t access those services because they could not afford the cost.

However, studies show a link between insurance coverage and positive outcomes for those with justice system involvement. In Michigan, a pilot program that linked formerly incarcerated people with care in the community saw a significant drop in recidivism rates. In Florida and Washington, studies showed increased access to mental health care for people with severe mental illness who were enrolled in Medicaid upon their release.

Changing federal policies, such as allowing Medicaid to provide coverage to people who are incarcerated, can support people with mental illness from becoming disconnected from their care while incarcerated. It can also provide access to services once they are released that prevent them from becoming re-incarcerated.

Having the resources to access mental health care is just one part of supporting diversions for people with mental illness. Communities need to build an array of services and supports that provide a holistic response to mental health and can meet the needs of people who are at risk of justice system involvement.

In addition to outlining our vision for crisis care, “Divert to What?” also creates a vision for what mental health care should look like in every community. This includes incorporating mental health care into primary care, offering case management support, and providing housing and other services. Communities must also make sure that the services and supports are working together to provide a coordinated response.

Building a System That Reflects Our Communities

Policy and system change will only be effective if they reflect the needs of the people in the communities they serve. People with mental illness and people of color — particularly Black people — are overrepresented in the criminal justice system. Yet there is alarming evidence that people of color are less likely to be identified as having a mental health condition and less likely to receive treatment during incarceration.

As shocking as this might be, it is consistent with research that shows significant disparities in mental health care for racial and ethnic minorities. Communities of color are less likely to engage in mental health services and often receive poorer quality of care. We must address these inequalities by implementing culturally competent and trauma-informed care. Providers must recognize that people of color often distrust the health care system due to the history of abuse they have faced.

To reduce the stigma of mental illness in communities of color, primary care providers should integrate mental health screenings and care into their service delivery. Finally, advocacy groups, including NAMI, must commit to engaging groups of people who embody the diversity of our communities as we advocate for a better mental health system.

As communities discuss reforms to the criminal justice system, it is important to consider the ways in which other systems intersect with it. Effectively investing in the mental health system is the most logical way to support the diversion of the millions of people with mental illness who are incarcerated every year.

To learn more about NAMI’s advocacy and public policy work to reform the mental health system and mental health care, visit nami.org/advocacy.

Shannon Scully is Senior Manager, Criminal Justice Policy, Advocacy & Public Policy at NAMI.

Note: This piece was originally published in the Fall 2020 issue of the Advocate.