Criminal Justice Involvement of People with Serious Mental Illness

Serious mental illness (SMI) and criminal justice involvement (CJI) have become synonymous for too many people in our community. We must debunk the myths about people with SMI and criminality. This starts with the fact that people with SMI are far more likely to be the victim of crime than a perpetrator and mental illness is not an indicator for criminality.

This understanding could help people realize that people with mental illness need empathy and treatment, even if a person commits a crime. Especially considering that the consequences of these criminal responses are disproportionate to the often minor non-violent and low-level crimes people with SMI are charged with, such as trespassing and disorderly conduct. But the response should consider and try to address that underlying cause, which is often judgement impaired by our SMI. Unfortunately, the typical criminal justice response today can be deadly. I know.

I have experienced three frightening 911 police-led mental health crisis responses. It has never escaped me that I, too, could have been an unlucky one. I was arrested and charged with criminal misdemeanors for trespass and mischief for breaking into a place of worship to pray during a psychotic manic episode. It took a letter from my psychiatrist and several thousands of dollars in legal fees and restitution before my charges were dismissed.

What if I did not have those financial resources? I could have easily been incarcerated. I am privileged, and my outcomes were comparatively good, so I feel a responsibility to do what I can to help stop the criminalization of mental illness. I want to help people who might suffer more severe consequences for their mental illness due to personal circumstances.

Major Risk Factors for CJ Involvement

Addressing criminal justice risks for people with SMI cannot merely focus on our illness, but often more importantly on social conditions. CJI can be strongly influenced by societal factors, such as:

• Poverty (about 2.5 million people with SMI live in poverty)
• Poor and unstable housing
• Adverse childhood experiences
• Racism
• Alcohol and drug abuse

It is easier to dismiss the need for change when we focus only on the individual and the criminal act, and not broader socioeconomic issues. We have to implement longer term community-wide solutions that address the underlying social determinants of health.

How Can We Reduce the Risks?

NAMI strongly advocates the promotion and utilization of community services as a way to enhance diversion. Here are a few critical ways to reduce the risks of CJI of people with SMI.

Access to Government Benefits
Access to government benefits can be critical, but too many people are unaware of what they may be entitled to, and the enrollment processes can be complicated.

The most important government benefits are Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), Medicaid and Medicare, Veteran Affairs’ benefits, food stamps and public housing programs.

Mental Health Treatment
The most important way to reduce the risks of CJI of people with SMI is to ensure they have adequate medical care and the medical attention they need when in a crisis. Too few people with SMI receive care, especially racial minorities. Nationally, only about 45% of adults with mental illness receive treatment yearly, but only 23% of jail inmates with mental illness had received treatment during the year prior to their arrest. Criminal activity is often linked to an individual’s untreated symptoms, including psychosis. Early, adequate and on-going care must be more accessible.

Substance Use Treatment
Where relevant, integrated treatment for co-occurring mental illness and substance use conditions is critically important. People with SMI experience extremely high rates of co-occurring disorders, which can increase the risk of criminal behavior. There are psychiatrists with expertise in addictions available through the American Academy of Addiction Psychiatry and SAMHSA’s behavioral health treatment services locator.

In addition, Assertive Community Treatment — ACT's person-centered, recovery-based approach might be useful. ACT is an evidence-based practice offered by multi-disciplinary teams with expertise in treatment, rehabilitation and support services. Forensic ACT has been found to be effective at reducing convictions for new crimes for people with SMI.

Employment
Sadly, people with SMI experience very high rates of unemployment. Meaningful self-chosen employment can be a powerful motivator to get and stay well and significantly reduce the risk for CJI. Supported employment can help us reach our career goals. It is an evidence-based practice designed to help people with mental illness quickly choose, secure and keep competitive employment while providing ongoing individualized, long-term support. Supported employment efforts are often part of Clubhouse programming.

Education
Research has found that states with higher levels of education also have crime rates lower than the national average. Unfortunately, mental disorders have been significantly linked with termination of studies, leading to higher risks of CJI. The frequent onset of mental illness during prime college years can also permanently interrupt studies.

Supported education programs involve a multidisciplinary team comprised of the person with SMI, family members, college personnel and others. Programs modify educational settings making them more supportive of students with SMI. They typically offer career planning, academic skills, direct assistance and outreach to various helpful services, including mental health treatment. Programs are offered in mental health centers and educational institutions. A college student’s disabilities/accommodations office may offer additional information.

Housing
Housing problems are often a key underlying factor for CJI. Specific to the SMI community, the impact of housing is clear. The overall rate of largely victimless crimes was 35 times higher in the SMI homeless population than in the SMI housed population. Tragically, 45% of homeless people have SMI.

Permanent Supportive Housing is a program designed to help vulnerable populations secure stable housing. It combines low-barrier affordable housing, health care, and supportive services to help individuals and families lead more stable lives. Each city typically has information available on city websites, like New York City, about available programs. Non-profits serving the homeless are also a good source of information regarding housing programs.

Mental Health Crisis Response
There is significant evidence that the traditional mental health crisis response model is grossly inadequate. A study found that 22% of deaths due to lethal force by law enforcement were mental health related.

At a minimum, a Crisis Intervention Team (CIT) should respond to a mental health crisis. They are located around the country. A CIT creates connections between mental health providers, hospital emergency services, and individuals with mental illness and their families. CITs have been found to reduce arrests of people with serious mental illness and increase the likelihood that they will receive appropriate treatment.

While CIT is helping in the short-term, the long-term goal is to develop a mental health crisis response system that takes police response out of the equation. We made a significant step toward this goal last year with the enactment of the National Suicide Hotline Designation Act. This act will establish 988 as a nationwide number for suicide prevention and mental health crises that will be implemented by July 2022. The calls will be routed through the National Suicide Prevention Lifeline to local crisis call centers to connect people to a mental health response rather than a police response.

Mental Health Courts
Mental health courts are specialized courts for certain defendants with mental illness. These courts can help divert defendants away from traditional criminal punishments and detention to more constructive treatment programs. Research has shown that mental health courts have reduced rearrest rates and helped connect individuals with mental health treatment in the community. People interested in having their case heard in a mental health court, should make inquiries with their defense attorney. You can find a mental health court using SAMHSA’s treatment court locators.

Many of us with mental illness are just at higher risk of committing a crime because of these socioeconomic conditions. Programs that can reduce the risk of CJI for mental health emergencies are very promising, but they are in short supply. We need more humane standards of living, including treatment that promotes the self-esteem we need to live fulfilling lives — and we deserve that.

Katherine Ponte is happily living in recovery from severe bipolar I disorder. She’s the Founder of ForLikeMinds’ mental illness peer support community, BipolarThriving: Recovery Coaching and Psych Ward Greeting Cards. Katherine is also a faculty member of the Yale University Program for Recovery and Community Health and has authored ForLikeMinds: Mental Illness Recovery Insights.