Mental Illness and the Criminal Justice System

This is the second essay in a two‐part series exploring the relationships between mental illness, criminal behavior, and the criminal justice system. The number of mentally ill persons in prisons and jails has increased substantially over the last several decades, and there are currently more people with mental illness behind bars than there are in mental hospitals. In this essay, we place these trends within a broader historical context of the social control of mental illness in the United States. We identify how and why mentally ill persons have come to be overrepresented in the criminal justice system and highlight the unique challenges this population poses for police, courts, and correctional facilities. Finally, we review several recent innovations in policy and practice that may help alleviate that burden of criminal justice involvement on mentally ill offenders, as well as the burden of mentally ill offenders on the criminal justice system.     

ATTITUDES TOWARD THE MENTALLY ILL:

Labeling theory posits that people labeled mentally ill experience negative societal reactions. Past research on this question is contradictory, due primarily to methodological problems. This study overcomes some of these problems by having respondents indicate their willingness to interact with a person with a specific mental disorder, or with an identically behaving person with a specific physical disorder. As expected, respondents reject the mentally ill significantly more than identically behaving physically ill persons, as supports labeling theory. Respondents also consider the mentally ill less predictable and to have less positive outcomes than those with physical illness. These beliefs highly correlate with rejection and account for some, but not all, of the effects of label on rejection.     

Meeting the Needs of the Mentally Ill Homeless in Massachusetts-Based Emergency Shelters

A statewide survey (response rate = 79.5%) of the emergency shelters designed for homeless individuals was conducted in Massachusetts to determine the prevalence of serious mental illness among residents and extent to which they received psychiatric services. An average prevalence rate of 22%, ranging from 1% to 70%, was reported despite the fact that 87% of the shelters restricted admission of those exhibiting severe behavioral problems. Nearly three-quarters of the shelters reported providing some mental health services as part of their program, and 80% had established ties with professional mental health agencies. Linkages with these mental health agencies greatly enhanced placement options for mentally ill persons. When queried on the most pressing community-based service needed for the homeless mentally ill, nearly two-thirds of the shelters reported a need for additional housing alternatives.     

Strategies for improving education

1. An extensive curriculum is required to prepare mental health professionals to adequately assess, plan, and implement the necessary comprehensive treatment plan and to sufficiently develop relevant social policy. 2. A majority of professionals believe they were not adequately trained in the care of the chronically mentally ill; this may be a result of the trend of integrating the teaching of mental health nursing concepts into the baccalaureate curriculum. 3. Frequently there is a lack of mental health professional role models. Nursing faculty are in an excellent position to implement innovative practice models. 4. Learning from a multidisciplinary team may increase the likelihood that students will apply these approaches to the chronically mentally ill.     

Deinstitutionalization: a public policy perspective

1. Deinstitutionalization was initiated in an era of social reform to protect the rights of the mentally ill; however, a strong research base was absent and led to major flaws in the policy's implementation. 2. The chronically mentally ill are frequently poor advocates for themselves and, without even the most simple needs fulfilled, end up homeless. 3. The homeless mentally ill require comprehensive support systems with assured continuity of care. An emerging concept to deal with this issue is that of case management. 4. The mental health professional can strive to influence future public policy as patient advocate and nonpartisan educator.     

Homelessness Among Older Adults with Severe Mental Illness

ABSTRACT

This article tackles a problem that is often overlooked in the literature-the plight of homeless elders with severe mental disabilities. Drawing on his personal experience working with sheltered homeless persons who were mentally ill, the author argues for a focus not on self-sufficiency but on closely supervised care for this vulnerable population.     

Immigration and the ethics of choice

"This paper begins by developing a language for ethical discourse on immigration and then examining the extent to which choices may be made at the micro-level and at the macro-level. States and individuals are examined as actors who are variously described as making choices or being choiceless. The concepts of cultural distance, reciprocity, the role of the individual and of the state and their interrelationships are evaluated in the perspective of choice. Whether an ethics of immigration can be successfully developed hinges on the degree of choice that individuals and state have or perceive themselves to have."     

Differential Labeling of Mental Illness Revisited: Patterns Before and After the Rise of Managed Care

With the National Comorbidity Survey of the early 1990s, Thoits (2005) recently showed that lower-status mentally ill individuals were not more often hospitalized or pressured into psychiatric treatment than comparably ill persons of higher status, disconfirming a central hypothesis of labeling theory. However, that finding may have been due to changes in the mental health treatment system introduced by the spread of managed care. The differential labeling hypothesis is reexamined here with data from the Epidemiological Catchment Area Studies (ECA) collected in the early 1980s before managed-care plans began to dominate the insurance marketplace and from the National Comorbidity Survey Replication conducted in the early 2000s when managed care had saturated the market. Little systematic support for the differential labeling hypothesis was found in the three studies, although, over time, the higher rates of mental hospitalization among less educated and low-income individuals found in the ECA survey disappeared. Trends across the studies suggest that educated and affluent persons with psychiatric problems more frequently sought hospital care. These findings further undermine the validity of the differential labeling hypothesis and suggest that service utilization or treatment-seeking factors may help explain mental hospitalization rates.     

Mental Illness in Assisted Living: Challenges for Quality of Life and Care

ABSTRACT

An unknown number of mentally ill elders in the United States receive care in assisted living, along with persons facing physical or cognitive challenges. While dementia is familiar in assisted living, our data indicate that neither staff nor residents are prepared to work or live with the mentally ill. Challenges are created for professionals, since these residents bring diverse needs. Daily interresident interactions are also disrupted or stressful. Qualitative data describe the impacts on quality of resident life as well as care and management dilemmas identified within five assisted-living settings having varying presence of mental illness among residents.     

Identifying Mental Disorder from the Faces of Women with Borderline Personality Disorder

Although appearance-based cues can help to diagnose physical illness, visual manifestations of mental disorder may be more elusive. Here, we investigated whether individuals could distinguish women with a serious mental disorder (borderline personality disorder) from demographically- and IQ-matched non-psychiatric controls. Participants rated mentally ill targets as more likely to have a mental disorder from photos more accurately than chance, despite not believing that such judgments were possible. The configuration of facial cues played an important role in these judgments, as interfering with the spatial relationships between facial features reduced participants’ accuracy to chance guessing. Further investigation showed similar results when participants rated the targets for specific mental disorders (borderline personality disorder, major depressive disorder) and rated the mentally ill targets as more depressed, angry, anxious, disgusted, emotionally unstable, distressed, and less happy. Moreover, the depression ratings significantly correlated with the targets’ actual depressive symptoms. Thus, individuals may be able to infer aspects of mental disorder from minimal facial cues.     

The need for policy direction in the provision of care to the mentally ill: an interdisciplinary view

This paper argues that mental health care is underprovided, and that the role of nonprofit providers should be expanded for three major reasons. First, a positive externality exists since society, as a whole, benefits when those in need of mental health care consume care. External benefits include lower crime rates, lower unemployment, and less homelessness. Second, consumers of mental health care are mentally ill and often do not believe that they need care, underestimate their need, or believe that care is not worth the time or expense. Third, common law, to a large extent, is based on individual liberty, largely ignoring the benefits individuals receive from treatment. It is argued that government policy is needed to increase the supply of mental health care, through nonprofit agencies.     

Students' Attitudes to the Inclusion of People with Disabilities in the Community

This study measures and compares the attitudes of students studying different subjects to the inclusion of people with mental retardation and mental illness in the community. The Community Living Attitude Scale (comprising the four subscales of Empowerment, Exclusion, Sheltering, and Similarity) was administered to a random sample of 149 Israeli college freshmen and women (social work: n = 43: law: n = 24; natural science: n = 42; and social science: n = 40). Overall, the students endorse Empowerment and perceive the Similarity of persons with disabilities to themselves more than they agree with the Exclusion attitude of segregating persons with disabilities from community life. Social work students showed more positive inclusion attitudes to people with disabilities than other students. Students were more likely to endorse Exclusion for people with mental illness than for people with mental retardation.     

Social class, mental illness, and social mobility: the social selection-drift hypothesis for serious mental illness

The assumptions and methods of previous studies of the social selection-drift hypothesis for serious mental illness are examined by using comtemporary log-linear methods for social mobility analysis. The null hypothesis of no difference in intergenerational social mobility between seriously mentally ill and general population control groups cannot be rejected in previous studies by Birtchnell (1971), Goldberg and Morrison (1963), Langner and Michael (1963), and Turner and Wagenfeld (1967). The findings of this study suggest that previous empirical support for intergenerational social mobility differences is an artifact of not controlling for group differences in origins and destinations when collapsed origin-by-destination tables are analyzed. This study suggests that intergenerational social mobility differences between seriously mentally ill and general population groups in previous studies provide very little, if any, empirical support for social selection-drift processes in serious mental illness.     

Against all odds: Revitalization of local self-help alternatives by longterm mental health consumers

The article presents a grounded theory case study of a consumer-run alternative services organization, operated by and for people labeled chronically mentally ill in Michigan. We analyze the organization's emergence and development as a process of revitalization through which participants mobilized to transform their private and public identities. Innovations, including self-disclosure rituals and advocacy strategies, were developed by the group's founder during a period of social dislocation following deinstitutionalization. Subsequently, through their advocacy efforts for and with other consumers, group members laid the foundation for a unique form of locally-based political activism, blending innovative self-advocacy strategies with a critique of conventional mental health care. Active participants' efforts have created a mental health consumer organization that members perceive as an empowering and sometimes rehabilitative alternative within Michigan's public mental health care system.     

How do they see themselves? Self-perception and functioning for people with chronic schizophrenia

In a supervised living situation, 15 individuals whose physical health was considered stable and who had diagnoses of chronic schizophrenia expressed varying perceptions of their mental health. Most perceived themselves as mentally well. This is in opposition to findings reported by Estroff (1981) and Dzurec (1986) that suggested that clients with schizophrenia tended to have negative self-perceptions. The author posits that this positive self-perception might be a function of respondents' expressed satisfaction with their housing situation. This is an area in which ongoing research is being conducted (Bininger, 1989; Dzurec, 1989). Housing satisfaction is thought by some researchers to precede successful community adaptation for the severely mentally disabled (Blanch, 1988). Respondents' perceptions of their mental health, as expressed in response to the interview protocol, appeared to be couched within primarily mundane, day to day issues. This finding is consistent with Estroff's conclusion that clients "seemed to have less control of their time, space, resources, and information than did outside and inside normals" (Estroff, 1981). The respondents gave themselves higher than average scores (ie, 3 or above on a five-point scale) overall on the PES, an instrument that measured aspects of their daily functioning. Their caretakers gave them somewhat lower overall scores on the PES. There was a moderate association between individual pairs of respondent-caretaker scores on the PES. Personal mental health perception did not appear to influence daily functioning.(ABSTRACT TRUNCATED AT 250 WORDS)     

An Exploratory Analysis of the Construct of Leavers versus Left as It Relates to Levinger's Social Exchange Theory of Attractions,Barriers, and Alternative Attractions

This study analyzed the construct of "leavers" versus "left" as it relates to Levinger's factors of attractions, barriers, and alternative attractions. Individuals who perceive themselves as the "leaver" were more positive in their attitudes toward divorce than the "left." Females were also more positive in their attitude toward divorce than were males. Although "leavers" and "left" did not differ in attractions to the marriage or in the number of barriers to divorce, leavers were willing to identify a greater number of attractive alternatives to the marriage. Furthermore, individuals having a more positive attitude toward divorce were more likely to identify fewer attractions to the marriage and a greater number of attractive alternatives to the marriage. There was no relationship between an individual's attitude toward divorce and the number of barriers he/she was willing to identify. Of the variables studied, "attractive alternatives" to the marriage was consistently identified as most significant.     

Preserving the Family: A Brief for Limited Commitment of Non-Dangerous Mentally Ill Persons

Society has the power—and the duty—to reach and treat certain non-dangerous mentally ill persons who are unwilling to commit themselves for treatment. This should occur within a system which offers procedural safeguards against unwarranted commitment, so that those who require active treatment receive it in the least restrictive setting and for a self-limiting period. Such a deprivation of liberty and instrusion upon personal lives can be justified under existing jurisprudential theory, is not proscribed by constitutional doctrine, and is required of a caring society. This parens patriae commitment would require a balancing of interests by a neutral law-trained officer who would consider, among other factors, the role of a caring family as a support system for the person and the impact of non-treatment upon that family.     

Marital status, social support, and health transitions in chronic disease patients

Married persons tend to be healthier, both physically and mentally, than unmarried persons. We tested the hypothesis that being married results in better physical and mental health outcomes for chronic disease patients (N = 1,817) by increasing social support. We modeled health outcomes one year later, controlling for initial health status. Cross-validation studies of two random halves of the sample supported an indirect effect of marital status on mental health through social support, but did not support a relationship, direct or indirect, of either marital status or social support with physical health outcomes. In addition, specific types of functional support were not differentially predictive of mental health status.     

The history, economics, and financing of mental health care. Part 1: 17th to 19th centuries

Families in colonial times cared for their mentally ill members at home, with little assistance from their communities. Community treatment is an old idea, not a new one. Early laws about containing the disturbances created by individuals with mental illness made no mention of clinical dimensions. The focus was strictly on the social and economic consequences of the mental disorders. Legislation about public mental hospitals in the mid-19th century was hardly enlightened. There were no particular plans, other than not to expend more dollars than actually necessary.