The Revolving Doors
Part Three of the From Hospital Beds and Back Wards to Prison Cells and Solitary Confinement series
Despite limited resources, many institutional and community-based mental health treatment providers offer caring quality services to some patients whom they are able to treat. However, improved coordination of services within the de facto system is required to more effectively utilize available resources.
In general, psychiatric hospital patients in overcrowded facilities receive treatment of insufficient breadth and intensity, and are discharged without the benefit of transitional programs. Patients in short term care hospitals, in particular, suffer from insurance-driven foreshortened lengths of stay. Many short and long-term patients return to “placements” in the community, without either sufficient supervision or sufficiently intensive or comprehensive treatment and related services, and without strengthening of family members and family ties.
Former patients predictably and repeatedly become ill under these circumstances. Thus, they repeatedly return to the hospital, or are arrested and imprisoned. In hospitals, the high rate of recidivism contributes to continued hospital overcrowding, insufficient human and program resources for patients, overburdened and demoralized staff, pressures for premature discharge, and policy-imposed limitations on admissions. These dynamics, including the exacerbation of illness by repeated acute episodes, impact on the quality of treatment, and preparation for discharge…and the cycle continues.
Other former patients, lacking access to necessary services in the community, or refusing timely voluntary treatment as they become ill, are arrested and incarcerated before becoming sufficiently “dangerous” to warrant involuntary hospital treatment. But jails and prisons lack the experience, human resources and environment, to provide effective treatment and rehabilitation to prisoners with mental illness.
Prisoners with mental illness pose serious problems for overcrowded correctional facilities. They can become victims or aggressors, posing a danger to themselves, other prisoners, and staff. They serve longer terms than other prisoners, because of their conduct and the absence of sufficient available supports in the community, thereby contributing to the more general problem of jail and prison overcrowding. However, most prisoners are eventually released to the community. Without timely access to appropriate community mental health and other social services, it is unsurprising that they are at high risk for recidivism.
The community mental health system, currently unable to even meet the needs of “civil” patients in the community or patients returning from hospitals, are inexperienced in dealing with people suffering from the traumas of incarceration and exposed to the pitfalls of prisoner re-entry. Such persons are doubly stigmatized because of their illness and history of incarceration. Without funding or training to deliver specialized services, community mental health agencies narrow their admissions criteria to exclude such persons. To protect the integrity of their programs and the safety of their traditional clients, they refuse or impose unrealistic expectations on former prisoners with mental illness, who are among those most in need of the most intensive and comprehensive services. Relapse and high rates of recidivism, to both hospitals and correctional facilities, are the predictable results of such practices.
These cycles continue, with persons suffering from mental illness moving through revolving doors between hospitals, correctional facilities and the community. Their dispersal to the dangers of the streets and the perilous cages and corridors of correctional facilities hides the scope of the problem and insulates the traditional mental health system from public and legislative pressures for change.
The current problems are daunting. But this state of affairs is neither inevitable nor impervious to change. Most providers in the expanded mental health system would vastly prefer to participate in a system that worked. Most people in the state, even those outside the 20% of families that include at least one person with mental illness, would not countenance our system of treating seriously ill people, if they were aware of it. And, most importantly, there are paths to change.
The Importance of Families
Many persons who have a mental illness receive invaluable support from their families and other individuals who are significant to them throughout the course of their lives. It is in the best interests of persons who have a mental illness to maintain enduring relationships with such individuals. The knowledge and experience of family members and significant others are also invaluable to mental health providers responsible for evaluation and treatment. Therefore, it is necessary that the mental health system foster relationships between patients and their family members and significant others.
The Need for Treatment bill supports the preservation of family relationships, encouraging and authorizing positive participation of family members and significant others as partners in treatment.
The Empowerment of Consumers (Patients and Clients)
The purpose of the public mental health system is serve persons with mental illness who are in need of treatment. On moral, clinical, legal and practical grounds, such persons must be authorized, empowered and encouraged to direct their own treatment, except when intervention is necessary to avoid grave danger to such persons themselves, or to others or property.
The Need for Treatment bill adopts these premises and provides numerous provisions to protect and empower patients when external intervention is necessary.
In order for any legal strategy to provide for the needs of people with mental illness in a rational, humane, and cost-effective manner:
Legislative intervention must address each component of the expanded mental health system and each point of transition between the primary treatment providers in hospitals, correctional facilities, and the community.
Legislative intervention at only one juncture, such as the addition of court ordered community treatment or mental health courts, will not modify the underlying dynamics, which are reflected in waiting lists for treatment, overcrowded hospitals, incarceration of people with severe mental illness, multiple correctional-hospital transfers, and premature discharges and high institutional recidivism within all institutional sectors of the de facto mental health system.
Until the state adopts a comprehensive approach to the quality of treatment and dynamics of patient movement in this system, incremental legislative efforts will simply move one set of presenting problems to another part of the de facto treatment system.
For example, privileging court ordered community treatment in a community system which is not accompanied by an increase in the quality, intensity and comprehensiveness of treatment will result in:
- the replacement of voluntary community patients by court ordered patients, in a system that cannot now accommodate even voluntary civil patients;
- the continued predictable failure of patients who do not receive the intensity and comprehensiveness of treatment they need in the community; and
- the consignment of voluntary patients, arguably more likely to succeed in the community than court ordered patients, at unnecessarily high levels of care.
Although programs may be implemented incrementally, the law must provide a vision and blueprint for systems change.
The community mental health system must have the capacity to provide comprehensive treatment and related services, including humane income maintenance and supportive housing, to persons with mental illness who need treatment and whose psychiatric condition and conduct do not require an institutional level of care.
The Need for Treatment bill, following cutting edge recommendations in the literature and in practice, provides a foundation for necessary change (e.g. The Criminal Justice/Mental Health Consensus Report).
THE PROPOSED NEED FOR TREATMENT BILL
The Need for Treatment bill supplies both impetus and hope for change to a cost-effective and accountable mental health system, which provides timely, coordinated, comprehensive, evidenced based treatment, by:
- addressing the expanded, de facto mental health system as a whole and requiring and providing a legal foundation for a better coordination of resources, responsibilities and relationships in the system; placing responsibility on the state mental health authority to resume its proper role as lead provider for the treatment of mental illness;
- choosing community treatment as the preferred locus for treatment;
- ensuring that people with serious mental illness be treated in the mental health, not the penal system;
- impacting on the revolving doors of the mental health system at each point of intersection between hospitals, correctional facilities and the street;
- using limited resources more effectively, by replacing a system of crisis care and high recidivism with one which emphasizes prevention and the management of mental health, by:
* privileging voluntary treatment (instead of discouraging it);
* authorizing timely involuntary treatment in the community;
* utilizing hospitals, as providing the most visible and least dangerous and inhumane environment for persons with mental illness, as the default locus of institutional treatment, and refusing to allow patients to be discharged from hospitals except pursuant to discharge plans which will provide them with a realistic opportunity to maintain their health and their lives in the community;
* requiring responsible and realistic release planning by correctional facilities, working in conjunction with mental health agencies;
- empowering consumers and their families and providing supportive advocacy and legal services and review mechanisms, to complement “professional” treatment providers and ensure that the state power attendant on involuntary treatment is used correctly and responsibly; and
- providing visibility for residual deficiencies and increasing monitoring and accountability, so that public and legislative support can be built for continuing necessary change.
JEAN ROSS is a volunteer prisoners’ rights attorney based in Princeton, New Jersey. She has spent most of her expansive career working with and on behalf of people confined in the only two public institutions that have the legal authority to confine people involuntarily — prisons and psychiatric hospitals. Before retiring, Jean was a public defender within Division of Mental Health and Guardianship Advocacy where she provided pro bono representation to psychiatric hospital patients. Since ‘retiring’, Jean has been a tireless advocate, activist, organizer, and leader on behalf of prisoners and their loved ones. She is “one of New Jersey’s most stalwart warriors against prisoner abuse.” She is a Board Member for the Center for Action Research and Director of the Prison Initiative Project.
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