Wednesday, July 14, 2010

Press Charges or Press for Change? The Criminalization of Mental Illness

by Michael J. Fitzpatrick, Executive Director
"I've heard family members say that the police told them, 'If you want treatment for this guy, press charges. This is the only way they'll get treatment.'"

One of the best things about getting together the NAMI community for a convention is that in the course of a conversation someone can share a story that gets right to the heart of the matter. Such was the case with the quote above from Dr. Robert Keisling, a psychiatrist with Pathways to Housing DC. He was part of one of several workshops dealing with one of the most difficult questions many of us will ever face—what to do when people don't want help? Or to put it another way, what would we want done for us when we are so sick that we don't feel we need help?

Assisted outpatient treatment (AOT) and mental health courts, two approaches for reaching people in the throes of a mental illness who do not believe they need treatment, are often divisive issues in our community. At a standing-room-only session about anosognosia (the condition when someone is sick but doesn't know that they're sick), AOT, and advanced directives, panelist Jonathan Stanley drew upon his 10 years of experience as a lawyer and advocate as well as his own journey with bipolar disorder. "I've been to Lansing, Mich., to Newark, N.J., and I've been to anosognosia—and I have no desire to return to any of them," he said of the year when his illness was at its worst. "At my most psychotic was when I was most sure I wasn't sick."

The problem is that the treatment system in America in many communities has failed.  The system that is meant to fix the people itself desperately needs to be fixed.

"Is this a mental health problem or a criminal justice problem? It will be handled one way or the other," noted Dr. Keisling in a subsequent workshop. A mental health system that leaves no recourse other than calling the police for a mental health crisis has been likened to "calling a plumber to fix a light bulb"— seeking the wrong expert for the problem. Crisis Intervention Teams or CIT has made great strides in educating the officers who are often the first line of defense for people in acute psychiatric distress. "In some areas 20 percent of 911 calls are about people with mentally illness," according to Keisling, who asserted, "It's really unfair to ask the criminal justice system to manage this problem because they're not trained to enforce compliance with treatment. The mental health system has fallen down on the job."

Other sources have reported family members, and individuals, turning to the criminal justice system to get their loved ones the help they didn't get through the mental health care system. "Some parents have resorted to filing criminal charges against their children in order to change out-of-control behaviors," the Child and Adolescent Bipolar Foundation confirms, cautioning, "once in the juvenile justice system, they are more likely to receive punishment than treatment."

No matter who answers that call for help, there is an obvious conflict about making it. Workshop participants who had been on the receiving end of help they didn't want said they were now thankful that someone intervened when they were very ill. Others have had experiences that drive them to take a strong stand in opposition to imposed treatment or interventions. NAMI community members who have been on either side of the issue—those who have resisted treatment while ill or who have tried to get a resistant family member help—what has been your experience? Have you been able to get help without entering the criminal justice system?

Read more about the criminal justice and mental health systems:

The many state budgets in crisis may be one factor leading to the criminal justice system picking up the pieces for an underfunded mental health system.

Fact Sheet: Mental Illnesses – Treatment Saves Money and Makes Sense (2007)
Crazy: A Father's Search Through America's Mental Health Madness by Peter Earley

Learn more about what is happening to address legal and law enforcement issues, including successful strategies, and register to receive NAMI's CIT In Action newsletter.


Anonymous said...

While mental health courts are a far better alternative to jail or prison, if an individual does not comply with mandated treatment they could still be incarcerated.

Assisted outpatient treatment (AOT) laws bring far more timely, preventative treatment, since a history of several hospitalizations with other criteria required with AOT laws can help someone become eligible for outpatient treatment in the community. Although a history of incarceration or violence could also be part of the criteria for court-ordered AOT, unlike a mental health court order, the only result for non-compliance might be inpatient hospitalization, not incarceration.

Providing effective treatment through AOT for someone with severe mental illness and anosognosia who is unable to ask for help on their own is a compassionate intervention as well as the most effective method of helping an individual find the road to recovery.

Anonymous said...

People with mental illness will no doubt run into problems with the law at some point. It is no surprise that a person with mental illness at times will not want to comply with treatment because (at times) the person may feel s/he has no real problem...Not being able to fully understand that there is a problem allows one to stray away from help...and at some point, may even discontinue taking medication...I do not think the courts should make the decision to hospitalize someone but that family should do so. When the state gets involved primarily, a feeling of "lost" or "loneliness" may overwelme the individual and sometimes patients get lost in the system, due most especially when insurance and money is being paid for the housing of the indiviual...

DJ said...

I think it is great NAMI is raising this issue, but they have to also acknowledge they are part of the problem. NAMI's failure to admit that people with the most serious mental illnesses, who are untreated, are more likely to be more violent than others, does a disservice.

Anonymous said...

If the person in question is believed to have a mental illness or not and the people closest to him/her feel threatened by behavior of that person, then it's best to notify authorities to protect both parties.

When our behavior affects others as being threatening by us the legal system (just going to jail in some instances) may have a way to educate the cognitive thinking we are lacking at the time.

An educated patient

tom said...

There are so many problems on so many levels, but everything really boils down to one thing: litigation.

In Florida, the Baker Act was originally enacted to eliminate fraud by family members institutionalizing their parents, siblings, or others in order to gain control of their estate. Along came HIPPA and patient's rights, and the whole interpretation of that law changed. Judgments are made based upon one single phrase taken out of context from the law. Where a patient may meet the criteria for involuntary placement, the decision is usually based upon whether or not the patient is suicidal or homicidal.

It is tragic when a judge's order can trump decades of psychiatric training in a process that turns caring for a patient into a confrontational and legalistic exercise. Add to that the woefully inept funding for adequate mental health facilities, an insurance industry that doesn't seem to care, and you have a recipe for disaster...right where we are now.

The answer doesn't just lie with legislation, interpretation of the law, or funding, it encompasses all of it. The effort to accomplish change will be formidable indeed.

MWP said...

I think its an abusive system. There are no blacks or white. Many of these sick people like myself are chronically ill and get swept up when they can not pay. I am sad he campaign season looks like it defeat Health care funding. I'm amazed the right wing party thinks this will win them seats. Even worse.. It might. I receive discrimination at every corner I turn. My own Girlfriend who worked at university hospital left me because of the stress of my chronic illness and mental health. This has made me very suicidal again. The media and popular thinking in the world is against the weak and vulnerable. How an we survive in such vol-ital society. Everyones listening but no one hears a word.

Contributors: said...


I appreciate your thoughtful comments about health care reform and stigma. However it is of great concern that you are feeling suicidal. I urge you to contact the NAMI HelpLine at 1 (800) 950-NAMI or contact your health care provider or go to the emergency room if need be. Living with a mental illness can bring great challenges. Many people do say that the complexity of their treatments can be a blessing--there are an almost infinite number of medications, therapists, psychiatrists and support groups you can try. If what you have now isn't working, one combination you haven't discovered yet is sure to make the difference for you.

Anonymous said...

The following information includes excerpts from NAMI's policy on AOT (shortened due to restrictions on number of characters permitted for this blog site)

NAMI Public Policy Platform. Revised, Eighth Edition, July 2009
(pgs. 50-52)

9.2 Involuntary Commitment/Court-ordered Treatment

(9.2.1) NAMI believes that all people should have the right to make their own decisions about medical treatment. However, NAMI is aware that there are individuals with serious mental illnesses such as schizophrenia and
bipolar disorder who, at times, due to their illness, lack insight or good judgment about their need for medical treatment. NAMI is also aware that, in many states, laws and policies governing involuntary commitment and/or court-ordered treatment are inadequate.

(9.2.2) NAMI, therefore, believes that:

(9.2.4) Methods for facilitating communications about treatment preferences among individuals with serious mental illnesses, family members, and treatment providers should be adopted and promoted in all states.

(9.2.6) Involuntary inpatient and outpatient commitment and court-ordered treatment should be used as a last resort and only when it is believed to be in the best interests of the individual.

(9.2.7) States should adopt broader, more flexible standards that would provide for involuntary commitment and/or court ordered treatment when an individual, due to mental illness

( is gravely disabled, which means that the person is substantially unable, to provide for any of his or her basic needs, such as food, clothing, shelter, health or safety; or

( is likely to substantially deteriorate if not provided with timely treatment; or

( lacks capacity, which means that, as a result of the serious mental illness, the person is unable to fully understand–or lacks judgment to make an informed decision about–his or her need
for treatment, care, or supervision.

(9.2.8) Current interpretations of laws that require proof of dangerousness often produce unsatisfactory outcomes because individuals are allowed to
deteriorate needlessly before involuntary commitment and/or court ordered treatment can be instituted. When the "dangerousness standard" is used, it must be interpreted more broadly than "imminently" and/or
"provably" dangerous.

(9.2.9) State laws should also allow for consideration of past history in making determinations about involuntary commitment and/or court-ordered treatment because past history is often a reliable way to anticipate the
future course of illness.

(9.2.10) An independent administrative and/or judicial review must be guaranteed
in all involuntary commitment and/or court-ordered treatment
determinations. Individuals must be afforded access to appropriate
representation knowledgeable about serious mental illnesses and
provided opportunities to submit evidence in opposition to involuntary commitment and/or court-ordered treatment.

(9.2.11) Responsibility for determining court-ordered treatment should always be
vested with medical professionals who–in conjunction with the
individual, family, and other interested parties–must develop a plan for treatment.

(9.2.12) The legal standard for states to meet to justify emergency commitments for an initial 24 to 72 hours should be "information and belief." For
involuntary commitments beyond the initial period, the standard should
be "clear and convincing evidence." Involuntary commitments and/or court-ordered treatment must be periodically subject to administrative or judicial review to ascertain whether circumstances justify the continuation of these orders.

(9.2.13) Court-ordered outpatient treatment should be considered as a less restrictive, more beneficial, and less costly treatment alternative to
involuntary inpatient treatment.

changeMHLawsinKY said...

Dear Mr. Fitzpatrick, Regarding <"I've heard family members say that the police told them, 'If you want treatment for this guy, press charges. This is the only way they'll get treatment.'">

My husband and I are one of thousands that have been forced to do this very inhumane act in hopes of saving the life of our loved-one. This is wrong! Would we send a sick person to jail for not taking their cancer medication?

It should be against the law that we force our most vulnerable to become criminals before receiving some small amount of medical attention … not to mention in the meantime they become part of a revolving door that can take years from their life, destroys family relationships and drains state budgets!

So thank you for providing support from NAMI regarding this serious subject.

NAMI provides excellent signature programs that need to be utilized more in our private businesses as well as state government offices. Far too many individuals; especially public officials have little training on understanding severe mental illness or an understanding regarding the lack of outpatient services available.

As we began to modify our mental health laws, we also need to advocate for more mental health courts. A change in the law is “only” one piece needed to help. I hope that NAMI will continue to aggressively advocate, “assisted outpatient treatment” nationally.
it is time to change!

Change Mental Health Laws in Kentucky

Anonymous said...

I live in Florida and have experience being Baker Acted on 2 ends of the spectrum, once for the sole purpose of purpose of dr protecting his butt once he discovered my Dx. He refused to listen to my husband or myself after I can in on an emergency basis and made a rash decision. I was furious! My husband was furious! I was stuck in ICU being treated like a piece of scum by the staff for days once word got out.

The 2nd time was it was enacted probably saved my life and as a result I ran across a patient who gave me information about Nami and I've been moving upward ever since. It's taken me 9yrs to get finally get my feet under me and find the resources I've sorely needed. Had my husband not had the forethought to understand where I needed to go and how to physically get me there on his own I could have ended up in the justice system.

Thinking back on that has motivated to me to start reaching out to other Peers to find ways to protect themselves from having this happen to them.
Medic Alert bracelets with emergency contact numbers on them, directives, anything that will help to keep them from being tossed in jail around here because once that happens it could mean having one heck of a time getting out. Florida is known for using criminal justice system as a housing facility for the MI. We get stuck in there!

stair chair lift said...

My experiences with several people being treated for mental illness as tenants in my rental properties have been quite frightening and sad. On their meds they have been the most delightful and charming people. However, when they went off their meds, they turned into aggressive and irrational people that caused problems not only with me as the landlord, but with roommates, neighbors, etc. And unfortunately, the only way for me to deal with it was to call the authorities as their families (two different people - two different situations) were not willing to come and deal with them, and the local organization that tries to advocate and help out was unavailable.

Anonymous said...

While I was not the one that had to press charges to get my 23-year-old son who has Bipolar Disorder help, it was the threat of incarceration that forced him into treatment. That being said, once he was in treatment, the threat of incarceration only increased. Following discharge from the hospital, he was "mistakenly" harassed and arrested. The cost of his medical care (all out of pocket of course) was put on credit cards so that we could help with some of the legal expenses.
As this young man's mother, a retired RN, now studying counseling, and working with the homeless, it infuriates me that we have to arrest someone to treat them. If we cannot resolve this ethically, then the criminal justice system needs to be reformed with mental health treatment as a priority, so that at each step in the process, the persons who enter the system have someone who understands their mental illness, the role it has played in their "criminal" activity and what appropriate measures are called for with this in mind.

Anonymous said...

Criminalization of Mental Illness is a wide spread epidemic across the nation and rural settings are no exception. I happen to fall victim of just that and out come was unpleasant, not just for me but my family and friends. One who seeks help from the authorities should receive just that.........instead one comes out of jail a c 5/6 quadriplic.

lyribe said...

My son went off his meds in 1998, I asked the MH Systems for help to no avail. He committed a crime, we had a lawyer that told us to pled, Not Guilty by Reason of Insanity. What a mis-take. He has been in a Mental Institution for going on 13 years. I pray that one day he gets out. Seems it is easier to just put the Mental Ill away somewhere so not one has to deal with them. I presently work for the MH System in my town, these individuals did not ask for this illness. I want my son out and with me. I do not no where to turn. ly

Anonymous said...

My mentally ill family memnber has been made the underdog on more than one occasion under the new alliance with the local police dept. She is quite frightened by the process. Case in point: her abusive boy friend pounding on windows and entry doors of home she was visiting all night wanting access to her. When daylight fell, she opened the door to tell him one final time to leave. He tried to enter, she hit him and slammed and locked the door to protect her and her child. End result? She was arrested for assault. Charges were dropped only days later. There is more to the story, but this is an example of one mentally unstable persons journey further into, not away from mental illness with cities new alliances.

Anonymous said...

I am the parent of a 23 yr old son. He has suffered depression with psychotic features for over one year. He has walked 25 miles until I have finally convinced him into the car, on more than one occasion. He has become paranoid and jumped out of our moving car multiple times. He wants to die but is a passive risk, would not care if someone else killed him. He was arrested when my husband called the police after our son put over 40 holes in our sheetrock, leaving notes about our lack of consrevation and saving the environment. My husband is a building contractor. This is second degree felony. We bonded him out, then 4 weeks later he was asked to leave an establishment, he did, but the officer continued to tell him to go, my son asked to have his rights read and the officer told he didnt have to do "nothing". My son put one fist up, then he was pepper sprayed twice and beaton with a baton. He was depressed and the stress brought on the adrenaline filled psychosis. He is facing another felony. We are not allowed to drop our charges so he is looking at time. He was never in troube before. A college grad with a degree in criminal justice 12/09..then his best friend commited suicide.He does not use drugs or drink and used to think clearly. He will not take any medication but forced committmnet for the depressive psychosis appears to be the only way he will not be in prison 5 or more years. Will this remain on his record...that he was committed and he's mentally unstable? We have had lawyer(one we found out is in the process of being disbarred) and an incompetent pyschiatrist who put him on an antidepressent without a mood stablizer that set off this cascade of events. I am an RN but I am lost for the answers.

James Morgan - Puritan Financial Advisor said...

The system that is meant to fix the people itself desperately needs to be fixed.

Anonymous said...

Nothing against the article, but I disagree with a couple of points to some extenct. I’m probably a minority though, lol. Thanks for sharing.