December 18, 2014

Scales of Justice

Several years ago, in partnership with Dear Abby, a request was sent out in her newspaper column asking those with mental illness or family members with mental illness who had “interfaced” with the criminal justice system. I was part of a committee called Psychiatry and the Community, with the Group for the Advancement of Psychiatry, and received almost 3,000 letters.

Each one was read and we decided a practical response was to develop a monograph entitled: “People with Mental Illness in the Criminal Justice System: A Cry for Help,” hopefully to be published soon with the help of the American Psychiatric Foundation (and available to the public, providers, and purveyors of care in the criminal justice system).

The demographics of the criminal justice system are devastating. In a year’s time:

  • 2 million arrests in the U.S. involve persons with serious mental illness
  • 550,000 people with serious mental illness are in jails and prisons
  • 900,000 are in some kind of community control

The system is woefully understaffed and often poorly educated about the needs of those with mental illness.

However, a few things about the criminal justice system became apparent as I read the letters.

  1. It can be ignorant and insensitive, usually not because providers are evil, but because they are tired and lack resources like time, money, training, space and manpower.
  2. It often lacks innovation in response to crises and focuses on safety and boundary setting via restraint and seclusion.
  3. It uses short-term fixes and “efficiencies” to save money, but lacks a commitment to assessing long-term consequences of these fixes.
  4. And importantly, it can and will respond to advice and training.

The document that was developed after reading this letters will hopefully offer guidance to mental health care providers on how to interact with the criminal justice system to advocate for skills development, provide training opportunities, develop partnerships and enhance care.

In addition, the final product will provide practical advice for individuals with serious mental illness and their families on how to be prepared for an interaction with the criminal justice system.

  • Carry the name and contact information of your psychiatrist/mental health care provider (they can be contacted to advocate and educate law enforcement, jail and court personnel). Sign and carry a pre-emptive release form allowing communication with your mental health provider and law enforcement.
  • Carry a sheet with your diagnosis and list of medicines (some of my patients have taken to wearing medical alert bracelets).
  • Keep the lines of communication open. Family members should ask to speak with local leadership such as a police chief, sheriff or patient advocate if care isn’t being provided in a timely fashion. Insist on treatment, but also understand that jails and prisons have very limited formularies that often contain the cheapest medications. You will need to lobby hard to get formularies to expand, or more practically, negotiate with the jail to use your family member’s own medication supply (there may be barriers to this tactic). Require adequate transition/discharge planning (a call at 11 p.m. telling you that your son is being discharged at midnight with no medication and no follow-up is basically a guarantee for failure).
  • If law enforcement has been trained, develop and share your WRAP (Wellness Recovery Action Plan) in advance.
  • Advocate for crisis intervention training of local law enforcement. Make sure to participate and offer your viewpoint as an individual with mental illness or as a family member. Personal stories carry incredible weight, especially if delivered face-to-face.
  • Support/advocate/demand the development of mental health courts and drug courts.

I’d be interested in hearing how y’all deal with these challenges and if these suggestions have been helpful.

This is Jackie Feldman’s inaugural blog since starting her volunteer position as Associate Medical Director. She is a family member of near and dear relatives who have experienced depression and psychosis, and the consequences of the stigma of hospitalization, side effects to medicine, and memory loss from ECT.

She is also a psychiatrist. When she retired in mid-2014, she had spent the last 24 years in community psychiatry, running a public mental health center at the University of Alabama at Birmingham. In this position, she was privileged to work with thousands of individuals with serious mental illness and their family members.  She was a member of the NAMI state board, a federal court monitor for the Alabama women’s prison system, and helped the Department of Justice investigate state hospitals in Georgia.

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