Suhaib Qasem

INDIVIDUAL AND FAMILY DEVELOPMENT AND WELL-BEING:

ACROSS THE LIFESPAN

Wendy Morrison

November 05, 2018

Section 2

Table of Contents 2

Introduction 3

Bronfenbrenner’s Model 3

Inquiry 5

Cultural Comparison 5

Implications 6

References 7

Introduction

The universe has witnessed change and evolution since the dawn of time. This fact can

never be denied. From biological to cultural, to technological phases, the evolution is palpable to

the observers. The stated factors are interrelated. There is a strong connection between

technological innovations, human & cultural evolution (Ambrose, 2001).

Technological evolution encompasses the shift from stone tools to mechanical to more

sophisticated practices that today’s generation witnesses. Geels mentions in his work,

technological evolution takes place as a result of stipulating and retaining. The innovation along

technological lines shape a system of components where new and modern components are made

from existing ones, and more convoluted components advance from simpler ones. Such

sophistication has led to immense behavioral alteration over a period of time. The adaptation by

human generations confirms the fact that this behavioral change can be termed as cultural, as they

have been transmitted by sociocultural learning. (Joseph Henrich, 2003).

Seeing how and when such socially developed adjustments emerge, requires

comprehension of both behavioral systems that underlie human social learning, and the

transformative elements of social frameworks. This report aims to bring light on the connection of

behavioral change to technological evolution.

Bronfenbrenner’s Model

The model proposes the associations between the individual and their environment, sorted

into different frameworks, that shape their improvement, mental as well as physical, over time.

This model emphasizes the influence of a child’s inherited qualities and the environment provided

to him, cooperate to impact how he will develop with time. Through the Bronfenbrenner

Ecological Theory, Bronfenbrenner focused on the significance of the environment a child is raised

in, with regards to numerous situations in the endeavor to comprehend his advancement. Each

complex layer of environment immensely affects the development of a child (Dede Paquette,

2001).

The model proposes four levels of human interaction. First and the closest to a child is

microsystem. It includes a child's human connections, relational cooperation’s, and instant

environment. A case of this framework would be the connection between an individual and his or

her siblings, friends at school etc. the impact of this level is strongest on the child’s development.

(Dede Paquette, 2001).

Then is the mesosystem, encompassing the microsystem and including the diverse

collaborations between several characters of a microsystem. For instance, the connection between

the person's family and their teachers. It can become apparent when a human spends time in more

than one microsystem. This combination of systems forms a mesosystem. (Jonathan, 2009)

The exosystem is the third layer and contains components of the microsystem which do

not influence the individual specifically, yet there may be an indirect contradiction. For instance,

if a parent were to lose income or have their hours cut back, this would influence their kid in an

aberrant manner. The child may not be directly involved at this level but they can be impacted in

a positive or negative way (Laura E, 2009). The macrosystem is the biggest and farthest

accumulation of individuals that still exert an immense effect on the child. The macrosystem is the

larger entity that incorporates financial status, beliefs, norms, ethnicity. These levels have a ripple

effect, meaning the effect of one level is cascaded to other levels as well. (Dede Paquette, 2001).

Inquiry

This paper aims to identify the effect of technological evolution on human development.

Innovation is advancing quickly, and it is changing the manner in which we live, work and play.

New creations are going on, and new ideal models are conceived relatively consistently.

Technology has greatly altered our societal environment as well (Dede Paquette, 2001).

Technological innovation has taken place at an incredible pace. In the prior times we were

physically dynamic, but now we depend on gadgets to do a large portion of our work.

The adjustments in our personal conduct standards, and adjustments caused by these

mechanical advances, could turn out to be the essential reason behind the following phase of

development for our generation. It is through technology that workers are capable of getting rid of

manual work (Henderson, 1995).

Data innovation has immensely affected the financial advancement and the best precedent

is the current worldwide economy. This has likewise delivered another relaxation influenced the

manner in which individuals live. Based on equivalent advancements, organizations have

embraced better approaches for different ventures and business matters. Cell phones, for example,

sophisticated mobile phone technologies, have changed the manner in which individuals carry out

business and offer better agility than was in prior times (Geels, 2001).

Cultural Comparison

As stated in the Bronfenbrenner’s model the macroenvironmental have an immense effect

on the development of a child (Jonathan, 2009). This research involves a comparison between the

effect of technology on different socioeconomic groups of individuals. certain technological

gadgets are not in reach for the poorer areas of the public.

Present day allopathy and pharmaceutical medicine, and operations procedures are costly.

Certain new medications and analytic strategies are expensive. Rich individuals can get to these

medications by spending just a little segment of their wage and enhance their wellbeing. Destitute

individuals, then again, need to burn through the majority of their cash for ordinary medications

but there is no assurance that their condition will progress. Technology has done quite severe harm

to our societal environment (Henderson, 1995)

Technology is, even more, exaggerating the difference between wealthy and poor humans

of the society. Those born fortunate enough to have been blessed with the wealth interact and

survive better in today’s digital age than those left behind. As Darwin suggested in his book “On

the Origin of Species”, wealthy groups are considered fit for today's digital age as compared to the

people with low-class families. This gap has been created by the ever-increasing use of technology

and the enormous influence it has on peoples’ daily activities. Apart from the harm that the

technological revolution has done to the physical environment, the societal environment has also

been influenced to a greater extent (Dede Paquette, 2001).

Implications

Technological advancements and sophistication have enormously affected human

development. The levels of interactions that a person does in his daily routine have been altered

with the increasing use of technological practices. Socioeconomic and cultural groups have been

parted to a much greater with the dawn of this technological era wealthy and poor, rural or urban

juvenile or adult, every group of society is influenced by this technological storm but in different

ways.

References

Ambrose, S. H. (2001). Paleolithic Technology and Human Evolution.

Dede Paquette, J. R. (2001). Bronfenbrenner’s Ecological Systems Theory.

Geels, F. W. (2001). Technological transitions as evolutionary reconfiguration.

Henderson. (1995). Renewing Our Social Fabric Human Ecology.

Jonathan, I. (2009). Uses and Misuses of Bronfenbrenner’s Bioecological Theory of Human

Development.

Joseph Henrich, R. M. (2003). The Evolution of Cultural Evolution. Evolutionary

Anthropology.

Laura E, B. (2009). Child Development.

84 CRIMINAL JUSTICE POLICY AND PLANNING

Seeking Participation in Goal Setting Is it necessary that everyone agree on the same goals of a specific program or policy? What are the implications if they don't? At the most basic level, the implications are that different individuals (stakeholders) perceive that they are each working toward some specific end point. They may believe, correctly or incorrectly, that they are working toward the same desired end. The problem is: if they have not articulated or discussed their own goals and values with each other, they may find out after considerable expen- diture of energy and resources that they are working toward very different ends. Cer- tainly no effective program or policy can be constructed if those responsible for designing the program or policy hold widely disparate or conflicting goals. Participants need some basic agreement about what it is they are trying to achieve, and why. Not every single stakeholder needs to agree on the final goals, but those responsible for implementing the program or policy must be held accountable for articulating what it is they are doing and why.

Once again, we stress the virtues of participation in program planning. Having the rel- evant stakeholders involved in setting program goals is crucial to gaining the support and cooperation necessary to make the intervention work. An important step, if it has not already been accomplished (see Chapter 1), is to identify relevant participants for inclu- sion in the goal-setting and objective-setting phase.

The change agent (e.g., the person responsible for coordinating the program planning effort) should involve ~arious participants in the planning process, not just agency admin- istrators. Participants might include program staff, potential clients, citizens in the sur- rounding community, representatives from justice and social service agencies, schools, and so on. This requires patience and negotiating skills, as there are likely to be different assumptions and opinions regarding the problem, its causes, and the type of intervention needed.

Targets and clients are often overlooked at this stage, as are front-line workers: what should they expect to see result from this planned change? A major question to ask at this point is whether goal-setting should proceed from a "top-down" or "bottom-up" approach.

Typically, change follows a top-down format. This is often the case because the change agent is likely to be working for, or contracted by, the agency that is funding the intervention, and the change agent owes some obligation to weight their definitions of goals more heavily. There may be advantages to this situation, as well as costs. It may be the case that those in the higher levels of the organization have the most experience with interventions of this type, and they might indeed be in the best position to state realistic, feasible outcomes to be expected. They might also be best equipped to formu- late goals that can garner widespread political support for the program (e.g., support from other stakeholders). However, there is a very real danger in ignoring the views of program staff and clients. The danger is that the goals handed down from above may be unrealistic to program staff, or irrelevant to the clients. In either case, the impact

Chapter 2 • Setting Goals and Objectives 85

of the intervention could be severely compromised. The goals might prove unrealistic, in which case the program would be held accountable for unreachable goals; or clients and program staff might refuse to cooperate with a new policy or provide information to program evaluators.

• • Goal Setting: Top-Down versus Bottom-Up Approaches • Top-Down

The change agent begins by getting goal definitions from top officials at the administrative level of his or her organization (e.g., the Chief of County Probation, the Chief of Police, the Director of Social Services, etc.), and then gets responses from lower levels of the organization: perhaps from agency supervisors, then program staff, and eventually from potential clients. Thus, those at the top of the organizational hierarchy have more "say" in defining the program's goals, because their definition is the first one, and it carries more weight and more power as subor- dinates and clients are asked to respond to it.

Bottom-Up

The change agent begins by seeking goal definitions at the client or staff level. In contrast to the top-down approach, here the change agent first gets definitions from clients and staff about what the program goals are or should be, and then gets responses to these goal definitions from successively higher levels of the agency responsible for implementing the intervention, as well as the agency that is funding the intervention. Other stakeholders to approach may include agency supervisors, administrators, and government representatives. The views of clients and program staff are given more priority using this format; their definitions guide subsequent responses. Obviously, this approach is favored when it is widely viewed that so-called "experts" are out of touch, and that front-line program staff and/or clients are in a better position to state the needs and goals of the target population. Many "grassroots" organizations follow this format.

Regardless of which approach is used to formulate initial goals, therefore, it is crucial that all stakeholders eventually have some input into defining program goals. These issues are examined in more detail in Case Study 2-1 at the end of this chapter.

Specifying an Impact Model We discussed causes and theories in Chapter 1. Examination of theories helps us to formulate what is called an impact model: a prediction that a particular intervention will bring about a specific change in the problem. Formulating such a model forces us to answer several important questions: What is the intervention? Why would a proposed intervention work? Which causes of the problem will it address? In other words, through what process will change occur, and why? What outcome (a change in the problem) is expected? Thus, the impact model is made up of three key elements

Chapter 11

Deliberate Indifference: Mental Illness and the Criminal Justice System

Jacqueline Bufiington-Vollum

Introduction Every year, hundreds of thousands of individuals with serious

mental ill-

ness are arrested and jailed, the majority for petty crimes (Clark, Ricketts, &

McHugo, 1999). Although the criminal justice system is not the place or the

system that can best serve this particular population, since the 1980s, it is the

criminal justice system—the system that c_an’t say “no”—that is increasingly

called upon to manage these individuals and the situations in which they find

themselves. Indeed, the three institutions in the U.S. that hold the largest pop- ulations of people with mental illness are not psychiatric facilities, but large

urban jails: L.A. County Jail, Cook County Jail in Chicago, and New Y0Y1<

City’s Riker's Island (Torrey, 1999). L.A. County Jail has an entire tower de-

voted to holding inmates with mental illness, holdingmore individuals with

mental illness than any state hospital or mental health institution in the U.S.

(Council of State Governments, 2002a). Although the general public might be surprised to learn this, most criminal justice professionals are not surprised,

as this is the reality they live with everyday in their jobs. This chapter is devoted to this population of offenders. It will begin With an

overview of statistics on the overrepresentation of individuals with serious mental illness in the criminal justice system. Reasons for these high numbers will be discussed. Finally, efforts to manage this dilemma, with an emphasis

on innovative strategies, will be described.

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Defining Serious Mental Illness It is important first to specify what is meant by “serious mental illness,” as

a wide range of psychological and/or behavioral maladies are apparentwithin the criminal justice system. Members of the lay public often mistakenly be-

lieve that anyone who commits a crime or engages in behavior to which the per- ceiver cannot relate personally is mentally ill. However, this is not what defines

mental illness. Moreover, although anxiety disorders and personality disor- ders‘ are prominent within the criminal justice system, just as they are in the general public, these are not included under the category of serious mental ill-

ness. As such, they will not be addressed here. Instead, this chapter focuses on “serious mental illness,” or substantial dis-

orders of thought, perception, or mood that significantly impair an individ-

ual’s functioning. This includes such mental illnesses as schizophrenia, bipolar

disorder, and severe depression. Schizophreniaprimarily involves a distur- bance of thought and perception, or psychosis, typically characterized by hal-

lucinations (i.e., false sensory experiences, such as hearing voices or noises), delusions (i.e., false beliefs that are held despite impossibility, such as para- noid delusions or delusions of grandeur/grandiosity),and severe disorganiza- tion (e.g., incoherent speech, bizarre behavior). Individuals with schizophrenia

also tend to exhibit social withdrawal and inappropriate social behavior and/or emotions. Bipolar disorder involves periods of opposingmoods: i.e., mania and depression. In particular, mania refers to episodes of extreme energy; re- duced need for sleep; elevated and/or irritable mood; racing thoughts, dis- tractibility, and talkativeness; and excessive involvement in pleasurable, and often dangerous, activities. Depression, conversely, involves depressed mood alone, characterized by diminished interest in things that typically bring them pleasure, feelings ofworthlessness and guilt, sometimes irritability, and often

recurrent suicidal ideation; cognitive problems, such as difficulty concentrat- ing; and physical symptoms, including lack of energy and disturbed sleep pat- terns and appetite. Whereas schizophrenia is the prototypical psychotic disorder,

1. Sometimes referred to as “character disorders,”personality disorders are a cluster of disorders characterizedby rigid, persistent, maladaptive personality traits and coping styles

that are manifested in psychosocial and occupational problems. The most common per- sonality disorderwithin the criminal justice system is antisocialpersonality disorder (APD),

which is largely defined by criminality. Specifically, APD is characterizedby a failure to con- form to social norms with respect to lawful behavior (i.e., criminality), reckless disregard

for the rights and safety of others, impulsivity, irresponsibility, deceitfulness, and lack of

remorse.

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severe mania and depression can also involve psychosis. As such, all of these disorders fall under the category “serious mental illness.”

Prevalence of Serious Mental Illness in the Criminal Iustice System

Mentally ill offenders comprise an ever—growing proportion of the U.S. jail and prison population. The most conservative, respectable estimate of the pro- portion of individuals with serious mental illness in jails and prisons is 16%

(Ditton, 1999)} Steadman, Osher, Robbins, Case, and Samuels (2009) cor- roborated this rate, findingthat 14.5% of the male jail population and 31% of the female population are diagnosed with serious mental illness. These rates are 2.5 to 10 times as high as the rate of mental illness in the general population, dependingon the statistic (Kessler, Chiu, Demler, &Walters, 2005). Looking

at the phenomenonfrom an alternative perspective, among all individuals with mental illness (i.e., not necessarily those within the criminal justice system), ar- rest by law enforcement is all too common. Approximately 50% of persons with mental illness have been arrested at least once (Frankle et al., 2001; Solomon 8: Draine, 1995; Walsh 8: Bricourt, 1997). This is despite less than 1°/o, ac- cording to some estimates, ever becomes violent (McCampbell, 2001)}

Reasons for the Overrepresentation of Individuals with Mental Illness in the

Criminal Iustice System There are a variety of converging factors that account for the overrepre-

sentation of people with mental illness in the criminal justice system. The lay

2. An updated BIS report (lames & Glaze, 2006) suggests mental illness afflicts over 50% of inmates in the jail and prison system. However, the study upon which the report was based has been criticized on methodological grounds (e.g., using self-report only, not taking into account the effects of substance abuse) and is believed to be an overestimate.

3. The rate of violence among individuals with severe mental illness varies widely, de- pending on the definition of mental illness and the methodology of the study. For exam- ple, a reviewarticle ofall studies examining violence among individualswith severe mental illness, defined by psychotic disorders and major affective disorders, found rates to vary from 2 to 13% among outpatients and from 17 to 50% among inpatients (Choe, Teplin, 8r

Abram, 2008).

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public tends to assume that the large number of people with mental illness in our criminal justice system is due to characteristics intrinsic to the individu- als themselves (e.g., that they are inherently unpredictable and violent). How- ever, because of the wide variability in the presentation of mental illnesses, individual-level factors are among the least influential reasons for the over- representation of individuals with mental illness in the criminal justice sys- tem. Instead, it is the historical events (e.g., deinstitutionalization) and societal-level factors (e.g., attitudes regarding mental illness and criminality), coupled with the nature of the criminal justice system, that have resulted in the system-level difliculties with—and problematic policies of—managing offenders with mental illness. Each is discussed below.

Historical Events Attitudes about individuals with mental illness and their treatment have

operatedon a pendulum swing since the foundingof the U.S. Specifically, this swing has consisted of alternatingperiods of, on the one end, massive insti- tutionalization, and at the other, periods ofdeinstitutionalization (Johnson, 2011). As Grob (1995) outlined in his book on the history of America’s care of the mentally ill, prior to the 1840s, people with mental illness were either cared for by relatives or were imprisoned. The conditions in which they lived in jails

were brutal and inhumane, characterizedby exceedingly tight quarters (e.g., “clos- ets”), freezing temperatureswith no heat, hay for bedding, and a few scraps of rags for clothing. It was not until the efforts ofDorothea Dix, who spent two decades traveling state—to—state exposing to the public the abuses that the men- tally ill were enduring in jails and prisons that the treatment of the mentally ill changed. She was responsible for convincing 30 states to build asylums, as they were called, whereby people with mental illness could be removed from jails and provided treatment. This marked the first deinstitutionalization move- ment (Johnson, 2011).

By 1900, every state had a psychiatric institution (Earley, 2006). However, these institutions were just as problematic as the jails before them. Getting someone admitted to one of these facilities was simple, requiringmerely the concern of a family member, a process that was frequently abused. The cause of mental illness was unknown, and the only available treatments—electric shock, insulin injections and other seizure-inducing medications, and eventually lobotomies—were only effective in halting disruptive behavior by permanently damaging the brain. Thus, these facilities essentially became warehouses of humans at the furthestmargins of society. Fueled by the Not In My Backyard (NIMBY) mentality, these facilities were built in the most remote areas of the

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country, far away from the love, support, and oversight of their families and friends. By 1950, approximately a half—million people were institutionalized in these asylums (Earley, 2006).

The first expose of the shameful conditions of the asylums appeared in a 1946 Life cover story entitled “Bedlam: Most U.S. Mental Hospitals are a Shame and a Disgrace,”detailing the case of a patientwho had been tortured to death in a state psychiatric institution and revealing the hospitals as “dilapidated, overcrowded, undermanned” (Earley, 2006). Several other exposés followed suit, including Mary Jane Ward’s novel, The Snake Pit ( 1946), in which she described her experiencesof confinement in a state hospital, and Albert Deutsch’s The Shame of the States (1948), in which he likened the conditions of the na- tion’s state hospitals to Nazi concentrationcamps. In response, President Tru- man signed a bill establishing the National Institute ofMental Health.

The next major event—seemingly hopeful for the treatmentof serious men- tal illness—was the discovery of the drug Thorazine to treat schizophrenia in 1952 (Earley, 2006). Touted as a “wonder drug” and “cure” for mental illness, Thorazinewas prescribed to more than two million patients in the first eight months it was on the market. Shortly thereafter, in 1961, the Joint Commis- sion on Mental Illness and Health released a report of its work, recommend- ing a reduction in dependence on institutionsand movement toward a system of communitymental health centers on grounds that these communitycenters were cheaper, more humane, and allowed for reintegration of people with mental illness into the fabric of society (Slate & Johnson, 2008). The combi- nation of these two events prompted lawmakers to reconsider the use of pub- lic funds: why use costly, seemingly inhumane state hospitals, when money could be invested in a drug to “cure” the illness and in community mental health centers to enable more successful rehabilitation?

It was this mentality that President Kennedy adoptedwhen he made men- tal illness a priority of his administration (Earley, 2006). Kennedy, whose sis- ter was institutionalized withmental illness for most of her life (Kessler, 1996), signed into law the CommunityMental Health Centers Construction Act of 1963. This bill authorizedCongress to spend $3 billion to construct a network of communitymental health centers (CMHCS) throughout the country (Slate 8: Johnson, 2008). However, with Kennedy?s assassinationand Congress’ attention turning to more publicized concerns such as Vietnam and Watergate, the money was never allocated. Most CMHCS were never constructed; the “system” of CMHCs was never realized.

Nevertheless, the impetus had been set into motion, and several social move- ments fueled the fire (Earley, 2006). An anti—psychiatry movement had been activated. Initiated by critical academic writings such as The Myth ofMental

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Illness (1961) by psychiatrist Thomas Szasz, the release ofKesey’s popularbook (1962) and eventually the film (1975), One Flew Over the Cuckoo's Nest, dis- trust of psychiatry spread throughout the nation. Moreover, the civil rights movementchampioned this sentiment by bringing lawsuits against state hos- pitals, fighting on behalfof people with mental illness to ensure better treat- ment and recognition of their rights. They also fought to make civil commitment, or the process of treating people with mental illness against their will, more dif- ficult. By the mid-1970s, most states had adopted the “imminent danger to self or others” standard (i.e., the individualmust present an imminent danger to harm him/herselfor others before he/she could be committed), an exceed- ingly rigorous standard to meet. Although an act of respect toward people with mental illness, these revised standards sometimes legally hindered much needed treatment.

All of these events converged to bring about the second deinstitutionaliza- tion movement involving the mentally ill (Johnson, 2011), which is generally regarded as being responsible for the current overrepresentation of people with mental illness in the criminal justice system. During this period of deinstitu- tionalization, hundreds of thousands of psychiatric inpatients were released from the state hospitals into the nations communities. Specifically, the num- ber of psychiatric inpatientsdwindled from 559,000 in 1955 to approximately 59,000 in 2000 (Lamb &Weinberger, 2005)—a 95% decrease. Although a well- intentioned decision to rehabilitate individuals with mental illness in their communitieswhere they could enlist the support of family and friends, with- out the treatment system and residential support services that were supposed to have been constructed, many deinstitutionalizedpatients rapidly decom- pensated into acute mental illness. And with the more restrictive civil com- mitmentcriteria, it became practically impossible to get treatment for those who needed it (Earley, 2006).

Thus, many became homeless, resorted to substance use to dampen their symptoms, and became increasingly embroiled in the criminal justice system (Earley, 2006). In an effort to “clean up the streets,” the homeless, mentally ill have been increasingly charged with minor nuisance crimes (e.g., loitering, trespassing) (Clark, Ricketts, 8:McHugo, 1999). Others are detained on “mercy bookings”—suchas arresting a homeless, mentally illwomanon a bogus mis- demeanor charge in order to protect her from potential sexual assault on the streets—bywell—intentionedpolice who perceive there to be no suitable treat- ment alternatives available (Lamb, Weinberger, S: DeCuir, 2002). Many, in an effort to subsist, are charged with misdemeanor shoplifting and minor theft charges. Others are charged with felonies when their behaviorescalates, often in response to paranoia, hallucinations, and/or mania. Moreover, when law

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enforcement is called to the scene to address minor nuisance crimes, individ- uals with mental illness sometimes strike out when the officer(s) moves to sub- due and/or arrest him or her—due to past negative experiences with law enforcement and/or their current symptoms—and are charged with felony as- sault of a police officer.

SocietalAttitudes Coinciding with the deinstitutionalization movement, in the 19805, U.S. so-

ciety shifted its attitudes about criminal justice. In particular, the criminal justice systemmoved from a rehabilitative model to a more retributive, punitive model. This was evident in the policies that were adopted, such as three strikes laws, tougher drug control laws, and zero tolerance policies (Tonry, 2004). As a result, U.S. jail and prison populations soared. For example, between 1978 and 2000— i.e., in half the time period as the 95% decline in state hospital populations cited earlier—thenumber of jail and prison inmates increased approximately 400%, from just under 475,000 to nearly 2 million (Lamb 8c Weinberger, 2005).

Moreover, these generally punitiveattitudeswith regard to criminal justice extended to people with mental illness and especially to those within the crim- inal justice system. Although mental illness has always been stigmatized, fear of individualswith mental illness has grown since the 1950s. Likely due to highly publicized and sensationalized acts of violence in the media, the pro- portion of U.S. society that believes people with mental illness are dangerous, violent, and/or frightening increased by 250% between 1950 and 2000, with 75% of the public currently holding such beliefs (Phelan, Link, Stueve, & Pescosolido, 2000). This is particularly noteworthy as decades of research have revealed that mental illness alone is not predictive ofviolence (Elbogen 8t john- son, 2009)!‘ Moreover, people in the lay public tend to believe other myths

4. Although a complete discussion of the relationship between mental illness and vio- lence is beyond the scope of this chapter, it is necessary to summarize the basic findings of the research, considering the pivotal role that this mistaken beliefhas on attitudes and pol- icy involving this population. First, most violent offenses are not committed by individu- als with mental illness. The risk of being assaulted by someone with serious mental illness, at 3 to 5%, is seven times less than being violently victimized by someone abusing sub- stances without mental illness (Friedman, 2006). Moreover, the vast majority of people with mental illness will never commit an act of violence (Choe et al., 2008; McCampbell, 2001); it tends to be concentrated in a fraction of the overall population of those with men-tal illness, and it is usually related to co-occurring substance abuse during periods ofnon- compliancewith medications (Elbogen 8: Iohnson, 2009; Swartz et al., 1998). Moreover, even when an individual with mental illness does become violent, contrary to the popular image

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about mental illness, such as persons withmental illness being responsible for causing their illness (Corrigan et al., 2000). Thus, coinciding with the general move away from rehabilitation by the general public, people with mental ill- ness in particularwere seen as worthyof arrest and unworthyof treatment in the criminal justice system (Lamb 8:Weinberger, 1998). By the 1980s, the men- tally ill began arriving in jails and prisons in such numbers that the term “transinstitutionalization”has been used in replacement of “deinstitutional— ization” (Barr, 2003); people with mental illness being released from state hos- pital institutionswere merely being deposited into the jail/prison institutions. Indeed, between 1980 and 1992, the number of individuals with mental ill- ness in jails increased by 154% (Watson, Hanrahan,Luchins, 8: Lurigio, 2001).

System Failures Individuals with Mental Illness and Law Enforcement

Early research on the subject found that individuals with mental illnesswere significantly more likely to be arrested than individuals withoutmental illness. In the seminal study on this issue, Teplin (1984) found that 47% of suspects who exhibited signs of mental illness were arrested compared to 28% of sus- pects ofwho did not exhibit such signs. This difference equated to a 67 times greater likelihood of arrest for mentally ill suspects than suspects withoutmen- tal illness. Fortunately, since that time, the situation appears to have changed somewhat (Engel 8: Silver, 2001). Nevertheless, given the sheer number of mentally ill individuals with whom law enforcement comes into contact, cou- pled with the power officers hold, they have an extremely important role. In- deed, as first responders, police officers have been referred to as “street—corner psychiatrists” (Teplin, 1984), providers of “psychiatric first aid” (Lamb et al., 2002), “de facto mental health providers” (Patch 8:Arrigo, 1999), and the “pri- mary gatekeepers”ofboth the criminal justice and mental health systems. Thus, it is imperative that law enforcement’s treatment and disposition of cases in- volving individuals with mental illness be closely examined. What accounts for this likelihood of arrest? Law enforcement has two com-

mon law powers that relate to their job responsibilities: police power, or that which enables them to do what is necessary to protect the welfare and safety

propagated by the media, most do not target strangers; instead, it is usually the peoplemost involvedin the person’s care, such as familymembers, who are the target (Steadman et al., 1998).

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of the community, and the power ofparens patriae, which they are able to in- voke when the paternalistic protection of an individual is warranted (e.g., an individual is threateningto attempt suicide) (Lamb et al., 2002). Within these powers, however, law enforcement officers have a great amount of latitude in determininghow to resolve situations. In situations involving individuals with mental illness, they can choose to handle the situation formally, in the form of arrest or transport to a hospital in pursuit of civil commitment, or they can resolve the situation informally, such as providing a verbal warning or refer- ring the individual to services in the community (Cooper, McLearen, 8: Zapf, 2004; Sellers, Sullivan, Veysey, 8: Shane, 2005). Which route an officer takes is determinedby a combinationof personal, situational, and systemic factors. For example, less experienced officers tend to be more likely to arrest than more seasoned officers (Watson 8:Angel], 2007). The more public of an event, if the event was invoked by a member of the community, and if a crime is being committed all increase the likelihood of arrest over informal resolution or transfer to a psychiatric facility (Patch 8: Arrigo, 1999).

Similarly, when calls involve police-invoked reports of the need for order maintenance—e.g.,the dispatcher reports an individual walking along the in- terstate, displaying erratic behavior—the personal biases and fears held by the officer are more likely to play a role (Patch 8: Arrigo, 1999). Officers who be- lieve individuals are responsible for their mental illness are less willing to pro- vide assistance and are more likely to arrest (Watson, Ottati, Lurigio, 8: Heyrman, 2005). Moreover, contrary to popular belief, persons with mental illness are four times more likely to be killed by police than vice versa (Cordner, 2006), un- doubtedlydue in part to officers’having preconceived notions that the person will become violent unless they respond first (Slate 8: Johnson, 2008).

Certain symptoms of mental illness also can contribute to detection and the increased likelihood of arrest by law enforcement. First, the crimes of in- dividuals with mental illness are more likely to be marked by disorganization and impulsivity, which draw the attention of law enforcement. People with mental illness might be more likely to remain on the scene, due to not recog- nizing they did anything illegal for which they could be arrested. They are also more likely to confess; sometimes to criminal acts they did not commit (Redlich, Summers, 8: Hoover, 2010). Furthermore, when police arrive on the scene, people with mental illness sometimes escalate their behavior related to mis- perceptionof officers’ intentions and/or clinically paranoid delusions. Finally, officersmight not recognize the individualspresentationasmental illness. In- stead, their behavior may be interpreted to be the result of illegal substance abuse, makingthem susceptible to arrest. In the chaos of the incident, the in- dividual’s mental illness goes unnoticed.

230 11 - DELIBERATE INDIFFERENCE

From a system—level perspective, even when mental illness is recognized, law enforcement’s (and by extension, the rest of the criminal justice system’s) hands are tied. When called to a scene involving a person with mental illness— whether it is by a familymember or a friend seekingassistance in obtaining treat- ment for the individual or as the result of an individual with mental illness having committed a crime—law enforcementcannot say “no” (Lamb et al., 2002). Unlike the mental health system, which may not accept an individual on grounds that there are no hospital beds available, the individual does not have health insurance? or that the individual has co—occurring substance abuse, the criminal justice system must act; law enforcement cannot deny “treatment.” Similarly, the ultimate irony is that with the strict civil commitment statutes described previously, an individual must become dangerous to him/herselfor others to be civilly committed; yet when a mentally ill individual does become violent, the mental health system may refuse to accept them. With nowhere else to take the individual, law enforcement officers—who are tasked with keeping the streets safe—maybelieve they have no option but to arrest (Lamb et al., 2002). It is usually more expedient for police officers to arrest and take the individual to jail than to wait at the hospital for the individual to undergo the cumbersome and time—consuming process of psychiatric evaluation for civil commitment (DuPont & Cochran, 2000). If the individual is not evalu- ated, his/her rights dictate that he/she cannot be detained. Even if the indi- vidual is evaluated, ifhe/she is found to not constitute a sufficient danger from a legal standpoint, he/she is released within hours, only to return to the streets where the officer might have to deal with the individual again (DuPont 8r Cochran, 2000). After having witnessed this scenario repeatedly, law enforce- ment officers might arrest due to the perception that the individual will re- ceive bettermental health treatment in jail than from the underfundedmental health system and/or that jail is safer than the streets, where the individual is vulnerable (i.e., “mercy bookings”) (Lamb et al., 2002).

Individuals with Mental Illness in [ails and Prisons As mentionedpreviously, it is estimated that, conservatively, approximately

16% of inmates in U.S. jails and prisons have a serious mental illness (Ditton, 1999), a rate that has grown significantly in recent decades. For example, be- tween 1980 and 1992 alone, there was a 154% increase in the number of in-

S. As of 1997, two-thirds of U.S. hospitals refuse patients with mental illness who are unable to pay (Coleman, 1997).

11 - DELIBERATE INDIFFERENCE 23,

dividuals with mentalillness in jails (Watson et al., 2001). Having such largepfiiarfibers of people with mental illness in jails and prisons poses significant

staff ergges, not only for the 'll’1dlVlClllalS themselves but for the jail and prisonponsible for managing them. As a result, the duration of imprison-

ment for persons with mental illness tends to be longer than for inmates with- outmental illness. For example, in Fairfax, Virginia, psychotic misdemeanams stayed in jail six and one—half times longer than non—mentally ill offenders (Ax-elson 8: Wahl, 1992). Moreover, people with seriousmental illness in Pennsylvania prisons in 2000 were three times more likely to serve their maximum sentence(Council of State Governments, 2002c). In some cases, inmates with mentalillness end up serving more time in prison than their allotted sentence. For ex-ample, one individual profiled in the PBS documentary, Frontline: The NewA5}’lum$ (Navasky 8r O’Connor, 2005), served 13 years on a 3 year sentence inOhio. The heightened rate of arrest and detention, coupled with longer lengthsof stay in jails, results in a backlog of individuals with mental illness in U.S. jailsand prisons.

AcutePsychopathology Not only is the number of inmates with mental illness growing but morepersons whose illnesses fall at the most severe end of the mental illness spec-t . . .rum are being incarcerated (Human Rights Watch, 2003). Severe, untreated,acute mental illness is especially prevalent in jails, where individuals with men-tal illness have just been delivered from the community—often literally fromth __ .

’

. ’

.foe strle/its after weeks, months, and even years of being off their medica- I _ . . . . .ns oreover, many of these 1ndividuals—-most estimates place it at around7:? (_Abf:m 3! Teplili, 1991)——'havealso been abusing alcohol and/or drugs llfotl 3 11“ t 9 Coltnmunlty. often just prior to their arrests. Abusing substances

als on y cor1r(iptjc:tes'me‘ntal illness (e.g., makes existing symptomsworse), it

0 can ma e e avior in the jail more erratic, impulsive, and aggressive, toboth self and others. Finally, with any inmate, withdrawal from substances in S‘ e early hou: of detention in jail can lead to delirium (e.g., cognitive confu-1

, ‘ - - - . .

S on errafic e avior), if not posing life-threatening complications (e.g., eizures, a terations in blood pressure or other heart functioning, respiratorydepression), that must be monitored closely.

Conditions ofIncarceration Although few individuals thrive while incarcerated, persons with mentalillness function particularly poorly under these conditions (Human Rights

232 11 . DELIBERATE INDIFFERENCE

Watch, 2003). The crowded and/or unsanitaryenvironment, excessive sensory stimulation (e.g., noise, lack of privacy, lights being on all day and night), and disruptions in eating and sleeping patterns are especially detrimental for

1l'1d1-

viduals with mental illness, whose senses tend to be enhanced and who have fewer psychological resources with which to cope with the chaos. Moreover, the

intake process, which usually consists of a strip search and other degrading rituals, and victimization by other inmates and even staff can re-activate prior traumas and, accordingly, post—traumaticsymptoms. Any and all of these cir- cumstances can trigger a psychiatric episode or exacerbate an existing episode

of psychosis, mania, or depression.

Disciplinary Infractions Individuals with mental illness often have a hard time following the strict

rules and regimen of the institution and, thus, accrue disciplinary infractions

and accordingly punishment, in the form of days in segregation, refusal of pa- role, and/or additional time in prison (Human Rights Watch, 2003). Individ-

uals with disorganized cognitive symptoms of psychosis or mental retardation

may not understand and/or be capable of complying with strict rules and un- familiar regimens. Similarly, rules do not mean much when one is hearing voices and having impulses to kill oneself. For others, symptoms ofmental ill-

ness render it difficult to control their behavior and/or manifest in disrup- tiveness, belligerence, paranoia, and aggression (HumanRights Watch: 2003)-

Regardless of the reason, noncompliancewith institutional rules and disrup- tive behavior is usually punished by security staff, often in the form of segre- gation or new charges and, thus, increased time. In short, individuals with schizophrenia or mental retardation commit more rule infractions, spend more time in segregation, and ultimatelyare less likely to be released (Slate 8< Iohn—

son, 2008). Because of rule violations, the average length of stay in the New York City jail system for inmates with mental illness is 215 days, versus 42 days

for inmates without mental illness (Council of State Governments,2002b).

Use ofSegregation A policy in many jails is to segregate people with mental illness in order to

place them in a location where treatment can be conveniently administered,

to protect them from assault or exploitation by other inmates, and/or to pro- tect other inmates from mentally ill inmates who might become assaultive. In

other circumstances, individuals with mental illness and/or mental retarda- tion are placed in segregation because they break the institutions rules. Seg-

l 1 - DELIBERATE INDIFFERENCE 233

regation, which is characterized by stressors such as being stripped and being forced to wear a thin paper smock in a cold, barren cell, sensory deprivation, and lack of social interaction, is known to have detrimental effects on mental health; but the effects are particularlypronounced for individuals with exist- ing mental health issues (Human Rights Watch, 2003). At the mild end, indi- viduals might experience anxiety, headaches, lethargy, trouble sleeping, oversensitivity to stimuli, and difficulties with concentrationand memory. At the extreme end, even short periodsof isolation can cause confusion, percep- tual distortions (e.g., hallucinations), paranoia, and motor excitement (e.g., “lash- ing out”). Ironically, although aggression is often the very thing that this punishment is intended to eliminate (Haney, 2003), segregation can often pre- cipitate aggression in a previously non-aggressive mentally ill inmate, leading to further disciplinary action, extended periods in segregation, and lengthier sentences.

Segregation is also used regularly for inmates who are at risk of commit- ting suicide, either by direct threats or history of suicide attempts. Ironically, while suicide reduction is a key consideration for jails and prisons due to lia- bility issues, the common practice of placing inmates at risk for suicide in iso- lation merely sets them up for further deterioration of their mental health and/or progression of their suicidal ideation (Haney, 2003). Although jail and prison staff have policies and procedures to monitor inmates in segregation, re- moval from general population inadvertently eliminates one of the staff ’s great- est assets for preventing suicide: peer supervision. Research consistently shows that self—mutilation and suicide risk is increased in conditionsof segregation, social isolation, and psychosocial deprivation (e.g., being placed in single cells with little supervision) (Haney, 2003). For example, 30 to 50% of suicides in NewYork state prisons occurred within the 8% of inmates confined in 23-hour isolation; and the three supermax prisons in California accounted for one- third of all prison suicides in the state (Human Rights Watch, 2003).

Lack ofServices Inmates in jails and prisons have a legal right to mental health treatment,

grounded in the Eighth Amendment’s prohibition of cruel and unusual pun- ishment and upheld by the U.S. Supreme Court case ofEstelle v. Gamble (1976). However, this right is quite narrow (Honberg, 2008), to the point that serv- ices in many jails and prisons are virtuallynon-existent. Mental health serv- ices in correctional institutions are mainly reactive, rather than proactive, focusing on responding to mental health crises andmanaging symptoms rather than improving coping skills and quality of life for their prisoners. From a

234 ll - DELIBERATE INDIFFERENCE

management perspective, this alone is likely to be inefficientand ineffective, some- times with dire consequences (e.g., suicide). Due to the current punitive phi- losophy and budget constraints on the correctional system, mental health services are severely understaffed, both in terms ofquantity and quality (Human Rights Watch, 2003). In prisons, the vast majorityof services are provided by “counselors,” who typically are not required to have mental health training (Human Rights Watch, 2003). In many jails, the only form of mental health

treatment is psychotropic medications, if that. In terms of quantity, Humans Rights Watch (2003) uncovered prisons in states like Arkansas operatingwith

one psychiatrist to serve 14,000 inmates; this is in stark contrast to the Amer- ican PsychiatricAssociation’s (2000) recommended inmate—to—psychiatrist ratio of 150:1. Similarly, in Wyoming, one psychiatrist is on the prison premises two days per month; and in California, a psychiatrist being paid for full-tirne work sees inmates only 36 hours per month (Human Rights Watch, 2003).

Medications In a further attempt to cut costs, many state legislatures impose on jails and

prisons restrictive drug formularies (Council of State Governments, 2002a), or lists ofmedications—usually generic and/or the cheapest—thatthe systemwill

pay for (Koyanagi, Forquer, 8:Alfano, 2005). In so doing, many institutions will switch an inmate’s medications from what he/she was taking in the community

to medications that are ineffective for the individual. Although an appeals process might be available, appeals are often denied and usually require a “fail first” pol- icy (Koyanagiet al., 2005). This practice has inconvenient, if not dangerous and often expensive implications (Slate 8: Iohnson, 2008). First, psychiatric medica- tions often take weeks to build up in an individual’sbody before having a thera- peutic effect. More importantly, changing an individual’smedications from those

that work for the individual to those that could be ineffective can result in de- compensationand potentially even more severe, and unexpected, symptoms. After such decompensation, even the medication that was previously effective

may no longer work in alleviating symptoms; and the attending psychiatrist must set out on the potentially long process of finding an alternative medication that does in fact work. This process renders this practice more expensive rather than less, not to mention the complication it adds to the jobs ofboth jail officers and mental health staff. Medications can also have side effects that are harmful—and even deadly—especially if combined with certain other medications and!or illicit substances thatmight not have cleared the individuals system (Slate 8r Iohnson, 2008). These side effects must be closely monitored, which is hard to do giventhe significant lack of psychiatric services available at most jails and prisons.

1 1 - DELIBERATE INDIFFERENCE 235

Even when medications are provided, however, individuals with mental ill- ness may be distrustful, to the point of clinical paranoia, about accepting med- ication from jail or prison staff. This frequently leads to medication noncompliance and/or further psychiatric deterioration. Iust as inmates have a limited right to treatment, they also have a right to refuse that treatment, based on due process protecting the fundamental right of individuals to make autonomousmedical decisions (Honberg, 2008). This has detrimental conse- quences, not only to themselves but to the institution and even to the court sys- tem, in which incompetency to stand trial is at issue (see below).

Individuals with Mental Illness in the Courts Incompetency to Stand Trial and CompetencyRestoration

In the traditional court system, mental illness is only formally considered when issues of competency to stand trial or the insanity defense are raised. First, competency to stand trial, or whether the individual is able to work with his/herattorneyand to understand the proceedings against him/her, both fac- tually and rationally (Dusky v. U.S., 1960), is required for all defendants to stand trial. Typically, questions of competence are raised by the individual’s defense attorney, and the court will order a psychological evaluation (Hon- berg, 2008). However, by definition, “incompetent” individuals are incapable of defending themselves legally. Thus, in acute psychiatric states, individuals with mental illness are unlikely to contact their defense attorneys to solicit their assistance in seeking bail, diversion, or planning a legal defense. They fre- quently lack insight into their symptomsand/or are paranoid about their at- torney's intentions. Many, due to the same symptoms, are vehemently resistant to having their competency questioned and/or being evaluated. Thus, too often, acutely mentally ill individuals languish in their jail cells alone, making

no progress toward going to court and resolving their charges. If an individual is evaluated and found incompetent to stand trial, he/she

will be ordered to undergo treatment to restore competency. This process is controversial for various reasons. First, in most states, this occurs in a state inpatient psychiatric facility, as opposed to the least restrictive alternative (Miller, 2003). Also, the quality of these services varies widely from facility to facility. Usually, the individual is stabilized on psychotropic medication and receivespsychoeducation about his/her charges, the court system, and the legal proceedings. Sometimes, however, the focus is purelyon rote memorization

236 ll - DELIBERATE INDIFFERENCE

of the proceedings, and the individual is taken to trial without a rational un- derstandingofwhat he/she will face (Earley, 2006). Moreover, the individual is often treated only to the point of being well enough (i.e., “restored”) to the standard defined above; regardless ofwhetherhis/her psychiatric condition is fully stabilized, he/she is returned to jail to await trial. Finally, even those who had been previously found incompetent to stand trial are allowed to refuse their medications once they return to the jail (Honberg, 2008), only to de-

compensate yet again. Some decompensate to the point of again becoming in-

competent and needing to be returned to the hospital for restoration. This process of revolving through the competencyrestoration system has earned the euphemism“riding the bus”—i.e., traveling back and forth, ostensibly by bus, between the jail and the state hospital (Earley, 2006). For some, this process can go on for years—even for misdemeanors—beforethey are put on trial to resolve their charges (Earley, 2006; Miller, 2003).

The Not Guilty byReason ofInsanity Plea and the Guilty butMentally Ill Verdict

The Not Guilty by Reason of Insanity (NGRI) defense, or the insanity de- fense, is evenmore controversial. Defendants found NGRI are legally regarded

as not responsible for their crimes due to mental illness and are sent to a state psychiatric facility for indefinite treatment. Much of the American public op- poses the NGRI defense primarily because they believe it is too frequently raised and is a way to evade justice (Borum 8r Fulero, 1999; Lamb 8r Wein- berger, 1998). In fact, however, studies reveal that the defense is actually used in less than 1°/o of felony cases and is successful in only 15 to 25% of the cases in which it is raised (Borum & Fulero, 1999). Moreover, persons foundNGRI are frequently spend much longer periods of time in the hospital, sometimes twice as long, than those who are found guilty for similar crimes spend in prison (Borum & Fulero, 1999).

Nevertheless, due to public outcry, in an effort to reduce the number of in- sanity acquittals, several states enacted Guilty But Mentally Ill (GBMI) legisla- tion (Borum 8: Fulero, 1999). Defendants found GBMI, instead ofbeing sent to a state hospital, are imprisoned in the state correctional system with a stipula- tion for mental health treatment. However, research has found that GBMI laws have been largely unsuccessful: they have not significantly reduced the overall

rate ofNGRI acquittals; there are no additional treatment accommodations in the prisons beyond the meager services described earlier; and, unlike NGRI ac- quittees, who are monitored closely after release from the hospital, many of those found GBMI are releasedwithout discharge services (Borum 8: Fulero, 1999).

ll - DELIBERATE INDIFFERENCE 237

Individuals with Mental Illness and CommunityRe-Entry

Lack ofSocial Support Individuals with mental illness often end up serving their entire sentence

in jail or prison, only to be returned to the streets with little or no resources. Social support is important to the success of an offender’s reintegration into society, and this is compounded for an individual with mental illness. How- ever, the stress of caring for an individual with mental illness—particularlyif he or she frequently becomes non—compliant with treatment, abuses substances, blames or becomes hostile towards those who try to help during periods of decompensation,and/or puts him or herself in danger—takes its toll on rela- tionships, sometimes becoming too much for friends and family to cope with. Especially when an individual has served a long sentence, ties to family and friends have often been severed long ago (Earley, 2006).

Lack ofAdequate DischargePlanningand Community Services

Discharge planning involves developing a plan for the continuationof treat- ment after discharge from an institution—in this case, from jail or prison. It is generally recognized to be critical in preventing an individual with mental illness from decompensating and re—cycling through the criminal justice sys- tem. Indeed, individuals withmental illness——especially those who do not re- ceive necessary community services—are known to have an extremely high rate of recidivism. For example, in Los Angeles County, 90% of jail inmates with mental illness are repeatoffenders, 31% ofwhich have been incarcerated 10 times or more (Council of State Governments, 2002b). Conversely, in lo- cations that have discharge planningand intensive community—basedservices, criminal recidivism decreases substantially. For example, among the first 24 individuals with mental illness who participated in the Thresholds Jail Pro- gram in Cook County, Illinois, there was a reduction of approximately 90% in the number of days in jail in a year’s time (e.g., from an average of 107.1 days in jail in the year preceding the program to 7.8 days in the year after begin- ning the program) (McCoy, Roberts, Hanrahan, Clay, 8: Luchins, 2004). De- spite such clear successes, discharge planning remains the least often provided mental health service by the criminal justice system (Steadman 8rVeysey, 1997). Although mental health treatment in jails and prisons has been mandated by

238 11 - DELIBERATE INDIFFERENCE

the U.S. Supreme Court, discharge planning has been largely ignored (Barr, 2003).

Possibly the most egregious example of a system’s failure to provide ade-

quate discharge services—at least, of those brought to the attention of the public—occurred in New York City in the 1990s. It had become a New York

City Department of Correctionspractice to drop off individuals with mental illness who had completed their jail time at Queens Plaza with $1.50 in cash

and a $3 Metrocard (Barr, 2003; Parish, 2007). This drop occurredbetween 2

and 6 a.m., ostensibly to avoid detection by the public. Discharge planning, such as assistance with obtaining treatment in the community, locating hous- ing, or applying for social assistance, was not provided. Twenty—five thousand mentally ill inmates per year were left to fend for themselves.

As a result of this irresponsible treatment, a class action lawsuit—named after a 44-year-old homeless man with schizophrenia, Brad H.-—was brought against the city (Barr, 2003). Brad H. had been in jail 26 times without ever receiving discharge services. On grounds of cruel and unusual punishment and violation of a New York state law that mandated providers of inpatient mental health treatment services to provide discharge planning, the parties settled in 2003, with the city agreeing to provide an adequate supply of med- ication, at least a shelter with a bed, access to mental health services, and re- instatement ofbenefits like Medicaid and food stamps without a 45-day waiting period (Barr, 2003).“

However, providing even a basic level of discharge services is often a chal-

lenge. There are frequently months-long waiting lists for treatment services, and this is for those without a criminal history. Once an individual is labeled

a “criminal” or “offender,” it becomes more difficult to obtain treatment in the community; and if identified as a “violent offender,” it is practically impossi- ble. Moreover, even ifmedications are made available, it is common practice in most areas to terminate Medicaid benefits upon entry into jail, even though federal law does not require it (GAINS/SAMHSA, 2002); and the process of re- applying for such benefits can take months. When single medications cost hun- dreds if not thousands of dollars per month, an individual is on multiple medications, and/or he/she is unemployed, disabled, and/or homeless, pay- ing for medications out of pocket is not an option; instead, the individual must do without.

6. Compliance with the agreement was to be monitored for five years by the plaintiffs’

attorneys and two special court appointed monitors. Notably, however, as of 2007, four years into the settlement, the City had yet to provide reliabledata documenting their com- pliance (Parish, 2007).

ll - DELIBERATE INDIFFERENCE 239

Without discharge planning connecting them to necessary mental health and social services in the community, justice—involved individuals with men- tal illness are doomed for almost certain failure. Yet successful discharge plan- ning is dependent on the availabilityof services in the community. If the services

are not available, which is often the case and is likely to increase as mental healthbudgets continue to shrink nationally, there are no linkages to be made.

Lack ofCommunication between the Agencies Providing Services

Furthermore, even when discharge services are provided, there is frequently

a lack of communication between the systems (and agencies within the sys- tems) involved and no follow—up component to ensure that individuals are ac- tually engaging with the treatment that is arranged (Slate & Iohnson, 2008). Such was the case in Blacksburg, Virginia, prior to the Virginia Tech massacre in 2005. After expressing suicidal ideation to a roommate, Seung Hui Cho was ordered by a special mental health magistrate into involuntary outpatient com- mitment (i.e., to undergomental health treatment in the community against his will). The judge believed that the court’s responsibility ended there, as- suming that the communitymental health agency would honor its statutorily mandated obligation to “recommend a specific course of treatment” and to “monitor the person’s compliance” (Schulte 8r Jenkins, 2007, p. A01). How-

ever, according to the mental health agency, these referrals were never com- municated to them. Cho did not follow through with treatment. He fell through

the cracks, and a national tragedy resulted.

Recommendations for Policy and Practice Involving Offenders with Mental Illness

Fortunately, the growing crisis involving the overrepresentationof people with mental illness in the criminal justice system has been recognized, and concerted efforts to identify solutions have been forged in the past decade. For example, the Criminal Iustice/Mental Health Consensus Project is an un- precedented, two—yearbipartisan collaboration of key stakeholders in the crim- inal justice and mental health systems, organized by the Council of State Governments, to improve the response to individuals withmental illness who

are involved with (or at risk of involvement with) the criminal justice system (Thompson, Reuland, 8: Souweine, 2003). This collaborationculminated in

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a 453—pagereport of policy recommendationsthat span all phases of the crirn- inal justice system and which are informed by research, program examples,

and the expertise ofdozensofpractitioners (Councilof State Governments, 2002a). Indeed, given the failings of the past, the possibilities for improving the way

the criminal justice system—-and by extension, society—react to and handle mental illness in the future are endless. As such, a comprehensive discussion

of recommendedstrategies is beyond the scope of this chapter. Therefore, the most common themes, categorized into criminal justice-specific innovations, criminal justice—mental health collaboration, and societal recommendations,

are discussed below.

Criminal Iustice-Specific Innovations Training

By far, the most widely recommendedand frequently implemented strategy for improvingthe criminal justice system’s response to individuals with men- tal illness is training. Countless criminaljustice agencies have developed train- ing on mental illness and appropriate strategies for working with this special

population, with positive practical results. A coinciding advantage has been

that stigma about mental illness by criminal justice professionals has been re- duced.

Likely the most well—known and widely adopted criminal justice program of mental illness training is the Crisis InterventionTeam (CIT).7 Initially de-

veloped by the Memphis, Tennessee, PoliceDepartment following a fatal shoot-

ing of a mentally ill individual, the program involves 40 hours of training for law enforcement officers on recognizing the characteristicsofmental illness, skills

to de-escalate situations rather than resorting to physical force, and informa- tion about local communitymental health services and resources (DuPont 8: Cochran, 2000). Currentlyimplemented in more than 1000 localities nation- wide (Ritter, Teller, Munetz, 8: Bonfine, 2010), CIT has been found to result

in increased knowledge and decreased stigma about mental illness by law en-

7. Although CIT is the most well-known, there are a variety ofother models ofpolice- based diversion programs (Steadman, Deane, Borum, 8: Morrissey, 2000). Examples in- clude Mobile Crisis Teams, in which interdisciplinary mental health teams operate in partnership with law enforcement, and Community Service Officers, in which an officer of a police department functions as a broker for social services for individuals with mental illness.

11 - DELIBERATE INDIFFERENCE 241

forcement officers (Bahora, Hanafi, Chien, 8: Compton, 2008; Compton, Es- terberg, McGee, Kotwicki, 8: Oliva, 2006). It has also resulted in a greater like-

lihood that those in psychiatric crisis will be diverted from the criminal justice

system, when appropriate (Munetz 8: Griffin, 2006). Moreover, the success of CIT has been recognized by the broader criminal

justice system and has been adapted for use within jails, prisons, and proba- tion—parole departments (Hodges, 2010). Only recently has the important role of correctional officers in the institution’s mental health care been recognized,

but officers’attitudes can influence whether inmates seek and/or receivemen- tal health services (Appelbaum, Hickey, 8: Packer, 2001). Indeed, officers can be invaluable in observing and providing essential information to mental health

staff about inmates’ behavior (including medication non—compliance); and when balanced between firmness and sensitivity, officers can even serve as

“treatment extenders,” providing necessary structure, support, and respon- siveness to inmates’ mental health needs.

Specialized Mental Health Units A corollary strategy to training criminal justice professionals about mental

illness is developing specialized units within criminal justice agencies to serve this group of offenders. For example, with 18% of persons under federal pro- bation and pretrial officer supervision required to receivemental health treat- ment, Slate, Roskes, Feldman, 8: Baerga (2003) recommended that federal probation offices have teams of officers who function as mental health spe- cialists. These probation officers would receive 40 hours of training on men- tal illness annually and maintain specialized caseloads of only probationers with mental illness. They found that such specialty caseloads reduce the risk

of probation violations (Slate, Feldman, Roskes, 8: Baerga, 2004). Similarly, mental health courts have been gaining in popularity. Composed

of court staff, probation officers, and community mental health treatment providers, these specialized court teams provide direct supervision in the com- munity, in lieu of traditional court processing, with the goal of diversion from

the criminal justice system (Redlich, Steadman, Monahan, Robbins, 8: Petrila,

2006). Modeled on principles of therapeuticjurisprudence, if participants re- main compliantwith community—based treatment and attend regular judicial

status review hearings, theymight have their charges suspendedor dismissed. Moreover, these courts—ofwhich there are now approximately 250 (Steadman,

Redlich, Callahan, Robbins, 8: Vesselinov, 2011)—haveyielded positive re- sults. A recent multi-sitestudy found that mental health courts are associated with lower arrest rates and reduced number of days of incarceration for par-

242 11 - DELIBERATE INDIFFERENCE

ticipants (Steadman et al., 2011). Likewise, participants in select mental health

courts required fewer inpatient treatment days and less crisis interventions, and showed decreased abuse of substances and improved psychosocial fiinc—

tioning (Slate & Johnson, 2008). Indeed, teams of trained staff in jails and prisons—similar to CIT officers in law enforcement, mental health specialists

in probation, and mental health court professionals—maywell be the wave of the future in regard to how the mentally ill are managed in the criminal jus-

tice system.

Divert WhenAppropriate There are two broad types of jail diversion programs for individuals with men-

tal illness, differentiated by the point at which diversion takes place. Pre—book—

ing, or police~based, diversion occurs prior to charges being entered by law enforcement, and post—booking diversion, such as mental health courts, occurs after an individual has been booked into jail with charges entered (Steadman

et al., 2000). Ideally, localities would have a combination of both pre- and post—booking types of jail diversion (Slate 8: Iohnson, 2008), but this is unusual.

The goals ofmental health diversion are to avoid or reduce jail time and reduce

recidivism rates, thereby conserving valuable criminal justice resources, and link-

ing detainees with community-basedservices (Steadman et al., 1999). Identi-

fying individuals with mental illness through early screening allows pretrial services, mental health providers, and court personnel to determinewhether continuation through the criminal justice system is the most appropriate av- enue for the individual, and/or whether the needs of

all involved can best be

served in the communityversus the institution (Council of State Governments, 2002a). Without prompt and consistent mental health treatment, such as medica-

tions and social support, and fulfillment ofbasic needs of living, such as hous-

ing, individuals with mental illness are bound to decompensateand recycle

into the criminal justice system. Thus, at a minimum, adequate community services should include assistance in obtaining mental health treatment, in- cluding access to at least a month of medication, housing, and expedited re-

instatement of public benefits (Barr, 2003). Medicaid should be suspended,

rather than terminated, when an individual with mental illness is jailed so that

they can be quickly restored upon release (Council of State Governments, 2002). Other important community services include treatment for co—occur-

ring disorders, life skills training, employment services, transportationarrange- ments, and peer involvement (Haimowitz, 2002), as well as establishmentof specialized probation/parole caseloads (Barr, 2003). A last, but integral and

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commonlyneglected, component of community services for justice-involved individuals with mental illness is creating a follow—up mechanism for ensur- ing an individual’s attendance and engagement in the mental health services arranged (Slate 8: Johnson, 2008).

MH-C]Collaboration Most efforts by the criminal justice system to better respond to and man-

age individuals with mental illness, however, are only as effective as the men- tal health services available (Slate 8t Iohnson, 2008). These are reliant on the adequacy of the mental health system itself, as well as successful collaboration between the two systems. Thus, policies to improve responses to mentally ill

offenders must be broader in scope—indeed, cross—system in nature—to be effective (Council of State Governments, 2002a).

Easy Access toMental Health Care Individuals with mental illness, particularlyduring psychiatric crises, often

lack the wherewithal to actively seek out and navigate the inherentlycompli- cated mental health system. Thus, in order to successfiilly engagejustice-involved individuals with mental illness, access to mental health care must be easy and straightforward.For example, probation and parole supervision of offenders with mental illness has been found to be optimized by using a Forensic As-

sertive CommunityTreatment (FACT) team. Such teams are multidisciplinary

in nature, typically consisting of a psychiatrist, nurse, social worker, substance abuse specialist, occupational therapist, vocational rehabilitation specialist, and peer specialist, as well as the individual’s probationor parole officer. They provide mental health services designed to respond to the special needs of an offender with mental illness. Specifically, FACT mental health services are (a) mobile, in which FACT team workers actively engage the client by going to the client rather than requiring the client to come to a mental health clinic, (b) provided 24/7, and (c) comprehensive, involving not only medicationbut case management, as well as substance abuse treatment, non-psychiatric medical care, education, employment, and housing assistance (Lamberti, Weisman, & Faden, 2004). Such teams have been found to assist individuals with functioning in the community, including preventing homelessness and reducing the need for hos- pitalization. Ensuring that there is easy access to mental health services not only serves

the needs of the offender withmental illness but also those of the criminal jus- tice system. Crisis InterventionTeams, for instance, can only “work” (e.g., re-

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duce turnaround time for police officers and, thereby, increase the likelihood that officers will engage the mental health system; divert, or reduce arrest, of individuals with mental illness) if there is a hospital or intake center that can expediently assume responsibility for the mentally ill subject. Moreover, the

facility must operate on the same schedule as law enforcement (i.e., open 24 hours a day, 7 days a week), with a no—refusal policy and a streamlined intake

process so that officers can quickly and easily return to their responsibilities

on the street (DuPont 8: Cochran, 2000).

Facilitating Release ofInformation An important aspect of providing appropriate responses to individuals with

mental illness in the criminal justice system is obtaining records of their men- tal health history. For example, for the sake of expedience, screening conducted

at booking is usually based on inmates’ self—report. However, such self-reports

are notoriously unreliable, especially for those with mental illness who may be too cognitively disorganized and/or paranoid to provide valid information about their history. Thus, corroboratinginformation on past symptoms, treat-

ment (both thatwhich did and did not work), and involvement with the crim- inal justice system can be invaluable, and this information should follow the

individual throughout both the criminal justice and mental health systems (Council of State Governments, 2002a).

As such, a mechanism by which criminal justice agencies can gain access to mental health information is invaluable. One useful—and easy, as it bypasses bureaucracy—methodby which access to historical information about an in- dividual’s mental health can be achieved is by encouraging and/or supporting the involvement of family members (Council of State Governments, 2002a). Moreover, developing a formal agreement with the local mental health system by which records of justice—involved individuals can be shared is recommended (Council of State Governments, 2002a). Although such an agreement is com- monly met with resistance by mental health agencies, who are typically pro- tected by confidentiality laws, whatmany mental health agencies don’t realize is that the federal confidentiality law, the Health Information Portabilityand Accountability Act (HIPAA), permits certain disclosures to criminal justice agencieswithout the individualsconsent (Petrila, 2007). In particular, HIPAA allows release of information, limited to the “minimal necessary” to accom- plish the following criminal justice purposes:

[For] judicial and administrativeproceedings; law enforcementpur- noses; [and] disclosures necessary to avert a serious threat to health

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or safety [as well as sharing] with a correctional institution or law enforcement official with custody of the individual, if the inforrna—

tion is necessary for the provision of health care; the health and safety of the inmate, other inmates, or correctional officials and staff (Petrila, 2007, p. 2).

Thus, mental health agencies can in fact provide information to the criminal justice system without bureaucratic red tape.8 Nevertheless, even if mental health agencies are resistant to disclosing records, merely developing the means of cross—referencing the names of individuals detainedby the criminal justice system with the names of mental health system clients can be useful by keep-

ing both systems “in the know” (Council of State Governments, 2002a).

Preparationand Communication Any successfulcollaboration—inthis case, between the criminal justice sys-

tem and the mental health system—requires both active preparationand com- munication. Unfortunately, as is seen in too many cases of the mentally ill

both harming and being harmed by others, such preparation and communi- cation is often not a reality. In particular, for any of the innovative programs mentioned above (e.g., CIT, FACT teams), the involved agencies must explic- itly define their separation of duties, make everyone involved aware of re- sources, and formalize agreements so as to avoid confusion and to ensure appropriate action (Council of State Governments, 2002a).

Cultural, Social, and Economic Reform

Increase FundingforMental Health Care Of course, none of the above recommendations are possible without in-

creasing funding for the mental health system. Unfortunately, this is unlikely

in the foreseeable future given the current state of the U.S. economy. State budgets for already poorly fundedmental health systems have been cut in the past several years. Specifically, according to a 2008 survey of the NationalAs- sociation of State Mental Health Program Directors, 32 state mental health agencies reported budget cuts on average of 5% for fiscal year 2009; one state

8. Of course, disclosing information can risk the mental health system’s therapeutic re- lationship with the client. Thus, the benefit ofdisclosuremust be weighed against the risk.

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reported a cut as high as 17.5% (National Association of State Mental Health Program Directors Research Institute, 2008). Moreover, the states expected an average budget cut of 8% (up to 25% in some states) in 2010 and in excess of 9% (again, up to 25°/o in some states) in 2011. In total, approximately $2.1

billion has been cut from state mental health budgets in the last three fiscal

years (Lacey, Sack, 8< Sulzberger, 2011). The most commonly affected pro- grams have been adult inpatient services and adult clinic services. Further- more, as an increasing share of mental health spending is routed through Medicaid (Mark, Levit, Buck, Coffey, 8<Vandivort-Warren, 2007), the policies of states lowering Medicaid payments to providers and eliminating coverage for certain programs that are not federally required have significant implications for the mental health system and, thus, mental health services available to con- sumers (Vu, 2009).

Unlike the past several decades of seemingly limitless funding for the crim- inal justice system, corrections budgets are currently facing similar cuts. Specifi- cally, a recent report by the Vera Institute revealed that at least 26 states have cut their corrections budgets (Scott—Hayward, 2009). Of course, among the first expenses to be reduced by the correctionalsystem are healthcare services, which include mental health care. Moreover, as a result of prison budget cuts, experts predict that states will begin to increase the number of inmates re- leased under supervision in the community, thereby increasing the number of offenders with mental illness who will be in need of treatment in the commu- nity (lohnson, 2011). Whether it will comprise America’s third deinstitution— alization movement remains to be seen.

Federal monies, although striking optimism, are frequently only short-term fixes. For example, the 2004 Mentally Ill Offender Treatment and Crime Re-

duction Act (MIOTCRA) authorized federal grant monies to fund the devel- opmentand implementation ofmental health courts and other criminal justice diversion projects, as well as correctional treatment and community re—entry

programs. However, the concern with any external funding sources is that they do not continue indefinitely. AlthoughMIOTCRA has been extended, with the current economic crisis the reliability of federal grant funds is uncertain. Likewise, the 2009 stimulus bill, the American Recoveryand Reinvestment Act (ARRA), among other things, mandated parity between mental and physical health coverage in private insurance coverage and supplementedstate budgets. However, closer examination of the fine print reveals that the mental health par- ity written into the bill does not require insurers to covermental health at all, only prohibiting limits on those policies that do provide such care; and it does nothing for individualswithoutprivate insurance (Hodgkin 81 Karpman, 2010). Moreover, the one—time stimulus did not go far enough in supplementingstate

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mental health system budgets, not even to return the services available to pre- 2008 levels.

Clearly, the current economic crisis has grave implications for those with men- tal illness. Both those with pre—existing mental illness who are losing treat- ment as a result of ailing state budgets, as well as those who are just beginning to experience mental health issues due to unemploymentand other economic stressors for whom appropriate treatment is unavailable are suffering. With-

out necessaryservices, both groups are vulnerable to entanglement with the crim- inal justice system. As such, the criminal justice system will be hit hard by the mental health system’s cuts, as law enforcement, jails, and prisons continue to be put in the role of responding to the mentally ill. Likewise, the mental health

system will be severely impacted by the cuts in the criminal justice system’s

budgets, as increasing numbers of persons with mental illness are released from prisons into the community. Thus, it would behoove both systems to work together.

DecreaseStigma Stigma toward mental illness is longstandingand pervasive in U.S. culture.

Stigmatizing attitudes, in turn, lead to discriminatorybehavior. This, coupled with the economic situation in the country, has important implications for public allocation of funding for services and treatment for the mentally ill. People who endorse myths about individuals with mental illness (e.g., people with mental illness are responsible for their disease, people with mental illness are dangerous) tend to respond to individuals with mental illness with greater avoidance, as well as endorsement of coercive treatment (Corrigan, Markowitz, Watson, Rowan, 8: Kubiak, 2003). People with mental illness are also more likely to face employmentdiscrimination (Bordieri 8: Drehmer, 1986), hous- ing discrimination (Page, 1977) and even to be falsely charged with violent crimes (Steadman, 1981), all ofwhich affect their involvement with the crim- inal justice system and successful reintegration into the community. Such dis- crimination can also be seen on a structural level, whereby public institutions restrict opportunities for personswith mental illness (Corrigan 8: Kleinlein, 2005); and there is reason to believe that this trend is increasing, not declin- ing. For example, Hemmens, Miller, Burton, and Milner (2002) found that, between 1989 and 1999, state laws became increasingly restrictive of civil rights for the mentally ill, including familial rights such as marriage and parenting. Furthermore, comparatively fewer public financial resources are being allo- cated to the mental health system than to the physical health medical system (Corrigan 8:Watson, 2003).

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Thus, persons with mental illness are left to struggle with not only the symp- toms of their disease, butwith the repercussions of “a largelyuninformed,mis- informedand apatheticpublic” (Slate & Johnson, 2008, p. 347). The stress of discriminationundoubtedlyexacerbates an individual’s mental illness. More-

over, many people with mental illness internalize the common prejudices against them (i.e., self—stigma). This frequently manifests in refusal to pursue much needed services, which hinders successful functioning in society (Cor- rigan & Kleinlein, 2005). This further contributes to the public and structural stigma against them. The self-perpetuatingnature of this cycle is obvious.

Many experts have advocated public educationas a means to address social stigma against persons with mental illness. And research reveals that educa- tional programs can in fact be effective in reducing negative attitudes and fears about individuals with mental illness, if conducted properly. For example, Corrigan, Watson, Warpinski, and Gracia (2004) found that people enrolled in a brief educational program focusing on the stigma related to mental ill- ness, compared to those in a controlgroup, were less likely to believe that peo- ple with mental illness were dangerous, to fear people with mental illness, to endorse social avoidance, or to favor segregation and coercive treatment. They were also more likely to help an individual with mental illness and to support putting money into rehabilitative services. Moreover, when individuals were provided accurate information about the relative risk of violence by people withmental illness, perceptionsof dangerousness were reduced (Penn, Kom—

mana, Mansfield, 8r Link, 1999). Research also suggests that, when individu- als have greater familiarity with mental illness, they are less likely to fear or to advocate social distance from individuals with such an illness (Angermeyer, Matschinger, 8: Corrigan, 2004; Corrigan, Green, Lundin, Kubiak, & Penn, 2001). Therefore, opportunities for contactwith individuals with mental ill- ness should be included as part of educationalprograms (Rusch, Angermeyer, 8r Corrigan, 2005).

Conclusion There is no denying that individuals with mental illness make up a sig-

nificant and growing proportion, not to mention an often challenging seg- ment, of our country’s criminal justice population. This group of offenders and their needs can no longer be ignored; they must be broughtout of the shad- ows of not only the criminal justice and mental health systems, but of soci- ety. As outlined in this chapter, there are many varied reasons for the overrepresentation of individuals with mental illness in the criminal justice sys-

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tem—in particular, decades of failed mental health and criminal justice pol- icy propelled by misconceptions aboutmental illness and mental health treat- ment. Fortunately, there are currently countless opportunities to implement new and more enlightened policies. Among these are innovative criminal jus- tice strategies, such as increased training, development of specialized units in criminal justice agencies, and jail diversion programs, to respond to this unique population.

However, improvements in responding to offenders with mental illnesswill

not result from reforms limited to the criminal justice system. First, any crim- inal justice program targeting this special population is only as successful as the mental health resources offered in the community; thus, improved collabora-

tion between the criminal justice and mental health systems is essential. Nor will criminal justice and mental health reforms, whatever their merits, be suc- cessfulwithout shifts in the prevailing cultural, social, and economic forces in

our country. Indeed, such reforms are contingent upon more well—informed

and empathic citizens, policymakers, and policies. The futility of continuing to imprison individuals on whom the goals of punishment are often wasted

must be acknowledged, and the will must be formed to put the moneyand re- sources into halting the revolving door for those with mental illness.

References Abram, K. M., 8r Teplin, L. A. (1991). Co—occurring disorders among men-

tally ill jail detainees: Implications for public policy. American Psychologist 46, 1036-1045.

American Psychiatric Association (2000). Psychiatric services in jails and pris- ons (2nd Ed). Washington DC: Author.

Angermeyer, M. C., Matschinger, H., 8: Corrigan, P. W. (2004). Familiarity with mental illness and social distance from people with schizophrenia and major depression: testing a model using data from a representative population survey. Schizophrenia Research, 69, 175-182.

Appelbaum, K. L., Hickey, I. M., 8: Packer, I. (2001). The role of correctional officers in multidisciplinary mental health care in prisons. PsychiatricServ- ices, 52, 1343-1347.

Axelson, G. L. 8:Wahl, O. F. (1992). Psychotic versus nonpsychoticmisde- menants in a large county jail: An analysis of pretrial treatment by the legal system. InternationalJournal ofLaw and Psychiatry, 15, 379-386.

Bahora, M., Hanafi, S., Chien, V. H., 81 Compton,M. T. (2008). Preliminary evidence of effects of crisis intervention team training on self-efficacy and