Running Head: SEVERELY MENTALLY ILL IN THE CRIMINAL JUSTICE SYSTEM

The Comprehensive Justice and Mental Health Act of 2015

Sari Kripke
University of Michigan School of Social Work
SEVERELY MENTALLY ILL IN THE CRIMINAL JUSTICE SYSTEM 1

Policy: The Comprehensive Justice and Mental Health Act of 2015

Up until the Civil Rights Movement, individuals who were diagnosed with severe mental
illness were often institutionalized in state-run psychiatric hospitals. The average stay was not
measured in days or months, but rather in years. By keeping these individuals inside of
psychiatric hospitals and mental asylums for such long periods of time, it became nearly
impossible to effectively transition them back into their communities. Many patients ended up
spending their entire lives inside of these institutions --- separated from their families, friends,
and communities. By 1955, almost 560,000 individuals were institutionalized in psychiatric
facilities (Lamb, Weinberger, & Gross, 2004). Long-term institutionalization was
insurmountably costly for the government, while still failing to provide its patients with humane
treatment in many cases. During the early 1960s, word of abuse, neglect, and poor conditions
within these institutions began to spread across the United States. In response to the public
uproar, the Community Mental Health Centers (CMHC) Act of 1963 was passed. This Act
provided subsidies for the construction of community mental health agencies around the United
States to serve the severely mentally ill population (Grob, 2005). Once the agencies were built
and opened, the individuals inside of the psychiatric institutions would re-enter their
communities and receive treatment there.
President Johnson passed the Omnibus Crime Control and Safe Streets Act in 1968. It
provided states with block grants to improve law enforcement. Some of the funding from this
Act went towards criminal justice research, such as examining which populations become
involved in the system and who is most likely to reenter (Anderson & Giles, 2005).
By 1980, only 140,000 people remained in state-run psychiatric hospitals, meaning over
400,000 individuals had re-entered their communities (Grob, 2005). Many of the long-term
psychiatric hospitals began to shut down despite there not being enough CMH agencies to serve
the large amount of people who re-entered their communities. Inside of these agencies, there was
a lack of evidence-based practices being used and little was truly known about whether the
severely mentally ill could get the integrated treatment they needed through CMH agencies in
their communities (Grob, 2005). While deinstitutionalization worked for some of the severely
mentally ill, many of them ended up being poor, homeless, repeatedly hospitalized, and involved
in the criminal justice system. To this day, some of the lasting effects of deinstitutionalization
SEVERELY MENTALLY ILL IN THE CRIMINAL JUSTICE SYSTEM 2

include law enforcement having more contact with the mentally ill population and individuals
with severe mental illness becoming increasingly involved in the criminal justice system.
In 2003, the Mentally Ill Offender Treatment and Crime Reduction Act (MIOTCRA) was
passed to create mental health courts for those involved in the criminal justice system, in addition
to implementing diversion programs for the mentally ill to lower the rates of recidivism. Mental
health courts were created because of the rising number of individuals with severe mental illness
involved in the criminal justice system (Seltzer, 2005). Essentially, these courts are a product of
the failing mental health system in our country and do not address the underlying problem.
The Comprehensive Justice and Mental Health Act of 2015 not only reauthorized the
MIOTCRA of 2003, but it also provided a number of grants for the Department of Justice to
improve mental health interventions at all stages of the criminal justice system. The grants are
being used to train law enforcement officers to recognize and effectively handle mentally ill
individuals in crisis, improve screening for mental illness in all stages of the criminal justice
system, implement rehabilitation programs within the prison systems, and enhance transitional
treatment for incarcerated individuals reentering society (“S.993 - 114th Congress”, 2016).
Ultimately, the Comprehensive Justice and Mental Health Act was passed to improve public
safety and decrease recidivism rates of the severely mentally ill. These policies, however, will
only do so much if we continue to ignore the root cause of these problems: the lack of access to
appropriate community mental health services.
The Sequential Intercept Model (SIM) explains the five major intercepts, or stages, of the
criminal justice system in which individuals with mental illness can be identified and redirected
to appropriate rehabilitative services. Contact with law enforcement is Intercept 1 of the SIM.
The following four intercepts are initial hearings and detention, courts and jails, reentry into
society after prison, and community corrections such as parole and probation (Heilbrun et al.,
2017). The Comprehensive Justice and Mental Health Act provides grants for the DOJ to
specifically improve on intercepts 1 (law enforcement), 3 (courts/jails) and 4 (transitioning into
society following prison).

Existing Research
The first part of the Comprehensive Justice and Mental Health Act of 2015 is the
continuing financial support for law enforcement trainings and Crisis Intervention Teams (CIT).
SEVERELY MENTALLY ILL IN THE CRIMINAL JUSTICE SYSTEM 3

These are special law enforcement teams that receive forty hours of training on recognizing signs
and symptoms of mental illness and properly handling mental health crises they may encounter
while on the job. The CIT model, which was implemented in 1987 in response to a police officer
shooting a man with schizophrenia who was experiencing psychotic symptoms, says that a social
worker should be a part of every team (Wood & Watson, 2016). While law enforcement is
typically trained to respond to situations with force, social workers are trained to respond with
compassion, patience, and in a more therapeutic manner. Also, crisis intervention teams are
supposed to have connections to local CMH agencies, such as Assertive Community Treatment
(ACT) programs that they can refer individuals to if needed (Wood & Watson, 2016). This poses
additional problems because many agencies have long waits and/or do not have staff willing to
take on difficult clients involved in the criminal justice system. Out of the 18,000 police
departments in the United States, only around 2,000 offer CIT training courses and even fewer
have actually implemented CIT teams with trained law enforcement officers and social workers
(Wood & Watson, 2016). The trainings offered are optional, rather than mandatory, even though
92% of law enforcement officers reported having already come in contact with severely mentally
ill individuals. Today, over 10% of police encounters are with mentally ill individuals, taking up
anywhere from 20-40% of a police officer’s day at work (IACP Net, 2015). Law enforcement
now responds to psychotic episodes, active symptoms of mental illness from medicine
noncompliance, homelessness, drug overdoses, violent outbursts, and aggravated assaults --- all
of which could be minimized with increased access to affordable mental health treatment in our
communities; out of the ten states with the least access to mental health care, six of those states
also have the highest incarceration rates (“Access to Mental Health Care”, 2017). With police
officers becoming the new first responders for the severely mentally ill, it is important to
nationally implement yearly trainings for them and ensure at least one social worker is part of
every police department.
The Comprehensive Justice and Mental Health Act continues to fund mental health courts
(MHC), which were started in the early 2000s to serve severely mentally ill individuals awaiting
trial. For those deemed fit, the courts mandate that they get community mental health treatment
in intensive programs such as ACT as an alternative to being incarcerated (Landess & Holoyda,
2017). Of course, there are individuals with severe mental illnesses who slip through the cracks
of the criminal justice system and end up being tried in a regular court and/or sent to prison.
SEVERELY MENTALLY ILL IN THE CRIMINAL JUSTICE SYSTEM 4

Some individuals are never identified as having a mental illness, some commit serious felonies
and are sent to prison despite their untreated illness, and some struggle to find a CMH program
that will accept them. The majority of mental health courts do not have written policies and
procedures, so the discretion is in the hands of the judge (Seltzer, 2005).
People with severe mental illness are greatly overrepresented in the current prison
system; while around four percent of the population has a severe mental illness, almost twenty
percent of the prison population is severely mentally ill. In total, an estimated 380,000 prisoners
have a severe mental illness and between 40,000 and 72,000 of them would have been placed in
state psychiatric facilities if it were not for deinstitutionalization (Raphael & Stoll, 2013). The
Comprehensive Justice and Mental Health Act provides funds to continue screenings for mental
illness within prisons (“S.993 - 114th Congress”, 2016). Many prisoners begin their sentences
already having been diagnosed with a mental illness and put on medications. However, it isn’t
uncommon for the dosage of their medications to be increased upon arrival to control and
stabilize them. It is much easier for the overworked prison staff to monitor prisoners who are
calm, dazed, and quiet as opposed to angry, volatile, and loud. Although some prisoners already
have diagnoses before incarceration, there is also a large group of prisoners who never received
any psychological interventions until prison. Some of their most common charges include
impulsive behaviors like aggravated assault, in addition to drug charges (Pope, Smith, Wisdom,
Easter, & Pollock, 2013). Individuals without any diagnosis prior to incarceration go through a
thirty day classification process where they receive a full psychological assessment to determine
if they have a mental illness or if they are at risk for developing one. After the initial thirty day
classification process, prisoners receive their permanent prison placement depending on if they
were given a diagnosis or not. Those with more severe mental illnesses are placed in special
units of the prison specifically for the mentally ill population (Anasseril, 2007).
The Comprehensive Justice and Mental Health Act of 2015 granted funds for prisons to
develop alternatives to solitary confinement and implement more rehabilitative programs (“S.993
- 114th Congress”, 2016). Despite the funding, medications and solitary confinement are still the
primary ways to handle mental illness within prisons because there are not enough qualified
employees to work with the amount of prisoners that need interventions. If a prisoner is suicidal,
experiencing psychotic symptoms, or is just being too difficult to handle, correctional officers
often use solitary confinement as a means to contain them. Solitary confinement has been known
SEVERELY MENTALLY ILL IN THE CRIMINAL JUSTICE SYSTEM 5

to exacerbate symptoms of mental illness and punishes prisoners who simply need more help
than they are receiving (Appelbaum, 2015). As far as therapeutic interventions go, prisoners may
attend group therapy sessions including anger management classes, Alcoholics Anonymous, and
other self help groups (Anasseril, 2007). Some prisons offer CBT groups if employees are
willing to run them, but most employees are unqualified to do so having only a Bachelor’s
degree in areas like psychology or sociology. Despite lacking qualifications to run a CBT group,
CBT is ineffective anyways for prisoners who are psychotic, delusional, and have a lot of past
trauma that has never been dealt with.
Finally, the Comprehensive Justice and Mental Health Act provides funding for
correctional facilities to enhance transitional services for inmates being released (“S.993 - 114th
Congress”, 2016). It was difficult to find where this money is actually going because despite the
funding, there are still barriers to ensuring inmates will have access to mental health treatment
upon release. Many CMH agencies have a waiting list and do not want to deal with individuals
who have been incarcerated. Each prison has their own policies and procedures, meaning there
are no federal policies regarding mandatory transitional services for prisoners. Some prisons do
not have enough staff, connections to CMH agencies, time, or energy to find each prisoner the
transitional services they need. When prisoners are being released, many are only given a packet
of resources that are available to them in the community and are left with the option of
connecting to these services. In one research study that interviewed mentally ill individuals who
were involved in the criminal justice system, only 5% of them were linked to transitional
services before being released from prison (Pope, Smith, Wisdom, Easter, & Pollock, 2013).

Recommendations for Policy Improvement

If all individuals with severe mental illness had access to the community mental health
services they needed, then the Comprehensive Justice and Mental Health Act would not be as
important as it is now. But unfortunately, a large percentage of the severely mentally ill become
involved in the criminal justice system because of a variety of systematic flaws limiting access to
necessary services such as substance abuse treatment, mental health treatment, and housing. The
best way to improve this policy would be to address the root problem. Many involved in the
criminal justice system would never be involved in the first place if they had been receiving the
interventions they needed for their mental illnesses. So instead of putting so much funding into
SEVERELY MENTALLY ILL IN THE CRIMINAL JUSTICE SYSTEM 6

criminal justice reforms, it would be most effective to increase funding for community mental
health agencies and substance abuse programs. There needs to be more agencies and more
qualified social workers and psychiatrists to provide treatment. There needs to be more assertive
community treatment teams to provide case management for the severely mentally ill, and more
outpatient availability for those who need psychiatric medications and therapy.
If the Comprehensive Justice and Mental Health Act were to be revised, the federal
government should have stricter guidelines for what the grants would be used for so the funds are
not aimlessly wasted. Currently, crisis intervention teams are only a model of practice for police
officers, and most police departments have yet to adopt the model. Although the current Act
funds mental health training for law enforcement, it does not specify what type of training, how
much training, or whether it is optional or mandatory. As a result, a police department in one
state may be trained way less or way differently on mental illnesses than a department in another
state. To improve practices, the block grants provided for law enforcement training would fund
mandatory crisis intervention teams for every police department in the United States. This means
that every police department would have at least one social worker on duty at any given time.
Also, forty hours of mental health training for all law enforcement officers would be required
annually. Another way to improve this policy would be to revise the schooling requirements to
become a police officer or a part of law enforcement. Since police officers have become the first
responders for handling mental illness crises, extensive understanding of severe mental illnesses,
symptoms, interventions, and de-escalation techniques would be useful for everybody. Police
officers would be able to more easily recognize individuals who need help, and individuals who
need help would be more likely to get what they need after coming in contact with law
enforcement for the first time.
Another improvement to this policy would be to mandate that every prison sets up
transitional services for those with severe mental illnesses. This would include making sure
inmates have Medicaid, are set up to be part of an ACT team or other community mental health
program, and have housing plans before their release from prison. Many prisoners who are
severely mentally ill are released from prison without having a place to stay, money to live off,
or any type of case management. Without having social supports who require they continue
taking their medications, many of them end up going off of their medications. Being poor,
SEVERELY MENTALLY ILL IN THE CRIMINAL JUSTICE SYSTEM 7

homeless, off their medications, and having a criminal record exponentially increases the
chances of recidivism.

Ways in Which Social Workers can Advocate for Change

Many social workers choose to focus on more of an interpersonal, clinical level rather
than on a social policy level. But by working directly with clients in the field, we are forced to
navigate and adapt to policy changes that impact our clients on a daily basis. Policy makers
typically lack contact with the very individuals who are being impacted by the policy changes;
social workers, on the other hand, can directly see the impact that policy changes have on clients,
agencies, and access to mental health care. With our knowledge comes power, as long as we are
able to effectively communicate our message in a clear and concise manner. On a small scale, we
can advocate for change by raising awareness of the problem and proposing some possible
solutions. On a larger scale, we can speak to policy makers and work with them to develop more
effective policies for improving access to mental health treatment. Since we know more than
politicians do about mental illness, access to treatment, and the impact of policies on the severely
mentally ill population, we must present them with a clear, straightforward argument stating
what we want to change and how we want them to change it. Policy makers are busy people and
are likely to set our proposals aside if they are too complicated and long. As social workers
trying to initiate policy change, it is essential for us to learn about politician’s constituents,
views, and their mindsets so we can better understand their perspective and organize our
argument to stick with them. While improving access to mental health treatment may not be a
priority for politicians, decreasing incarceration rates are a priority because of how costly it is for
our country. By developing an argument that aligns with their priorities, we are more likely to
get what we want from them. Another way social workers can advocate for change is by actually
becoming politicians to bridge the gap between policies and practice.
Social workers must advocate for increased funding for substance abuse and mental
health treatment so that individuals do not have to wait until prison to receive the treatment they
need. Instead of deinstitutionalizing mental illness, our policies have unintentionally
transinstitutionalized mental illness; prisons have become the new state psychiatric hospitals for
the severely mentally ill. Currently, there are more people with severe mental illness in prisons
than there are in state psychiatric hospitals (Raphael & Stoll, 2013). As social workers, we must
SEVERELY MENTALLY ILL IN THE CRIMINAL JUSTICE SYSTEM 8

educate others on the importance of increasing funding for the root of the issue as opposed to
continuing funding for the lasting effects of the barriers to service.
SEVERELY MENTALLY ILL IN THE CRIMINAL JUSTICE SYSTEM 9

References

Access to Mental Health Care and Incarceration. (2017). Retrieved from

http://www.mentalhealthamerica.net/issues/access-mental-health-care-and-incarceration
Anasseril, D. E. (2007). Care of the mentally ill in prisons: Challenges and solutions. Journal of
the American Academy of Psychiatry and the Law, 35(4) 406-410.
Anderson, M. C., & Giles, H. (2005). Review of Fairness and effectiveness in policing: The
evidence. Journal of Communication, 55(4), 872–873.
https://doi.org/10.1093/joc/55.4.872
Appelbaum, K. L. (2015). American psychiatry should join the call to abolish solitary
confinement. Journal of the American Academy of Psychiatry and the Law, 43(4),
406–415. Retrieved from
http://proxy.lib.umich.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true
&
db=psyh&AN=2015-57171-001&site=ehost-live&scope=site
Grob G. N. (2005). Public policy and mental illnesses: Jimmy Carter's Presidential Commission
on Mental Health. The Milbank quarterly, 83(3), 425-56.
Heilbrun, K., Goldstein, N. E. S., DeMatteo, D., Newsham, R., Gale, B. E., Cole, L., & Arnold,
S. (2017). The sequential intercept model and juvenile justice: Review and prospectus.
Behavioral Sciences & the Law, 35(4), 319–336. https://doi-
org.proxy.lib.umich.edu/10.1002/bsl.2291
IACP NET. (2015). Issue: Calls Involving Mental Illness. Retrieved March, 2019, from
http://www.commandanswers.com/wp-content/uploads/2015/07/CaseStudy-Holliston-Fin
al.pdf
Lamb, H. R., Weinberger, L. E., & Gross, B. H. (2004). Mentally Ill Persons in the Criminal
Justice System: Some Perspectives. Psychiatric Quarterly, 75(2), 107–126.
https://doi.org/10.1023/B:PSAQ.0000019753.63627.2c
Landess, J., & Holoyda, B. (2017). Mental health courts and forensic assertive community
treatment teams as correctional diversion programs. Behavioral Sciences & the Law,
35(5–6), 501–511. https://doi.org/10.1002/bsl.2307
Pope, L. G., Smith, T. E., Wisdom, J. P., Easter, A., & Pollock, M. (2013). Transitioning
between
SEVERELY MENTALLY ILL IN THE CRIMINAL JUSTICE SYSTEM 10

systems of care: Missed opportunities for engaging adults with serious mental illness and
criminal justice involvement. Behavioral Sciences & the Law, 31(4), 444–456.
https://doi.org/10.1002/bsl.2074
Raphael, S., & Stoll, M. (2013). Assessing the Contribution of the Deinstitutionalization of the
Mentally Ill to Growth in the U.S. Incarceration Rate. The Journal of Legal Studies,
42(1), 187-222. doi:10.1086/667773
S.993 - 114th Congress (2015-2016): Comprehensive Justice and Mental Health Act of 2015.
(2016). Retrieved from https://www.congress.gov/bill/114th-congress/senate-bill/993
Seltzer, T. (2005). Mental health courts: A misguided attempt to address the criminal justice
system’s unfair treatment of people with mental illnesses. Psychology, Public Policy, and
Law, 11(4), 570–586. https://doi.org/10.1037/1076-8971.11.4.570
Wood, J. D., & Watson, A. C. (2016). Improving police interventions during mental
health-related encounters: Past, present and future. Policing & society, 27, 289-299.