MENTAL ILLNESS, VIOLENCE AND INCARCERATION IN MODERN AMERICA

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1 MENTAL ILLNESS, VIOLENCE AND INCARCERATION IN MODERN AMERICA

2 TABLE OF CONTENTS 3 Introduction 4 Are the Mentally Ill More Violent? 6 Public Misconceptions About Mental Illness and Crime 10 How Pop Culture Reinforces the Violence Myth 13 The Mentally Ill Are More Likely to Be Victims Than Perpetrators 16 Risk Factors of Violent Crime by the Mentally Ill 19 Substance Abuse, Mental Illness and Crime 22 From Institutionalization to Incarceration: A Brief History 26 Prison: The New Asylum 28 Treating Mental Illness in Prison 31 The Consequences of Incarceration Instead of Treatment 33 Alternatives to Incarceration 37 Can Early Treatment Prevent Crime? 40 What You Can Do 43 Sources

3 INTRODUCTION Mass shootings in the United States have become the norm rather than the exception in recent years, with 330 mass shootings in 2015 alone. 1 In the aftermath following a mass shooting, politicians often commend several beliefs that are embraced by the general public. According to an article published in the American Journal of Public Health, the first opinion is that mental illness is the cause of gun violence; secondly, that a diagnosis of mental illness can predict gun violence; and thirdly, that mass shootings are the work of mentally ill loners. 2 From Adam Lanza at Sandy Hook and Seung-Hui Cho at Virginia Tech to Mohammad Abdulazeez in Chattanooga and James Holmes in Aurora, we speculate and obsess over details of the mental illnesses that plagued these men and purportedly led them to kill large numbers of people in cold blood. Some Americans even nodded in agreement when NRA spokesperson Wayne LaPierre called for a national registry of the mentally ill a week after the Sandy Hook massacre. These shootings and other high-profile cases have led to a higher level of stigmatization of mental illness. 3

4 ARE THE MENTALLY ILL MORE VIOLENT?

A large body of research shows that people with mental illnesses even serious ones are statistically no more likely to commit violent crimes than those without a mental illness: A 1994 study

5 A large body of research shows that people with mental illnesses even serious ones are statistically no more likely to commit violent crimes than those without a mental illness: A 1994 study published in the journal Hospital & Community Psychiatry found no association between mental illness and the likelihood of being involved in a violent incident. 3 Harvard Medical School cites studies finding that while people with bipolar disorder or schizophrenia were slightly more likely to commit acts of violence than people in the general population, it was found that the differences in these rates of violence were more likely caused by genetic vulnerability, poverty and early exposure to violence than by mental illness. 4 The comprehensive MacArthur Violence Risk Assessment Study of 2001 found that the prevalence of violence among people with a major mental illness who did not engage in substance abuse was the same as non-substance-abusing controls from the same socioeconomic background. 5 A 2006 Institute of Medicine study that found that while overall rates of violence among people with a mental illness are low, the public perception of the relationship between mental illness and violence is greatly exaggerated. 6 5

6 PUBLIC MISCONCEPTIONS ABOUT MENTAL ILLNESS AND CRIME

The stigma associated with mental illness in the United States is largely due to the public's perception of the link between mental illness and violence, according to a 1999 report by the U.S. Surgeon General.

7 The stigma associated with mental illness in the United States is largely due to the public's perception of the link between mental illness and violence, according to a 1999 report by the U.S. Surgeon General. 7 Ironically, this stigmatization and the resulting discrimination may be to blame for the large number of people with mental illnesses who try to conceal their symptoms rather than seek treatment. THE STIGMA ASSOCIATED WITH MENTAL ILLNESS IN THE UNITED STATES IS LARGELY DUE TO THE PUBLIC S PERCEPTION OF THE LINK BETWEEN MENTAL ILLNESS AND VIOLENCE. 7

According to the President s New Freedom Commission on Mental Health, the stigma of mental illness leads to the general public avoiding living, socializing, employing, working with or renting housing

8 According to the President s New Freedom Commission on Mental Health, the stigma of mental illness leads to the general public avoiding living, socializing, employing, working with or renting housing to people with mental disorders, particularly severe ones like schizophrenia or bipolar disorder. 7 For those with a mental illness, the associated stigma leads to the internalization of public attitudes, which in turn leads to low self-esteem, hopelessness and isolation and deters them from seeking treatment. 8

An in-depth study of American attitudes toward mental illness found that the number of Americans who believe that mental illness is associated with violent behavior nearly doubled between 1950 and

9 An in-depth study of American attitudes toward mental illness found that the number of Americans who believe that mental illness is associated with violent behavior nearly doubled between 1950 and 1996 and that a majority of Americans believe that people who have a mental illness are a threat to themselves and to others. 7 A 2006 national survey that found that 60 percent of Americans believe that people who have schizophrenia are likely to act violently, and 32 percent believe that those with major depression are likely to be violent. 8 9

10 HOW POP CULTURE REINFORCES THE VIOLENCE MYTH 10

In 1999, the National Mental Health Association undertook a survey for the Screen Actors Guild and found that characters in prime-time television who are portrayed as having a mental illness are

11 In 1999, the National Mental Health Association undertook a survey for the Screen Actors Guild and found that characters in prime-time television who are portrayed as having a mental illness are depicted as the most dangerous of all demographic groups, with 60 percent of these characters involved in crime and violence. 7 Dr. George Gerbner, Dean Emeritus of the Annenberg School for Communication at the University of Pennsylvania and founder of the Cultural Indicators Project, studied how television influences Americans societal views. According to Dr. Gerbner s research, while 40 percent of all of prime-time s normal characters are violent, 73 percent of characters with mental illness are violent. Compared with normal characters, nearly twice as many of those with mental illness are victims of violence. 11

12 Says Dr. Gerbner, The mentally ill is a stigmatized group that serves as a lightning rod for [viewers ] pent-up insecurities and, at the same time, demonstrates the moral and physical price to be paid for deviance. 9 In other words, society seems to believe that not only are the mentally ill more violent than those without mental illness, but they somewhat deserve any victimization they encounter. SOCIETY SEEMS TO BELIEVE THAT NOT ONLY ARE THE MENTALLY ILL MORE VIOLENT THAN THOSE WITHOUT MENTAL ILLNESS, BUT THEY SOMEWHAT DESERVE ANY VICTIMIZATION THEY ENCOUNTER. 12

13 THE MENTALLY ILL ARE MORE LIKELY TO BE VICTIMS THAN PERPETRATORS 13

The public grossly exaggerates the relationship between mental illness and gun violence. People with mental illnesses are far more likely to be victims of violence rather than perpetrators.

14 The public grossly exaggerates the relationship between mental illness and gun violence. People with mental illnesses are far more likely to be victims of violence rather than perpetrators. According to a 1999 study, people with severe mental illnesses like schizophrenia or bipolar disorder are more than twice as likely to be victims, rather than perpetrators, of violent crime. 6 THE PUBLIC GROSSLY EXAGGERATES THE RELATIONSHIP BETWEEN MENTAL ILLNESS AND GUN VIOLENCE. PEOPLE WITH MENTAL ILLNESSES ARE FAR MORE LIKELY TO BE VICTIMS OF VIOLENCE RATHER THAN PERPETRATORS. 14

The MacArthur Violence Risk Assessment Study found that: 63 percent of mentally ill individuals reported physical victimization by a dating partner in the previous year 46 percent reported being

15 The MacArthur Violence Risk Assessment Study found that: 63 percent of mentally ill individuals reported physical victimization by a dating partner in the previous year 46 percent reported being physically abused by family members A separate study on the victimization of mentally ill individuals found that: Over eight percent of people with a severe mental illness were victimized in the past four months, compared to 3 percent of the general population. A history of victimization and bullying may cause people with a mental illness to react violently when provoked

16 RISK FACTORS OF VIOLENT CRIME BY THE MENTALLY ILL 16

Based on the findings of a number of research studies, Harvard Medical School concludes that violence by people with mental illnesses stems not from the mental illness itself as much as a number of

17 Based on the findings of a number of research studies, Harvard Medical School concludes that violence by people with mental illnesses stems not from the mental illness itself as much as a number of overlapping factors that paint a complex picture. 4 These factors include: A HISTORY OF VIOLENCE People who have acted violently in the past are more likely than their nonviolent counterparts to become violent again, and research indicates that past violence may be the single most reliable predictor of future violence. PERSONALITY DISORDERS Some personality disorders, such as borderline personality disorder and antisocial personality disorder, frequently manifest in violent behaviors, and when they co-occur with another psychiatric disorder, the risk of violent behavior may be increased. AGE AND GENDER Older adults are less likely than young people to become violent, and men are more likely than women to engage in violent behaviors. 17

18 SOCIOECONOMIC STATUS People of low socioeconomic status are more likely to become violent than those of a higher socioeconomic status. PERSONAL STRESS Divorce, the loss of a job, the death of a loved one, being the victim of a violent crime and other personal stressors increase the risk that someone will become violent. EARLY EXPOSURE TO VIOLENCE Those who are exposed to violence as a child, either through being abused or witnessing aggression perpetrated by parents or other adults, are more likely to be violent than those not exposed to violence as a child. SUBSTANCE ABUSE Drugs and alcohol almost always worsen a mental illness and can even cause the onset of a mental condition where one didn t previously exist. 18

19 SUBSTANCE ABUSE, MENTAL ILLNESS AND CRIME

A study in which 1,410 people with schizophrenia were surveyed found that those who abused drugs or alcohol were four times more likely to engage in violent behavior.

20 A study in which 1,410 people with schizophrenia were surveyed found that those who abused drugs or alcohol were four times more likely to engage in violent behavior. 4 One theory to explain this is that drugs and alcohol affect emotional stability, impair judgment and remove cognitive inhibitions. They may increase the severity of symptoms like hostility and paranoia. Additionally, those who abuse substances are less likely to manage their mental illness, further compounding the problems. Another theory suggests that the substance abuse itself is often due to other factors that also increase the risk of violence, such as childhood trauma, childhood conduct disorder and psychotic symptoms. In the previously mentioned survey, the impact of substance abuse on violence was insignificant when the researchers adjusted for these other factors. 20

The MacArthur Violence Risk Assessment Study states that a co-occurring substance use disorder doubles the risk of violence among individuals with mental illness.

21 The MacArthur Violence Risk Assessment Study states that a co-occurring substance use disorder doubles the risk of violence among individuals with mental illness. It is a major determinant of violence whether a mental illness is present or not. The study found that co-occurring substance abuse accounts for up to 70 percent of violent crimes perpetrated by mentally ill offenders, with 31 percent of dual diagnosis patients committing an act of violence in the last year, compared to just 18 percent of those with only a mental illness. 5 Over 70 percent of people who are imprisoned with a serious mental illness also have a substance use disorder, and veterans returning from combat are overwhelmingly represented in this population. 11 A CO-OCCURRING SUBSTANCE USE DISORDER DOUBLES THE RISK OF VIOLENCE AMONG INDIVIDUALS WITH MENTAL ILLNESS. 21

22 FROM INSTITUTIONALIZATION TO INCARCERATION: A BRIEF HISTORY

In 1955, the number of Americans hospitalized for mental illness peaked at 560,000.

23 In 1955, the number of Americans hospitalized for mental illness peaked at 560, By 1980, that number had decreased to just 130,000, and between 1982 and 2001, the number of public hospital beds in the U.S. for the mentally ill decreased by 69 percent. 13 While some of the decline of institutionalization can be attributed to the advent of behavior therapy and anti-psychotic drugs that enabled patients to live a relatively normal life in the community, many people who had been hospitalized received no follow-up care and became homeless, further increasing their risk of perpetrating or being the victim of violence. 23

According to Stanford Law School s Three Strikes Project, some politicians found that shutting down mental institutions was a viable way to save money, but in many cases, no treatment alternatives

24 According to Stanford Law School s Three Strikes Project, some politicians found that shutting down mental institutions was a viable way to save money, but in many cases, no treatment alternatives were provided, further disenfranchising scores of mentally ill people. 14 Although some of the savings realized by shutting down these institutions were supposed to help fund public mental health services, much of it was never used for those purposes, and a study published in 1980 found that the closing of mental health hospitals had forced a large number of mentally ill people into the criminal justice system. In 1971, the California prison population was around 20,000, and in 2010, that number had reached 162,000, with an estimated 45 percent suffering from a serious mental illness

This trend of incarcerating the mentally ill quickly spread across the country in the 1970s, and as of 2014, more than 1.2 million mentally ill people were incarcerated.

25 This trend of incarcerating the mentally ill quickly spread across the country in the 1970s, and as of 2014, more than 1.2 million mentally ill people were incarcerated. People who have mental illnesses are on parole or probation at up to four times the rate of the general population. 15 AS OF 2014, MORE THAN 1.2 MILLION MENTALLY ILL PEOPLE WERE INCARCERATED. 25

26 PRISON: THE NEW ASYLUM

27 U.S. Bureau of Justice statistics show that 16 percent of prisoners in the United States are mentally ill. 13 The Bureau attributes this high prevalence to the fact that there is often nowhere else for the mentally ill to go, stating that a single jail in Los Angeles has effectively become one of the biggest mental institutions in America. The number of incarcerated people who have a mental illness is ten times the number of those in state psychiatric hospitals. 16 Most of the mentally ill prison population would once have been institutionalized, and as state hospitals continue to close even now, the number of people being treated in the criminal justice system continues to rise. THE NUMBER OF INCARCERATED PEOPLE WHO HAVE A MENTAL ILLNESS IS TEN TIMES THE NUMBER OF THOSE IN STATE PSYCHIATRIC HOSPITALS. 27

28 TREATING MENTAL ILLNESS IN PRISON

29 The U.S. Supreme Court has affirmed the right of prisoners to receive treatment for a mental illness while incarcerated. In many states, prisoners also have the right to refuse medical care, and many people with serious mental illnesses refuse treatment, often because they don t believe they need it. Thirty-one states allow treatment of the mentally ill over their objection, but it requires a long administrative process that is grossly underutilized

In the remaining 18 states, treatment over objection is much more difficult to institute and requires going through the court system or transferring an inmate to a state psychiatric hospital, but

30 In the remaining 18 states, treatment over objection is much more difficult to institute and requires going through the court system or transferring an inmate to a state psychiatric hospital, but such measures are usually not taken because state hospitals are almost always full. Despite the right to receive health care and despite the ability to treat over objection in many states, between 83 and 89 percent of people with a serious mental illness who are in prison or jail do not receive any care at all. 11 Moreover, the mental health treatment that is administered is generally inadequate at best. THE MENTAL HEALTH TREATMENT THAT IS ADMINISTERED IS GENERALLY INADEQUATE AT BEST. 30

31 THE CONSEQUENCES OF INCARCERATION INSTEAD OF TREATMENT

Incarcerating mentally ill people who would be better served in a state hospital results in a number of far-reaching consequences: 15 Jails and prisons are overcrowded due to the notoriously longer

32 Incarcerating mentally ill people who would be better served in a state hospital results in a number of far-reaching consequences: 15 Jails and prisons are overcrowded due to the notoriously longer sentences given to mentally ill offenders. Correctional staff are on the receiving end of more physical attacks and must cope with other severe behavioral issues. The mentally ill themselves are victimized in disproportionately higher numbers than the general prison and jail population. The conditions of those who refuse treatment typically get progressively worse, especially for the disproportionately high number of people with mental illnesses who are kept in solitary confinement. The overall cost of incarceration to taxpayers is increased, as are rates of relapse and prison/jail suicides. 32

33 ALTERNATIVES TO INCARCERATION

Ultimately, reversing the trend of sending mentally ill people to prison instead of hospitalizing them boils down to creating a public mental health treatment system that functions optimally and

34 Ultimately, reversing the trend of sending mentally ill people to prison instead of hospitalizing them boils down to creating a public mental health treatment system that functions optimally and efficiently. Specific alternatives to incarceration include forming partnerships between community mental health providers and local police forces with the aim of using minimal force to de-escalate situations and using crisis intervention teams to link people with mental illnesses to appropriate treatment instead of putting them in jail. Trained crisis intervention teams have been shown to dramatically reduce the use of unnecessary force, and they help reduce the stigmatization of mental illness. 34

35 Jail diversion is another alternative that can help people with mental illnesses get treatment in the community instead of in jail. Jail diversion may also effectively prevent subsequent criminal activity, while jail time often increases the risk of repeat offenses. Court-ordered outpatient treatment could help at-risk individuals remain safely in the community as an alternative to jail time. COURT-ORDERED OUTPATIENT TREATMENT COULD HELP AT-RISK INDIVIDUALS REMAIN SAFELY IN THE COMMUNITY AS AN ALTERNATIVE TO JAIL TIME. 35

36 For those who are incarcerated, preventing repeat offenses should be a priority. A comprehensive screening process upon arrival ensures that medication needs are met and other risks associated with mental illness, such as elevated risks of victimization and suicide, are meaningfully addressed. Many advocates for the mentally ill promote instituting mandatory release planning and aftercare that includes community supports and accessibility to a variety of resources, including cognitive behavioral therapy to address criminal behaviors, drug treatment, vocational training and help finding safe housing. 36

37 CAN EARLY TREATMENT PREVENT CRIME?

Early identification and treatment of substance abuse problems among those with serious mental illnesses is a potential strategy for preventing violence among that population.

38 Early identification and treatment of substance abuse problems among those with serious mental illnesses is a potential strategy for preventing violence among that population. Research suggests that the integrated treatment of mental illness and co-occurring substance use disorders may also reduce rates of violence. 4 The Department of Health and Human Services recommends putting more focus on preventing mental disorders by addressing the known risk factors that contribute to criminal behavior, including childhood trauma and exposure to violence. 16 Doing so will not only help prevent violence, but will also lead to lower overall crime rates, better educational outcomes and lower healthcare costs. 38

39 Preventing repeat criminal activity for the previously incarcerated is another essential way to reduce crime. 17 Easier access to care through better insurance coverage may also reduce the societal costs of health care and enable former inmates to better acclimate to the community, maintain employment and lead a productive life. PREVENTING REPEAT CRIMINAL ACTIVITY FOR THE PREVIOUSLY INCARCERATED IS ANOTHER ESSENTIAL WAY TO REDUCE CRIME. 39

40 WHAT YOU CAN DO

Mental illness, with or without a co-occurring substance use disorder, is a far-reaching problem that affects individuals, families and communities.

41 Mental illness, with or without a co-occurring substance use disorder, is a far-reaching problem that affects individuals, families and communities. The stigmatization of mental illness, perpetuated by pop culture and the media feeding frenzies that inevitably follow a mass shooting, all too often leads to isolation instead of integration and hiding instead of getting help. Encourage the people you know and love to seek help for a mental illness, substance abuse problem or co-occurring disorder. 41

Advocate for the mentally ill, either in your attitudes and interactions on social media and in real life or by getting involved with community organizations that work to provide essential services

42 Advocate for the mentally ill, either in your attitudes and interactions on social media and in real life or by getting involved with community organizations that work to provide essential services and resources to the mentally ill. Vote for politicians who are dedicated to funding community-based prevention programming, mental health clinics, veterans services, crisis intervention programs and other essential community services. In the long run, these investments will improve countless lives and save taxpayers money by easing prison overcrowding, reducing the costs associated with lost productivity, keeping numerous people out of the criminal justice system and producing other far-reaching benefits for both individual communities and society at large. 42

43 SOURCES Toll of Gun Violence. (2015). Retrieved from 2 Metzl, J., & MacLeish, K. (2015, February). Mental Illness, Mass Shootings, and the Politics of American Firearms. American Journal of Public Health, 105(2), Retrieved from 3 Mulvey, E. (1994, July). Assessing the Evidence of a Link Between Mental Illness and Violence. Hospital and Community Psychiatry, 45(7), Abstract retrieved from 4 Mental Illness and Violence. (2011, January 1). Retrieved from 5 The MacArthur Violence Risk Assessment Study. (2001). Retrieved from 6 Mental Health Reporting: Facts About Mental Illness and Violence. Retrieved from 7 Violence and Mental Illness: The Facts. (2008). Retrieved from 8 Mental Illness and Violence. (2011, January 1). Retrieved from 9 Gerbner, G. (1980). Stigma: Social Functions of the Portrayal of Mental Illness in the Mass Media. In Rabkin, J., Gelb, L. & Lazar, J. B., Attitudes Toward the Mentally Ill: Research Perspectives (pp ). Retrieved from aspx?assetid=

SOURCES 10 Stuart, H. (2003, June). Violence and Mental Illness: An Overview. World Psychiatry, 2(2), 121-124. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/pmc1525086/ 11 Cloud, D.

44 SOURCES 10 Stuart, H. (2003, June). Violence and Mental Illness: An Overview. World Psychiatry, 2(2), Retrieved from 11 Cloud, D. & Davis, C. (2013, February). Treatment Alternatives to Incarceration for People with Mental Health Needs in the Criminal Jusice System: Cost-Savings Implications. Retrieved from treatment-alternatives-to-incarceration.pdf 12 Timeline: Treatments for Mental Illness. Retrieved from 13 Okasha, A. (2004, February). Mental Patients in Prisons: Punishment Versus Treatment? World Psychiatry, 3(1), 1-2. Retrieved from 14 Steinberg, D., Mills, D. & Romano, M. (2015, February 19). When Did Prisons Become Acceptable Mental Healthcare Facilities? Retrieved from 15 Peterson, J. (2014, April 21). Mental Illness Not Usually Linked to Crime, Research Finds. Retrieved from 16 Fuller Torrey, E., Zdanowicz, M. T., Kennard, A. D., Lamb, H. R., Eslinger, D. F., Biasotti, M. C. & Fuller, D. A. (2014, April 8). The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey (abridged). Retrieved from 17 Mentally Ill Persons in Corrections. Retrieved from 44

45 1 (877) Sylvia Brafman Mental Health Center 6555 Powerline Road, Suite 204 Fort Lauderdale, FL 33309

Policy and interventions for adults with serious mental illness and criminal justice involvement

Policy and interventions for adults with serious mental illness and criminal justice involvement Allison G. Robertson, PhD, MPH Duke University School of Medicine Department of Psychiatry & Behavioral