The differential impact of deinstitutionalization on white and nonwhite defendants found incompetent to stand trial

Previous studies have reported that state mental hospital deinstitutionalization has resulted in the processing of the mentally ill through the criminal justice system. Using pre- and postdeinstitutionalization samples of defendants found incompetent to stand trial (IST) selected from three states, this study examines changes in the mental health and arrest histories of white and nonwhite ISTs. These data reveal a significant increase in the number of nonwhite ISTs. Also, after deinstitutionalization, nonwhite ISTs had significantly more prior arrests and hospitalizations than white ISTs. There were, however, no differences in the offenses for which whites and nonwhites were arrested.     

THE IMPACT OF STATE MENTAL HOSPITAL DEINSTITUTIONALIZATION ON COMMITMENTS FOR INCOMPETENCY TO STAND TRIAL*

Previous studies have reported that state mental hospital deinstitutional-ization has resulted in the criminalization of the mentally ill. Utilizing two samples of defendants found incompetent to stand trial (IST) pre- and post-deinstitutionalization, selected from three states, this study examines the correlation between the rate of deinstitutionalization and increases in the frequency of incompetency commitments, as well as changes in the characteristics of incompetent defendants. These data suggest that increases in IST commitments and the mental health histories of the post-deinstitutional cohort are positively related to deinstitutionalization. Contrary to the criminalization hypothesis, there is no evidence that incompetent defendants are now being arrested for less serious offenses.     

Police officer attitudes and use of discretion in situations involving the mentally ill. The need to narrow the focus

Research to date has very effectively highlighted the fact that the mentally ill are vulnerable to systematic criminalization. The reasons cited for this range from decreasing mental health resources, to restrictive civil commitment statutes, to increased numbers of mentally ill citizens in the community as a result of deinstitutionalization. However, the research has also shown that the presence of a criminalization phenomenon is not yet generalizable. The prevailing research emphasizes a macro-level approach, using either archival data or large groups of police-citizen contacts without regard for factors intrinsic to the police-citizen exchange. This article examined two such variables (police-citizen contact type and police officer type) to illustrate the need to narrow the focus in the research. We contend that our emphasis moves the criminalization debate forward and helps provide a more comprehensive understanding of the interaction between the police and the mentally ill. Further, we submit that by controlling for these two variables, research findings will more likely be generalizable and replicable.     

PSYCHIATRIC HOSPITAL CAPACITY,HOMELESSNESS, AND CRIME AND ARREST RATES*

As a result of developments in pharmacology, stricter standards for involuntary commitment, and changes in public expenditures, there has been a dramatic decline in the capacity of public psychiatric hospitals to maintain America's most severely mentally ill. Psychiatric deinstitutionalization has led to an increased presence of persons with mental illness in urban areas, many “falling through the cracks” of community‐based services. This is hypothesized to have contributed to homelessness, crime, and arrests. Individual‐level research has documented disproportionate and increasing numbers of mentally ill persons in jails and prisons. It has also found higher rates of violence and arrest among persons with mental illness compared to the general population. This study takes a macro‐level social control approach and examines the relationships between psychiatric hospital capacity, homelessness, and crime and arrest rates using a sample of eighty‐one U.S. cities. I find that public psychiatric hospital capacity has a statistically significant negative effect on crime and arrest rates, and that hospital capacity affects crime and arrest rates in part, through its impact on homelessness. In addition, I find no crime‐reducing effect of private and general psychiatric hospital capacity.     

The right of caregivers to access health information of relatives with mental illness

This article reviews the legal, ethical and practical challenges of complying with the Ontario Personal Health Information Protection Act (PHIPA) within the context of a Canadian mental health system that is overburdened and under resourced. The advent of deinstitutionalization has placed significantly increased responsibilities on the families of mentally ill individuals. While research evidences that involving family members in the care of their mentally ill relatives improves treatment outcomes, mental health practitioners constantly face the challenge of engaging family caregivers while also complying with privacy laws. The authors propose an Ontario Caregiver Recognition Act (OCRA) to formally recognize family caregivers as informal health information custodians based on the practice of other jurisdictions which incorporate the rights of family members actively engaged in providing care to their mentally ill relatives.     

Origins of the "Third psychiatric revolution": the Community Mental Health Centers Act of 1963

In recent decades the community mental health movement has achieved a dramatic reduction in the census of state and county mental hospitals in the United States, and hundreds of federally-funded community mental health centers have been established nationwide. At the same time, national controversy has arisen in response to what in places has seemed the haphazard process of implementing "deinstitutionalization" and the fate of many chronically mentally ill persons who are without needed social services and psychological care. Despite the widespread attention that this contemporary program has received, theoretical analysis of the complex social, scientific, intellectual, and political origins of America's community mental health policy remains deficient. This article examines the background and development of the Community Mental Health Centers Act of 1963, tracing how an important shift in national policy toward the mentally ill grew out of changing perceptions--among policymakers, professional groups, and the general citizenry in the post-World War II era--of the nature of the problem of mental illness.     

Shrinks vs. shysters

In 1976, the Pennsylvania legislature passed a new mental health law which was designed to give civil and due process rights to the mentally ill, as well as to speed up the deinstitutionalization process. The psychiatric profession voiced loud disapproval of the new law. The public interest bar entered the issue, opposing the psychiatrists. In 1978, the law was amended, and most of the hard-won patients' rights were lost. This paper analyzes the reasons behind the psychiatric demand and victory, as well as the reasons for the lawyer's unsuccessful opposition, using two similar battles, one fought in the British Parliament in the eighteenth century, and one in the California legislature in the early twentieth century. Conclusions are drawn concerning the reason for the legislative “turnabout,” and predictions concerning the course of future battles are made.     

Victimization of mentally ill patients living in the community: Is it a life‐style issue?

Purpose. Although criminal victimization of mentally ill patients has been researched, what little work there is focuses on in‐patient samples. This study aimed to compare crimes against mentally ill patients living in the community with crimes against students who have a high life‐style risk of victimization. Methods. The samples were selected via community‐based mental health services and a university population. A group of 40 mentally ill patients and 80 students reported experiences of victimization in the previous 12 months and attitudes towards the police. Results. Female mentally ill patients reported the highest victimization, but both male and female patients reported more victimization than did students. Mentally ill patients also held more negative opinions of the police. Conclusions. The results show that mentally ill patients experience more victimization when compared with the victimization experiences of a similar life‐style risk group. Discussion focuses on the implications for mentally ill patients living in the community, the support networks available to them, and relations between the police and mentally ill patients.     

Redefining mental health law

Mental health law traditionally focuses on preserving the civil and constitutional rights of people labeled mentally ill. However, because of fundamental changes in the public mental health system. most people labeled mentally ill no longer reside in state psychiatric hospitals. As a result, the core policy issue in mental health today is assuring access to community based services, supports, and housing which enable people to live successfully in the community. Because of this different environment, the definition and scope of mental health law must be expanded dramatically if those interested in the subject are to continue to influence mental health policy. This article examines five contemporary mental health policy issues, including changes in reimbursement systems and the growth of the consumer and family movements, that illustrate the legal, policy, and research questions which will emerge in an expanded and redefined mental health law agenda. The author thanks Ingo Keilitz, Thomas Hafemeister, and Pamela Casey for their review of earlier drafts of this article.     

Greek police officers' attitudes towards the mentally ill

The deinstitutionalization of the mentally ill and their shift into the community lead the police to play an important role in the management of acute psychiatric states. This study examines the attitudes of the Greek police towards the mentally ill, and the problems that arise during the transfer of mentally ill people to psychiatric emergency departments. Results highlight policemen misperceptions, and the difficulties encountered during transport procedures, which may be attributed to insufficient knowledge about mental illness and lack of training, respectively. Furthermore, this article discusses the need for police educational intervention, and the formation of specialized teams to improve the handling of mentally ill in crisis situations.     

论精神病人的民法监护——以民事强制住院司法实践为视角

目前．世界多数国家关于精神病人强制住院的立法都直接与广义上的监护法律相联系。监护制度在保护民事行为能力欠缺的精神障碍患者的身心安全和提供必要的住院及医疗措施方面发挥了重要作用。然而,由于我国关于精神病人监护制度的法律规定较为简陋和滞后,导致了实践中,特别是在涉及民事强制住院措施适用时,很多精神病人的人身自由和健康权益并没有得到有效照管,甚至受到严重侵害,由此引起的医疗纠纷和诉讼也日益增多。在此试图对我国精神病人民法监护制度进行解构分析,以期为进一步完善适合我国国情的精神病人监护制度和维护精神病人健康权益提供一些立法建议。     

Professional attitudes regarding treatment and punishment of incest: Comparing police,child welfare,and community mental health

Brief case histories involving incest were presented to police officers, child welfare workers, and community mental health practitioners in a rural area in Canada. Intervention priorities involving “treatment versus punishment” were assessed across the three professional groups for each specific case vignette. Attitudes were assessed on three factors: perpetrator mentally ill rather than criminal, view regarding treatment of victims and mothers, and support for court mandated treatment. Police and community mental health practitioners had significantly different attitudes as to whether perpetrators of child sexual abuse should be viewed more as criminals or as mentally disturbed. Both mental health and child welfare staff differed significantly from police with a less punitive view towards victims and their mothers. All three profressional groups showed no difference in their modest endorsement of the use of mandated treatment by the courts. Gender was not found to influence response to case vignettes.     

Jails in the United States: the phenomenon of mental illness in local correctional facilities

During the last decade, the number of mentally ill inmates in local jails has increased while courts have imposed standards of inmate care upon jail administrators which require appropriate treatment of that inmate group. While jail administrators are seeking assistance from mental health agencies as well as additional resources to deal with these problems, little specific information is presently available about the numbers and correlates of jail inmates nationally that are mentally ill; their prior contacts with mental health agencies, criminal histories, employment backgrounds, etc; and the services jails presently offer to that population. In addition, little is known by geographic region or by jail capacity. Such information is essential in developing future strategies to manage that population. This paper is a preliminary contribution to the development of that information. In addition, the data analysis can serve as a base line against which to evaluate in the structure of the mentally ill jail inmate population as well as changes in services provided by jails by comparing this analysis to future jail surveys conducted by the Bureau of Jail Statistics (BJS) or the National Institute of Justice. The research will be a secondary analysis of the Survey of Inmates of Local Jails, 1983, conducted by BJS, (made available through the Inter-University Consortium for Political and Social Research: University of Michigan, First Edition, Fall, 1985, #8274). In general an exploratory approach was used; however, a loglinear model has been asked to further refine and explore the phenomena of the mentally ill in jails.     

TRENDS IN VIOLENT CRIME AMONG EX-MENTAL PATIENTS

A central component of the public's conception of the mentally ill is that they are dangerous. This belief receives support from recent studies of the arrest rates of ex-mental patients which suggest that arrests for violent crimes have increased. In order to investigate this issue, samples were taken at two points in time. Analysis of arrest rates revealed that very few ex-mental patients were subsequently arrested for violent crimes, although these rates were higher and increasing faster than these of the general population. Mast significant were the findings that subsequent arrests were best explained by the number of prior arrests and that the percentage of patients with a history of criminal behavior has increased dramatically over time. The implications of these trends in violent crime among ex-mental patients for the perceived link between mental illness and violence and for the social control functions of society are discussed.     

The character of danger in psychiatric practice: are the mentally ill dangerous?

This paper explores the question of dangerousness and the mentally ill. Research for this paper was stimulated by the death by homicide of two psychiatrists in Oregon in 1985. The paper reviews three distinct areas in the psychiatric literature: the arrests of mental patients, assaults against psychiatrists and other mental health professionals, and assaultive behaviors exhibited by patients in hospitals and other psychiatric settings. The author concludes that the risks are real but are dependent, for the most part, on setting and the acuteness of illness. Realism in regard to risk is critical for the mentally ill, their families, professional caregivers, and society in general.     

Review of point-of-reception mental health screening outcomes in an Australian Prison

The point-of-reception into prison is a critical juncture as it provides early opportunities to identify mental illness and initiate treatment. Although large numbers of mentally ill prisoners are received into prison each day, research investigating mental health screening outcomes at the point-of-reception is limited. This study aimed to address this gap by examining reception screening outcomes for all prisoners received into an Australian prison during 2009 (n?=?4229). Overall, 19% of all prisoners were mentally ill, and another 20% had a history of psychiatric illness that required ongoing care. Mentally ill prisoners had a higher risk of suicide or self-harm and required more observation than other prisoners. At reception, no mentally ill prisoners were transferred to the state’s forensic hospital and few were transferred to the prison’s mental health unit, or provided support service referrals. These findings highlight that outcomes made at the point-of-reception are heavily influenced by the availability of prison mental health resources.     

Forensic mental health law reform in Japan: from criminal warehousing to broad-spectrum specialist services?

Since the 1980s Japan has undergone a number of mental health law reforms culminating in the 2005 forensic law. This added to its enactments on involuntary commitment, long-term aged care and substitute decision making, bringing Japan into focus as an industrialized state now possessed of a full package of civil and forensic provisions. This article seeks to demonstrate that the new forensic law cannot achieve its own stated goals without seeking to put into place financial and administrative supports aimed to integrate the myriad of patient populations that will be inevitably affected by the new forensic system. In order to avoid the widespread syndrome that has already been experienced internationally of warehousing mentally ill offenders in jails, it is critical that the Japanese government develop effective and culturally sensitive techniques for dealing with low risk populations through a diversionary process. Furthermore, although the legislation addresses serious crimes, it is imperative that policies be put into place to avoid directing young offenders, violent patients from the general hospital system, the developmentally handicapped, already convicted persons found in hospital settings and problematic cases in the correctional system, to the new forensic units established by the legislation. It is only though contemplating unintended outcomes of the legislation that the Japanese government will be able to avoid the ongoing stigmatization and prolonged institutionalization of mentally ill populations. Despite apparent cultural differences internationally vetted human rights requirements must be properly protected, not only in the forensic context, but throughout the mental health system at large. The coordination of services and the development of specialty training are necessary conditions for the realization of improved and humane conditions for mentally ill persons in Japan.     

Evolution of the psycho-legal studies program

This article describes Saleem Shah's role as a mentor and consultant to the author. The author focuses on his influence in the development of the author's research program, examining issues in the police arrest of mentally ill offenders and the need for mental health services for jail detainees.     

Civil commitment in Turkey: reflections on a bill drafted by psychiatrists

Involuntary hospitalization of the mentally ill has been an issue that still remains outside the judicial system in Turkey. Despite the new Turkish Civil Code, which includes several articles relevant to involuntary psychiatric hospital admissions, there still appears to be a need for a comprehensive mental health law to address specific issues concerning civil commitment of the mentally ill. As a result of the lack of specific statutory regulation, an insufficient number of psychiatric hospital beds and limited appreciation of the safety risks involved in untreated mental illness, involuntary hospitalization remains an underutilized option by psychiatrists and the courts alike. In response to its concerned members, the Psychiatric Association of Turkey has appointed a task force to draft a proposed mental health law, entitled the "Psychiatric Patients' Bill of Rights." Although the draft suggests a model with emphasis on the right to psychiatric treatment, it also recommends close judicial oversight to prevent potential abuses of discretion by the system. However, this might present logistic problems in a country with already overburdened courts. Authors discuss the highlights of the draft within the context of Turkey's current cultural, social and judicial structure, and compare it to similar laws of other countries.     

Jones v. Gerhardstein: the involuntarily committed mental patient's right to refuse treatment with psychotropic drugs

The question of whether an involuntary committed mental patient has a fundamental right to refuse treatment with psychotropic drugs continues to be a subject of much debate. Over the past twenty-five years, psychotropic drugs have become the most common form of treatment for the mentally ill. For many patients, these drugs provide substantial benefits; for others, however, they produce severe, sometimes debilitating, side effects. Because of the possibility of serious harm to the patient and because of the potential for abuse of drug treatment by psychiatric staffs, the mental health bar generally has argued for increased procedural protection for mental patients. In Jones v. Gerhardstein, the Wisconsin Supreme Court responded to these concerns by requiring that a judicial hearing be held on the issue of a patient's competency to refuse treatment before the attending physician may administer medication without the patient's consent. This Note discusses the controversy between the legal and medical communities over treatment refusal by mentally ill patients in light of the impact of the Jones decision on institutional practice and on refusing patients. The author argues that the strictly rights-based analysis used by the Jones court has done little to benefit involuntarily committed mental patients. The author suggests alternative ways of approaching treatment refusal that might be more responsive to the distinctive needs of the mentally ill.