A criminal justice service sector is emerging

Today, our traditional four-sector service structure for behavioral health care is undergoing radical change. A criminal justice sector is emerging as a new fifth sector of care. We could not even have anticipated this dramatic change as short as a decade ago.

For more than 30 years, the actual (de facto) mental health and substance use care system in the United States has consisted of four service sectors: specialty care; primary care; social services; and self-help/support. Research that I coauthored in 1993 showed that 5.9% of the U.S. population received care from a specialist each year, 6.4% sought such services from general medical physicians, 3.0% sought these services from other human service professionals, and 4.1% turned to the voluntary self-help/support sector for care.

In the intervening years, the primary care sector has grown relative to the specialty sector, so that the distribution of care is about 70%/30% today, compared to the 52%/48% in 1993. In addition, since about 2010, these two sectors are beginning to merge together into integrated service programs, such as health homes operated by behavioral health entities and medical homes operated by primary care entities. At the same time, field reports indicate that the self-help/support sector has grown rapidly with the introduction of consumer operated service programs, recovery community organizations, and the rapid influx of peer support providers.

No clear picture

Unfortunately, however, we do not have a clear statistical picture of the four sectors at present. We know next to nothing about how the social service sector has changed. And we know very little other than anecdotal information about the degree to which the self-help/support sector has grown.

Similar to the self-help/support sector, the criminal justice sector has grown rapidly during the past decade. Today, county and city jails provide care each year to about 2 million persons with behavioral health and developmental conditions. At the same time, state prisons and federal penitentiaries serve about 1 million persons with these conditions annually, and juvenile justice facilities, about 250,000  teens annually.

Under federal law, correctional facilities are required to provide health and behavioral health services to inmates who need such services. Thus, it should come as little surprise that many county sheriffs and local chiefs of police in the US are either planning or already are providing locked behavioral health care facilities.

Put in the very baldest terms, we are beginning to re-establish in our city and county jails locked facilities for behavioral healthcare that bear strong resemblance to those we abandoned a generation ago when we deinstitutionalized our state mental hospitals. These new hospital-like and clinic-like programs frequently offer services that are inferior to those routinely available through local community mental health and substance use programs.   

As a field, we should debate whether establishing this new criminal justice service sector is the right course of action going forward. We need to have this debate quickly before cities and counties commit large sums of public funds to establish these programs.

Many, including me, will argue strongly that a better course of action would be to invest these funds into improving our city and county community behavioral health services. A clear need exists to improve our continuum of crisis response services, including much more effective care coordination, in these community programs.

At the same time, we also need to improve our city and county social services. Many who arrive at our city and county jails lack the fundamentals of life: permanent housing, a job, and a network of friends. We need to change this untoward situation.

On balance, it will be more humanitarian, more effective, and less costly to serve these persons in our communities rather than in our jails. We have much work ahead to turn this goal into a reality.