Our outrage can drive a decarceration movement

Only a single word—outrage—is even close to adequate to describe the inappropriate criminalization of those who have a mental or substance use condition. We should not remain silent at the inhumane treatment and the lack of urgent care suffered by those with these conditions who are so unfortunate that they become incarcerated in jails and prisons. On his recent trip to the United States, even His Holiness Pope Francis showed us the way by reaching out to disabled persons when he visited the Philadelphia City Jail.

Clearly, incarceration of persons with mental or substance use conditions simply because of their illnesses violates the most fundamental principles of social justice. Not to provide appropriate care for protracted periods after incarceration further violates fundamental human rights. To isolate and to shackle compounds these human violations.

This year’s National Dialogues in Behavioral Healthcare, “Preventing the Criminalization of Persons with Mental Illness: Solutions and a Call to Action” held in New Orleans on November 8-11, engendered considerable outrage, empathy, and strong support for urgent action to address this issue. We know that the issue has grown from a problem into a crisis: tonight, more people with these conditions will be incarcerated in county jails than all the people hospitalized in state mental hospital at their zenith in 1955. This is tragic!

But where should we start? At the Dialogues, powerful support was expressed for development of a short action plan to move this agenda. This plan must be prepared quickly; it must be direct and clear; it must be the product of many partners assembled from the criminal justice and behavioral health communities, the public and private sectors, and peers and family members; and it must commit to urgent, but achievable action.

Reasonable targets

Our plan must set reasonable targets, such as decarceration of 25% of this disability population by the year 2020. To achieve this goal, we must attack the problem from all vantage points: court action, prevention, intervention, recovery, and benchmarking. Here are some recommendations for inclusion in our plan:

Court Action: The Americans with Disabilities Act (ADA) and the Olmstead Supreme Court Decision provide a very powerful basis for a series of class action suits challenging mental health and substance use care delivered in the restrictive setting of a jail or prison. The case is even stronger when care delivery is delayed, if only for a day or more. (One case, AB v. DSHS, has been filed in U.S. District Court for Western Washington on behalf of individuals who have experienced lengthy delays in receiving court-ordered competency evaluation and restoration services in criminal cases.)

Prevention: Our plan must include a broad array of prevention activities--direct work on the negative social and physical health determinants; targeted action to reduce trauma and its effects; early screening for signs and symptoms of a disorder; and early intervention when a disorder is detected. All of these actions must take place in the community, and they must involve mobilization of the community.

Intervention: We also must deploy our behavioral health system to reduce the number of community residents with behavioral disorders who linger without any care and who then fall through the cracks into our jails and prisons. The interventions are well known—better crisis response systems, better care coordination, better community supports. Every effort should be made to divert these persons from jail before their first incarceration.

Our interventions also must extend into the jails and prisons. Good behavioral healthcare must be made available quickly; every effort must be made to return the person to the community as quickly as possible; and follow-on care must be available immediately upon release to prevent recidivism.

Recovery: Care alone will be insufficient. If we are to prevent recidivism to the jail or prison, then we also must help the person build a life in the community. A central concern will be permanent housing. Another will be a job. A third will be social supports.

Benchmarking: Comparing the actions taken in different counties and cities will permit us to benchmark which practices are most effective, so that they can be disseminated to others. We will need some fundamental measures to do this, such as reduction in the number of persons with initial incarcerations; reduction in the number of persons who recidivate; increase in the number of persons with permanent housing, etc.

Outrage can be good when it drives positive action. We must deploy this outrage to configure a plan and move quickly to decarcerate persons with mental and substance use conditions. Urgent action is essential today!