Fault Lines
24 April 2017

A Place for the Mentally Ill, Other Than Jail

May 11, 2016 (Mimesis Law) — The New York Times Room for Debate tackled the longstanding issue of the mentally ill and their strained relationship with the criminal justice system.  Throwing the question to debate to a total of seven contributors, the Times asked:

Do we need to return to mental hospitals and other forms of institutional commitment to treat those with severe mental illness?  Or are there other, more effective means of treatment?

Fred Osher, director of Health and Services Policy at the Council of State Governments Justice Center, called for better funding for a variety of different mental health services.  Jamie Fellner, a senior advisor at Human Rights Watch, advocated for keeping the mentally ill out of jail by providing better training for police officers who deal with the mentally ill.  Ayesha Delany-Brumsey and Chelsea Davis ,of the Substance Abuse and Mental Health program at the Vera Institute of Justice, pointed out that tight correlation between drug abuse and mental illness.

Each of these essays focused on three glaringly obvious issues when it comes to addressing the mentally ill:  funding, training, and drug addiction.  They also touched on an underlying, yet much more pressing issue:  where should the severely mentally ill live rather than staying in custody?  Delaney-Brumsey and Davis noted:

Housing-first models, in which people who are chronically homeless are provided permanent housing and support services as needed – without any preconditions, such as abstaining from substance use – have been shown to keep people with mental illnesses housed, with reduced recidivism and improved wellbeing.

It should be self-evident that all people need a place to live, even those suffering from severe mental illness.  While the fact that the severely mentally ill represent a disproportionate percentage of the nation’s prison population is far from shocking, a deeper look into those statistics would be most helpful.  It would be interesting to see how many of those classified as “severely mentally ill” are also classified as homeless.  One would imagine that the correlation between homelessness and severe mental illness would be an extremely direct one, with both factors drastically exacerbating the other.

While better funding, drug treatment and training for police officers may help keep mentally ill individuals out of the criminal justice system or, worse, killed in police confrontations, they are situational answers.  A mentally ill person experiencing a police encounter without being killed or arrested is certainly a wonderful outcome, but where does he or she go from there?  Remaining in the same surroundings and atmosphere as before that police encounter doesn’t give one much hope that another police encounter isn’t imminent.

The issue of housing for the severely mentally ill is addressed by the remaining three contributors to Room for DebateDominic Sisti, the director of the Scattergood Ethics Program, made a bold call for the return of psychiatric asylums, a position he has previously advocated for.  Sisti’s position initially causes a reflexive opposition.  The term asylum carries many negative connotations that harken back to the days when a lack of understanding of mental health issues led to unspeakable abuses.  But today is a new age, according to Sisti, and the idea deserves reexamination.

High quality, ethically administered psychiatric asylums would provide the seriously mentally with a place to stabilize and recover; they are a necessary part of a comprehensive mental health care system.  In contrast to those of the past, modern asylums would be settings that restore hope, support recovery and provide an array of treatments.  Their quality and costs should be fully transparent and they should be integrated into the broader health care system, perhaps as a part of an accountable care organization.

Naturally, there is opposition to Sisti’s ideas.  Tom Burns, professor emeritus of social psychiatry at the University of Oxford, opposed the idea of asylums and called for an increase in “skilled case managers.”

The bedrock of care is a durable relationship with a skilled case manager (in Europe, usually a nurse, in the U.S., a social worker).  That case manager needs to be mobile, reaching out to their 20 to 25 patients around two to three times per month.  Case managers need to work within a multidisciplinary team that can coordinate on health and social care; at a minimum, many of these patients need regular supervision to get their medicine and have reasonable accommodation.

While Burns advocates for a less intrusive solution for the mentally ill, his article also seems to argue for more intrusive treatment at the same time.  Noting that “America’s traditional emphasis on personal freedoms fits poorly with the needs of the severely mentally ill,” he notes:

There seems to be a huge emphasis on assisted outpatient treatment – court-ordered treatment for those who cannot live safely in their communities – despite plenty of high-quality evidence showing that it does not work, no matter how you cut it.

Overzealous protection of very ill patients from effective compulsory hospital treatment is no real freedom if it leaves them to “die with their rights on” or results in them being imprisoned.

The most intriguing position was written by Ann-Marie Louison, the director of adult behavioral health programs at the Center for Alternative Sentencing and Employment Services, who called for Supportive Affordable Housing, staffed with support services for the mentally ill.  Citing the example of New York City’s congregate housing, Louison urges for the creation of “shared apartment buildings, scattered site supported housing and community residences” that are “supplemented with case management and treatment supports.”

Acknowledging that there is currently not enough housing for this type of program, Louison makes the a persuasive argument that there is merit in devoting more funding to this type of plan.

. . . the housing retention rate for those who were shuttling in and out of jails and the shelter system in New York City – and then got supportive housing through the FUSE model developed by the Corporation for Supportive Housing – was more than 90 percent over two years.  They had a 53 percent reduction in jail days, and a 92 percent reduction in shelter days – saving more than $15,000, an amount that essentially paid for two-thirds of the programs cost.

Obviously the model provided by Louison provides more personal freedom than the asylums proposed Sisti.  However, both recognize the importance of housing as the cornerstone for making a difference.  Those suffering from mental illness benefit with as much stability as can possibly be offered and a roof over their head is key.  Permanent housing in an asylum is not ideal, and as pointed out by Burns, not likely to be adopted by us “die with our rights on” Americans.  However, an asylum program that ultimately transitions to a supportive housing program as proposed by Louison sounds much more appealing.

Ultimately, supportive housing for the mentally ill doesn’t just keep them out of the jails (or worse), it provides a building block for becoming a functioning member of society.  That scenario should prove appealing to everyone.

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