The new state mental hospitals in the community.

Serious problems result when the community alternatives to state hospitalization, often driven by lower costs and an ideology that highly structured care is seldom needed, are not adequate to meet the needs of those who are severely mentally ill.

Persons with severe mental illness in jails and prisons: a review.

One of the greatest problems of deinstitutionalization has been the very large number of persons with severe mental illness who have entered the criminal justice system instead of the mental health system.

Deinstitutionalization at the beginning of the new millennium.

This overview of deinstitutionalization explores its accomplishments and disappointments.

Community treatment of severely mentally ill offenders under the jurisdiction of the criminal justice system: a review.

Community treatment of severely mentally ill offenders who fall under the jurisdiction of the criminal justice system has important differences from treatment of non-offenders. It is critical to identify a treatment philosophy that strikes a balance between individual rights and public safety and includes clear treatment goals.

Court intervention to address the mental health needs of mentally ill offenders.

Mental health consultation is provided to a municipal court that recommends court-mandated interventions for mentally ill persons who have committed minor crimes. This study demonstrates that a significantly better outcome results when the judge not only mandates but monitors mental health treatment.

Outcome for psychiatric emergency patients seen by an outreach police--mental health team.

Outreach emergency teams comprising police officers and mental health professionals can help to avoid criminalization of the mentally ill.

Therapeutic use of conservatorship in the treatment of gravely disabled psychiatric patients.

Mental health conservatorship can play an important role in the clinical management and treatment of persons with severe mental illness.

A century and a half of psychiatric rehabilitation in the United States.

After a brief history, this chapter describes important modalities and models of psychiatric rehabilitation.

Some perspectives on deinstitutionalization.

The authors discuss what can be learned from our experience with deinstitutionalization. The deinstitutionalization of mentally ill persons has three components: the release of these individuals from hospitals into the community, their diversion from hospital admission, and the development of alternative community services. The greatest problems have been in creating adequate and accessible community resources. Where community services have been available and comprehensive, most persons with severe mental illness have significantly benefited. On the other hand, there have been unintended consequences of deinstitutionalization-a new generation of uninstitutionalized persons who have severe mental illness, who are homeless, or who have been criminalized and who present significant challenges to service systems. Among the lessons learned from deinstitutionalization are that successful deinstitutionalization involves more than simply changing the locus of care; that service planning must be tailored to the needs of each individual; that hospital care must be available for those who need it; that services must be culturally relevant; that severely mentally ill persons must be involved in their service planning; that service systems must not be restricted by preconceived ideology; and that continuity of care must be achieved.

Community treatment of severely mentally ill offenders under the jurisdiction of the criminal justice system: a review.

OBJECTIVE: Very large numbers of severely mentally ill persons now fall under the jurisdiction of the criminal justice system. A number of conditions are placed on those who are returned to the community, including specific ones related to treatment. This paper reviews the principles and practice of forensic outpatient mental health treatment. METHODS: MEDLINE, Psychological Abstracts, and the Index to Legal Periodicals and Books were searched from 1978, and all pertinent references were obtained. RESULTS AND CONCLUSIONS: Community treatment of severely mentally ill offenders who fall under the jurisdiction of the criminal justice system has important differences from treatment of nonoffenders, which focuses on alleviation of symptoms. Patients must comply with legal restrictions on their behavior, and treatment first addresses a patient's risk of harm to the community. Mentally ill offenders are often resistant to treatment. The mental health system may be disinclined to treat them due to their resistance and their criminal history, especially a history of violence. It is critical to identify a treatment philosophy that strikes a balance between individual rights and public safety and includes clear treatment goals, a close liaison between treatment staff and the criminal justice system, adequate structure and supervision, treatment staff who are comfortable with using authority, interventions for managing violence, incorporation of the principles of case management, appropriate and supportive living arrangements, and a recognition of the role of family members and significant others in treatment.

Persons with severe mental illness in jails and prisons: a review.

OBJECTIVE: The presence of severely mentally ill persons in jails and prisons is an urgent problem. This review examines this problem and makes recommendations for preventing and alleviating it. METHODS: MEDLINE, Psychological Abstracts, and the Index to Legal Periodicals and Books were searched from 1970, and all pertinent references were obtained. RESULTS AND CONCLUSIONS: Clinical studies suggest that 6 to 15 percent of persons in city and county jails and 10 to 15 percent of persons in state prisons have severe mental illness. Offenders with severe mental illness generally have acute and chronic mental illness and poor functioning. A large proportion are homeless. It appears that a greater proportion of mentally ill persons are arrested compared with the general population. Factors cited as causes of mentally ill persons' being placed in the criminal justice system are deinstitutionalization, more rigid criteria for civil commitment, lack of adequate community support for persons with mental illness, mentally ill offenders' difficulty gaining access to community treatment, and the attitudes of police officers and society. Recommendations include mental health consultation to police in the field; formal training of police officers; careful screening of incoming jail detainees; diversion to the mental health system of mentally ill persons who have committed minor offenses; assertive case management and various social control interventions, such as outpatient commitment, court-ordered treatment, psychiatric conservatorship, and 24-hour structured care; involvement of and support for families; and provision of appropriate mental health treatment.

Deinstitutionalization at the beginning of the new millennium.

Deinstitutionalization, which began in the mid-1950s, has had dramatic effects. It has decreased the number of occupied state hospital beds from 339 to 29 per 100,000 population. The plight of the new generation of chronically and severely mentally ill persons has posed the most serious problem: these individuals no longer receive life-long hospital admission and thus permanent asylum from the demands of the world. A comprehensive, integrated, and adequately funded system of care for this population needs to be established in the community. Where such systems exist, they can lead to higher levels of functioning and a better quality of life. Unfortunately, treatment, housing, and rehabilitation resources are presently insufficient to serve the substantial population of mentally ill in the community. Moreover, some patients who have been deinstitutionalized cannot be effectively treated without highly structured 24-hour care. The way deinstitutionalization has been implemented has probably contributed to the large numbers of severely mentally ill persons on the streets and in jails. Although deinstitutionalization can result in a much richer life experience in the community, much more needs to be done to make that occur.

The new state mental hospitals in the community.

OBJECTIVE: The study examined a 95-bed locked community facility (an institute for mental disease), one of 40 such facilities in California to which patients with increasingly difficult problems in management have been referred over the past few years as an alternative to more highly structured state hospitals. The purpose was to determine the characteristics of patients admitted to such facilities and assess whether the facilities are adequate for treating them. METHODS: A hundred and one randomly selected patients in one institute for mental disease were studied by record review and by discussion of each case with staff. RESULTS: The patients were characterized by psychotic diagnoses; the presence of psychotic symptoms even though they took antipsychotic medications in the facility; and histories of previous hospitalizations, serious violence against persons, poor medication compliance, and substance abuse. Ninety-nine percent had been admitted under psychiatric conservatorship. Forty-four percent had been violent toward persons during the current admission, and the level of bizarre, socially inappropriate behavior in the facility was high. CONCLUSIONS: Despite a high-quality rehabilitation program, treating and rehabilitating difficult-to-manage patients normally treated in state hospitals in a facility that had a considerably lower degree of structure had become increasingly difficult and dangerous. The use of community alternatives to state hospitalization, which is often driven by lower costs and an ideology that highly structured care is seldom needed, is not suitable for all patients.

Court intervention to address the mental health needs of mentally ill offenders.

OBJECTIVE: The authors examined the outcomes of mental health consultation provided to a municipal court and the court's resulting interventions for mentally ill persons who committed minor crimes. One aim of the consultation program was to avoid criminalization of mentally ill people who committed minor offenses. METHODS: Clinical and forensic records of 96 persons charged with misdemeanors and referred to a clinical psychologist court consultant for evaluation were studied. Determination of good versus poor outcome during a one-year follow-up period was based on clients' status during the year after the court's disposition. Poor outcome was defined as the occurrence of one or more of four events during the follow-up year: psychiatric hospitalization, arrest, significant physical violence against persons, and homelessness. RESULTS: Fifty-six defendants (58 percent) were mandated to receive judicially monitored mental health treatment, as recommended by the psychologist court consultant, and 33 of them (59 percent) had a good one-year outcome. The relationship was statistically significant. CONCLUSIONS: Nonclinicians in the criminal justice system should have psychiatric assistance in making appropriate dispositions for mentally ill persons. If the judge is considering mental health treatment as a condition for eliminating or reducing punishment, then, to the extent justified by the law and the nature of the offense, the judge should both mandate and monitor the treatment on an ongoing basis.

Outcome for psychiatric emergency patients seen by an outreach police-mental health team.

OBJECTIVE: The study examined whether outreach teams of mental health professionals and police officers could assess and make appropriate dispositions for psychiatric emergency cases in the community, even in situations involving violence or potential violence. The study also assessed whether such teams could reduce criminalization of mentally ill persons. METHODS: One hundred and one consecutive referrals to law enforcement-mental health teams in Los Angeles were studied through records review. Subjects' status during a six-month follow-up period was also examined. RESULTS: Referral had a high rate of past criminal arrests, violence, and major psychopathology. Sixty-three had a history of violence against persons, 59 had a criminal arrest history, 79 had prior psychiatric hospitalizations, and 66 were serious substance abusers. At referral, 70 manifested severe psychiatric symptoms, 20 were overtly violent, and 29 others exhibited threatening behavior. However, only two of the group were arrested; 80 were taken to hospitals. At six-month follow-up of 85 referrals, 22 percent had been arrested (12 percent for crimes of violence), and 42 percent had been rehospitalized. CONCLUSIONS: Outreach emergency teams composed of a police officer and a mental health professional are able to deal appropriately with persons who have acute and severe mental illness, a high potential for violence, a high incidence of substance abuse, and long histories with both the criminal justice and mental health systems. Such teams apparently avoid criminalization of the mentally ill.