Current and Prior Mental Health Treatment of Jail Inmates: The Use of ...

Journal of Social Distress and the Homeless,

Vol. 10, No.3, July 2001 (© 2001)

Current and Prior Mental Health Treatment of Jail Inmates: The Use of the Jail as an Alternative Shelter! ,2 Harris Chaiklin+"

Changing policies in mental health and welfare are altering the character of urban jail populations. Homeless people, many of them ex-mental-hospital patients, occupy jail space in increasing numbers. They almost never commit violent crimes and seldom commit any real crime. They are given a charge and put in jail as a way to take them off the streets. The way in which official statistics are created and kept makes it difficult to demonstrate the nature and extent of this problem. This paper reports on one way this can be done. KEY WORDS:

jail; homeless; mental illness; data quality.

The relationship between homelessness, jail, and mental illness is well established (Kingree, Stephens, Braithwaite, & Griffin, 1999; Lamb & Grant, 1982, 1983). The details of this relationship are difficult to specify because the directors of relevant agencies will not agree on operational definitions that they can share. Despite this, it is necessary to consider the policy and treatment implications connected to these ideas. Homeless and disturbed people who are incarcerated seldom have their needs met and contribute to unnecessary jail overcrowding (Sweeney, 1984). The pressures are building to resolve these issues in the courts

I Parts

of this paper presented at the Annual Meeting of the Academy of Criminal Justice, Orlando, Florida, March 19, 1986. 2Some of the data used in this paper was obtained as part of a subcontract by the Maryland State Department of Mental Hygiene to the University of Maryland School of Social Work under NIMH Grant (MH 15916-06). 3School of Social Work, University of Maryland, Baltimore, Maryland. 4Correspondence should be directed to Harris Chaiklin, 5 I 73 Phantom Ct., Columbia, Maryland 2 I 044; e-mail: [email protected].

255 1053-0789/01/0700-0255$19.50/0

© 200 I Human Sciences Press, Inc.

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(Schwitzgebel, 1979). The problem with going through the courts is that change is slow even after a positive verdict. This paper's argument is the major problem with understanding the jailed homeless mentally ill is not methodological but reflects the refusal of contending parties to agree on a working definition so that planning can proceed. Ideological argument is masked as scientific difference. This will be illustrated by presenting data that documents prisoners' past or current mental problems. HOMELESSNESS Homelessness estimates range from 500,000 to 7,000,000 (Breakey & Fischej' 1990; Cordray & Pion, 1991). In the last decade shelter capacity has almost do~bled. Welfare reform is exacerbating the problem. The National Coalition for the Homeless, NCH (1999) says, "Recent studies suggest that the United States generates homelessness at a much higher rate than previously thought" (NCH, 1999, NCH Fact Sheet #2, p. 4). Regardless of whether the upper or lower estimates are used the policy issues connected with homelessness are the same. People who are homeless have a high probability of being jailed. One reason that homeless people end up in jail is that the jail is unique among public institutions, it has no formal control over either its admission or its discharge operations. Other institutions, such as the hospital, come close but they have options, especially where overcrowding is concerned. This absolute right to admission has important implications for the way the jail functions in American society. One of the most important of these is that it has become the repository for the people society is "stuck" with. In particular, there are many incarcerated people with past and current mental illness. They folloJ, a familiar path. They are released from the hospital, often to a halfway hous Their release is marked in the hospital records as a success. When their time ip the transition placement runs out they often become homeless (Appleby & Desaj' 1987). When they become too big a nuisance in the community, often because of alcoholism, jail is a frequent resource (Adler, 1986; Judiscak, 1995; Virginia State Crime Commission, 1981). Winerip (1999) says, "There are now more mentally ill in the nation'sjails (200,000) than in state hospitals (61,700)" and those remaining in state hospitals are more likely than in the past to have criminal records (Winerip, 1999, p. 46). So many former patients are arrested jails have come to be called "The New Asylums" (Shenson, Dubler, & Michaels, 1990, p. 655).

1.

THE DISTORTED

DATA PICTURE

Good quality public statistics are supposed to be important for determining social policy and monitoring agency operations. Whether they actually play this role is not clear, but there is always a hue and cry when the data are suspect in some way.

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and Prior Mental Health Treatment

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Most of the disputes center on methodological issues connected with definition and technique or with the political implications of the technical choices that are made. Within the jail there are problems connected with planning treatment and other services because the conditions to be treated are not correctly enumerated. One of these concerns double diagnoses such as drugs and alcohol. This distorts problem counts because jails often report only one of the problems, usually drugs because this is an illegal activity. The number of people with alcohol problems injail tends to be greatly undercounted. The issue is larger than that because many ofthese inmates have several major and reportable social and emotional problems. Not having accurate diagnoses means that jail treatment services not only are perpetually overwhelmed but they also are not in a position to ask for what they need. Another thing that happens is that when public policy changes clients or agency workers orient their existing needs to the new policy. If more money were made available for alcohol treatment many offenders identified as drug addicts would suddenly show up in this category. The shift in policy changes the problem label but behavior does not change. This institutional labeling is an important variation of labeling theory. According to the proponents of labeling theory people suffer negative effects when they are given a pejorative label. The presumed effects oflabels on individuals have not been well demonstrated. Institutions use labels when they report their data. It is possible that the organization is harmed when these institutional designations do not accurately reflect what is happening. The jail reports its statistics in terms of its legal function. It is difficult to ascertain how many of these people are there just because they are homeless, just because they are mentally ill, or both (Wright, 1988). Snow, Baker, and Anderson (1988, p. 195) say just to call the homeless "losers" avoids the question of what forced them into a no win situation. From their perspective the search for accurate counts is a waste oftime. Regardless of that, identifying people injail only in terms of their offense hides the fact that the correction system provides more psychiatric services than any other institution in this country (Altman, 1999). THE FUNCTION

OF THE JAIL AS AN INSTITUTION OF LAST RESORT

The values of police and correctional officers revolve around handling criminals. To the extent that handling the mentally ill contradicts these values, there is stress. When officers have to handle the mentally ill: This "honor core" of policing affects service delivery insofar as the assumptions made about the types of persons encountered and the types of work entailed lead officers to see their jobs not only as "shitwork," but as potentially dishonoring. They can bring no honor as the handling of a criminal, but they can bring shame, errors in handling, embarrassment, and encounters with citizens who are unruly and unpleasant even though they are viewed as members of the "respectable classes" (Manning, 1984, p. 194).

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The majority of the homeless and disturbed are public nuisances who have committed no real crime (Steadman, Monahan, Duffee, Hartstone, & Robbins, 1984). Since one can't be charged with being mentally ill the police come up with a charge that will require bail. A homeless person usually can't make any bail (Finn & Sullivan, 1988; Peele, Gross, Arons, & Jafri, 1984). It can also lead to denial mechanisms whereby the police do not recognize when they are dealing with a mentally ill person (Teplin, 1984). Regardless of the reasons when the mentally il~ are criminalized there is a distortion in reported offenses, which makes it difficullt to bring attention to the mental health needs of those in jail (Teplin, 1985). Thf extent to which changing mental health and welfare policies have combined te make the jail an alternative homeless shelter is masked.

THE JAIL PROJECT One way to demonstrate the extent to which jail and mental illness statistics are confounded is by checking mental hospitals to see if they contain a record for current jail inmates. This provides a record count rather than depending on self-report surveys or estimates. This was done for Baltimore City Jail inmates on a day in October 1984 (Chaiklin, 1986). There were three data sources. The first was the daily inmate status report that contains demographics, cell loc~tion, and offense characteristics. The second was a record check of state mental hospitals in the Baltimore metropolitan area and two Baltimore City community mental health psychiatric centers. Name and birth date were used as a basis for identification. The figures developed for hospitalization are a least estimate. A more COl plete count would have required reviewing all public and private inpatient instit~tions in the state, community hospitals, and a similar check in institutions in the states of origin for those who have recently moved to Baltimore. I The third data source was from jail treatment programs. The jail treatmellt director identified all inmates who were receiving help for psychiatric, drug, dlr alcohol problems. Some of these were in a treatment cell and some were not. , complicated set of designations distinguishes between physical and mental conditions. Overcrowding makes these distinctions almost meaningless. A person with ~ problem or living in a treatment section is usually displaying behavior that reflects emotional disturbance. Physically ill people are transferred to a hospital. On the study day there were 1837 people in the Baltimore City Jail; 273 (15%) of them had a record in a state mental hospital, 165 (9%) were in a treatment cell, and 278 (15%) were identified as having an emotional problem. These categories overlap. The 1 day findings have to be multiplied by 10 to get a full idea of how many ex-mental patients and disturbed people the Jail handles in a year. Given that the jails population has doubled since these data were gathered, the numbers are large.

J-

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of Jail Inmates

Table I. Age and Problem Distribution Age 15-24

25-39

40+

Total

1%

4%

7%

62

Hospital and cell Hospital and problem Hospital only Cell and problem Cell only Problem only No treatment

_a

_a

I 3 I 2 6 86

3 10 3 2 7 71

2 7 17 5 3 8 51

11 49 151 46 46 121 1351

n

703

875

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1837

All sick

"Less than 1%.

The population is constantly shifting. Only 2% (31) had been there more than a year; whereas 81% (1496) had been there 6 months or less. Only 7% (126) had been sentenced. Most of those who are ultimately convicted were sentenced to time already served. Almost all the ex- and current mental patients are being held there because they cannot make a relatively low bail. Table I presents data that shows past and current disturbance by location and age. Overall 18% (335) of the jail population is identified as disturbed and 15% (273) had a prior file in a Maryland State mental hospital. The overlap between the two categories is high with 45% (121) of the prior mental patients currently identified as disturbed. Examination of social variables in relation to past and current emotional illness helps explain Table 1. The older inmates are more likely to have either been in a state mental hospital or to be currently a disturbed; 49% of those over age 40 but only 14% of those under age 25 have either been in a state mental hospital or were in a jail treatment cell or program. The younger people show up in greater numbers in the problem and cell categories. Those under age 25 are 33% of the problem only category whereas those over age 40 are 21% in the problem only category. In the cell only category these differences are more striking. Those under age 25 are 39% of this category whereas those over age 40 are 20% of this category. Young people in the jail, who have severe problems, have been in a state hospital with less frequency than older prisoners with severe problems. The policy of deinstitutionalization is also a policy of non institutionalization. The age difference is explained by the fact that a few years ago the State policy was changed and alcoholics are no longer sent to mental hospitals. CHARACTERISTICS

OF FORMER

PATIENTS

The three categories: ex-mental patient, currently disturbed, and living in treatment cell have social characteristics that are different from the average

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prisoner. Those who have been in a mental hospital, in comparison to those who have not, are more likely to be White, over age 40, and Catholic. There is a tendency for ex-state-hospital patients to be female and to have not finished high school. Even though a greater proportion of the Whites have been hospitalized, there are twice as many Blacks as Whites, 183 as compared to 90. The numerically greater number of Black ex-mental-hospital patients is a smaller proportion of the total number of Blacks in jail because Blacks are arrested in greater numbers. Their offenses are usually related to poverty. In contrast to Whites injail the Blacks sh04 a wide range of personality patterns. Whites injail tend to have serious diagnosesj. Whites in jail tend to be of a higher social class than Blacks. In effect, for a White to be locked up he has to be both "bad and mad." I In terms of criminal justice characteristics the ex-state-hospital patient, in contrast to other prisoners, is significantly more likely to be charged with a nuisance offense and to have a low bail. The ex-hospital patient is also more likely to have been in jail more than a year. This was not an expected finding and there is no ready explanation for it. The numbers are small; only 31 people have been in the jail more than a year and 32% of them have also been in a state mental hospital. Almost all the significant characteristics represent categories that have small numbers. Women are 7% of the jail residents, Whites are 17%, and those over age 40 are 14%. A critical question is whether the charges placed against these past and currently disturbed people in the jail reflect an offense or a way to get them off of the street. Even though those with emotional problems tend to be charged with nuisance offenses they also have serious charges, especially property offenses and assault. Table II reflects this pattern. Once again the numbers are small. Those charged with nuisance offenses are 7% of the jail population and those with a bail of less than $500 are less than 2%. Although they those with past and present disturbance are more likely to be charged with nuisance offenses a majority of them are charged with index or other offenses. Fischer (1988) in a study of arrest patterns in Baltimor~ notes that tho proportion of serious charges among homeless arrestees is about 1

0t

Table II. Charge by Type of Problem Nuisance All sick Hospital and cell Hospital and problem Hospital only Cell and problem Cell only Problem only No treatment n

10% 2 2 13 4 2 8 61 132

Index

Other

4%

2% I

I

2 7 3 3 7 74 895

3 9 2 2 6 75 810

1837

Current


of Jail Inmates

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less (25% vs. 35%) than in the general population ofarrestees. Her study does not show how many of these people were later sent to jail. These data are interpreted as reflecting the way race, poverty, and mental illness are interrelated. The low count categories the ex-mental patient shows up in are the opposite of the modal picture of the Baltimore Jail inmate. He is young, male, Black, and charged with a serious offense. The jail population usually is within lOOof a court mandated limit. Although pressure from the court is helpful in improving the general lot of prisoners it is at the cost of legitimating a standard that leaves the jail with a population almost twice its rated capacity. Almost 20% of the jail population was identified as disturbed. In practice that means that they were upset enough to warrant some kind of attention from jail treatment personnel. People with problems who cause no "trouble" do not come to the attention of jail personnel. They have no time. Problems with drugs and alcohol are almost endemic in this population. They afflict a larger proportion of the jail population than that which is identified as having an emotional problem. The patterns reported in this data have a rough correspondence to a 1998 national survey, based on inmate self-reports (Ditton, 1999). The definition of mental illness that was used was that a person either said they had a mental condition or reported an overnight stay in a mental health treatment center. Based on these self-reports 16.3% of those in jail are estimated to be mentally ill. Taking all those incarcerated the estimate of those who are mentally ill is 16% or 283,800 people. The patterns of social characteristics are similar. There are high rates of homelessness, unemployment, alcohol and drug abuse, and they serve longer sentences. That a national survey done some years later reflects the same patterning of the Baltimore data indicates that consistent and long term social processes are involved in determining how the homeless end up in jail. Based on the Baltimore data another conclusion can be drawn about the self-reported data. That is that the current data seriously underestimate the prevalence of mental illness in the jail population. The Baltimore estimates of mental illness are based on having found a state hospital record. This means that the person had a stay that was longer than a few days. And the Baltimore data were considered minimal because they did not track commitments to general medical hospitals or hospitals in other states. The problem grows at a great rate. From 1990 to 1998 the jail population increased 45% from 403,019 to 584,372 (Beck & Mumola, 1999; Bonczar & Glaze, 1999). This was an average of 4.8% a year. In the Baltimore City Jail additional space has been added and there are now over 4,000 inmates there. Overcrowding is still severe. The pressures from welfare reform and factors contributing to homelessness among the mentally ill can only lead to incarcerating more homeless mentally ill people. Whatever its initial goals de institutionalization has now come to stand for, "an image of homeless former mental patients who inhabit the streets

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of virtually every major urban area and seem to threaten the community as well as themselves" (Grob, 1995, p. 51).

DISCUSSION The data presented in this paper are innocuous. They contain only simple de l scriptors of who the prisoners are, what their criminal justice characteristics were, and a few items on past and current mental health history. Yet, it was viewed witf. apprehension by all of the agencies concerned. Administrators felt that even a bald statement like "In the current jail population 15% have been in a state mental hospital" should be surrounded with words so a reporter would not "use it out of context." Everyone knew before the data were collected that mental health was a problem in the jail and that there were many ex-mental patients in the jail. All that was done to provide an accurate but minimal count of the problem. One explanation for all the caution may lie in an old saying, "It isn't whether you win or lose, but where you place the blame." Putting homeless and mentally ill people in jail is something that is criticized when attention is called to the practice. No one wants to be responsible for this. In addition, there are those who are committed to the idea that de institutionalization is a successful policy and they try to protect their position and their reputation. All of this adds spice to the traditional battles over budget and power. It also calls into play traditional devices for obfuscating and delaying action. One of these is a call for more study. Although there is a need to have a continuous data monitoring, in Baltimore, the problem has been well studied and the recommended courses of action are clear. Breed and Friedman (1984) say the police should not arrest the mentally ill, there should be cooperation between human senvice and criminal justice agencies, and that appropriate referral should be madcl. These are good suggestions. They have been made by others (Maryland crimin,II Justice Coordinating Council, 1984; State Division of Corrections, 1984). When agencies can't delay action by calling for more study they can block action by making data inaccessible, useless, or use the problem they created by saying that differing operational definitions of mental illness make coordinated planning difficult. The multiplicity of definitions is not the problem. Given the ease with which data can be manipulated on a computer, having multiple operational definitions only permits greater flexibility in data management. Differing definitions will have a different utility for different aspects of planning. If agencies want to work together all they have to do is agree on a working definition. Experience will identify when a change is needed. The refusal of agencies to test what shared problem definitions mean is the key to blocking effective planning and action. Controlling reporting units is a way that agencies use to maintain their unique definition of the situation (Chaiklin & Lewis, 1964).

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Public agencies in Maryland report data in a bewildering maze of individual districts, postal zones, and other lines of convenience. Few use census tracts. Lack of standardization on a simple thing like census tract reporting deprives Maryland agencies of a wealth of data from Census Bureau and other research endeavors. Baltimore was one of three cities used in a major NIMH prevalence study (Myers et a!., 1984). At very little cost concerned agencies could have taken advantage of one of the most sophisticated mental health studies ever done. The need to get a more accurate picture of the relationship between homelessness, mental illness, and being in jail grows. Recent policy changes add to the problem. Welfare "reform" is creating family transitions that soon will add to the jail population (Thornberry, Smith, Rivera, Huizinga, & Stoutharner-Loeber, 1999). Even though delinquency is decreasing the numbers of adjudicated juvenile delinquents who are placed out of home continues to rise. The greatest increase in placement came in drug cases and offenses against the person (MacKenzie, 1999). Because the best predictor oflater incarceration is early arrest and incarceration the number of potential jail occupants rises whereas crime declines. If these youth are charged as adults they already are in jail. As welfare reform proceeds the number of people on welfare who have difficulty in finding work rises (Zedlewski, 1999). If these people are removed from welfare a significant number of them will end up in some combination of jail and mental hospital. The use of chemical treatment for psychiatric disorders also means that diagnosis must be accurate. Studies that have checked the accuracy of diagnosis in public facilities have shown a low rate of diagnostic accuracy (Lipton, 1985). Giving the wrong drug for a psychiatric condition is a major contributor to tardive dyskinesia. There is a rapidly growing number of people who are neurologically disabled because of their drug treatment. Once in this condition they will be dependent the rest of their lives. Many of the emotionally disturbed people reported on in this paper show evidence of this condition. The structural bases for this cooperation are clear. It requires being accurate about the number of people who enter the system, how long they are in the system, and the capacity of the system (Harris & Siebens, 1981). There is a paramount need to examine "jail mental illness" in terms of current reality. One thing about this reality is that because of wide differences in mental health and criminal justice policy every state and jurisdiction will have to do its own studies (Steadman, Monahan, Duffee, Hartstone, & Robbins, 1984; Whitmer, 1980). There is no single correct approach to solving the problem. Any such examination should be comprehensive and involve all relevant health and welfare agencies. In addition to any local requirements for defining problems such as homelessness it should also use standardized definitions so data can be compared from jurisdiction to jurisdiction. In terms of data kept for generating official reports ex-mental patients are indistinguishable from other prisoners. The official statistics report social, offense,

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and criminal justice characteristics. It is possible to identify the some of the currently disturbed by looking at where the person resides in the jail and others by looking at treatment reports. Aside from the difficulty in reporting in terms of standardized units no effort is made to monitor the number of past and current emotionally disturbed people in jail. This is so even though there is widespreaa acknowledgment that past and present emotionally disturbed people may be mis l placed in the jail. Although money is the usual reason given for not obtaining this data there is no net saving to society. The most expensive way to care for people is to put them in facilities that are not designed to meet their needs. I Something other than a penal resource is needed (Palermo, Gumz, & Liska, 1992; Torrey et al., 1992). Such programs exist and they are reported to be successful (Center on Crime Communities and Culture, 1996; Mcintyre, 1993; SOlomod, Draine, & Meyerson, 1994; Stovall, Cloninger, & Appleby, 1997). Good quality jobs reduce the rate of incarceration (Uggen, 1999). When there are appropriatr follow-up services for the homeless mentally ill who leave jail the recidivism rate is reduced (Draine & Solomon, 1994).

WHAT CAN BE DONE? Any program designed to keep poor and homeless ex-mental patients out olf jailor to see that disturbed people are not inappropriately locked up are going to have to start with better follow-up by the mental hospitals, better screening by th~ police, and a greater availability of housing and treatment resources. Grob (1 995r says that estimates of the single adult homeless population who have a severe mental illness range from a quarter to a third. Inevitably many ofthese people wi~l end up in jail. .1 If state and local governments would adopt standards for reporting that permit comparison over time and with other agencies and problems there would at leaJt be the basis for planning to take action. It would not prevent agencies from using ak many additional definitions as they want. It will not eliminate the power struggles either. If academicians want to engage in this struggle they should at least own up to it. When matters of scientific investigation shift into the political policy arena ~t becomes difficult to establish what the facts are, let alone determine their import. Einstein once said, "Politics is for the moment. An equation is for eternity"!' Commager (1985, p. 12) used this epigram to support his analysis of the compli l cations that ensue when the rational search for truth encounters the disorder of politics: Now scholars who cannot function without that "illimitable freedom of the human mind" ... are being seduced, deflected, pressured, even drafted into service-not to the ends of science, but to the ephemeral and often squalid ends of particular administrations

When this happens people suffer (Talbott, 1984).


265

A start on the problem can at least be made if government will at least insure that it is possible to describe what is happening. Good data will not solve the problem. Poor data can help make it worse. The jail should not be an "alternative shelter" for the mentally ill.

CONCLUSION Those who are injail because ofhomelessness associated with mental illness are doubly disadvantaged because neither problem gets attention. If they are to be helped both problems must be addressed. Charging sick and homeless people with crimes as a way of getting them off the street means that their real needs are not addressed. The emotional and other problems this person has will seldom be counted in official statistics. To the extent that sick and homeless are placed injail only for this reason their significant contribution to the problem of overcrowded institutions does not reflect an increase in the crime rate but shifts in social policy related to deinstitutionalization, housing, and other services. At the same time the real problems for which they need help are undercounted and it is difficult to argue for resources appropriate to the problems that do exist. To incarcerate the mentally ill, the homeless, and the otherwise sick, who have not committed real offenses, is the most expensive way of handling the problem. Since localities tend to pay for their jails this increased cost also reflects program changes as the Federal government has cut back on such things as housing and community mental health. Communities could save money if they correctly identified the problems people have and met these needs in appropriate agencies. Even though the data reported on in this paper were collected 15 years ago things haven't improved in the Baltimore City Jail (Siegel, 1999). The relationship between homelessness, mental illness, and jail is not more widely examined because it is not in the interest of the agencies concerned. For example, even though the higher the welfare benefit the less the crime rate neither agency examines the implications of this relationship (Hannon & Defronzo, 1998). Welfare departments are more interested in showing that welfare reform is working. Correctional agencies are more interested in the resources that come their way because the imprisonment rate is rising. Social scientists under the need to specialize have usually looked at one institutional area and not institutional interrelationships. What can be done is to pay more attention to the standards by which evidence is accepted. In a careful examination Link, Monahan, Stueve, and Cullen (1999) conclude that relatively few mental patients are violent and that concern about the violence of mental patients is related more to their image than to actuality. Lipton and Hershaft (1985) report that dubious medical findings are widely accepted because of(l) an abundance of medical literature that is not carefully read, (2) poor editorial reviews, (3) methodological defects, (4) dishonesty, and (5) lack of social

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responsibility. But even paying attention to the tools of the craft is not easy. In a litigious society professionals spend a lot of time in defensive practice (Kanigel, 1988). It is difficult for people who work in public bureaucracies to "blow th~ whistle." Coser (1956) and Young (1955) say that when a social scientist goes to work in a public bureaucracy he must work with the problems selected by thos~ he works for. This work usually is designed to preserve the existing institutionJI order. Douglas (1985) calls it a "regularly scheduled obliviousness" and says: Persistent shortsightedness, selectivity, and tolerated contradiction are usually not so much signs of perceptual weakness as signs of strong intention to protect certain values and their accompanying institutional forms (Douglas, 1985, p. 3).

I

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