Reprinted from "Criminal Justice" issue of Visions Journal, 2005, 2 (8), p. 10-12
An alarming trend
Over the past several years the Psychiatric Patient Advocate Office (PPAO) has watched a troubling trend develop—the criminalization of individuals with mental illness. The trend began with the deinstitutionalization of individuals with mental illness— which was, theoretically, a positive step because individuals would have an opportunity to live in their home communities and participate in society. However, deinstitutionalization was not supported with the necessary resources, which has led to: lack of bed based care; lack of appropriate, safe and affordable housing; premature discharges from hospital; inability to gain admission to hospital in some cases lack of adequate income and work opportunities; and inability of individuals to access the services and supports they require. The problems created by this lack of resources have led to a societal environment of intolerance and a “get tough” attitude toward those with mental illness.
In our experience, many individuals who come into conflict with the law are at the low point of their illness. A mental health crisis may begin a journey through a complex and legalistic process, where an individual’s vulnerability and fragility becomes all too evident.
Many of these individuals become disconnected from services, supports, friends and other individuals. Many have relied so heavily on their families over the years and the course of their illness that their loved ones have nothing left to give, are burnt out, and experiencing both caregiver and compassion fatigue.
Some clients may be homeless or have a transient lifestyle due to the cyclical nature of their illness, and may become ‘known’ to the local police due to their mental health histories. In smaller and rural communities, it may be difficult for mental health clients to escape the attention of the authorities. In contrast, individuals with mental illness become invisible in larger urban centres. Large urban communities may afford individuals the anonymity needed to avoid undue scrutiny, disguise symptoms of illness, and help them to blend into the population at large. In each instance, individuals with mental illness may fail to access or be connected to needed and wanted services and supports. Interactions between law enforcement agencies and individuals with mental illness can be positive or negative for the individual, depending upon the attitude and training of law enforcement personnel.
For individuals with mental illness who are incarcerated in a correctional facility, the experience is often both negative and bleak. Many will languish without appropriate mental health care and treatment. Many will be isolated and segregated from other inmates, while some will find themselves harassed and belittled by fellow inmates who take advantage of their vulnerability. An individual’s mental health history may be exploited to demean and dehumanize them. Such mistreatment at the hands of others will not speed recovery or enhance mental health. Indeed, for vulnerable individuals, incarceration will exacerbate symptoms of mental illness and accelerate decline in wellbeing. Continued incarceration often places an individual at risk, at times with tragic results and at the expense of both their physical and mental health.
The correctional system is not capable of providing the level of care and supervision required for this vulnerable population of inmates. Those working in the correctional system have become mental health practitioners by default, as they are now more and more called upon to provide service to individuals with mental illness—but without the appropriate resources to do so. Correctional facilities are not conducive to supporting individuals in their quest for wellness, recovery and rehabilitation.
’’ Many will languish without appropriate mental health care and treatment. Many will be isolated and segregated from other inmates, while some will find themselves harassed and belittled by fellow inmates who take advantage of their vulnerability’’
Many individuals with mental illness who are incarcerated would be better served by receiving care and treatment in a hospital or through communitybased programs that are capable of developing an individualized plan of care and providing a full range of mental health services and supports. Their care must be provided by qualified health practitioners in a health care environment that supports a recovery model of care.
Some individuals who are found unfit or not criminally responsible for their actions are hospitalized in a forensic mental health program, instead of being sent to jail. There are those who believe this system provides a “gold standard of care,” but sadly, this is not the experience of many in care. Some of these forensic programs look more like correctional facilities than hospitals, as they struggle to balance care and treatment versus safety and security. One cannot be at the expense of the other, as that has an immediate impact on the quality of care and life of the individuals receiving care and treatment in the forensic program. The forensic mental health system has also been slow to embrace the recovery model or to explore how the principles of the model could enhance the services they provide and prepare individuals for reintegration into the community.
Additionally, individuals who have been involved in both the criminal justice and the “forensic” system have to deal with the stigma for the rest of their lives, which complicates their recovery and reintegration into the community. For the public, the forensic label generates a negative response, fear and a sense that everyone in the forensic mental health system has been charged with a heinous crime. More education is required to dispel this myth and smooth transition back into the community.
Ontario has taken some positive steps to address and stem the trend of criminalization of individuals with mental illness, including the creation of a mental health court, diversion programs, and investment in community based programs and services. However, issues related to housing, income, employment, education, social and recreational opportunities, access to a full range of community mental health services and supports, and an enhanced standard of living and quality of life remain outstanding.
Reversing the trend
This trend toward correctional ‘solutions’ to mental health problems must be reversed. We must provide access to appropriate care and treatment, including a full range of treatment modalities, not simply view incarceration as the solution.
The first step would be to introduce an independent advocacy and rights protection program for inmates, addressing inequities, power imbalances and the lack of access to resources, and enabling inmates to better defend their interests before the courts. Independent and partisan advocates would assist individuals at all stages of the criminal justice process, ensuring that their rights are protected, linking them to services and supports, and assisting them to meet their individual needs. The advocate would have a unique role, distinct from that of a court support worker or volunteer advocate: they would empower the individual by following that person’s instruction and by providing information about their legal options while ensuring their rights are fully protected.
Education will be a key component of any plan to reverse the trend toward criminalization, with health practitioners, court workers, lawyers, police, the public and families jointly learning about the unique needs of individuals with mental illness and relevant mental health legislation.
And, we require a national action plan that sets standards, provides access to care and treatment, and vigorously protects the rights of individuals with mental illness so that they do not become criminalized and incarcerated. Canadians have an expectation that individuals with mental illness will have their rights protected, will not be marginalized or disenfranchised, and will be given access to appropriate care and treatment. These are not unreasonable expectations in a fair and just society that prides itself in a Charter of Rights and Freedoms that is supposed to guarantee equality under the law for all—including those with mental illness.
As the late Hubert Humphrey, former vice president of the United States, once expressed, a society is judged by how it treats its most vulnerable citizens. We must pause and reflect on how history will judge our efforts and the way in which individuals with mental illness who come into conflict with the law are treated by Canadian society. Will we be found wanting? Or will history recognize our efforts to preserve and support human dignity, autonomy, and human rights as a caring, compassionate and respectful society? The choice is ours. And we need to act now.
About the Author
David is Acting Director of the Psychiatric Patient Advocate Office, an arms length program of the Ontario Ministry of Health and Long-Term Care. The PPAO protects the legal and civil rights of inpatients in Ontario’s current and divested provincial psychiatric hospitals
To learn more about the PPAO visit www.ppao.gov.on.ca