Appropriate Treatment for Incarcerated People with Schizophrenia - Episode 6
Peter Salgo, MD: Are criminal justice and law enforcement professionals getting the proper training? If not, what should that training look like?
Nneka Jones Tapia Psy.D: Some law enforcement agencies are getting the right training. There’s a model law enforcement training called “Crisis Intervention Training” [CID]. It was developed in Memphis, Tennessee in the late ‘80s. At the crux of it is the collaboration between law enforcement, mental health agencies, and the community because it takes the establishment of an ecosystem to support the individuals with schizophrenia. It’s a 40-hour training schedule.
We talked about how many families have disengaged and how we bounce people from the criminal justice system into the community. It really does take a village to develop this comprehensive model of care. But this Crisis Intervention Training teaches law enforcement all about mental illness—the different types—and where to take individuals. They work hand-in-hand with the mental health community so they can drop them off at one of those centers in the community to have an assessment.
Mauricio Tohen, MD, DrPH, MBA: In the May issue last year of the American General of Psychiatry, we published a paper in collaboration with the University of New Mexico Department of Psychiatry and the Albuquerque Police Department. The clear conclusion was that cooperation was the only solution.
Nneka Jones Tapia Psy.D: Yes.
Mauricio Tohen, MD, DrPH, MBA: Another important factor, besides training, is communication. Every time the officers bring a patient to the Psychiatric Emergency Services, it’s an opportunity for training and conversation. The best information that we receive about a patient’s condition is through collaboration.
Judge Steven Leifman: Let me give you an example of how successful it can be: we have the largest training school of CIT officers in the United States, and I have over 6000 police officers in my community alone; all 36 departments are trained—and between them, over the past 8 years, the 2 largest agencies handled 83,427 mental health CIT calls and made only 149 arrests.
The arrests in Dade County, Florida, as a result of these programs went from 118,000 per year to 56,000. We closed a jail, which is saving around $12 million a year; it’s been closed for 6 years, garnering $72 million of real savings into my county. People didn’t get shot or hurt, police officers didn’t get injured, and the jail audit was cut in half. These programs work, but it’s not enough to train police officers. You also have to train the entire legal system, which involves a lot of politics.
Prosecutors are elected and they understandably worry about protecting public safety. There’s a lot of misinformation and they think we have to lock up people who are mentally ill. What they don’t understand is that these people they’re so concerned about are released from the correctional facility 98% of the time. The choice is: Do we release them with or without treatment? If we’re going to release people, they need to be released with a seamless system of care.
Richard Jackson, MD: What’s important is where these people are going to obtain treatment, because the primary prevention is keeping them out of interaction with law enforcement. When we see every State has been closing programs for patients that often don’t have better means of treatment, and we see that the correctional facilities are our largest inpatient facilities of psychiatric programs. We’re certainly going in the wrong direction.
Judge Steven Leifman: That’s the great irony here, because it’s not an entitlement to get cured in the community but it is, inside the correctional facility, as we’ve seen with these massive increases over the past 10 years of mentally-ill utilizers. What the States are doing is taking the funding from the community mental health system and diverting it to the correctional mental health system. They’re making access more difficult in this system and pushing more people into the other.
Mauricio Tohen, MD, DrPH, MBA: To my previous point: patients get treatment in the correctional system and then they’re discharged and treatment stops—they get rehospitalized.
Peter Salgo, MD: In my untutored perspective, I maintain the decision that people cannot be involuntarily committed because they look “crazy” on the streets. The total number of folks hasn’t changed as a percentage of the community.
Judge Steven Leifman: Correct.
Peter Salgo, MD: If you squeezed down on this side, that side’s going up.
Nneka Jones Tapia Psy.D: That’s right. In almost every state in this country the largest mental health institution is the correctional system.
Richard Jackson, MD: The problem is not the incorrect commitment laws, but not having treatment facilities to treat them.
Peter Salgo, MD: Whether it’s in the correctional facility or not—deprivation of treatment should not be an option.
Judge Steven Leifman: Many people will voluntarily take treatment. You need to reserve those laws for people that are incredibly resistant to the treatment system. The problem is, as has been mentioned, we don’t have an adequate system of care in the community—they’re not funded appropriately, using inadequate practices and medications, and giving wrong diagnoses. People consequently end up as defaults in our system.
Peter Salgo, MD: If you take a look at television, which is where a lot of folks seem to get their impressions of the mentally ill, the stereotypical image is that of a mentally instable person threatening a police officer with a weapon; the law enforcement agent is faced with a second-by-second decision, and violence typically ensures—often with poor outcomes for the mentally ill. The scenario is deeply embedded in American culture.
Judge Steven Leifman: It is wrong. What usually happens is the officer isn’t trained and they inadvertently escalate the situation where deadly force becomes necessary—it’s everything that happens beforehand. If you have someone who’s paranoid, sometimes they’re having what we call these ideations where the government is out to get them. A law enforcement officer shows up in a uniform, and they begin playing into their paranoia. They’ll say and do things that will make the person go after them in a way they wouldn’t if the officer hadn’t approached them inadvertently.
Mauricio Tohen, MD, DrPH, MBA: There’s a term that did not exist 10 years go, which is “suicide by cop.” We have individuals who are suicidal, and one of the methods they use is to put themselves into a situation in which they can be shot. I’m sure this is a big challenge for officers.
Judge Steven Leifman: None of us are immune to these illnesses. We know that trauma is a major contributor to these serious mental illnesses. There was a fascinating study that was conducted last year which found that law enforcement officers get 6 to 9 times more cortisol per day than non—law enforcement officers.
Peter Salgo, MD: Endogenous cortisol—their bodies are manufacturing it.
Judge Steven Leifman: Correct, because they’re in stressful situations. We get, in Miami, about 150 officers a month call my coordinator for their own personal mental health issues.
Peter Salgo, MD: Really?
Judge Steven Leifman: Yes. It’s a huge problem. It explains why last year more police officers died from suicide than in the line of duty. They have some of the highest suicide, domestic violence, substance use, and divorce rates because of all the traumas they face. We need to be treating the whole system.
This also contributes to a portion of the shootings in the community because the officers become doubly stressed while involved in these situations with the mentally ill, and they may overreact to a situation.
Transcript edited for clarity.