Civil commitment and arrests. An investigation of the criminalization thesis.

This study examined one part of the criminalization thesis, which holds that the dangerousness standard of reform civil commitment law has led to the frequent arrest of mentally ill persons. It followed a large statewide sample of civil commitment candidates for 6 months through arrest records to observe their number and type of arrests. It found that: ex-candidates were seldom arrested; over half of arrests were accounted for by a few with multiple arrests; the nonviolent and those released were no more likely to be arrested than the violent and those committed; and charges were more often for the less serious offenses, but not predominantly for nuisance offenses [corrected].     

Chronic mental illness and the criminal justice system

A total of 260 family members responded to a survey seeking information about their mentally ill relatives' contacts with the criminal justice system. Reports by family members indicated that the mentally ill relatives were mainly men in their early thirties with a diagnosis of schizophrenia or bipolar disorder; they had had an average of four admissions to a state mental hospital. The majority had been arrested, but only a fifth had been convicted of a crime. Substance abuse and noncompliance with psychiatric medications were significant predictors of arrest. Family members overwhelmingly attributed the arrests to psychiatric crises, and in about half the cases a failed attempt at commitment had preceded the arrest. However, only a minority of the mentally ill relatives were taken to a hospital at the time of the arrest. The findings highlight the need for closer collaboration between mental health specialists and law enforcement personnel.     

Criminal activity among the homeless: a study of arrests in Baltimore

To illuminate the role of criminal activity among the homeless, particularly the homeless mentally ill, the author compared 634 arrests of homeless persons with 50,524 arrests in the general population that were made in Baltimore in 1983. Significant differences were found in the demographic characteristics of the two groups of arrested persons and in the types of offenses prompting the arrests. Among the homeless, those arrested were more likely to be male, white, and over age 45 and to have committed trivial, victimless crimes. Evidence suggests that ostensibly serious offenses such as assault, larceny, and burglary charged to homeless persons tended to involve petty thievery, entry into vacant buildings, and other acts aimed at maintaining subsistence in the absence of housing.     

Incompetency to stand trial. Appropriateness and outcome

Of 85 persons (38% of those found incompetent to stand trial in Los Angeles County in 1983), 92% were currently charged with felonies and 62% with crimes of violence. Eighty-seven percent had a history of serious physical violence against persons and 68% had prior felony arrests. This study indicated that in this jurisdiction, incompetency to stand trial is not being used to divert mentally ill persons, charged with minor offenses, into intermediate or long-term psychiatric hospitalization to circumvent obstacles such as restrictive commitment laws and rapid hospital discharge policies. The lack of adequate postrelease planning and follow-up for most of these chronically and severely mentally ill offenders was clear. Neither the criminal justice nor the mental health system is inclined to take responsibility for their care. Mandatory community treatment on release is recommended.     

Family members' opinions about civil commitment

As part of a survey of 260 Oregon family members with mentally ill relatives, respondents were asked about their experiences with civil commitment and their opinions about proposed modifications in the commitment statutes. Family members typically described their mentally ill relative as a schizophrenic man in his thirties who had had six psychiatric hospitalizations and was currently being treated with medications at a community mental health center. Three-fourths of the relatives had been committed. A majority (57 percent) of the respondents were in favor of mandatory outpatient treatment and medication after involuntary hospitalization but were not enthusiastic about outpatient commitment without hospitalization. Family members also wanted more education about mental illness, more information about the commitment process, and assignment of a professional to help in the commitment process.     

A follow-up of chronic patients committed to outpatient treatment

Data collected in a statewide study of psychiatric patients involved in civil commitment hearings in North Carolina were used to evaluate the effectiveness of outpatient commitment as a less restrictive alternative to involuntary hospitalization. Six months after the commitment hearings, outcome data for patients who were committed to outpatient treatment were compared with outcome data for patients who were released and patients who were involuntarily hospitalized. All three groups comprised patients who were chronically mentally ill, had previously been hospitalized, and had histories of medication refusal and dangerousness. Patients who were committed to outpatient treatment were significantly more likely than patients with the other two dispositions to utilize aftercare services and to continue in treatment.     

Arrest rates among young adult psychiatric patients treated in inpatient and outpatient settings

Within a statewide random sample of 611 young adult patients who received public inpatient, outpatient, and community residential care, 38 percent were found to have been arrested at least once in their adult lifetimes. Thirty-five percent had been arrested for felonies and 18.9 percent for violent crimes. Analyses by five major diagnostic groups showed that patients with a primary diagnosis of drug or alcohol abuse had the greatest overall frequency of arrests and also the greatest frequency of arrests for burglary, offenses against public order such as peace disturbance or loitering, and probation and parole violations. No significant differences between diagnostic groups were found for arrests for violent crimes. Characteristics that predicted which patients would be arrested in the year after receiving mental health services were a greater number of lifetime felony arrests, younger age, being black or a member of another minority group, and more years since first receiving public mental health care.     

Recidivism and use of services among persons with mental illness after release from prison

OBJECTIVE: Despite large numbers of mentally ill offenders in prisons, few studies of mentally ill offenders released from prison have been conducted. This study describes such a population of mentally ill offenders, the postrelease services they received, new offenses they committed, and factors associated with recidivism. METHODS: The authors reviewed electronic files and archived medical charts from the state corrections department to identify mentally ill offenders who left Washington state prisons in 1996 and 1997. Data on the individuals identified were then provided by several public agencies. Summary statistics were computed on subjects' characteristics and postrelease outcomes, and logistic regression analysis was used to identify variables that predicted convictions of new felonies and new crimes against persons. RESULTS: A total of 337 mental ill offenders were identified. Men and women differed with regard to offenses, diagnoses, rates of drug abuse, and use of mental health resources. Although most subjects (73 percent) received postrelease social or mental health services, few received clinically meaningful levels of service during the first year after release. Charges for new crimes or supervision violations were common (70 percent of subjects), but only 10 percent committed new felonies against persons, and 2 percent committed very serious crimes. Youth, frequency of past felonies, and variables such as misbehavior in prison were associated with new offenses. CONCLUSIONS: Whether community mental health treatment affects recidivism cannot be assessed fairly in the absence of higher levels of service during the first months after release. This study also identifies actuarial risk factors that predict new offenses at a level comparable to that of published risk assessment instruments. Commission of less serious offenses that usually precede felonies may provide an early warning of risk for new felonies and an opportunity for strategic intervention. The low rate of serious violence in the community by mentally ill offenders released from prison suggests that the risk of violence may be a weak and potentially counterproductive rationale for community support and mental health treatment of mentally ill offenders.     

The effects of a jail diversion program on incarceration: a retrospective cohort study.

The objective of this retrospective cohort study was to determine whether a jail diversion program significantly reduced the number of days of incarceration over the year following arrest in a sample of seriously mentally ill (SMI) people who had been arrested for a minor crime. Methods: A group of 314 SMI detainees were diverted out of jail and into mental health treatment. They were compared with a sample of 124 people who would have been eligible for diversion but were not diverted. For each group, the authors compared the total days incarcerated in the year after index arrest. Analyses indicated that jail diversion significantly reduced incarceration time during the next year (40.51 versus 172.84 days, p = .0001). However, the effect of diversion differed depending upon the level of criminal charge: diversion significantly reduced jail time only among those who were arrested for more serious offenses. Those arrested for Class D felony and Class A misdemeanor charges and diverted into mental health treatment spent significantly less time in jail in the next year than those not diverted (260 and 110 fewer days, respectively; p = .0001 for both). Those arrested for Class B or C misdemeanors had similar days incarcerated regardless of diversion. These results remained after adjusting for age, race, gender, and diagnosis. This study presents the first evidence that jail diversion may produce positive longitudinal criminal justice outcomes for SMI people. It also suggests that diversion may not reduce incarceration in all sub-groups of SMI people who are arrested for minor crimes.     

APA's model law: protecting the patient's ultimate interests

As a mental health advocate and the parent of a chronic mentally ill son, the author argues for adoption of the provisions in APA's model law on civil commitment. He believes that a shift in mental health law from absolute protection of civil liberty to an emphasis on the ultimate good for an individual will dramatically improve the lives of the seriously mentally ill by ending the deterioration that they currently must experience to receive treatment. The author also discusses the merits of a proposal that would expedite treatment for patients who repeatedly require emergency care.     

Childhood risk factors for criminal justice involvement in a sample of homeless people with serious mental illness

It has been suggested that criminal justice involvement among the homeless, particularly those with mental illness, is largely situational. The objective of this study was to assess, in a sample of homeless seriously mentally ill people, the prevalence of childhood conduct disorder behaviors as a risk factor for adult criminal activity as well as the extent and types of adult criminal justice contact. Data were taken from the national ACCESS program, which conducted extensive baseline interviews with 7,222 homeless seriously mentally ill adults. The interview assessed demographics, childhood risk factors for criminal activity such as conduct disorder behaviors, foster care, and parental abuse, as well as current illness severity and recent criminal justice contact. The 2-month arrest rate in this sample was much higher than national rates (11% compared with 1% annually in the general population). Although most arrests were for minor crimes (10.8%), there were also substantial rates of arrest for major (2.7%) and substance-related charges (2.0%). The prevalence of a history of conduct disorder behavior was also substantial (55% in male subjects, 40% in female subjects), and conduct disorder was a strong predictor of recent criminal justice involvement, even after controlling for other predictors of arrest (odds ratio = 1.76 for major crimes, 1.49 for minor crimes, and 1.98 for substance-related crimes). Recent literature has criticized a trend to criminalize homeless mentally ill persons for attempting to get needed food, shelter, or medical attention. However, these data indicate that at least some proportion of arrests in this population are of people who have been exhibiting antisocial behavior since early adolescence, and that early antisocial behavior is a strong predictor of all types of recent arrests in this population.     

Violent crime arrest rates of White House Case subjects and matched control subjects

White House Case subjects typically are schizophrenic patients who have been psychotically preoccupied with a prominent political figure. The authors report the arrest rates for murder, aggravated assault, other assault, and robbery among 192 male White House Case subjects 20-59 years old who were discharged from civil commitments in the early 1970s. These rates were compared with those for the same crimes in a random matched sample of arrested subjects and with the general population arrest rates. When rates were covaried for prior violent crime arrests, White House Case subjects with prior arrests had a significantly higher rate of total posthospitalization violent crime arrests than the matched control sample.     

Outpatient commitment for "revolving door" patients: compliance and treatment

This paper describes the use and effectiveness of outpatient commitment in inducing compliance with treatment among chronically mentally ill "revolving door" patients, those who recurrently become dangerous and revolve though civil commitment courts as well as state mental hospitals. Patients characteristics, treatment modalities, and mental health center actions to ensure compliance are described. Comparison of those patients ordered to outpatient commitment with those having other court dispositions (involuntary hospitalization and release) indicates that outpatient commitment induces compliance and leads to treatment maintenance even after the court order terminates.     

Some problems associated with war experience in men of the Vietnam generation

A national sample of men who were of military age during the Vietnam War (n = 1,342) was interviewed six to 15 years after veterans in the sample had left the service. Our findings showed that violent experiences in war were associated with a variety of behavioral and emotional problems. When preservice background factors were statistically controlled, combat exposure showed an association with arrests and convictions (generally for nonviolent offenses), with drinking, and with symptoms of traumatic stress. Participants in atrocities reported more stress symptoms and greater use of heroin and marijuana than did other veterans. Veterans who experienced no combat and did not take part in atrocities, however, did not differ appreciably from nonveterans. Not all men who experienced combat or took part in atrocities reported personal difficulties; almost three fourths of heavy-combat veterans were not arrested after the service. Tape recorded responses of the ten blacks and 18 whites who took part in atrocities suggested that soldiers' emotional responses may have been determined by their ability or inability to dehumanize the victims. Future research would benefit from a closer coordination of clinical and epidemiologic approaches.     

Mental illness and criminal violence

This article examines the relationship between criminal violence and mental illness. Our data suggest that mentally ill persons tend to have an increased risk for committing violent offenses, and that the violent offending by these individuals tends to be recidivistic. Our findings suggest that parents who have both committed violent offenses and experienced a psychiatric hospitalization increase the risk of violent offending among their offspring. We propose the hypothesis that mentally ill parents transmit a biological characteristic which may genetically predispose their child towards criminal violence. Prenatal disturbances during critical periods of fetal development may provide clues regarding the etiology of criminal violence.     

The case for involuntary hospitalization of the mentally ill.

The author examines three points of view on the question of society's right to involuntarily hospitalize a mentally ill individual. The "abolitionists" oppose involuntary hospitalization entirely; the medical model psychiatrists support the need for commitment under certain circumstances and so do the civil liberties lawyers, but by different standards. The author believes that with the current overreliance on the dangerousness standard, we are witnessing a pendular swing in which the rights of the mentally ill to be treated and protected are being set aside in the rush to give them their freedom. He favors a return to the use of medical criteria by psychiatrists, albeit with constructive legal safeguards.     

The use of the insanity defense as a jail diversion mechanism for mentally ill persons charged with misdemeanors

Heightened awareness and concern regarding the large number of mentally ill misdemeanants in jails has led to a search for alternatives to jail and to the development nationwide of jail diversion programs for offenders with mental illness. Two such mechanisms-diversion to civil commitment and the use of mental health courts-are briefly reviewed. In Oregon, however, a rather unique mechanism is used to defer mentally ill misdemeanants (in addition to felons) from the criminal justice system: the insanity defense, with subsequent placement of the individual under Psychiatric Security Review Board jurisdiction. Statistics regarding such use from 1978 to 2001 are provided. The authors compare and contrast this jail alternative with both mental health courts and diversion to civil commitment, and discuss questions related to the feasibility of larger-scale use of this mechanism.     

The Massacre of Mental Patients in Ukraine, 1941-1943

Germany attacked the Soviet Union in June 1941 with a view to advancing on Moscow and, en route, killed all hospitalized mentally ill patients (except those who could be used as laborers), thus liberating the hospitals for military use. The Nazi attitude toward the mentally ill was markedly different from the tradition in Ukraine, which regarded mentally ill individuals as "God's fools," to be treated with charity and humanity. How many psychiatric patients were exterminated during the German occupation is still unknown. The speculation is that the number is in the tens of thousands.     

The historic antecedents to the current polemics on involuntary psychiatric hospitalization

The problem of involuntary psychiatric hospitalization (civil commitment) continues to be divisive and is characterized by an ongoing tension and polemics between those who lay stress on individual liberty and those whose human rights' concerns are in the direction of a paternalistic care for the mentally impaired. This paper reviews in a historical way five areas of acrimony dealing with involuntary psychiatric hospitalization, namely: the standards (who gets committed), the process (who gets to do the committing), the issues of due process and appeal, the right to treatment, and the right to refuse treatment when hospitalized involuntarily. The paper emphasizes that the current problems in the United States and Great Britain have been, to a significant degree, faced and resolved in the historical past.