Closing state mental hospitals in Massachusetts: policy, process, and impact

Triple Stigma: Persons with Mental Illness and Substance Abuse Problems in the Criminal Justice System

This article offers a review of the literature that exists on individuals with dual diagnosis and discusses policies creating the trajectories for mentally ill individuals with substance abuse problems and their community reentry after involvement with the criminal justice system. For this analysis, basic comparisons are made across mentally ill individuals involved with the criminal justice system and the dually diagnosed portion of the population and an analysis of the current trajectory and post-incarceration disposition of the dually diagnosed group. The differences between offenders with mental illness and the dually diagnosed are pronounced. The dually diagnosed are more likely to be serving sentences related to their substance use, to be homeless and violate probation after release, and recidivate to correctional custody. An examination of substance abuse histories, short-term community outcomes, and service trends 3 months postrelease suggests public policy and social service directions.

Preventing Persons Affected by Serious Mental Illnesses from Obtaining Firearms: The Evolution of Law, Policy, and Practice in Massachusetts

A history of commitment to a mental health facility disqualifies applicants for gun licenses. Identifying such a history has become increasingly complex as the locus of confinement has become more diversified and privatized. In Massachusetts, prior to 2014, the databases used to identify individuals who would be disqualified on such grounds had not contemporaneously matched the evolution of the state's mental health systems. A survey of Massachusetts police chiefs, who, as in many jurisdictions, are charged with certifying qualification, indicates that some have broadened the scope of their background checks to include the experience of their officers with respect to certain applicants. The survey identifying these patterns, conducted in 2014, preceded by one month significant legislative reforms that mandate the modification of the reporting into a centralized database commitments to all types of mental health and substance use facilities, thus allowing identification of all commitments occurring in the state. The anticipated utilization of a different database mechanism, which has parallels in several other states, potentially streamlines the background check process, but raises numerous concerns that need to be addressed in developing and using such databases.

The changing role of the state psychiatric hospital

State hospitals were once the most prominent components of U.S. public mental health systems. But a major focus of mental health policy over the past fifty years has been to close these facilities. These efforts led to a 95 percent reduction in the country's state hospital population. However, more than 200 state hospitals remain open, serving a declining but challenging patient population. Using national and state-level data, this paper discusses the contemporary public mental hospital, the forces shaping its use, the challenges it faces, and its possible future role in the larger mental health system.

Patterns and prevalence of arrest in a statewide cohort of mental health care consumers

OBJECTIVE

Although criminal justice involvement among persons with severe mental illness is a much discussed topic, few large-scale studies systematically describe the patterns and prevalence of arrest in this population. This study examined rates, patterns, offenses, and sociodemographic correlates of arrest in a large cohort of mental health service recipients.

METHODS

The arrest records of 13,816 individuals receiving services from the Massachusetts Department of Mental Health from 1991 to 1992 were examined over roughly a ten-year period. Bivariate relationships between sociodemographic factors and arrest were also examined.

RESULTS

About 28 percent of the cohort experienced at least one arrest. The most common charges were crimes against public order followed by serious violent offenses and minor property crime. The number of arrests per individual ranged from one to 71. Five percent of arrestees (roughly 1.5 percent of the cohort) accounted for roughly 17 percent of arrests. The proportion of men arrested was double that of women. Persons 18 to 25 years of age had a 50 percent chance of at least one arrest. This rate declined with age but did so unevenly across offense types.

CONCLUSIONS

The likelihood of arrest appeared substantial among persons with severe mental illness, but the bulk of offending appeared concentrated in a small group of persons and among persons with sociodemographic features similar to those of offenders in the general population. Data such as these could provide a platform for designing jail diversion and other services to reduce both initial and repeat offending among persons with serious mental illness.

Involuntary outpatient treatment as "desintitutionalized coercion": the net-widening concerns

In American jurisprudence, two justifications have traditionally been put forth to support the government's social control of persons with mental illness: police power and parens patriae. As public mental hospitals became less available as loci in which to exercise these functions, governments sought alternative means to achieve the same ends. One prominent but quite controversial means is involuntary outpatient treatment (IOT). While the concerns about IOT have been myriad, one often alluded to but never documented is that of "net-widening." That is, once IOT became available, it would be applied to an ever greater number of individuals, progressively expanding the margins of the designated population to whom it is applied, despite the formal standard for its application remaining constant. We tested the net-widening belief in a naturalistic experiment in Massachusetts. We found that net-widening did not occur, despite an environment strongly conducive to that expansion. At this time, whatever the arguments against IOT might be, net-widening should not be one of them.

Patterns and prevalence of arrest in a statewide cohort of mental health care consumers

OBJECTIVE

Although criminal justice involvement among persons with severe mental illness is a much discussed topic, few large-scale studies systematically describe the patterns and prevalence of arrest in this population. This study examined rates, patterns, offenses, and sociodemographic correlates of arrest in a large cohort of mental health service recipients.

METHODS

The arrest records of 13,816 individuals receiving services from the Massachusetts Department of Mental Health from 1991 to 1992 were examined over roughly a ten-year period. Bivariate relationships between sociodemographic factors and arrest were also examined.

RESULTS

About 28 percent of the cohort experienced at least one arrest. The most common charges were crimes against public order followed by serious violent offenses and minor property crime. The number of arrests per individual ranged from one to 71. Five percent of arrestees (roughly 1.5 percent of the cohort) accounted for roughly 17 percent of arrests. The proportion of men arrested was double that of women. Persons 18 to 25 years of age had a 50 percent chance of at least one arrest. This rate declined with age but did so unevenly across offense types.

CONCLUSIONS

The likelihood of arrest appeared substantial among persons with severe mental illness, but the bulk of offending appeared concentrated in a small group of persons and among persons with sociodemographic features similar to those of offenders in the general population. Data such as these could provide a platform for designing jail diversion and other services to reduce both initial and repeat offending among persons with serious mental illness.

Short-term outcomes for offenders with mental illness released from incarceration

Using data on 247 offenders with mental illness, this analysis seeks to identify characteristics that distinguish those who are returned to prison or a psychiatric hospital with those who remain in the community. Sociodemographic, mental health, criminal history, and service variables are compared across a range of outcome categories with a focus on those reinstitutionalized and those reincarcerated. Those returning to institutions have somewhat different mental health service and criminal justice histories than the engaged/community group. In particular, the group that is reincarcerated is more likely released from misdemeanor sentences, and the group being released from felony sentences is more likely to be found in a psychiatric hospital after release from correctional custody. These findings have implications regarding the cumulative effects of engagement with the criminal justice system and the process through which persons with mental illness and a criminal history cycle through institutions.

Insurance status and length of stay for involuntarily hospitalized patients

General and private psychiatric hospitals are becoming increasingly common as sites for involuntary hospitalization. Unlike the public facilities that these settings are supplanting, these hospitals must pay strict attention to issues associated with reimbursement, insurance status, and managed care. This article examines the effects of insurance status on length of stay for involuntarily hospitalized patients in general and private hospitals in Massachusetts. Using a two-stage sampling procedure, data on episodes of involuntary hospitalization were gathered and assessed using multiple regression. The primary effect was found between patients with Medicare, who had the longest stays, and individuals who were uninsured, who had the shortest. The data raise concerns that warrant closer scrutiny on the part of administrators and clinicians.

A systemic and value-based approach to strategic reform of the mental health system

Most writers now recognize that mental health policy and the mental health system are extremely resistant to real changes that reflect genuine biopsychosocial paradigms of mental disorder. Writers bemoaning the intransigence of the mental health system tend to focus on a small analytical level, only to find themselves mired in the rationalities of the existing system. Problems are acknowledged to be system-wide, yet few writers have used a method of analysis appropriate for systemic problems. Drawing upon the General System Theory (GST) analytical perspective, this article advances a systematic approach to understand the mental health system and to facilitate the development of reform strategies that recognize the system's complexity and changing nature. The article first discusses the failure of major reform efforts in the mental health system and the limitations of mainstream analysis of mental health politics and policies with respect to the objectives of analysis and reform. This article describes how systems thinking has thus far influenced the study of the mental health policy and politics system, and argues that a systemic perspective is profitable for reconceiving the mental health system, enabling a fresh basis for the development of reform strategies. The mental health system should be seen as a social system influenced by larger political and economic dimensions, not just as a 'delivery system' scientifically constructed by neutral experts. Furthermore, the policy planning process should be viewed as part and parcel of a mental health system modeled as complex and dynamic. The systemic perspective outlined here should help both to clarify the value-based objectives that we hold for the system and, consequently, to plan for the strategic reforms that have so far eluded us.