Tree Branch Breaker

Road Map Shows Route From Punishment to Treatment

by Mark Moran Psychiatric News August 6, 2010
http://pn.psychiatryonline.org/content/45/15/7.1.full

(due to problems with cut and paste, readers may find the above link as being easier to read than the below)

Decreasing inpatient beds and an increasingly punitive approach to deviant behavior, along with greater involvement of legislatures in mandating sentencing, has resulted in a “perfect storm of criminalization.”

A 62-year-old woman making a call from a Washington, D.C., subway pay phone refuses to relinquish the phone to another commuter impatient to use it.

A fight ensues, and the police are called. When approached by the police, the caller begins to yell at them, refusing to leave the premises. She is arrested for disorderly conduct, trespassing, and resisting arrest.

Taken to a hospital, she appears to be hearing voices and expresses the belief that she is “the president.” She initially refuses medication, but after a few days she develops a relationship with one of the nurses who is able to persuade her to begin taking medication.

The incident was recounted in a June 21, 2010, Weblog by forensic psychiatrist Erik Roskes, M.D., on “The Crime Report” at <www> under the title “The Charge: Being Mentally Ill in Public.”

In the report, Roskes—who was the forensic psychiatrist assigned to evaluate the woman's fitness to stand trial—recounts calling the arresting officer and inquiring why the woman wasn't taken immediately to the emergency room. The officer replied, “She wasn't doing anything dangerous. They wouldn't have taken her.”

In his blog, Roskes asked, “What is wrong with our system that a person can be perceived by a police officer as being dangerous enough to require arrest and detention in jail, but not dangerous enough to be admitted to a hospital for treatment?”

It's a question that has long gone unanswered, even as the criminalization and incarceration of people with mental illness has skyrocketed from year to year. A report in May by the Treatment Advocacy Center found that Americans with severe mental illness are now three times as likely to be in jail as they are to be in a hospital (Psychiatric News, June 4).

Roskes is a member of APA's Task Force on Outpatient Forensic Services, whose report “Outpatient Services for the Mentally Ill Involved in the Criminal Justice System”—approved by the APA Board of Trustees in December 2009—outlines historical reasons for criminalizing this population in the last 30 years, reviews evidence regarding the impact of ordinary outpatient services on rates of incarceration of mentally ill individuals, provides an overview of the characteristics of mentally ill individuals in the justice system and the risk for violence, and describes model treatment approaches to those with mental illness involved in the justice system.

And it issues a strident wake-up call to psychiatrists who remain—in the view of the task force—underinformed about this alarming civic trend toward criminalization and underinvolved in responding to it.



Few Know Extent of Problem

“The psychiatric community is becoming increasingly aware of the problems of correctional mental health care,” the report stated. “Few, however, are aware of the magnitude of how many public-sector patients now fall within the domain of the criminal justice system and are destined to receive poor care and follow-up. Nor are most psychiatrists aware that the prison environment is antitherapeutic, engendering maladaptive behavioral patterns that render future care more difficult.... [I]t is no longer possible to believe that problematic patients not served by public-sector psychiatrists are receiving good care in the criminal justice system.”

Past APA President and forensic psychiatrist Paul Appelbaum, M.D., was chair of the Council on Psychiatry and Law when the task force was formed. “Other countries, including Canada and England, are far ahead of the U.S. in recognizing that patients coming out of correctional facilities have particular characteristics and special needs,” Appelbaum told Psychiatric News. “The council requested this report because we believed that it was time for American psychiatrists to think seriously about how best to meet the treatment needs of this growing and often neglected population.”



‘A Perfect Storm of Criminalization’

In an interview with Psychiatric News, Task Force Chair Steven Hoge, M.D., said bluntly, “Correctional psychiatry is the new public psychiatry.”

Hoge, who is director of the Columbia-Cornell Forensic Psychiatry Fellowship Program, said the turn toward criminalization of individuals with mental illness has historic roots involving multiple factors—diminishing availability of public psychiatry beds, an increasingly punitive approach in the “war on drugs,” increasing hostility on the part of a public fearful of mentally ill people and the perceived risk of violence, and greater involvement of legislatures, as opposed to courts and judges, in mandating sentencing.

The result, he said, “has been a perfect storm of criminalization.”

This has happened in the context of a sharp rise in incarceration generally. “If you look at the incarceration curve for the general population, it has gone up from 100 per 100,000 to 900 per 100,000,” Hoge said. “It's extraordinary. The United States has the highest rates of incarceration of any country in the world, including some of the most repressive regimes.

“It's ironic that just as we have been deinstitutionalizing people with mental illness, the society has taken a wholesale turn toward a punitive approach to deviant behavior,” he told Psychiatric News. “We are more likely to charge someone with possession [of drugs] than to try to find a treatment program for someone who is an addict.”

Among the summary conclusions outlined by the task force are the following:

The quality of care in correctional settings varies from nonexistent to adequate. In general, psychiatric care in jails and prisons is fragmented and inconsistent.
For an outpatient-based system to function in providing better care for mentally ill offenders, better access to inpatient beds is necessary.
There is evidence that mandated outpatient treatment may be useful in reducing rates of arrest and incarceration when properly funded and monitored.
Programs must be designed to treat and manage patients with comorbid substance abuse problems and antisocial personality disorder, and outpatient programs must be prepared to address the problems related to chronic disability, unemployment, and homelessness.
Mentally ill women in the criminal justice system have special needs due to high rates of trauma history and PTSD. In addition, many will need assistance in parenting, supporting, and providing care for children.
Models for caring for mentally ill offenders exist in other countries. They may be useful as starting points in designing a system for the United States.
The task force offers four recommendations for the field of psychiatry (see What Psychiatrists Can Do).

“The overall message is that these are our patients,” Roskes told Psychiatric News. “People with mental illness who are involved in the criminal justice system are and should be of interest to every psychiatrist.”

Roskes, who does not stint on criticism of organized psychiatry for failing to be more involved in the issue, said other groups—the National Alliance on Mental Illness, the National Association of State Mental Health Program Directors, the Bazelon Center for Mental Health Law, and the Council of State Governments—have taken the lead in working on alternative treatment approaches to criminally mentally ill people.

He added, “A history of arrest is not the same as a history of violence. I work in a state hospital where two-thirds of our patients are forensic. Clinically they are no different from the nonforensic population except that they have gotten caught. But people are afraid of this population, and that is to our discredit as a field.”

“Outpatient Services for the Mentally Ill Involved in the Criminal Justice System: A Report of the Task Force on Outpatient Forensic Services” is posted at www.psych.org/TFR200921

I agree. ...as a society, we have made that decision.

....but as individual, I do not always agree with society's decision.

I believe that society not only has the right, but an obligation, to provide treatment to those who have a history of being violent to themselves and others.

In this situation, I believe that we shirk our responsibilites under the convenient guise of "civil liberties and autonomy".

...and that we, as a society, could come up with better solutions than we have.

Surely we can develop and refine the options available.

With the advent of advanced psychotropics, I have a hard time believing that the only options are as stark as

Pilgrim State and Willowbrook, as they existed for much of their history http://en.wikipedia.org/wiki/Willowbrook_State_School
http://en.wikipedia.org/wiki/Pilgrim_Psychiatric_Center
http://www.opacity.us/site23_pilgrim_state_hospital.htm

vs.

Letting them suffer a miserable life of delusions in the community, where their illnesses put themsevles, their family members and the larger community at risk.

vs.

the present "bug" units of the Criminal Justice system

In this situation the individual was permitted to damage an estimated 200k in city property before concerned citizens and authorities acted on the situation.

Seemingly, no value was assigned to the damage he was permitted to do to himself or his family.

I believe we, as a society, are smarter than this. ....and that we can come up with better solutions that will simultaneously allow us to create choices that are not as stark. We can create treatment options that provide a better balance than our present polarized struggle, which using your definitions, pits

"autonomy"

VS

"benificence"

We can change the struggle and the debate.
Can't the pendulum stop swinging so wildly?
Surely there is a middle ground that would not cause the pendulum to constantly whack the opposing sides of the grandfather clock.

In otherwords, I believe that in the vast majority of the time, a system based on consent is superior to one based on coercion. Most folks are not ill to the degree that they are a danger to themselves, and I am not suggesting that we return to the days of having the ability to hospitalize our most annoying relative.

But, what do we do with Steve?

I'm an optimist. I think we can do better.

I am familiar with the terms and the debate.

I am of the perspective that the debate should be always ongoing, because it should reflect both the advances in treatment AND abuses by providers as they occur.

It's all about that pendulum analogy. The media and courts make it swing from side to side. ....Whenever folks like me request moderation, we are told that we:

endorse or mitigate the abuses of Willowbrook/Pilgrim State

and/or

have no respect for Autonomy and consent

and/or

want people with mental illness to have a complete "pass" on being held accountable. (the opposite of Criminalization)


In this case, I am pleased the guy is finally getting the care he needs.

....but yea, I think we could improve on this whole routine. Who knows, in many instances we might be able to prevent the need for inpatient care. ....one easily could argue that is what Steve is receiving now.

While I believe a system based on consent has its problems, I also believe that 99.99% of the time, it is better than one based on coercion.

Steve is among the 00.01% of the population.
In my idealism (which others will doubtlessly call "naivete"), I believe we can do better.

Is Steve still in custody? i've seen some branches on the ground along underhill and on dean - hope he's not back to it.

smw380 wrote: Is Steve still in custody? i've seen some branches on the ground along underhill and on dean - hope he's not back to it.

Those were from the garbage trucks today

OpossumQueen wrote: He's made the news : /

http://www.nypost.com/p/news/local/brooklyn/tree_branch_madman_is_sent_to_psych_dLbLRsqXTMIsCHcm45sGHL?CMP=OTC-rss&FEEDNAME=

"after a reign of terror that caused about $200,000 in damage to street trees"

Pretty pathetic that the Post is citing the Brooklyn Paper as a source. Weak journalism.

An article about the number of mentally ill people served by Rikers, and the revolving door caused by a lack of outpatient treatment..

http://www.gothamgazette.com/article/searchlight/20100929/203/3374

Unfortunately, the article does not point out that this trend is occuring as more inpatient psychiatric beds are being closed.

....The only way to obtain treatment for the seriously mentally ill is quickly becoming via the correctional system.

I received it as well. Based on the article in the NY Post referenced by OPPQueen, I predict it means that he is now a ward of the Office of Mental Health, and no longer the Department of Corrections.

The Department of Corrections has several large psychiatric facilities on Rikers, and contracts with HHC hospitals for short term care. One has to be in need of long term care to be transferred to OMH.

Here are the various possibilities we had after his arrest:

1. The system would dismiss the charges and release him with no MH aftercare.

2. Steve would be found competent and either plead guilty or be found guilty. He'd spend sometime in Rikers, perhaps getting a little MH care. He'd probably be released with a metrocard and no aftercare.

3. Steve would be found incompetent initially and spend time in the HHC hospital getting better via the use of heavy dosages of psychotropics. His hospital time would count toward his time served and then be released WITH mandated aftercare.

4. Thru a process involving both the Criminal Court system and the Supreme Court system (aka Civil Court) Steve is deemed not merely temporarily incompetent, but deemed to be in need of long term, involuntary inpatient care. The NYC Department of Corrections convinces the Office of Mental Health that they are the ones to care for him. He needs to get well enough to get rid of Supreme Court before he can address the charges pending against him in Criminal court. At that point, Criminal Court can either dismiss the charges or sentance him. .....when he is eventually released, it'll be with aftercare.

Clearly, we are pursing a version of #4.

So this is good news then? :scratch:

This depends on your point of view...

a. Had he been released after 1 or 2, it seems likely he would have continued to wander the streets suffering from delusions. Characters like me would try get him community care; care that he would have the right to refuse. If he resumed destroying trees, I would resume trying to have him brought to the ER or arrested.

b. Had he been released after 3, he would have been required to participate in AOT. Characters like me believe that AOT and ACT would have been overwhelmed by his needs, simply on the basis that he has now been an inpatient for several months and a team of State appointed psychiatrists feel he is not only not ready for the community, but not ready to stand trial. [Note inherent bias: State Psychiatrists and/or his lawyers would quickly release him to criminal court system if they felt he was competent]

c. Once he is released after 4, he will participate in the aftercare described above. Clearly, #4 is what we should discuss....

--If you believe that the OMH and Civil Court systems have enough safeguards in place to prevent an endless incarceration under the guise of mental health, you like #4.

---However, if you believe psychiatry in OMH is complete BS, you likely view him as having to serve two sentances (One for being mentally ill, another for killing trees) and you are understandably concerned about his human rights. if someone you love has a mental illness, #4 worries you.

---Finally, if you are the variety that believes he would have never been able to get inpatient care via another means (such as the ER) and has desperately needed it for years, you really don't care that he got it via the criminal justice system. You likely feel that until we get a better system, this "end is justified by the means". #4 sucks, but sucks less than anything else.

Putting concerns about two sentances aside for a moment, I will state that I believe that OMH provides better care to its patients than DOC is able to provide to its mentally ill inmates.

[My opinion is shared by a well meaning, overworked, Deputy Warden who runs one of the mental health units on Rikers. To paraphrase past conversations I have had with him: "They don't give us what we need to help these guys. Why are they paying us to do this over and over without the support of OMH and community based care? What do they think my guys and a once a week psychiatrist are going to accomplish? This is stupid."]

To make a long story short:
Yes, my faith in this very flawed system allows me to believe that in this circumstance we have obtained the best our system has to offer.

If there is a God, may he/she help us all.

MOD NOTE: discussion of religion and morality split off to its own thread here:
http://brooklynian.com/forums/viewtopic.php?t=59996

Continue discussion of Steve Maynard in this thread.

Thanks for the update and glad NYPD is finally doing this.

I wish you the best of luck improving mental health policy and of doing a better job than your predecessors. Talk to any front line staff and they'll give you an earful. The disconnect between theory and reality remains gigantic.