Systemic, Racial Justice-Informed Solutions to Shift "Care" From the Criminal Legal System to the Mental Health Care System

Community-Based Mental Health Crisis Response: An Overview of Models and Workforce Implications

Communities across the United States are working to improve community-based mental health crisis response, with 1 goal being to reduce criminal legal system involvement among individuals with mental illnesses, behavioral disorders, or mental health crises. Existing and recently developed models can generally be divided into non-law enforcement-based response models and law enforcement-based response models. Wide variation exists in terms of staffing, how response teams are called out or dispatched, hours of operation and immediacy of response, and approaches to crisis resolution.

Approaching Jail Diversion and Prevention of Criminal Legal System Involvement Simultaneously

Despite prolific jail diversion initiatives, people with serious mental illness continue to be overrepresented in the criminal legal system. This continued overrepresentation has led to recent calls to address social determinants of health and criminal risk factors rather than to allocate new resources to diverting people from the criminal legal system. This shift toward prevention by addressing social factors that influence health and criminal legal outcomes should occur alongside a continued focus on diversion to understand what works and for whom. An effective, well-funded, and comprehensive community-based mental health services system could serve as the ultimate intercept for preventing criminal legal system involvement.

Crisis Response Model Preferences of Mental Health Care Clients With Prior Misdemeanor Arrests and of Their Family and Friends

The overrepresentation of people with serious mental illnesses in the criminal legal system has spurred the development of crisis response models to improve or reduce police response to a mental health crisis. However, limited research has explored preferences for crisis response, and no research in the United States has examined the responses desired by mental health care clients or their family members. This study aimed to understand the experiences of people with serious mental illnesses interacting with police and to learn about their preferences for crisis response models. The authors interviewed 50 clients with serious mental illnesses and a history of arrest who were enrolled in a randomized controlled trial of a police-mental health linkage system, as well as 18 of their family members and friends. Data were coded with deductive and inductive approaches and were grouped into larger themes. Clients and family or friends described needing a calm environment and empathy during a crisis. They selected a nonpolice response as their first choice and response from a crisis intervention team as their last choice among four options, highlighting the importance of trained responders and past negative interactions with police. However, they also noted concerns about safety and the shortcomings of a nonpolice response. These findings build understanding about clients' and family members' preferences for crisis response and highlight concerns that are relevant for policy makers.

Competing Concerns in Efforts to Reduce Criminal Legal Contact Among People with Serious Mental Illnesses: Findings from a Multi-City Study on Misdemeanor Arrests

People with serious mental illnesses are disproportionately involved in the criminal legal system, often for low-level, non-violent misdemeanors. This paper examines how decision-makers at different stages of the criminal legal system articulate unique visions of the "best approach" for addressing this problem of over-representation. Focus groups and in-depth interviews were conducted with 94 stakeholders from Atlanta, Chicago, New York City, and Philadelphia to understand how decision-makers from different agencies use and process specific misdemeanor charges in relation to people with serious mental illnesses. Data were analyzed using a thematic approach. The data reveal a series of tensions regarding how criminal legal system stakeholders process people with serious mental illnesses through the misdemeanor system. Three key themes emerged from analysis. The first characterizes the shared commitment across agencies to reducing system contact among people with mental illnesses. The second explores how agencies differ on how to make good on that commitment because of the distinct values and goals they bring to the table. The final theme explores the limits of current approaches to reducing system contact for people with mental illnesses. Findings are discussed in the context of literature on "loose coupling" and the focal concerns framework and demonstrate that decisions about how and when to intervene with people with mental illnesses in the criminal legal system are influenced by the varying orientations, goals, and values of stakeholder agencies. Understanding these core differences is a critical step toward value alignment in strategies to reduce system involvement among people with mental illnesses.

Contexts shaping misdemeanor system interventions among people with mental illnesses: qualitative findings from a multi-site system mapping exercise

BACKGROUND

People with mental illnesses are disproportionately entangled in the criminal legal system. Historically, this involvement has resulted from minor offending, often accompanied by misdemeanor charges. In recent years, policymakers have worked to reduce the footprint of the criminal legal system. This paper seeks to better understand how misdemeanor systems intervene in the lives of people with mental illnesses.

METHODS

System mapping exercises were conducted with misdemeanor system stakeholders from the jurisdictions of Atlanta, Chicago, Manhattan, and Philadelphia. Narrative detail on decision-making and case processing, both generally and in relation to specific types of behavior, including trespassing, retail theft/shoplifting, and simple assault, were coded and analyzed for thematic patterns. Based on the qualitative analysis, this paper offers a conceptual diagram of contexts shaping misdemeanor system interventions among people with mental illnesses.

RESULTS

All four sites have been engaged in efforts to reduce the use of misdemeanor charges both generally and in relation to people with mental illnesses. Decision-makers across all sites experience contexts that shape how, when, and where they intervene, which are: (1) law and policy environments; (2) location of the behavior; (3) expectations of stakeholders; (4) knowledge of mental illnesses; and (5) access to community resources. Law and policy environments expand or constrain opportunities for diversion. The location of offending is relevant to who has a stake in the behavior, and what demands they have. Clinical, experiential, and system-level knowledge of mental illnesses inform a chain of decisions about what to do. The capacity to address mental health needs is contingent on access to social services, including housing.

CONCLUSION

People making decisions along the criminal legal continuum are critical to illuminating the dynamic, inter-related contexts that facilitate and frustrate attempts to address defendants' mental health needs while balancing considerations of public safety. Multi-sector, scenario-based or case study exercises could help identify concrete ways of improving each of the contexts that surround whole-of-system decisions.

Association of Residential Racial and Ethnic Segregation With Legal Intervention Injuries in California

IMPORTANCE

The continued harm of Black individuals in the US by law enforcement officers calls for reform of both law enforcement officers and structural racism embedded in communities.

OBJECTIVE

To examine the association between county characteristics and racial and ethnic disparities in legal intervention injuries.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, cross-sectional study was conducted among 27 671 patients presenting to California hospitals from January 1, 2016, to December 31, 2019, with legal intervention injuries (defined as any injury sustained as a result of an encounter with any law enforcement officer) as identified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes.

MAIN OUTCOMES AND MEASURES

Legal intervention injuries were classified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision external cause of injury code Y35. Expected injury counts were calculated for each county by multiplying statewide median rates of injury per capita for each age-racial and ethnic group, and then observed to expected injury ratios were measured. The association between county injury ratio, percentage of Black individuals, and residential segregation (measured using an index of dissimilarity) was modeled, stratifying by race and ethnicity.

RESULTS

A total of 27 671 patients (24 159 male patients [87.3%]; 1734 Asian and Pacific Islander [6.3%], 5049 Black [18.2%], 11 250 Hispanic [40.7%], and 9638 White [34.8%]; mean [SD] age, 34.2 [12.5] years) presented with legal intervention injuries in California from 2016 to 2019. Observed to expected injury ratios ranged from 0 to 7 for Black residents and from 0 to 5 for White residents. High observed to expected injury ratios for Black residents (408 observed vs 60 expected; ratio = 7) were clustered around San Francisco Bay Area counties and corresponded with a higher proportion of Black residents. High observed to expected injury ratios for White residents (57 observed vs 11 expected; ratio = 5) clustered around rural northern California counties and corresponded with higher mean percentage of residents with income below the federal poverty level and fewer urban areas.

CONCLUSIONS AND RELEVANCE

This study suggests that residential segregation may be associated with increased legal intervention injury rates for Black residents of California counties with a large percentage of Black residents. Reform efforts to address racial and ethnic disparities in these injuries should carefully consider and address the legacy of discriminatory policies that has led to segregated communities in California and the United States.