Administration and Policy in Mental HealthVol. 25, No. S.January 1998

COUNTY MENTAL HEALTH DIRECTORS'PERSPECTIVES ON FORENSIC MENTAL HEALTHDEVELOPMENTS IN NEW YORK STATE

Marjorie Rock and Gerald Landsberg

Adults who suffer from serious mentalillness are increasingly becoming involvedwith the criminal justice system (Lamb &Grant, 1982; Lamb, Weinberger, & Reston-Parham, 1996; Teplin, 1983). They arearrested and jailed at disproportionallyhigher rates than the general populationwith the result that community correc-tional institutions, the jail and the policelockup, have become the nations new asy-lums. Upon incarceration, this populationis likely to have longer lengths of stay, lessaccess to alternative incarceration/deten-tion programs, limited access to critically

Marjorie Rock, Dr.P.H., M.S.W., is Associate Pro-fessor, and Gerald Landsberg, D.S.W., M.P.A., isAssociate Professor and Chair of Social Policy;both at Ehrenkranz School of Social Work, NewYork University.

An earlier version of this paper was presentedat the Academy of Criminal Justice Sciences An-nual Meeting, Las Vegas, NV, March 1996. Theauthors are grateful to Nadene Salzman andElizabeth Liebeskind, students at EhrankranzSchool of Social Work, for their assistance withdata collection and analysis.

Address for correspondence: Marjorie Rock,Dr.P.H., Ehrenkranz School of Social Work,New York University, 1 Washington SquareNorth, New York, NY 10003.

needed treatment programs, and face in-creased personal risk (i.e., suicide) anddeterioration in their clinical condition(Craig & Kissel, 1986; National Coalitionfor Jail Reform, 1984; New York State Fo-rensic Task Force, 1991; Teplin, 1984).

Prevalence rates for mental illness forthe incarcerated population vary by typeof incarceration and by study methodol-ogy, with a range from less than 10% to ahigh of 25% (in New York City) (Adams,1988; Cecire, 1992; Teplin, 1984, 1990).Steadman (1995) based on Teplin's calcu-lations (Teplin, 1994), indicates that ap-proximately 6.6% of U.S. jail detaineeshave a serious mental illness. These ratesdo not include persons with serious men-tal illness involved with probation, alterna-tives to detention, and/or the parole sys-tem.

New York State is no exception with re-spect to the criminalization of mental ill-ness. The local correctional system is com-prised of 85 county and municipal jailsand over 300 police lockups. On any givenday, as many as 700 persons are detainedin police lockups and over 32,000 peopleare incarcerated in local jails (New York

327 © 1998 Human Sciences Press, Inc.

328 Administration and Policy in Mental Health

State Office of Mental Health, unpub-lished manuscript, 1995). Accepting a lowprevalence rate, i.e., 6%, would mean thaton any given day 2,158 persons with men-tal illness are detained/arrested in com-munity correctional facilities in New YorkState. Actual numbers may be muchgreater.

A significant problem is that the co-dis-ordered population (the mentally illchemical abuser) is becoming more evi-dent at public mental health facilities(Teplin, 1990, 1994). Yet this population iseven less likely to be treated in the publicmental health system and is more likely tobe seen as "mental health system failures"(Ridgely, 1991). Research indicates that itis the MICA client who represents a signifi-cant percent of the mentally ill confinedin jails. Abram and Teplin (1991) suggestthat this population may represent 70% ormore of the mentally ill offender popula-tion.

The New York State Office of MentalHealth is responsible for planning and ad-ministering services for New York Stateresidents with a mental illness. It dis-charges this responsibility through the Bu-reau of Forensic Services. In the fall of1989, a Forensic Task Force was estab-lished, comprised of state and local offi-cials from the criminal justice and mentalhealth systems, consumers and familymembers. Its mission was to identify thebarriers and feasible resolutions to thosebarriers which prevent persons with men-tal illness involved in the criminal justicesystem from appropriate and accessible le-gal alternatives and mental health services(New York State Office of Mental Health,1991).

This article summarizes the Task Forcefindings and recommendations. The au-thors report on a statewide survey ofcounty mental health directors. The pur-pose of the survey was to examine countydirectors' perceptions of the implementa-tion of forensic initiatives sponsored bythe State Office of Mental Health in re-sponse to the Task Force Report.

TASK FORCE FINDINGS

The 1991 Forensic Task Force Reportnoted a plethora of issues and problems,and made numerous recommendationsfor change. Some problems noted were:

• Forensic clients throughout the crimi-nal justice system are seriously under-served in terms of mental health ser-vices.

• Even where some mental health ser-vices are provided, the range of neces-sary service is limited.

• The planning process for this popula-tion is inadequate and fails to inte-grate the needs of both the criminaljustice and mental health systems.

• There is limited to no coordinationbetween mental health and criminaljustice staff. Responsibilities and com-munications between the systems areoften unclear.

• There is a lack of family participationand input into planning for servicesand discharge options.

TASK FORCE RECOMMENDATIONS

The major Task Force recommenda-tions covered the following areas: planningfor appropriate services; coordination be-tween mental health and criminal justiceagencies; funding and resource development,and training activities.

TASK FORCE IMPLEMENTATION

In response, the State Office of MentalHealth instituted reforms that includedadditional funding for model programsand the development of training initia-tives.

Training developments focused on thestrengthening of the Suicide PreventionCrisis Intervention Project, begun in re-sponse to the growing rate of suicides injails and lockups in 1985. This project ini-tially included the development of suicideprevention intake screening guidelines for

Mar/me Rock and Gerald Landsberg 329

jail and lockup staff, an 8-hour training pro-gram and policy and procedure guidelinesfor county jail, police lockup and mentalhealth agency staff. New efforts include up-dated training components in crisis inter-vention (for criminal justice staff) and atraining component for local mental healthstaff serving the forensic population.

A second training and coordination ini-tiative was the Police Mental Health Coor-dination Project. Recognizing that policeofficers are often the first responders to amental health crisis in the community, a14-hour curriculum for police recruits wasdeveloped and implemented. This in-creased the statewide police training re-quirements from 3 hours. In New YorkCity, a 38-hour training program had beeninstituted for members of the EmergencyService Unit of the New York City PoliceDepartment in 1985. Representatives ofthe New York City Police and MentalHealth Departments served as members ofthe SOMH Committee, to develop theprogram, with family members and repre-sentatives of other criminal justice andmental health agencies.

Coordination activities involved fundingseveral counties, including New York City,to develop linkage projects between thepolice and the local mental health system.Primary linkage activities were to occur be-tween the police and psychiatric emer-gency room staff, since that is a criticaljuncture in the decision to arrest or treat.

A third follow-up to the Task Force wasthe development of mental health "alter-native to incarceration" programs in sev-eral counties. Activities varied by county,although all were supported by the NewYork State Office of Mental Health.

METHOD

In 1995 the authors conducted a state-wide survey of county mental health direc-tors in order to assess the impact of theforensic mental health projects on the lo-cal mental health and criminal justice sys-

tems. There are 55 local counties and NewYork City which is composed of five bor-oughs but counts as one local governmen-tal unit. The counties are divided into fivestatewide regions by the Office of MentalHealth, each region having (at the time ofthe survey) an SOMH Regional Office.The Regions are: Western (18 counties),Central (18 counties), Hudson(16 coun-ties), Long Island (2 counties) and NewYork City.

A questionnaire, consisting of 20 ques-tions in Likert format and five open-endedquestions, was mailed to all county mentalhealth directors. The time period coveredwas 1990-1995.

The first 10 questions related to generalimpact of the state initiatives with respect tomental health services in community cor-rectional facilities, linkages to police, publicdefenders, DA's office, alternative to incar-ceration (ATI) services, and services to pa-rolees. The five-point Likert scale rangedfrom significantly increased to significantlydecreased. The next 10 questions referredspecifically to the impact of the Suicide Pre-vention/Crisis Intervention Project. The fi-nal four questions were open-ended andconcerned services to MICA clients, sex of-fenders, and about planning/coordinationactivities. The final question concerned fu-ture needs.

The overall response rate was 78%. Therange of response rates varied by regionfrom 66% to 94%, however on Long Is-land, composed of two large counties, onlyone county responded. The omission ofone county's data may skew the results inthis region.

RESULTS

For clarity in analysis, variables have beencombined into the following categories.

Services to the Forensic Populationin Localities

Questions in this category include ser-vices to county district attorneys, public de-

330 Administration and Policy in Mental Health

fenders, police, probation, alternative to in-carceration (ATI) programs, and changesin services in jails and lockups.

Overall, services in this category wereseen to have increased, with some varia-tion by region and county within each spe-cific question. Only 25% of the respond-ing counties in the Western and CentralRegion reported an increase in services tolockups, but services to jails in almost allcounties were reported to have increased.In this broad category, most regions re-ported some increase in services to the po-lice, to probation, and an increase in ATIprograms for this population.

Services for Parolees

Although parolees are part of the com-munity, because of their history of incar-ceration in prison and the nature of thecrime, they have been categorized sep-arately. The response to this question wasmixed. New York City reported an increasein services for parolees, while the Western,Central, and Hudson regions reported nochange in service levels. The one respon-dent county on Long Island indicated thatthere was a decrease in services to thispopulation.

It should be noted that during the surveyperiod the State Office of Mental Healthceased the direct provision of mental healthservices to parolees. In many counties therewas an effort to "mainstream" the paroleepopulation into community clinics. How-ever efforts were uneven, and problems of-ten beset the integration of this populationinto community programs.

Impact of the Suicide PreventionProject on Services

Results generally showed an increase inservices statewide in these areas with thefollowing notable exception: fewer countiesreported increased services in lockups, how-ever almost all counties reported increasedservices in jails. It is important to note thatmany of the upstate counties are quite smalland have few jail cells and fewer lockups.Persons detained in lockups are usually

quickly released, or more formally incarcer-ated. Overall, it appears that the SuicidePrevention Project has had a positive impacton services.

Perceptions of the county mental healthdirectors can be compared to data gath-ered by the Bureau of Forensic Serviceswith respect to the Suicide PreventionProject. SOMH reports that the overallnumber of suicide in jails in all areas ofthe State with the exception of New YorkCity, have significantly decreased. In 1984,unpublished data gathered by the Bureauof Criminal Justice indicates that therewere 11 jail suicides (based on a jail popu-lation of 7,450), while in 1990 there were6 jail suicides based on a jail population inexcess of 12,000 (Paravati, 1991). TheState Office of Mental Health further re-ports that in 1991 there were seven sui-cides in the upstate jails and at the end ofDecember, 1992, there were five suicidesin jails. This was occurring as the popula-tion in jails was increasing (State Office ofMental Health, 1995).

Training and Linkage Activities

Training initiatives, including policetraining, jail and lockup staff training andlinkage activities questions were com-bined. In every region, there was a signifi-cant increase in these activities. This in-dicates that these state initiatives weresuccessful, a significant objective of the Fo-rensic Task Force.

Planning Activities

This question asked whether Local Gov-ernment Plans for mental health servicesincluded a section dedicated specifically tothe forensic population; another impor-tant recommendation of the Task Force.All regions indicated that they now have aspecial section in the Local GovernmentPlan detailing services to this population.

Resources

This question asked about the difficultyof finding resources for this population.Resources include funding and staff. The

Marjorie Rock and Gerald Landsberg 331

upstate regions (Western, Central, andHudson) reported difficulties. New YorkCity reported decreased difficulty, and theLong Island county responding reportedthat resources remained about the same.With respect to staff, only one region re-ported an increase in staff dedicated tothis population (Western). Long Islandnoted a decrease in staff, and Central,Hudson, and New York City reportedabout the same staff availability.

Special Services

This question asked about the adequacyof services to the MICA forensic popula-tion and about service access for sex of-fenders. Not surprisingly, most regions re-ported that adequate services for thispopulation did not exist. Specifically, re-sponses to access for services for sex of-fenders was mixed, with some regions(Central, Western, and Hudson, all up-state regions), reporting access while LongIsland and New York City reported no ac-cess.

Future

The final question asked respondents toindicate whether they felt that in the next5 years the need for forensic mentalhealth services will increase, decrease, orreflect no change. Unsurprisingly, all re-gions anticipate that the need for theseservices will increase.

DISCUSSION AND CONCLUSIONS

This survey reports the perceptions ofcounty mental health directors on the re-sults of initiatives undertaken by the NewYork State Office of Mental Health with re-spect to the forensic population. The im-petus for these initiatives was drawn fromthe recognition of the increasing criminal-ization of persons with severe and chronicmental illness and the issues this presentsto both the criminal justice and mentalhealth systems.

While the survey's findings cannot begeneralized to other jurisdictions, and no

information from law enforcement andcriminal justice agencies was sought toconfirm results, there are some suggestivefindings.

It appears that several of the recommen-dations of the Forensic Task Force imple-mented by the State Office of MentalHealth have had a significant impact onservices to the forensic mental health pop-ulation in New York State. There is aheightened sensitivity to the needs of theforensic population, and it is particularlyencouraging that localities include thispopulation in their overall planning formental health services. There also appearsto be some attempts at coordination, train-ing, and linkage activities. The increases inservices in the community corrections(i.e., probation, ATI, jails) setting is quiteencouraging as is the decrease in the rateof suicide in the jails, a finding confirmedby State Office of Mental Health data.

The study is suggestive, therefore, thatwith increased attention to the problem,and with the infusion of resources, signifi-cant gains in service to this population canbe realized. It is our hope that decision-makers will concur.

REFERENCES

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Adams, R.D. (1988). Exemplary county mentalhealth programs: The diversion of people with men-tal illness from jails and in-jail mental health ser-vices. Washington, DC: National Associationof Counties.

Cecire, R. (1992). Jail-based mental health servicesin New York City Department of Correction facili-ties. Unpublished report.

Craig, R.T., Kissell, M. (1986). The mentally illoffender: Punishment or treatment. Paper pre-sented at the National Conference of StateLegislators, Denver, CO.

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Lamb, H.R., Weinberger, L.E., & Reston-Parham, C. (1996). Court intervention to ad-dress the mental health needs of mentally illoffenders. Psychiatric Services, 47, 275-281.

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