Millions of people across the United States live with a mental illness and/or substance use disorder. These conditions, commonly known as behavioral health (BH) disorders, affect a disproportionate number of people involved in the criminal justice system. More than half of people in prison and more than two-thirds of people in jail have or have had a mental health problem, and more than half of people serving prison sentences and nearly two-thirds of people serving jail sentences met the criteria for drug dependence or abuse.

Prisons and jails are often unequipped to provide the necessary treatment, services, and care to address BH needs. In fact, BH disorders often worsen while people are incarcerated, and people also have trouble accessing services upon release. This increases formerly incarcerated people’s risk of hospitalization, emergency room use, and, ultimately, reincarceration.

Investing in community-based supports and eliminating barriers to accessing services are critical to decreasing the US’s reliance on prisons and jails for addressing BH needs.

Barriers to community-based behavioral health supports are persistent

Research shows community-based and home-based BH treatment helps improve psychiatric symptoms. Though federal, state, and local governments are taking steps to expand access to and improve these treatment options, barriers to quality BH care persist.

Many people with BH disorders cannot access services in their communities because they face an insufficient number of providers, long wait times, prohibitive costs of care, a lack of insurance coverage, and social stigma. Barriers to community services are particularly challenging for Black and Latinx people, who have similar rates of BH disorders as the general population, but have significantly less access to treatment (PDF) because of bias and discrimination in treatment settings, language barriers, lack of insurance coverage, and intersecting socioeconomic disparities.

In communities with insufficient BH supports, jails and prisons are some of the only places in which people with BH disorders can receive treatment, making community supports particularly critical to reducing justice system involvement. One study found that 6 of the 10 states with the least access to mental health care also have the highest rates of incarceration. In fact, judges in North Dakota have sentenced people to prison to connect them with BH treatment. Because they experience disproportionate rates of policing and cumulative disadvantages, Black and Latinx people are disproportionately involved in the criminal justice system, which creates additional barriers to accessing treatment for BH disorders.

States have used the Justice Reinvestment Initiative process to address BH needs

Several state governments have used the Justice Reinvestment Initiative (JRI) process to address gaps in BH care. JRI is a data-driven, consensus-based approach that provides a framework for states to examine their criminal justice systems and develop and implement policy changes to improve outcomes. Through JRI, states have adopted strategies to address BH needs among justice-involved people in the following ways.

• Improving identification of people with BH disorders. Though about 50 percent of lifetime mental health conditions begin by age 14 and 75 percent begin by age 24, it takes an average of 11 years from when symptoms first appear for people to receive treatment. Mental health screenings and substance use screenings help close this gap by enabling early identification and intervention and ensuring people with BH disorders receive the supports they need.
  
  In its 2012 JRI legislation, Oklahoma made criminogenic risk assessment, mental health screening, and substance use screening available before sentencing to help guide decisions about sentencing, treatment, and supervision. Certified treatment providers conduct risk assessments and screens for everyone charged with a felony in county jails, which inform referral recommendations to connect people to community-based alternatives to incarceration.
• Enhancing diversion mechanisms to prevent deeper system involvement for people with BH disorders. Community-based crisis services—separate from hospitals and jails—show promising results in providing safety and security for people in crisis and in diverting people from emergency department use and justice system involvement (PDF).
  
  In 2017, Arkansas passed JRI legislation to establish crisis stabilization units (CSUs) and implement crisis intervention team training. CSUs are partnerships between law enforcement, health care providers, and mental health professionals that help communities respond to people experiencing BH crises and divert them to CSUs rather than jails or hospitals. By November 2019, four 16-bed CSUs were operational and expected to provide care to approximately 4,800 people annually. The CSUs’ referrals and admissions have increased since they opened, and some are considering expanding their service areas.
• Expanding BH treatment and improving supervision practices. Telehealth use among BH providers is a promising way to improve the distribution of providers and expand access to treatment (PDF). Telehealth is particularly important for people in rural areas, who experience BH disorders at similar, and sometimes higher, rates than people in urban areas but have less access to BH care. In addition, telehealth can provide critical care to people who are incarcerated or otherwise justice-involved (PDF).
  
  South Dakota recognized the critical need to expand treatment to rural areas. In 2014, its JRI oversight council invested in a rural telehealth substance use disorder pilot program. The program provides videoconferencing in lieu of in-person group substance use disorder counseling programs to people on probation or parole who are living in rural areas. The telehealth platform alleviates common barriers to accessing services, including service availability, transportation, and child or elder care.

As states and jurisdictions across the country work to better serve people with BH needs, policymakers and practitioners can consider Arkansas’s, Oklahoma’s, and South Dakota’s strategies of BH screenings, community responses to BH crises, and telehealth programs to provide BH supports in communities rather than through incarceration. Using community-based strategies to address the needs of people with BH disorders can help reduce justice system involvement and improve access for people who have historically faced barriers to accessing care.

This project was supported by Grant No. 2019-ZB-BX-K004, awarded by the Bureau of Justice Assistance. The Bureau of Justice Assistance is a component of the Department of Justice's Office of Justice Programs, which also includes the Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention, the Office for Victims of Crime, and the SMART Office. Points of view or opinions in this document are those of the author and do not necessarily represent the official position or policies of the US Department of Justice.