Sep 12, 2012

Ordinary folks and the next big idea for mental health

When expert systems have no capacity to help, ordinary people can pitch in. It can work for mental health the same as for anything else. That's the message I've been trying to convey in this blog for the past few months. It's the same message Vikram Patel has for us in his recent TED talk.

I want to make mental illness accessible to the general public, and give ordinary people something to do about it. There is untapped capacity to deliver results below the level of our formal treatment systems, capacity that can change the whole experience of mental illness in America.

  • People in churches, schools and workplaces can learn what they need to about mental illness, and possibly even pick up a few things to do about it, in a couple of hours, sometimes less. 
  • Nothing prevents the mental health field from popularizing itself, other than its own self-imposed rules and culture. 
  • Ordinary people have always been mental health’s reformers, and they have always used the widest-reaching  popular technology of the day. Clifford W. Beers was cutting-edge. 
  • Another challenge for the mental health field is a culture focused on scarce and shrinking resources. The field has been stuck on doing less with less for decades. Even advocacy groups have chased money that comes with too many strings and interferes with true “consumer protection.” 
I believe the greatest opportunity for improving the lives of people with mental illness lies in building the strengths and capacities of ordinary non-expert people in communities across the US. We need solutions that bring recovery and successful living with mental illness within the skill level of the mass of society. We need to de-emphasize experts and allow people to support each other (as they have indeed been doing, under or above the radar, in every culture, since the dawn of time). 

We need something that delivers broad social impact at low cost or free, exactly what AA did for sober recovery.  That’s the focus of my current work. My book Defying Mental Illness focuses on how to create success instead of having one’s illness, and helps family members support people they love. The Redesigning Mental Illness blog project focuses on systems change efforts and developing skills within communities. I even have a stripped-down mini-support group concept that lets anybody support another’s mental health (or overcome other challenges). 

All my work is consensus based, and strength-based, and designed to bridge the factionalism that has plagued this work.  We need a modest infrastructure that supports broad-based social inclusion initiatives, the only kind of anti-stigma effort that actually works.

Those are my ideas – but I know that others across the US have other ideas, and the capacity to implement them. I support a social innovation model developed by NESTA in the UK called “radical efficiency.” It delivers new solutions that are different and better and lower-cost, not less-for-less or same-for-less. The basic principles of radical efficiency are:

  1. Make true partnership with users the best choice for everyone.
  2. Enable committed, passionate and open-minded leaders to emerge from anywhere.
  3. Start with people’s quality of life not the quality of your service.
  4. Work with the grain and in the spirit of families, friends and neighbors.
  5. Manage risks, don’t just avoid them.
One of the programs identified in NESTA’s report is Mental Health First Aid. I think that community-based, peer-delivered, non-medical brief respite fits in this mold, as do restorative justice programs in homeless shelters, as do many other sorts of diversion and health education initiatives. 

So take a look at Vikram Patel's video. What's your big idea for really changing the experience of mental illness in America?

Sep 9, 2012

Don't Blame Deinstitutionalization

We know for certain that too many people with mental illness are locked up in U.S. jails and prisons. But deinstitutionalization is not to blame.

We have some of the facts from Arthur Lurigio of Loyola University Chicago, writing in the June 2011 issue of Federal Probation Journal. He points out that the number of people with psychiatric histories in jails and prisons did not increase during the first twenty years of deinstitutionalization. Lurigio notes:

The 2 percent increase in the proportion of men with previous psychiatric hospitalizations sentenced to prison between 1968 and 1978 is much too small to account for all of the men who were released from psychiatric hospitals.

Some people think that a certain proportion of our population is unfit for society and will always end up locked up somewhere. They believe that if hospital populations go down, prison populations must go up, and vice versa. Lurigio calls this “the hydraulic fallacy.” Every modern society has a different rate of imprisonment, and these rates change over time. The current U.S. imprisonment rate is the world’s highest, with 724 people incarcerated per 100,000 population. The imprisonment rate of England and Wales is at about the midpoint worldwide, at 145 per 100,000. Hospitalization does not account for the difference. The U.S. now has about 30 psychiatric beds per 100,000 population. The U.K. has about 60.

The real difference is criminal justice policy. In the 1980s, U.S. law enforcement ramped up the war on drugs, while legislatures imposed zero tolerance sentencing policies, and passed three-strikes legislation. These changes disproportionately affected the urban poor, and swept tens of thousands of Americans into jails and prisons, including many people with mental illness. There are many more people with mental illness in our prisons and jails today simply because people with mental illness entered prison with their friends and neighbors, brothers and sisters and cousins. Throughout this period the census in state psychiatric facilities remained relatively flat while the prison population shot up.

According to Lurigio, the real risk factor for increased criminalization is poverty.

The risk factors that predict crime among people with severe mental illness are the same factors that predict crime among people with no serious mental illness…A large-scale, seven-year study of the relationship between socioeconomic status and mental illness suggested that poverty, acting through economic stressors, such as unemployment and lack of affordable housing, is more likely to be a precursor to, than a sequela of, serious mental illness.

The emphasis on incarcerating people for drug crimes also selected high numbers of people with co-occurring mental health and substance abuse disorders for criminal justice involvement.

Like dolphins among tuna, many mentally ill, drug-using persons are caught in the net of rigorous drug enforcement policies.

Another myth is the notion that treatment is the first step to reduce criminalization of people with mental illness. According to Lurigio, no studies have shown that the alleviation of psychiatric symptoms alone affects recidivism among criminally involved people with serious mental illness. What really helps is addressing other root causes of criminal behavior – substance abuse and other so-called criminogenic factors. This should not surprise us. As Lurigio writes,

Serious mental illness alone rarely leads people to commit crimes and, therefore, the treatment of mental illness alone is unlikely to prevent or reduce crime or recidivism. People with severe mental illness can benefit from the same evidence-based cognitive behavioral therapies that affect criminal thinking among people with no mental illness. Most important, integrated treatment for co-occurring psychiatric and substance use disorders is critical in helping people with severe mental illness manage their symptoms and change their potential criminal trajectories.

I am also struck by the role that stigma may have in all this. Many people among our new criminal justice populations are being diagnosed during jail house intake. If they were never diagnosed in today’s relatively accessible outpatient treatment environment, they would certainly not have had a place among the deinstitutionalized.

Mike Hogan's talk at the 2012 National Council conference also supports deinstitutionalization as a good thing. He mentions the incarceration patterns Lurigio identifies, and says one of the big problems with deinstitutionalization was that mental health experts did not get to control how it played out. He also notes that people who live in the community do prefer to stay there. People with experience of long-term psychiatric hospitalization do not ask to move back in..

Lurigio, A. (2011). Examining Prevailing Beliefs About People with Serious Mental Illness in the Criminal Justice System. Federal Probation Journal, June 2011.

European Sourcebook of Crime and Criminal Justice Statistics. Downloaded 9/10/12 from

Harcourt, B. (2007]. The mentally ill, behind bars. New York Times. Downloaded 9/9/12 from

Mike Hogan's 2012 National Council IdeaTalk

Sep 2, 2012

How to Cure Injustice of the Brain

Mental health activists have promoted treatment over jail since Dorothea Dix promoted humane treatment in asylums in the 1840s. Judges, prison officials, prosecutors, even jailers are getting this message. Unfortunately, our partially effective and under-resourced mental health treatment system is still failing to keep people out of jails.

We need to take another look at changing justice. 

The central focus of the American criminal justice system is offenders getting what they deserve. Public dollars drive the system. The institutions of our justice system have a certain level of effectiveness for the people that participate in it. The system has its strengths, its limits, its own economy, and a variety of collateral effects. Certainly it has flaws. The system is not very precise. Punishment (imprisonment) affects family members, not just the person who committed the crime. Criminal convictions shut people out of housing and employment long after the sentence ends. The interests of crime victims are seldom adequately addressed. And the whole process does not help people with mental illness at all. But whatever its problems, the institutions embedded in our criminal justice system won’t be going away. Our society is heavily invested in the existing system.

Justice system reforms mostly adjust the output, the punishment part of the system. The current trend is to move punishment for lower-risk inmates to smaller facilities. This does not move the system very far.  If we want major change, we need new insights from a different perspective. We need a new mental model for justice.

A relevant model exists right now. It is called restorative justice.

Restorative justice is a well-defined, but different, viewpoint on justice, used in the United States and throughout the world, a viewpoint embedded in hundreds of effective programs that address crime and disorder. The core of restorative justice arises around three principles:
  1. Crime is a violation of people and of interpersonal relationships.
  2. Violations create obligations.
  3. Justice involves victims, offenders and community members in an effort to put things right.
I propose that we consider restorative justice as a potential solution for people with mental illness. We can embed restorative justice programs in respite centers, homeless shelters, and medical offices at very low cost. 

Restorative justice can become the intake filter that keeps vulnerable people with mental illness from becoming stuck in the formal criminal justice system, but still addresses the needs of victims. Restorative justice processes are always voluntary. And because they are voluntary, we don’t have to dismantle our institutions to use them effectively.

Restorative justice programs put offenders in touch with persons harmed and with community members, for the purpose of finding ways to move forward. These encounters are emotionally powerful. They are designed to build empathy, support accountability, and change thinking. Programs are implemented in ways that protect people harmed from further victimization.

Restorative justice programs, properly implemented, work as well or better at preventing crime as our formal justice system. A 2010 European Union study of restorative justice programs in the US and across the world generated these key findings:
  • Many communities and the public at large would benefit from its implementation without risk for public safety or feelings of safety.
  • Most restorative justice cases seem to have a beneficial effect on the likelihood of reconviction.
  • Restorative justice interventions appear to be more effective with low-risk offenders.
  • For high-risk offenders (those at highest risk of re-offending) restorative justice in itself may not be sufficient enough to decrease recidivism.
  • Restorative justice works better with serious crimes. The strong emotional basis is seen as the reason for this. The emotions of anger, shame, guilt and regret form a complex cocktail of feelings associated with crime and justice.
  • No significant effect of any demographic variables (age, ethnicity, gender).
  • Where offenders have decided to try to stop offending, a conference can increase motivation to desist (because of what victims and offender supporters said) and provide the support offenders may need to help tackle problems relating to their offending.
  • No differences on recidivism rates among programs that operate along different criminal justice system entry points.
  • Crime victims benefit. Research indicates that victims in general show high levels of fairness and satisfaction resolving from the restorative justice experience, and a decrease in victim’s fear of re-victimization.
  • Factors that increase the effectiveness of restorative practices for youth offenders:
    • Seeming fair to the parents and involving young people in the process and the decisions.
    • Avoiding leaving parents and young people feeling bad about themselves.
    • Achieving a process that increases the chance that the young person will feel truly sorry for what they have done, show their remorse to the victim and make amends from what happened.
    • Helping the young person acquire skills or remedy deficiencies such as psychological problems, drug and alcohol abuse and learning deficits.
The 2010 European Union study supports the idea of using restorative justice programs as the baseline response to disorder in communities. Deterrence strategies come next, with incarceration reserved for the most difficult offenders. This approach seems to say that everyone needs opportunities to learn and practice accountability.  It’s actually pretty close to a public health view of crime prevention. Prevention theory tries to match the right technique to the appropriate risk level in the target population. If an important objective is to reduce the burden of criminalization (the destruction of family life and the capacity to maintain employment after conviction), restorative justice programs could stand alongside and connect with the criminal justice system much the same way that mental health and addictions treatment programs do today.

For that to work, we must create the capacity to deliver restorative justice programs at multiple points within schools, in community settings, and within criminal justice institutions. This approach matches the “sequential intercept” model used to divert persons with mental illness from the criminal justice system. Remember that the later in the path diversion takes place, the more collateral damage a person and his family suffers.

The biggest benefit of diversion comes if the person is never formally charged with a crime.
  • After arrest, the person is in the public system, where many participants (judges, prosecutors, defense attorneys, investigators) are completely focused on their justice system role. Making room for discretion becomes more difficult, more of a technical issue.
  • Many situations seem well-suited for a restorative justice intervention. If jails are at capacity, lower risk offenders simply don’t get in. Low-end offenders, public order violators are hardly even interrupted when arrested, brought to jail, and are immediately let go with a court date that will likely be ignored. 
  • First responders need a way to connect with restorative justice as diversion. The program must connect promptly, be safe, and actually resolve the situation the officer is encountering. Officers need to be authorized to make these referrals. Diversion choices must match the expectations of the officer’s supervisors and built into department procedures.
  • Another place for restorative justice programs is post-conviction, as part of re-entry programs. There is relatively wide discretion around types of programming that might be beneficial for people returning to society.
Restorative justice programs set people up for powerful engagements. These can be “whole-body experiences” of conflict. The encounters between offender, person harmed and community representatives encourage thinking through the justice of the situation and figuring out remedies. It’s what people who design anti-poverty programs try to achieve. Certain “restorative questions” are used to process challenging behavior.
  • What happened?
  • What were you thinking about at the time?
  • What have your thoughts been since?
  • Who has been affected by what you did?
  • In what way have they been affected?
  • What do you think you need to do to make things right?
Restorative justice is meaningful to participants because it is founded on respect. Howard Zehr, an important figure in the development of restorative justice in the US, writes:
If I had to put restorative justice into one word, I would choose respect: respect for all, even those who seem to be our enemies.
Creating meaningful capacity to deliver restorative justice programming is possible if we are willing to take on the task. Restorative justice work is often performed by volunteers. The training is experiential. Nearly anyone can learn to do the work. It sounds like a great match for peer specialists.

Who is ready to start?

Amstutz, L. S. (2005). The little book of restorative discipline for schools: teaching responsibility, creating caring climates. Intercourse, PA: Good Books.
Block, P. (2002). The answer to how is yes: acting on what matters. San Francisco, CA: Berrett-Koehler Publishers.
DeVol, P., Payne, R. and Smith T. (2006) Bridges out of Poverty: Strategies for Professionals and Communities. Highland, TX: aha! Process Inc.
Fabelo, T. et al. (2011). Breaking Schools’ Rules: A Statewide Study of How School Discipline Relates to Students’ Success and Juvenile Justice Involvement. Washington, DC: Council on State Governments Justice Center
Fontaine, J., & Debus-Sherrill, S. (2010). Violence prevention in schools: a case study of the Thurgood Marshall Academy Public Charter High School. Washington, DC: Urban Institute Justice Policy Center.
Gillinson, S., Horne, M., & Baeck, P. (2010). Radical efficiency: different, better, lower cost public service. London: NESTA.
International Institute for Restorative Practices (2006).  Restorative Justice and Practices. Bethlehem, PA: Author.
International Institute for Restorative Practices (2009).  Improving School Climate: Findings from Schools Implementing Restorative Practices. Bethlehem, PA: Author
Italian Ministry of Justice. (2010). Restorative Justice and Crime Prevention: Presenting a theoretical exploration, an empirical analysis and the policy perspective. Leeds, UK: European forum on Restorative Justice. Downloaded 8/11/11 from
John D and Catherine T MacArthur Foundation. (2011). Models for Change: Systems Reform in Juvenile Justice. Retrieved 2/1/2011, from
Lederach, J. (2003). The little book of conflict transformation. Intercourse, PA: Good Books.
McKnight, J., & Block, P. (2010). The abundant community: awakening the power of families and neighborhoods. San Francisco: Berrett-Koehler Publishers.
Meadows, D. (1997). Places to Intervene in a System. Whole Earth Review, Winter 1997. Retrieved 1/10/10, from
Munetz, M., & Griffin, P. (2006). Use of the Sequential Intercept Model as an Approach to Decriminalization of People With Serious Mental Illness. Psychiatric Services, Vol 57 No. 4, 544-549.
Nugent, W., Williams, M., & Umbreit, M. (2003). Participation in Victim-Offender Mediation and the Prevalence and Severity of Subsequent Delinquent Behavior: A Meta-Analysis. Utah Law Review, pp. 137-166.
Obbie, M. (2010). Why Victims Face the Criminals Who Hurt Them. Miller-McCune(Dec. 2010). Retrieved from
Price, M. (2001). Personalizing Crime: Mediation Produces Restorative Justice for Victims and Offenders. Dispute Resolution Magazine, Fall 2001.
Sherman, L., Strang, H. (2007). Restorative Justice: The Evidence. London: The Smith Institute.
Toews, B. (2006). The Little Book of Restorative Justice for People in Prison. Intercourse, PA: Good Books.
Umbreit, M., Vos, B., & Coates, R. B. (2006). Restorative Justice Dialogue: Evidence-Based Practice. Minneapolis, MN: U Minn Center for Restorative Justice & Peacemaking.
Western, B., & Pettit, B. (2010). Incarceration & social inequality. Daedalus, Summer 2010, 8-19.
Zehr, H. (2002). The little book of restorative justice. Intercourse, PA: Good Books.
Zehr, H. (2005). Changing lenses: a new focus for crime and justice. Scottdale, PA.: Herald Press.