Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at .
In October, psychiatrist Katherine Warburton, medical director of California’s state hospitals, toured the mental health systems in Puglia and Trieste, Italy. She hoped to understand better how, in practice, the nation that has no psychiatric hospitals managed to divert people in psychosis from jails.
Warburton wasn’t new to Italy’s history. California, like the greater US, had long moved away from institutionalization but contrary to Italy, people with serious mental illness often find themselves caught in the web of America’s criminal legal system.
“There’s a strong correlation between rising rates of incompetent to stand trial populations and the rate of deinstitutionalization,” she says.
Trying to better understand the populations most vulnerable to falling between the cracks of California’s mental health system, the state partnered with University of California, Davis, examining several thousand people who had been sent to the state hospital system as incompetent to stand trial between.
“The vast majority had a psychotic illness or some type of schizophrenia spectrum disorder.”
Nearly two-thirds had been experiencing homelessness at the time of their arrest on felony charges. Half hadn’t received mental health services in the six months before their arrest; the remainder were mostly seen in the emergency room.
What Warburton found most shocking was that the percentage of people admitted for competency restoration who had been arrested 15 or more times had increased over the past seven years, from roughly 18% in 2009 to 46% in 2016.
“We started developing a hypothesis that people living in psychosis were drifting into an untreated, unsheltered condition and experiencing more criminal justice contact.”
She and the other researchers began sifting through arrest reports and found people were often arrested for offenses stemming from behavioral and quality of life issues, such as poverty and positive symptoms of psychosis. (In California and many other states, having prior offenses can escalate specific misdemeanor charges into felonies.)
“Many of the arrests were related to symptoms of psychosis — like hallucinations or persecutory delusions — in public because they were unsheltered.
“Police were called but the person didn’t recognize them as police because they weren’t experiencing a consensual reality.”
Like the US, Italy had also moved away from institutionalization but people weren’t deteriorating and falling through the cracks into the penal system. After visiting a 15-person villa where patients could live up to two years, the nation’s highest level of care, the group visited the prison. A psychopharmacologist in the group asked the psychiatrist giving the tour if he could meet some of the people living with psychosis in the prison.
“The psychiatrist was horrified and asked him, ‘Why would we have someone living in psychosis in a prison?’”
In 1978, Italy’s mental health care system was reformed by Law 180. The law is commonly known as the Basaglia Law, named after Franco Basaglia, the Italian psychiatrist who closed asylums and innovated community care in Gorizia and Trieste.
The legislation laid the foundation for the nation’s current mental health system, guaranteeing people a right to mental healthcare, says Warburton. It also eliminated the dangerousness standard for compulsory treatment in favor of a medical necessity standard.
“This aligned the standard to that of other disease conditions, where if someone lacking medical decision-making capacity requires treatment, that treatment is given.”
Changing the standard didn’t result in reinstitutionalization but instead made it easier to provide treatment and incentivized the system to engage with people living with psychosis before they deteriorated.
“When I dug into that further, I found involuntary treatment of any kind is very, very rare in Italy.”
In the US, a similar nationwide push for deinstitutionalization had been underway, marked by President John F. Kennedy’s 1963 Community Mental Health Centers Act, which offered reimbursement to states for treating people in the community.
Four years later, in an effort to decrease institutionalization, California passed the Lanterman-Petris-Short Act, raising the bar for involuntary hospitalization to a dangerousness, gravely disabled standard, creating the precedent for a 5150, an involuntary 72-hour psychiatric hold.
Without a robust community-based system of care, people with serious mental illness quickly funneled into the criminal legal system.
Psychiatrist Marc Abramson, who worked in San Mateo County’s Courts and Corrections Unit, found a marked increase in the number of jailed people with mental health issues in the year after the Lanterman-Petris-Short Act went into effect.
He noted the original Short-Doyle Act of 1957 was a “pioneering effort by the state to stimulate mental health programs” by reimbursing 50% of approved county mental health program costs but the revision’s new dangerous or gravely disabled standard meant “…mentally disordered persons are being increasingly subjected to arrest and criminal prosecution.” (Abramson, who authored the article “The Criminalization of Mentally Disordered Behavior: Possible Side-Effect of a New Mental Health Law,” is often cited as the first to discuss the criminalization of mental health in a journal.)
Today, the pendulum in the US is swinging back to discussions on reinstitutionalization and a push for more psychiatric beds because of rising homelessness, incarceration, hospitalization and rehospitalization of those experiencing mental health issues. The authors of a 2015 article published in JAMA, controversially titled “Improving Long-term Psychiatric Care: Bring Back the Asylum,” argued modern, long-term psychiatric facilities should be added to the crisis continuum of mental health care.
“There’s a way to take care of people living in psychosis in the community that doesn’t involve locking them up in a prison or psychiatric hospital,” says Warburton.
She notes Italy’s movement away from the dangerousness standard and toward medical necessity has incentivized the nation to provide people with compassion, education and engagement early on.
In recent years, California has adopted a medical necessity standard for psychiatric inpatient care, expanding clinician authority and reimbursement for mental health services. In its 988 legislation, the state also overtly invokes the federal Mental Health Parity and Addiction Equity Act of 2008 and state parity law requirements for fostering parity between Medi-Cal reimbursement for mental health and physical health services.
Warburton says policymakers and behavioral health leaders nationwide need to talk about the unintended consequences of the dangerousness standard and institutionalization.
“In the US, we have reinstitutionalization through our jails, prisons and psychiatric hospitals through the mechanism of criminal legal involvement.”
Although Italy’s Basaglia Law is nationwide, Warburton notes the best practices model is in Trieste, where social services provide a safety net.
“That’s their special sauce.”
The social services include housing, employment and connection, described as “familiar warmth through human contact,” explains Warburton. Microenvironments and social collaboratives provide vulnerable populations, such as people with mental health or substance use challenges, developmental or intellectual disabilities and the elderly with community.
“One of my colleagues called it relentless engagement.”
Housing is dynamic — an apartment building also functions as a community center. Staff who run the building can fill prescriptions and provide rides. Paid workers, volunteers and residents bake and have coffee together.
A social collaborative for women in downtown Trieste provides similar support. The women engage in activities together, like watching movies and traveling.
“This ‘familiar warmth’ prevents decompensations and gives people an additional layer of protection.”
Despite efforts to replicate the Trieste model in the US, Warburton notes the initiatives are often unsustainable because the mental health system is incentivized not to engage with people living with serious mental illness.
“We have to balance the pendulum from swinging from institutionalization to having people locked up or unsheltered and find a way to keep people stable in the community.”
