Criminalization of mental illness and prevention in Miami

Prevention, Consultation, and Advocacy
Social Change Portfolio

Contents
Introduction
Scope and Consequences
Social-ecological Model
Theories of Prevention
Diversity and Ethical Considerations
Advocacy

INTRODUCTION
Criminalization of Mental Health in Miami, Florida

Crime and mental health are closely connected issues that impact both public safety and quality of life. Up to twenty percent of inmates are mentally ill, their criminal behaviors a symptom of an untreated mental illness (Eide, 2018). Lack of access to mental health services is one facet of the problem. Another is the criminalization of the mentally ill or the diversion of mentally ill persons to the criminal justice system. In many cases, ethnicity, gender, and age are compounding variables that increase the propensity for persons to be diverted towards jail rather than towards effective mental health services. Yet in other cases, even Harvard graduates have fallen through the cracks in the system that are contributing factors to the proliferation of both violent and nonviolent crimes in Miami, Florida (Rivero & Green, 2019).
Recent initiatives to address the problem have demonstrated the promise of applying the social-ecological framework to focus more on prevention, taking into account biophysical, psychological, social, and spiritual risk and protective factors (American Mental Wellness Association, 2019; Eide, 2018; Reupert, 2017).
This project focuses first on the scope and consequences of the issue of criminality and mental health. The scope of the problem will be analyzed using current data and statistics on the local trends, and show how those local trends compare with national averages. Then, the analysis will address the many consequences of criminalization of mental health, including long-range factors such as the impact on educational attainment in affected communities, on income disparities, and on social justice outcomes. The goal statement of this project is aligned with the conscientious efforts on the part of local lawmakers, policymakers, and healthcare advocates dedicated to reducing barriers to mental health care.

References American Mental Wellness Association (2019). Risk and protective factors. Retrieved from https://www.americanmentalwellness.org/prevention/risk-and-protective-factors/ Eide, S. (2018). Keeping the mentally ill out of jail. City Journal. Autumn 2018. Retrieved from https://www.city-journal.org/miami-dade-criminal-mental-health-project Rivero, D. & Green, N. (2019). How Miami-Dade’s mental health program steers people to treatment, not jail. WJCT. 13 March, 2019. Retrieved from https://news.wjct.org/post/how-miami-dades-mental-health-program-steers-people-treatment-not-jail Reupert, A. (2017). A socio-ecological framework for mental health and well-being, Advances in Mental Health, 15:2, 105-107, DOI: 10.1080/18387357.2017.1342902

PART 1: SCOPE AND CONSEQUENCES
Criminalization of Mental Health in Miami, Florida

The scope of the matter is huge. According to the Eleventh Judicial Circuit of Florida (2019), Miami-Dade County is “home to the largest percentage of people with serious mental illnesses...of any urban community in the United States,” at 9.1% of the population (p. 1). Thus, even if criminalization were not a major cause for concern, the prevalence rates of mental illnesses in Miami are. Serious mental illnesses include schizophrenia, bipolar disorder, major depression, yet only 13% of those suffering from these mental illnesses ever receive care (Eleventh Judicial Circuit of Florida, 2019). Because of inadequate prevention and care, the majority end up behind bars. Yet as Eide (2018) points out, “incarceration tends to worsen serious mental illness,” (p. 1). The problem of criminalization therefore needs to be addressed as a primary social change issue.
The consequences of the criminalization of mental illnessare severe, given Miami-Dade County has twice the national rates of both violent and non-violent crimes (“Overview of Miami-Dade County,” 2019). Many of these crimes can be prevented through effective interventions and preventative strategies. A large proportion of violent and non-violent crimes can be traced to “a severe lack of access to quality and affordable mental healthcare,” (Rivero & Green, 2019, p. 1).
Not only does the problem affect public safety and quality of life for all residents, but also reduces the effectiveness of the criminal justice system. For example, 17% of the total inmate population has serious mental illnesses, costing taxpayers more than $50 million per year (Eleventh Judicial Circuit of Florida, 2019). The criminal justice system is not designed to be a mental health care facility, and using it as such increases wastefulness in public spending. Furthermore, ineffective responses to mental health problems leaves lingering scars on the lives of individuals, their families, and entire communities due to problems related to violence, poverty, and isolation.

References Eide, S. (2018). Keeping the mentally ill out of jail. City Journal. Autumn 2018. Retrieved from https://www.city-journal.org/miami-dade-criminal-mental-health-project Eleventh Judicial Circuit of Florida (2019). Criminal mental health project. Retrieved from https://www.jud11.flcourts.org/Criminal-Mental-Health-Project “Overview of Miami-Dade County,” (2019). US News and World Report. Retrieved from https://www.usnews.com/news/healthiest-communities/florida/miami-dade-county#public-safety Rivero, D. & Green, N. (2019). How Miami-Dade’s mental health program steers people to treatment, not jail. WJCT. 13 March, 2019. Retrieved from https://news.wjct.org/post/how-miami-dades-mental-health-program-steers-people-treatment-not-jail
PART 2: SOCIAL-ECOLOGICAL MODEL
Criminalization of Mental Health in Miami, FL

The social-ecological model provides a holistic framework for responding to the criminalization of mental health in Miami, Florida.Comprised of a systematic analysis of biophysical, psychological, social, and spiritual risk and protective factors, the social-ecological model can effectively reduce mental health disparities and lead to comprehensive solutions for both prevention and intervention (American Mental Wellness Association, 2019). Research on severe mental health issues like suicide require a “multi-level approach” that takes into account numerous and diverse risk and protective factors (Cramer & Kapusta, 2017, p. 1). In fact the social-ecological model can be used for developing the most appropriate methods of assessment, treatment, and prevention according to the needs of specific population subsets (Cramer & Kapusta, 2017). The social-ecological model is therefore effective at addressing the needs of the diverse populations in Miami, Florida.
Both risk and protective factors will vary depending on demographics, socioeconnomic conditions, political climate, and individual differences. Risk factors can compound a propensity to develop a severe mental illness or can trigger mental illness. Biophysical risk factors include family history of mental illness, chronic physical illness, drug or alcohol use, and poor nutrition. Psychological risk factors include stressful life events, lack of effective coping strategies, lack of self-efficacy, and low educational attainment. Social risk factors include exposure to violence, abuse, and neglect, lack of social or cultural capital including linguistic barriers, poor social support networks, mental health stigma, poverty, discrimination, and low awareness or lack of access to mental health services. Some members of the Miami community might also experience spiritual risk factors related to existential beliefs about the meaning or purpose of one’s life or one’s perception of sin and death (American Mental Wellness Association, 2019). The most effective social change strategies take multiple factors into account.
The social norms related to mental health will also have a strong impact on whether a person will perceive stigma or lack of support. Likewise, social norms will affect the individual’s outlook on life, promoting either an optimistic or pessimistic worldview. As Swearer & Hymel (2015) point out in a social-ecological model related to bullying prevention, peer group influences, family influences, community factors, and cultural influences can also have strong bearings on either risks or protective factors.
Protective factors provide the individual or family with coping strategies and other means to build resilience. Biophysical protective factors include overall sound physical health and healthy lifestyle. Psychological protective factors include a positive outlook, high self-esteem or self-efficacy, emotional intelligence, trust in the mental healthcare system, and willingness to accept help. Protective social factors include access to financial and social resources, engagement with family and community, access to mental health services, and participation in mental health services such as counseling or support groups. The goal of any social change initiative should be to decrease risk factors and increase protective factors for all target populations.

References American Mental Wellness Association (2019). Risk and protective factors. Retrieved from https://www.americanmentalwellness.org/prevention/risk-and-protective-factors/ Cramer, R.J. & Kapusta, N.D. (2017). A social-ecological framework of theory, assessment, and prevention of suicide. Frontiers in Psychology 2017(8): doi: 10.3389/fpsyg.2017.01756 Swearer, S. M., & Hymel, S. (2015). Understanding the psychology of bullying: Moving toward a social-ecological diathesis–stress model. American Psychologist, 70(4), 344-353

PART 3: THEORIES OF PREVENTION
Criminalization of Mental Health in Miami, Florida
Theories of prevention help policymakers and social workers design effective and evidence-based programs, policies, and initiatives. Several theories of prevention can be applied to the issues related to mental health criminalization. The two theories of prevention that may be most applicable to the issues at stake in Miami would include the ecological theory and the social cognitive theory of prevention.
Ecological theories of prevention take into account various contextual variables that might cause a problem, or which might help bring about an ideal solution. For example, an ecological theory of prevention would address not just the individual psychological causes of criminal behavior and mental health, but also the community-level factors and even broader variables like public policy. Using the ecological theory of prevention, it becomes more possible to design cost-effective interventions that target specific populations.
When applying the ecological theory of prevention to the issue of diverting persons with mental health issues away from the criminal justice system and towards mental health services, it is important to factor in social support networks and how to rebuild them, institutional factors such as the availability and design of all organizations like public schools or mental health clinics, and community factors. Community factors are especially important because of the way they can influence social norms and other methods of individual identity and behavior.
The social cognitive theory is similar to the ecological theory of prevention. Both of these theories of prevention could be combined to construct an ideal solution to the criminalization of mental health in Miami. According to the Rural Health Information Hub (2019), the main components of social cognitive theory of prevention are self-efficacy, behavioral capability, expectations, expectancies, self-control, observational learning, and reinforcements. These components combine personal and environmental factors that influence mental health and behavioral outcomes.
As Silverman (2003) points out, though, prevention is a separate function that should be given a “unique status” in public health and policymaking initiatives (p. 27). There are also different types of prevention in public health models. For example, primary prevention is different from early intervention (Silverman, 2003). Primary prevention refers to the structural variables that help reduce the likelihood that any given person will develop a mental health problem or exhibit problematic behaviors that would otherwise lead that person into the criminal justice system unnecessarily. Primary prevention is often challenging to construct and may require long-term solutions resolving issues like structural poverty and institutionalized racism or sexism. Secondary prevention, on the other hand, refers to the ongoing need for early intervention. No matter how robust a primary prevention program is, there will always be a need to identify early warning signs and risk factors.
The biopsychosocial model shows how some individuals, due to genetics or any other set of first conditions, may be prone to certain mental or physical health issues. Those issues, when left untreated or unrecognized, could erupt into more serious concerns. Therefore, prevention efforts need to focus both on the long-range and contextual variables that reduce the likelihood for problems, but also on the best means by which to provide early detection and treatment. When people do not have access to mental health services in their neighborhood, or when they view those services through a stigmatized lens, they become more prone to evolving problematic behaviors rather than seeking the help they need. A comprehensive program of prevention based on the ecological and social cognitive model would help reduce stigma against mental health while also making early identification more likely through public education and awareness campaigns.
To create the most effective model of prevention for Miami, it would be important to involve the cooperation of schools, faith-based organizations, and even small businesses in the community. Changing the attitudes of people is required. Top-down methods will not be nearly as effective as methods that inspire individuals to take action, or to raise the expectations or standards of living in the community. The social cognitive theory of prevention takes into account both expectations and expectancies because of how important it is to teach all members of the community new ways of looking at pressing social problems. Instead of viewing problematic behaviors as indicative of a bad person who needs to be locked up in prison, members of the community would come to see problem behaviors as signs of an underlying issue that could be addressed through early intervention or primary prevention.
The National Cancer Institute (2005) recommends a participatory model of prevention. The participatory model of prevention is rooted in both the ecological model and the social cognitive model of prevention. Three of the elements required for effective participatory prevention strategies include community development/consensus, task-oriented planning, and social action (National Cancer Institute, 2005). No factor is ignored; social justice becomes the primary objective using the participatory model, in which all voices are heard and in which the values, belief systems, and worldviews of diverse persons are taken into account before coming up with the right solution. In a multicultural city like Miami, diversity is the key to evolving cost-effective and results-driven interventions. The reason why decriminalization efforts have already proven effective is that they are based on the ecological and social-cognitive preventative models, both of which are systems theories. Doing away with binary thinking about right or wrong behaviors, these solutions are more realistic and more likely to yield desirable results.

References National Cancer Institute (2005). Theory at a glance: A guide for health promotion practice. Washington, DC: U.S. Department of Health and Human Services: National Institutes of Health. https://cancercontrol.cancer.gov/brp/research/theories_project/theory.pdf Rural Health Information Hub (2019). Social cognitive theory. Retrieved from: https://www.ruralhealthinfo.org/toolkits/health-promotion/2/theories-and-models/social-cognitive Silverman, M.M. (2003). Theories of Primary Prevention and Health Promotion. In: Gullotta T.P. et al. (eds) Encyclopedia of Primary Prevention and Health Promotion. Springer, Boston, MA, pp. 27-42. Social Programs that Work (2018). What works in social policy? Retrieved from http://evidencebasedprograms.org/.
PART 4: DIVERSITY AND ETHICAL CONSIDERATIONS
Criminalization of Mental Health in Miami, Florida
Research consistently shows that non-white minorities are perceived as being more likely to commit crimes than their counterparts, which may account for disproportionate numbers of minorities with mental health issues being diverted into the criminal justice system (Carter, 2018). For example, there is an “assumption of criminality,” which causes first responders and law enforcement officials to attribute deviant behaviors to criminality rather than to an underlying mental health problem (Weber, Collins, Robinson-Wood, et al., 2018). If the goal is to provide broad preventative services, early intervention, and more robust community support for mental health care in order to increase public safety and promote social justice goals too, then attention must be paid to the needs of diverse populations. Specifically, the problem of the criminalization of mental health affects LGBTQ minorities disproportionately due to multiple, intersecting stigmas.
Culture, age, religion, gender, and other diversity correlates may also have a strong impact on personal attitudes towards mental health and illness. For instance, if stigma against seeking mental health support is disproportionately strong within a sub-population, that sub-population may be more likely to engage in criminal behaviors due to untreated mental illnesses. Research also shows that specific sub-populations may receive discriminatory care, resulting in inadequate responses to mental health problems and ineffective interventions. Discrimination against LGBTQ individuals, and especially against non-white LGBTQ individuals, has been shown to be a particularly pernicious problem (Weber, Collins, Robinson-Wood, et al., 2018). Therefore, it may be important to focus on LGBTQ minorities as a vulnerable population.Risk of self-harm and suicidality also needs to be taken into consideration when designing the most effective prevention program and strategies for reducing criminalization. An intervention program designed to increase the number of people who are diverted from criminal justice to the mental health care system must take into consideration the experiences of LGBTQ minorities.
Contact with the criminal justice system is directly correlated with minority group status (Sugie & Turney, 2017). Adding sexual minority status to the mix means that LGBTQ minorities will be even more likely to find mental health preventative and intervention services inadequate for their needs, thereby leading to criminogenesis. To combat this problem, attention must be paid first to the ways school counselors work with LGBTQ minorities exhibiting the early warning signs of mental illnesses. Likewise, any behavioral indicator of a possible mental health issue should be resolved first through the mental health system. Evidence shows that LGBTQ minorities deal consistently with discrimination and microaggressions that need to be addressed with sound leadership both at the level of the mental health system and also the criminal justice system (Weber, Collins, Robinson-Wood, et al., 2018). Providing equitable mental health interventions to all sub-populations should become an ethical imperative.
Diversifying the approach to mental health and criminal justice will likely lead to measurable outcomes including lower rates of criminal and self-harming behavior among LGBTQ minorities. As Crocker, Martin, Leclair, et al. (2018) point out, “distinguishing subgroups of forensic clients based on the sequence of onset of mental illness and criminal behavior and on the age of onset of criminal behavior may be useful to identify criminogenic needs and predict outcomes upon release,” (p. 83). To increase the cultural relevance of the prevention program for the LGBTQ minority population, a focus group or structured interview method of gathering data for a needs assessment is strongly recommended. Because there is diversity within the LGBTQ minority population, the needs assessment would reveal whether or not there is also a need to further stratify the options for offering preventative services that would prevent the criminalization of mental illness.
Ethical considerations with designing the prevention program for the LGBTQ community include involving multiple stakeholder groups within the community. Faith-based organizations, schools, LGBTQ resource centers, and community centers, as well as small businesses can all take part in discussions about how to improve the accessibility of mental health services. More importantly, stakeholder groups can collaborate on the most effective means by which to raise awareness about mental health stigma and especially about stigma against LGBTQ individuals. Because factors like microaggressions and other covert forms of discrimination often go undetected and may even be delivered in an unconscious or unknowing manner, there may also be a need for sensitivity training among educators, counselors, small business owners, and any other stakeholder group (Weber, Collins, Robinson-Wood, et al., 2018). The LGBTQ community is already at high risk for microaggressions, compounded when being of a minority status increases the likelihood of falsely attributing behaviors to criminality
In addition to stakeholder collaboration, the prevention program for the LGBTQ minority population in Miami would need to be designed in ways that ensured confidentiality, while also making sure that all participating individuals receive informed consent to participate in programs. Likewise, informed consent must be given to family members or other third parties who agree to participate in the prevention or treatment plan. By creating a more ethical, culturally sensitive prevention program, it becomes possible to respond more effectively to the unique needs of vulnerable minority groups. Prevention efforts like these depend on rigorous research, needs assessments, collaboration and strategic partnership, and also culturally appropriate service delivery.

References Carter, R.A. (2018). Illusory correlation and perceived criminality. College of Arts and Sciences Senior Theses. Retrieved from: https://ir.library.louisville.edu/honors/179/ Crocker, A.G., Martin, M.S., Leclair, M.C., et al. (2018). Expanding the early and late starter model of criminal justice involvement for forensic mental health clients. Law and Human Behavior, 42(1), 83-93. http://dx.doi.org/10.1037/lhb0000269 Sugie, N.F. & Turney, K. (2017). Beyond incarceration. American Sociological Review 82(4): 719-743. Weber, A., Collins, S., Robinson-Wood, T., et al (2018). Subtle and severe: microaggressions among racially diverse sexual minorities. Journal of Homosexuality 65(4): 540-559.
PART 5: ADVOCACY
Criminalization of Mental Health in Miami, Florida
Almost two decades ago in the year 2000, Miami-Dade County became a leader in providing a viable alternative to the criminalization of mental health with the creation of the Criminal Mental Health Project. The Miami-Dade Criminal Mental Health Project has since been “hailed as a national model for decriminalizing mental illness,” (Rivero & Green, 2019). The numbers are promising: leading to such dramatic drops in inmate populations that the county was even able to close a jail (Rivero & Green, 2019). Also promising is the new $22 million Miami Center for Mental Health and Recovery, designed also to “divert individuals with mental illness away from jails,” (Looker, 2019, p. 1). Yet more needs to be done in order to advocate for the most disadvantaged members of the population: the ones still lacking access to effective, accessible, and affordable mental health services. Perhaps more importantly, the Miami-Dade Criminal Mental Health Project needs to coincide with more aggressive legislative reform that will address the need for drug policy reform.
Successful advocacy work requires not only the passionate desire to serve the community. Strategy, goal-setting, and effective frameworks help guide the public policies that uplift vulnerable populations, empowering individuals to enact the desired changes in their own lives, the lives of their loved ones, and in their communities. Following the Multicultural and Social Justice Counseling Competencies (MSJCC) can help stakeholders reach mutual goals of achieving social justice and equity related to the target problem of the criminalization of mental health in Miami. The MSJCC acts as “a framework to implement multicultural and social justice competencies into counseling theories, practices, and research,” (p. 3). Before using the MSJCC, stakeholders need to consider what barriers prevent change, including psychological and sociological resistance to change. Institutional, community, and public policy barriers should not be viewed as impediments, but merely as challenges that can be effectively overcome with conscientious effort and teamwork,
In this case, the barriers that need to be overcome include resource allocation, education, and access/awareness. Resource allocation is a critical barrier that involves both the private and the public sector, and also involves interventions from the non-profit sector too. State, local, and federal organizations dedicated to reducing the numbers of people who serve time in penitentiaries instead of receiving the mental health supports they actually need can become strategic allies working hard toward the removal of such barriers. The private sector should also become involved, by soliciting support and reaching out through the community, using brands and marketing techniques to connect consumers to the social justice causes that matter most to Miami-Dade r4esidents. With the right public policies in place, all stakeholders can effectively pool and allocate resources to provide cost-effective solutions.
Education is crucial because a great number of healthcare workers, and also members of the criminal justice system, may not be fully aware of the services and opportunities available already. The county and individual municipalities already offer many options counselors, low enforcement officers, attorneys, and other allies can use to help people who struggle with mental illness. Effective education includes public service announcements, but also formal training and education for school administrators, law enforcement leaders, faith-based leaders, and community activists. Related to education is public awareness that increases the ability for all persons to access available mental health services. Informing persons of their legal rights, empowering friends and family members with information, and preparing effective documents such as websites or pamphlets can help the advocacy effort. Advocacy is a crucial component in any prevention plan, because meaningful and lasting change occurs through advocacy and empowerment.
The social-ecological model offers an ideal framework to pursue advocacy and social justice (Multicultural and Social Justice Counseling Competencies, 2015). Advocacy actions can take place on institutional, community, and public policy levels. At the institutional level, advocacy entails training staff in cultural competency, as well as in interpersonal communications strategies. Nurses, mental health professionals, and educators working at the institutional level need to understand how to appropriately intervene, how to recognize early warning signs, but also how to operate within the parameters of ethical and professional standards. For example, counselors and other mental health professionals must maintain client confidentiality during the advocacy process. The same holds true for educators and others who are not as familiar with the importance of confidentiality and privacy.
At the community level, the key to advocacy is teamwork and strategic partnership. Community organizations, including small business, need to frequently meet to discuss strategies to divert residents from the criminal justice system towards the mental health services they need. To achieve this goal, the community policing model becomes critical. Fusing the institutional and community advocacy strategies, working with law enforcement provides the optimal way to educate police about best practices when working with the mentally ill. Law enforcement professionals also need training in recognizing warning signs, and building trust within the community so that they remain committed to public safety.
Finally, advocacy hinges on public policy changes. Public policy will eventually reflect the prevailing social norms and the political climate. Public policy can ensure that punitive justice methods are no longer viewed as the optimal means by which to mitigate problematic behaviors. Municipal and state public policies can also impact federal public policies, which in turn make a real impact on the social norms related to the criminalization of mental health.

References Looker, R. (2019). Miami-Dade County builds a center for mental health and recovery. NACO. Retrieved from https://www.naco.org/articles/miami-dade-county-builds-center-mental-health-and-recovery Multicultural and Social Justice Counseling Competencies. (2015). Retrieved October 27, 2015, from http://www.counseling.org/docs/default-source/competencies/multicultural-and-social-justice-counseling-competencies.pdf?sfvrsn=20 Rivero, D. & Green, N. (2019). How Miami-Dade’s mental health program steers people to treatment, not jail. WJCT. 13 March, 2019. Retrieved from https://news.wjct.org/post/how-miami-dades-mental-health-program-steers-people-treatment-not-jail