Primary Prevention for Criminal Justice System Involvement

“Prevention is better than cure.” 
― Desiderius Erasmus, circa 1500 

Desiderius Erasmus, a Dutch philosopher, describes the principle which is at the core of modern medicine: preventing an illness, called primary prevention, is better than curing an illness once it has begun, called secondary prevention. As a psychiatrist working in the Emergency Department (ED) of a large urban hospital, I see people every day who could have benefitted from both types prevention, people who have experienced the devastating consequences of severe mental illness (SMI) — poverty, homelessness, substance use, isolation, trauma — and criminal justice involvement. In this piece, I provide a fictional case to demonstrate how missed opportunities to identify and treat SMI occur contemporaneously with missed opportunities for addressing social challenges, leading to criminal justice system involvement. I believe that proactive intervention in these areas holds potential for primary prevention of criminal justice system involvement. 

Samuel was 15 the first time he heard the voices. At first, he thought his brother Ronald left the TV on, except it wasn’t. A few weeks later, it happened again and he thought his Mama was talking to him, except she wasn’t. Over time, it happened more and more. It took Samuel a full year to realize that God was talking to him, and by that time, he knew he had to obey.

Schizophrenia often begins in adolescence with brief, intermittent psychotic symptoms, which gradually progress to frequent, impairing symptoms. The early symptoms of schizophrenia often go unrecognized, leading to delays in accessing psychiatric care. The longer the delay in receiving care, the worse the prognosis (1).  

Samuel was 16 when he got kicked out of school. He was failing anyway, couldn’t pay attention, couldn’t do his homework, could only listen to God. The kids made fun of his mumbling, his blank stare, his unwashed hair. After school one day, three boys followed him down to the corner where he caught the bus home. Two boys held him down while a third used a cigarette lighter to set his jacket on fire. Samuel didn’t go back to school after that, and eventually they just kicked him out.

Children with mental illness are more likely to be bullied (2), and children who are bullied are far more likely to experience mental illness (3). Isolated from peers, scared and suffering, children who are bullied are also more likely to drop out of school (4). When children are no longer involved in the school system, an avenue to enter the mental health care system has been removed. No longer are teachers observing them each day, no longer are guidance counselors tracking their progress, no longer are adults able to detect the signs of early mental illness and intervene.

Samuel was 17 when Mama knew something was really wrong, that it wasn’t just a teenage phase. He was talking to God all the time, sometimes yelling about the Devil’s mark, not leaving his room, barely taking a shower. Mama tried to find a doctor for him, calling office after office after office. She finally got an appointment, but then she lost her job and they didn’t have insurance to see the doctor or any money to pay for treatment. So God kept talking and Samuel kept listening.

Approximately 1 in every 6 children in the US (16.5%) has at least one mental health disorder, yet 49.4% of them do not receive any treatment (5). People with lower income and less education are significantly less likely to receive mental health care (6). Accessing psychiatric care requires literacy, executive function, a working telephone, time, and persistence. And health insurance. While Medicaid (for example, MassHealth) can provide health insurance for low income children and families, the application process is complex, and it can take up to 45 days to receive a determination. Many psychiatrists do not accept Medicaid, and those who do have long waitlists or are unable to see new patients. 

Samuel was 19 when he tried to get a job. Ronald got him the interview, but Samuel showed up late because he got lost and he didn’t understand the questions, so he got scared, and all of that just made God talk louder. He didn’t get the job.

People with severe mental illness (SMI) can experience chronic functional impairment. Even with access to early intervention and high quality psychiatric treatment, only 36% of people with schizophrenia are employed (7). Without employment, people with mental illness struggle to afford food, housing, and clothing. A lack of employment means a lack of day structure, a lack of purpose, a lack of meaning. A lack of employment compounds marginalization.

Samuel was 21 the first time he was arrested. With no diploma, no job, no money, he spent his time wandering the streets, going wherever God told him to. When he could find it, he smoked pot; it mellowed him out, made him feel just a little closer to normal. That day, he saw the man on the corner with the red hat, the Devil’s mark. He followed the man and when his back was turned, grabbed the hat, knocking the man down. As Samuel tried to run away, another man punched him. This time, Samuel fought back, and he kept fighting until the police took him away.

People with SMI are over-represented in the US criminal justice system (8), and it has been reported that the number of people with SMI in correctional facilities is more than three times the number of people in psychiatric hospitals (9). Race only compounds these disparities- among inmates with psychotic disorders, African Americans are overrepresented (10). Psychiatric illness comorbidities serve to increase risk even further. Substance use disorders, comorbid in nearly 50% of people with schizophrenia (11), increases risk of criminal justice involvement (12). Low educational attainment, poverty, and unemployment, social challenges all commonly associated with SMI, are also key factors in further increasing the risk of criminal justice involvement (12)

Samuel was 21, in prison, the first time he saw a psychiatrist. The doctor prescribed him pills to take, and God got quieter and quieter. Samuel stopped seeing the Devil’s mark and he felt a little easier in himself, a little less worried all the time. Samuel behaved in prison, he slept, he ate, he listened to the radio, he took his pills. The day he got out of prison, they sent him with a bus ticket to his Mama’s apartment, a bubble pack with two weeks’ worth of his pills and the number to call to see a psychiatrist, like the one he saw in jail. Except when he got to Mama’s apartment, she said he couldn’t stay, she couldn’t have a felon in her subsidized housing. So Samuel left and went back to the streets. On the streets, he lost track of time, he ran out of pills and he never did call that psychiatrist. Pretty soon, God started talking loudly again, pointing out the Devil’s mark everywhere Samuel could see.

Only 30% of people with SMI released from prison receive either mental health treatment or psychiatric medication within 90 days of release, less than 13% of people receive both (13). People of color are even less likely to receive mental health or substance abuse treatment after release (14). In addition, those with a felony conviction may be unable to access subsidized housing, government assistance, or gainful employment after release (8). It is not surprising then that people with SMI face higher risk of recidivism and reincarceration than those without (10,15)

Recently, there has been a focus on interventions to decriminalize mental illness. Police officers receive crisis intervention training, there are pre- and post- booking diversion programs, and mental health courts have expanded (12). These initiatives are undeniably worthwhile, but they focus on secondary prevention, with the goal of reducing the impact of involvement in the criminal justice system after the criminal behavior has already occurred. To truly change the criminalization of mental illness, community systems need to focus on primary prevention of criminal behavior in people with SMI through coordinated identification and connection to comprehensive care for mental illness and proactive interventions to address challenges with social systems. 

Samuel was failed by the educational system, his peer system, the insurance system, the mental health care system, and the employment system long before he was failed by the criminal justice system. One by one, each potential door to a healthier life closed, until the only door left open was prison.

Primary prevention means opening up all of those doors, and keeping them open at all times, for every person. Primary prevention means educating teachers and guidance counselors to recognize the signs of mental illness and giving them the resources to intervene. It means providing public schools with the financial and personnel support they need to address bullying before it starts and to support vulnerable students before they drop out. Primary prevention also means increasing early access to psychiatric care, not just for the white and wealthy, but for every person, regardless of their health insurance. It shouldn’t be easier to go to prison than to see a psychiatrist. Primary prevention means access to supported employment for those with SMI, a chance to earn a living, develop a trade, contribute and feel pride from that contribution. A way to stay off the streets, a reason to stay sober, a direction and a purpose. Mental illness doesn’t have to lead to criminal behavior, but the doors need to be open, for everyone. 

Abigail Donovan, MD
Director, MGH First Episode and Early Psychosis Program
Associate Director, MGH Acute Psychiatry Service
Assistant Professor of Psychiatry, Harvard Medical School


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