Friday, January 23, 2015

The California Dream of Justice & Terror of Mental Illness: A Behavioral Indictment Of The “Three Strikes and You’re Out” Policy – Ryan Manganelli

Justice is not served best with a singular solution. For the United States, the path to justice is undeniably intertwined with incarceration. Compared to all other nations of the world, with a staggering 2.2 million inmates, the United States possesses the largest imprisoned population in the world (1). America’s most populated state (2), the Golden State, California played a major role in augmenting the nation’s incarcerated population over the last twenty years. Enacted in 1994, California’s Proposition 184, or as the infamous piece of legislation is also titled, the “Three Strikes and You’re Out” policy was crafted with the intent of deferring repeat criminal offenses. As the title denotes, under the “Three Strikes” policy, Californian criminals are punished relative to the amount of felony offenses they have committed. Repeat offenders receive twice the sentencing length otherwise mandated by law for their second offense and a third offense leads to a life imprisonment with the minimum term being 25 years (3). The law catalyzed a tremendous influx of jailed prisoners in California since its enactment. Beyond the ethical and legal dilemmas posed by the Proposition 184, the law offers profound implications for the public health sector of California. In particular, the incarceration of criminals suffering from severe mental illness creates a need for systematic reform.
Examining the “Three Strikes” policy through the lens of behavioral science provides a medium to address the disenfranchisement of mentally ill prisoners in the state of California. One of the nation’s most prestigious academic institutions, Stanford Law School has launched the discussion regarding Proposition 184’s role in the imprisonment of the mentally ill with their publication “When Did Prisons Become Acceptable Mental Health Care Facilities?” According to Stanford’s extensive report, approximately 45 percent of Californian inmates are suffering from a mental illness. The most alarming disparity highlighted in the report is the disproportionate number of inmates sentenced to life in prison under the “Three Strikes” law. Prisoners sentenced under the “Three Strikes” law are nearly twice as likely to be mentally ill compared to other California prisoners (4). Rather than establishing public institutions that assist the mentally ill prisoners combat their diseases, the state of California is shackled by its inadequate criminal justice legislation, the “Three Strikes” policy. Stemming from such inadequate policies, a vicious cycle plagues people who are mentally ill not only in California, but also the entire nation. In the fractured mental health care system of the United States, people diagnosed with severe mental illnesses face tremendous barriers to receive the necessary medical care to manage their illness. When severely ill patients are left untreated, the unfortunate reality of their illness manifests in the form of erratic and illegal behavior (5). With a policy such as the “Three Strikes” rule, mentally ill criminals are relegated to serving as cogs in the vicious cycle of repeated imprisonment and neglected treatment. Indicting Proposition 184 with several evidence-based social and behavioral science theories can bring the Golden State closer to justice.
 Issues of Stigma
            Consider the trajectory of a prototypical civil rights movement. Each civil rights trajectory can be placed in the confines of a narrative with heroes and villains. With each civil rights narrative, the villain is continually embodied by an ominous social phenomenon – stigma. Ervin Goffman, one of the most influential sociologists of the 20th century, was a founding scholar in the examination of stigma as a social concept.  By Goffman’s foundational account, stigma is a reference to a social attribute (race, occupation, religion, sexual orientation, educational status etc.) that is labeled as “deeply discrediting” by the “normals,” or exclusive factions in a society (6). Stigma plagues the socially discredited in a cyclical fashion. As Patrick Corrigan outlines, stigma unfolds in a three-part act: signals, stereotypes, and discrimination. Physical characteristics and language exuded by the stigmatized provide signals for exclusive members of society to construct stereotypes about discredited factions. With the stereotypes on the conscious of the elite, the discredited faction is subject to confront discrimination in various arenas of social life (7). As investigative journalism published in the New York Times reveals, the “Three Strikes” policy has created a medium for California to stigmatize the mentally ill.
Dale Curtis’ confrontation with the “Three Strikes” policy exemplifies the villainous nature of stigma. Curtis is a 55 year-old, Californian male who suffers from mental retardation and schizophrenia. Multiple non-violent, robberies of negligible monetary values committed by Curtis earned him three strikes in the California court of law. The tragedy of stigma ultimately confronted Dale Curtis in the courtroom. Although Curtis displayed severe episodes of mental impairment during questioning and with the negligence of his public defense attorney to mention his extensive record of illness, Curtis was awarded the status quo, life sentence for his third strike (8). Corrigan’s three-part act of stigma was exemplified in the case of Dale Curtis. Through his actions in the courtroom, Curtis provided the surrounding audience signals to justify stereotypes and discriminatory sentencing. Despite the clearly visible signs and records available to validate Curtis’ illness, the court opted to discredit his illness and ignore mental health care treatment options. Addressing issues of stigma can alter the tragic course of mental illness in California to form a story of triumph & redemption. 
The Role of Social Norms
            Before detrimental stigmas around mental illness can be resolved, there is a pressing social issue underlying the phenomena of stigmatization. Perceived social norms of mental illness are at the foundation of the injustice perpetuated by the “Three Strikes” policy.  Social norms are beliefs shared within a social environment (school, occupational setting, church, city, etc.) regarding a set of behaviors or “customary codes.” The theory of planned behavior explains the potential for social norms to impact communities. Before an individual can reach an intention to facilitate a certain behavior, the attitude that individual holds toward the particular behavior is influenced by the prevalent social norms in an environment (9). The perceptions individuals share of one another and the nature of social interactions are tremendously impacted by the prevalent social norms shared in an environment. Social norms have the potential to influence the manner that human beings treat one another. Stigmatizing and discrediting social norms regarding mental illness can further complicate disparities of mental health among individuals in a social setting.
One recent study featuring a cohort of undergraduate students demonstrates the role perceived social norms have in the stigmatization of mental illness. In the study’s primary experiment, the students were asked to describe their level of comfort to interact with individuals who display symptoms of schizophrenia and depression, as designated by the Diagnostic and Statistical Manual of Mental Disorders. Before the investigators assessed the subjects’ comfort in the hypothetical scenarios, they assessed the subjects’ perceived social norms of behaviors and personal beliefs related to mental illness using questionnaire instruments. Ultimately, the analysis revealed an association between subjects reporting less comfort with interaction among mentally ill people and perceived normative expectations about general behavior (10). The study validates the role of social norms in the stigmatization of mental illness. If people approach those battling a mental illness with discrediting preconceived notions, the ill are subject to face discrimination and stigma. Dale Curtis’ story mirrors the conclusion of the social norms study. Curtis’ symptoms and history of illness were subsequently discredited and approached with tremendous social distance, or an ambivalent interaction based on a set of collectively recognized norms in a social group (11). Perhaps, discrediting institutional norms regarding mental illness were at the foundation of Dale Curtis’ stigmatized experience.
Frames that Make the Mentally Ill Invisible
            Perspectives surrounding the implementation of the “Three Strikes” policy and subsequently proposed amendments completely ignore the role played by California’s criminal justice system in the manifestation of mental illness. With the aid of framing theory, California’s ignorance toward the mental health of its inmates can be brought to the forefront.  Framing is the manner in which information is packaged and arranged to convey an intended connotation, or message is framing (12). Polarizing issues, such as policies surrounding incarceration and the treatment of mental illness, evoke a vast spectrum of frames in the media and political forums. In the construction of public policies, framing creates a significant impact on the perspective of voters and politicians in their consideration of issues debated in legislative arenas. One of the fundamental tasks in frame analysis is identifying the core values, or the “appeal to principle” offered by a frame presented in the media. Core values are terms that link the underlying position of the frame and its attempt to resonate with an ideal that is ubiquitously valued in society (13). With the use of core values, frames have the power to influence which values and beliefs are instilled within a society. In the case of the “Three Strikes” policy, the frames surrounding the policy neglect to include health as a core value.
Proposition 36 is the most recent proposal on behalf of California’s legislature to mend the oversight embedded within the “Three Strikes” policy. Established in 2012, Proposition 36 raised the valid concerns of revising the “Three Strikes” policy to save the state money and continue to ensure the safety of its citizens. One glaring piece was missing in the frames constructed to support Proposition 36 – an emphasis on the mentally ill prisoners who are marginalized by the “Three Strikes” policy. Safety, justice, and economics are core values disseminated throughout Proposition 36’s website Fix Three Strikes. The highlighted potential benefits of the proposition include: “saves California over $70-100 million annually,” “restores the original intent of the Three Strikes law,” and “no rapists, murders, or child molesters will benefit from Prop. 36”(14). While public safety, resurrecting California’s budget, and incarcerating legitimate felons are valid concerns built upon core values that resonate with the public, there are no statues in Proposition 36 that speak to the mental health burden of inmates. As the Stanford report examines, the lack of attention devoted to the mentally ill that are incarcerated under “Three Strikes” sentencing has consequences. While nearly 1800 prisoners reaped the benefit of gaining a revised sentence following the Proposition 36 approval, 75 percent of the inmates denied a revised sentence after the proposition was passed were mentally ill (4). Proposition 36 was an opportunity to leverage the influence of framing theory to afford the mentally ill who are imprisoned by the “Three Strikes” a path to seeking treatment. The unfortunate reality is that frames in support of Proposition 36 neglected health as a core value and the negligence continues to haunt prisoners struggling with illness. Frames provide an outlet to bring an issue, not unlike prisoners battling mental illness, from subterranean media and advocacy circles to the center of mass media. With the use of health and equality focused frames, citizens imprisoned by mental illness will be granted a previously absent voice and platform in the conscious of the public.
Campaign to Address Social Norms & Stigmatization
            Mental health is gaining momentum in reaching the center of public health interventions and awareness campaigns. On the other hand, outreach and campaign efforts specific to mental illness within the criminal justice system are incredibly scarce. Invisible social issues, like the oppression of the mentally ill through imprisonment, require drastic social measures to foster legitimate social change. In the plight of the mentally ill who are imprisoned, establishing a campaign to raise awareness of Proposition 184’s role as an oppressor is the necessary social measure. Marketing principles can lend the necessary tactics to construct an effective campaign aimed at debunking stigma and reframing social norms of mental illness among the incarcerated. Social marketing, in particular, is a theoretical model pertinent to what would best assist the design of a mental illness social norm campaign. The ultimate goal of social marketing is to garner effective campaigns by utilizing principles of commercial marketing (product planning, pricing, communication, and marketing research) to leverage influence on the acceptability of social ideas and norms. To achieve significant social change, the principles of commercial marketing must address historical, cultural, political, and social environments surrounding an issue (15). Each component, or tool offered by social marketing can be applied to the predicament of the mentally ill affected by the “Three Strikes” law to design an effective social norms campaign.
Historically, California has struggled with transitioning from the deinstitutionalization of mental illness in the 1960’ s-1970 and subsequent  “emptying” of the ill released from closed state hospitals to prisons during the proceeding decades (4).  While California legislature has offered several policies to address mental health, such as the Mental Health Services Act in 2004, politically the state has been silent on issues of mental illness among the incarcerated. Considering the stigma encountered by Dale Curtis in the courtroom, the social environment in California surrounding mentally ill criminals is not one of reconciliation. With the historical, political, environmental, and social factors surrounding the “Three Strikes” law in mind, social marketing tools can be leveraged to design an effective campaign aimed at changing the social norms regarding mentally ill prisoners.
Building a social norms campaign with a product, price, place, promotion, and partnership as the pillars of intervention is paramount in the design phase. In particular, considering the product disseminated in social media, television, and print campaign materials will foster the most relevant campaign to a 21st century audience. The product, or an immediate benefit (15) to be acquired by the audience (the state of California) in the case of the norms campaign is an abstract commodity – social purpose. For instance, in promotional material, the issue of incarcerating the mentally ill can be framed as the current generation’s marquee civil rights issue. To illustrate the campaign’s product, compiling images of mentally ill persons in hospital gowns behind prison bars with images of the 1960’s civil rights movement, or the AIDS movement of the 1980’s will add historical relevance to the campaign. Like previous generations, the current generation can acquire social purpose by participating in a social movement. Politically, the campaign can engage the audience by instituting a pledge for Californians to call on their representatives and senators to craft legislative action that aids the mentally ill whom the “Three Strikes” law repeatedly oppresses.  If the historical and political components are successful, the goal of systematic social change will follow. With social marketing, a social issue can be afforded a social resolution and newfound visibility.

Establish Multi-Dimensional Care Options
            Mental illness is an immensely complex issue that requires multi-faceted solutions. Combine the difficulty of managing a mental illness with confronting the criminal justice system on a regular basis, and the issue becomes even more baffling. Maslow’s “Hierarchy of Needs” is a behavioral model that resonates with the complex and multi-dimensional nature of mental illness. Utilizing Maslow’s hierarchical model as a platform to design treatment programs for mentally ill and legally troubled populous, such as those affected by the “Three Strikes” policy, provides an outlet to compartmentalize a densely faceted issue. Abraham Maslow devised his theory to identify the most fundamental human needs, which when fulfilled, can lead to the achievement of “self actualization.” The diverse array of human needs highlighted by Maslow includes: physiological, safety, love and belongingness, esteem, and self-actualization. If all of the fundamental needs are met, individuals theoretically reach an empowered state of being that spawns the development of critical thinking and problem-solving abilities (16). Addressing the “Hierarchy of Needs” for the mentally ill poses a valid model to provide coordinated care to mental health patients and assist those who frequently confront the law assimilate into society, rather than prison.
            On a national scope, there are examples of health care facilities that provide treatment options to assist mentally ill patients meet their “hierarchy of needs.” Bridgeview Manor is an adult care home in Ashtabula, Ohio that provides mental health treatment to patients suffering from severe mental illnesses who have also served prison sentences. The facility was featured in PBS’ Frontline documentary series, “The Released,” which depicts the plight of mentally ill prisoners in the United States. In Frontline’s interview with the Bridgeview Manor director, Sherri Sullivan, she acknowledges the mentally ill patient’s unique need for assistance with routine tasks (physiological needs), such as practicing daily hygiene and preparing meals. Regaining connection with family members (love and belongingness), access Social Security and Medicaid Benefits (safety), and motivational interventions (esteem) are other services that Bridgeview Manor offers to patients.  Sullivan also noted about the patients at Bridgeview, “they need a lot of additional help that's not available particularly in an outpatient community setting” (5). Although operating a facility like Bridgeview Manor poses significant funding and administrative challenges, the facility offers an outstanding example of how mental health patients leaving prison should be treated. If California allocated more resources in community settings to address the unique “hierarchy of needs” for the mentally ill, versus imprisoning the ill as a substitute for treatment, self-actualization for the mentally ill can be realized.
Enhance Public Defense & Police Mental Health Training
            Modifying the norms of an institution is approachable through the use of individualized behavioral models. To prevent future instances of stigma within legal forums, such as the case of Dale Curtis, bolstering mental health training programs for criminal justice authorities in California is a viable solution. For the design of such training programs, social cognitive theory provides a behavioral framework to assist legal authorities transcend prejudice thought regarding mental illness and embrace social differences in their line of work. Social cognitive theory (SCT) is a dynamic behavioral model that focuses on the relationship between individual factors, environmental variables, and subsequent human behavior. At the core of SCT, is the classic nature-versus-nurture debate – are individuals a product of their environment, or is the environment a product of the individuals? According to SCT, the adoption of new behavior causes both the onset of social modifications that alter the individual and the environment (17). In the plight of the mentally ill affected by the “Three Strikes” law, the previously suggested interventions are aimed at creating environmental, or macro-level social changes. California’s individual, or micro-level solution: adopt SCT-modeled training programs for figures in the state’s criminal justice system. Through the use of a SCT model, law enforcement, judicial, and correctional professionals can develop the self-mastery to constructively interact with mentally ill persons, to recognize symptoms of illness, and to identify safe and ethical methods to coerce untreated individuals experiencing heightened states of illness.
            Patrick Corrigan also presents thought provoking literature regarding the dynamic between social-cognition, institutional stigma, and life-chances for the oppressed. Corrigan expresses the dynamic in a formulaic manner. As a product of social cognitive function, authoritative individuals exercise institutional stigma, which pressures society to undermine access to care (18). Because of pressures in the courtroom (environment) and the negligence of the judicial and legal professionals (individuals), Dale Curtis did not receive equal due process (discrimination and stigma). Expanding mental health training programs for California’s criminal justice system will reconcile the environmental and individual elements in Dale Curtis’ narrative. The National Alliance for Mental Illness (NAMI) offers one of the most comprehensive law enforcement mental health training programs in the country – Crisis Intervention Training (CIT). With a bi-dimensional program design, CIT combines an individual component: “training for law enforcement to improve response to people experiencing a mental health crisis;” and an environmental component: “a forum for partner organizations to coordinate diversion from jails to mental health services” (19). CIT focuses on social cognition by intervening the approach of individual police officers and the approach of communities, or larger social environments to treating mental illness. By addressing the individual and environmental components of the SCT model, the CIT program is a shining example of an alternative approach to incarceration of the mentally ill.
             Managing mental illness is an immense challenge for both individuals and societies. The complexity of addressing the issue is beyond daunting. In the world of criminal justice, the complexities of mental health serve as an excuse to perpetuate the oppression of the mentally ill through imprisonment. Embracing social differences will allow societies to mitigate the consequences of inadequate and antiquated policies, such as the “Three Strikes” policy. Campaigns to address social norms, establishing more multi-dimensional community mental health care facilities, and funding criminal justice mental health training programs, are viable interventions to address the systematic disenfranchisement of the mentally ill in California. Social endeavors are a balance of exercising patience and urgency. Profound societal change does not transpire instantaneously, yet the consequences of injustice do not rest.
  1. The Sentencing Project. Incarceration. The Sentencing Project.
  2. State of California. Facts. Sacramento, CA: State of California.
  3.  Legislative Analyst’s Office. A Primer: Three Strikes – The Impact After More than a Decade. Sacramento, CA: Legislative Analyst’s Office.
  4. Stanford University. When Did Prisons Become Acceptable Mental Healthcare Facilities? Stanford, CA: Stanford Law School – The Three Strikes Project. 2014.
  5.  Public Broadcasting Services. Frontline – The Released. Arlington, VA: Public Broadcasting Services.
  6. Goffman E. Stigma: Notes on the management of spoiled identity. Englewood Cliffs, N.J: Prentice-Hall. 1963
  7. Corrigan P. Mental health stigma as social attribution: Implications for research methods and attitude change. Clinical Psychology: Science and Practice 2000; 7: 48-67.
  8. 8.    Staples B. California Horror Stories and the Three Strikes Law. New York, New York: New York Times, 2012.
  9. Edberg M. Individual health behavior theories (pp. 35-49). In: Edberg M. Essentials of Health Behavior: Social & Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.
  10.  Norman, R. et al. The role of perceived norms in the stigmatization of mental illness. Social psychiatry and psychiatric epidemiology 2008; 43: 851-859.
  11. Karakayali, N. Social Distance and Affective Orientations1. In Sociological Forum 2009; 24: 538-562.
  12. Menashe, C.  Siegel, M. The power of a frame: an analysis of newspaper coverage of tobacco issues-United States, 1985-1996. Journal of health communication 1998; 3: 307-325.
  13. Winett, L. Advocate’s Guide to Developing Framing Memos (Chapter 46). IN: Iyengar S, Reeves R, eds. Do the Media Govern? Politicians, Voters and Reporters in America. Thousand Oaks, CA: SAGE Publications, Inc., 1997, pp.420-432.
  14. Three Strikes Reform. About Proposition 36. NAACP Legal Defense and Educational Fund, Inc.
  15. Siegel, M, & Doner, L. Marketing principles applied to public health (pp.203-228). In: Siegel, M, & Doner, L. Marketing public health Gaithersburg, Maryland: Aspen Publishers, 1998.
  16. Simons, J, et. al. Psychology - The Search for Understanding. New York, NY: Drinnien West Publishing Company, 1987.
  17. National Cancer Institute. Theory at a Glance: A Guide for Health Promotion Practice. Part 2. Bethesda, MD: National Cancer Institute, 2005, pp. 9-21 (NIH Publication No. 05-3896).
  18. Corrigan, P. How Stigma Interferes With Mental Health Care. American Psychologist 2004; 614-625.
  19. National Alliance for Mental Illness. Crisis Intervention Training – FAQ. Crisis Intervention Training. Arlington, VA: National Alliance for Mental Illness.

No comments:

Post a Comment