Many mental health professionals who previously may not have been involved in treating mentally 511 offenders are now finding themselves with treatment responsibilities for this population.1
As we enter the new millennium, we seem to be turning back the clock in our treatment of the mentally ill. In the early 1800s in the United States, repeated incarceration for mentally ill persons was commonplace. Through the actions of psychiatric reformers such as Reverend Louis Dwight and Dorothea Dix, the mentally ill were placed in public psychiatric hospitals instead of jails and almshouses.2 Their success was reflected in the 1880 census: 91,959 "insane persons" were identified, of which 41,083 lived at home, 40,942 resided in "hospitals and asylums for the insane," 9,302 were in almshouses, and only 397 were in jail (235 were unaccounted for). The latter group constituted only 0.7% of the incarcerated population.
Today, 6% to 15% of jail detainees suffer from severe psychiatric disorders (schizophrenia, bipolar disorder, and major depression). For many, the jail has a "revolving door." With approximately half a million jail inmates and even larger numbers released into the community or out on probation, the comments of Lamb et al. signal new demands for mental health treatment services.
Not since 1988 has Psychiatric Annals devoted an issue to correctional psychiatry, and then it specifically dealt with the Federal Bureau of Prisons.? Herein we address newer approaches to a centuries-old problem, dealing with mentally ill offenders as they move between the jail and the community. The use of psychotropic medication to alleviate psychiatric symptoms is an important treatment component, as detailed by Kravitz, Davis, and Silberberg, and helps to maintain these individuals in the community.
However, these persons with severe mental illness need more than medication; symptom control often is just the tip of their multiproblem iceberg and aftercare needs. Watson, Hanrahan, Luchins, and Lurigio address the problems and service needs of mentally ill offenders. In describing the environment encountered and the struggles that ensue as these persons try to survive in the community, they offer a contextual basis for understanding the complexities involved. A community model in which representatives of mental health, criminal justice, and human services participate is essential to ensure that a spectrum of needed services are available.
Simply releasing mentally ill offenders into the community and offering services is not enough. To paraphrase an old adage, "If you build it, maybe someone will come" (J. Swartz, PhD, personal communication, April 28, 2000). Silberberg, Vital, and Brakel propose that the potential for breaking the cycle of criminal recidivism, which mostly involves relatively minor offenses, and diverting mentally ill offenders into treatment on release into the community, can be enhanced by implementing a rarely used legal option - mandated outpatient mental health treatment. They review the legal authority for using this mechanism to ensure treatment delivery, and discuss how to develop effective interactions between mental health and criminal justice professionals.
Despite innovations that exist to overcome barriers to treatment and available effective treatments, some mentally ill offenders remain rather resistant to our best efforts. Daghestani, Dinwiddie, and Hardy describe one such group of individuals who remain a challenge for clinicians, mentally ill offenders with antisocial personality disorder. Regardless of where they are found, and they move rather elusively between correctional, forensic, general psychiatric inpatient, and community settings, they continue to frustrate therapeutic efforts. Although cautioning that therapeutic expectations should be limited, the authors encourage us that specific behavioral changes can occur, especially if treatment planning includes collaboration with other agencies, particularly the legal system.
Another particularly tragic consequence of incarcerating persons with severe mental illness is suicide. Freeman and Alaimo remind us that, although the treatment of mentally ill detainees has improved remarkably during the past two decades, we need to be attentive to factors that impact on this untoward outcome. Via literature review and vignettes, the authors illustrate these contributing factors. They also describe preventive interventions, both interpersonal and environmental, taken within the confines of a large urban jail to reduce the risk and to deal humanely with this sensitive issue within a dehumanizing setting.
Finally, Judge Lerner-Wren and Appel give us a glimpse of new horizons for judicial intervention in cases involving arrested mentally ill defendants. Judge Lerner-Wren, presiding Judge of the Broward County (Florida) mental health court, applies "therapeutic jurisprudence" to remedy "revolving door justice" and to reduce jail overcrowding. In diverting mentally ill offenders from the criminal justice system into treatment programs, the court becomes the therapeutic agent that balances treatment needs against public safety and the individual's constitutional rights. The authors describe the development and implementation of the program, and provide data from their first 2 years of operation. These results, in light of the preceding articles, deserve careful review.
1. Lamb HR, Weinberger LE, Gross BH. Community treatment of severely mentally ill offenders under the jurisdiction of the criminal justice system: a review. Psychiatr Sew. 1999;50:907-913.
2. Toney EE lails and prisons. In: Out of tfie Siwdows. New York: John Wiley & Sons; 1997:25-42.
3. Johnson SC, guest editor. Mental health care in the Federal Bureau of Prisons. Psychiatric Annals. 1988;18: 671-705.