Major changes in mental health policies and laws have placed untold numbers of persons with serious mental illness in the community. Although well-designed community programs have been developed, many mentally ill persons who are involved in the criminal justice system receive inadequate or intermittent care, or no care at all. These changes have caused criminal justice professionals to become involved with persons with mental illnesses at every stage of the justice process.
In this article, we explore the blurred boundaries between the criminal justice system and the mental health system in the United States. First, we describe the characteristics, problems, and service needs of mentally ill offenders. Next, we examine the environmental context, including characteristics of the service system. Third, we describe the criminal justice services for persons with mental illness, and related research. Finally, we discuss the implications for service systems, model programs, and our conclusions.
PROBLEMS AND SERVICE NEEDS OF OFFENDERS WITH MENTAL ILLNESS
Prevalence of Mental Illness
Across the country, studies have found a 6% to 15% prevalence of serious mental illness in jails.13 Of the 10 million arrestees admitted to jail each year, approximately 13%, or 1.3 million, have severe mental illness, compared with 2% of the general population. The proportion of mentally ill persons in jail increased by 154% between 1980 and 1992.4 A recent Bureau of Justice Statistics survey found that 16% of state prison inmates, 7% of federal inmates, 16% of jail inmates, and 16% of probationers reported having a serious mental illness or a mental hospital stay at some point in their lives.5 Jails, de facto, have become sites of care for persons with serious mental illness.
Comorbid Substance Use
More than 90% of jail inmates with severe mental illness, including schizophrenia, bipolar disorder, or major depressive disorder, have lifetime drug or alcohol disorders.6 Their reported rate of current substance use problems, including alcohol, ranges from 62% to 72%.6-7 More than half of mentally ill persons in jails and prisons report having used drugs or alcohol while committing their current offenses.5
Mentally ill persons with substance use problems are more likely to become homeless, to have more severe symptoms, to be hospitalized, to have greater difficulty sustaining employment, and to be noncompliant with treatment.8-13 They present a special challenge in terms of treatment and discharge planning because they are seen as "too mad" for substance abuse programs and "too bad" to be treated in mental health facilities.6,14 Thus, the path to jail for persons with a dual diagnosis is circular: substance use contributes to arrest and incarceration, and is followed by inadequate treatment after discharge, which leads to continued substance use, which creates an increased likelihood of another arrest.
Homelessness is another significant problem reported by mentally ill persons in the criminal justice system. In a national, Bureau of Justice Statistics survey, 20% of state prison inmates, 19% of federal prison inmates, and 30% of local jail inmates with mental disorders reported having been homeless during the year prior to their arrest, compared with 9%, 3%, and 17%, respectively, for those without mental disorders.5 Similar rates of homelessness have been reported among mentally ill inmates of an urban jail, 33% to 40%, 14'15 and among defendants referred to the Manhattan Forensic Psychiatry Clinic, 33%.16 The rate of homelessness in the New York sample was 40 times the rate in the general population.16 Homeless versus domiciled mentally ill defendants were substantially overrepresented among those charged with reckless endangerment, assault, robbery, attempted murder, and murder.
Poverty is pervasive among persons with serious mental illness.17 The mentally ill have low rates of employment, and are often supported by Supplemental Security Income (SSI). Despite their poverty, many have difficulties in acquiring and maintaining entitlements such as SSI and Medicaid.18,19 Although federal regulations do not require it, incarceration results in loss of benefits in most U.S. communities.20 Following their release from jail, these individuals must reapply for Medicaid and SSI, a process that can take weeks.
High rates of substance abuse and homelessness among mentally ill offenders, together with the likelihood of losing benefits while incarcerated for those who were able to obtain them, make this group especially vulnerable to poverty and an inability to meet their most basic needs on discharge. Rearrest may then occur when these individuals resort to illegal means of meeting basic needs. Linkage to housing and benefits, particularly SSI and Medicaid, is an essential component of discharge planning for mentally ill detainees.
Compliance With Treatment
Refusal of treatment by persons with severe mental illness is believed to play an important role in the large proportion of mentally ill persons in jails.1 However, little data are available on this problem. In a longitudinal study of mentally ill persons who were arrested, only approximately half had community providers (51%), and only half of that subgroup were compliant with treatment recommendations.21 More than half (54%) were rearrested after 12 months. Among those who were rearrested, only 19% were compliant with treatment. Noncompliance with treatment has many negative consequences in addition to a greater likelihood of rearrest Noncompliant persons are also more likely to be hospitalized, to be rehospitalized, and to experience greater symptom severity.22-24
From the perspective of the criminal justice system, the most dangerous consequence of noncompliance with treatment is violence.25 Yet no studies have been identified that examine this issue directly among mentally ill offenders. Related research finds that, in general, the risk of violence among persons with mental disorders is no greater than that in the general population.26 However, two conditions that are common among mentally ill offenders are linked with violence in persons with serious psychiatric problems: noncompliance with medications25 and symptoms of substance abuse.26 The combination of noncompliance and substance abuse is particularly dangerous, being strongly related to the commission of a violent act.26
No studies have been identified of medical problems among incarcerated mentally ill persons. However, in related research, individuals with mental illness were found to experience poorer health, have higher mortality rates, and have more limited access to care than members of the general population.27-30
ENVIRONMENTAL CONTEXT: SYSTEM AND SOCIAL CHARACTERISTICS
Criminalization of the mentally ill refers to the increasing numbers of mentally ill persons in the criminal justice system. In encounters with the police, persons exhibiting symptoms and signs of serious mental illness are more likely to be arrested,31 and, if taken to jail, are more likely to spend more time there than persons without serious mental illness.32 Commonly cited causes include changes in mental health laws, the declining public hospital census, limited access to services, and public attitudes toward crime and mental illness.31-3336 Civil commitment criteria have become more stringent, and the right to refuse treatment has been strengthened.1 The public's fear of the mentally ill and its growing intolerance of offenders in general have led to harsher laws and have hampered effective treatment planning for mentally ill offenders.1,34
Service System Coordination and Fragmentation
Mentally ill offenders require access to a variety of services and resources to remain stable in the community. Appropriate services, such as supportive housing, are often unavailable for persons with serious mental illness, and such persons typically experience multiple obstacles in accessing existing services. Inability to maintain stability in the community is what led many mentally ill persons into the criminal justice system in the first place, and it is what leads them back, absent resources and care. The treatment of mentally ill persons involved in the criminal justice system requires communication between treatment staff from community mental health centers and criminal justice staff working in the courts, probation departments, and state attorney and public defender offices. However, interagency communication and effective discharge planning appear to be the exception, rather than the rule.37
Lack of Access to Appropriate Care
Lamb et al.35 noted that reluctance to treat mentally ill offenders is apparent in virtually all areas of community-based care, including housing, social and vocational rehabilitation, and medical care. Service agencies are unable to ensure staff safety, have no legal authority or leverage over clients, and have little experience in providing treatment to mentally ill offenders. Furthermore, many clinicians are uncomfortable with the added role of social control agent, a role that often is inconsistent with their training and treatment philosophy. Others may simply be afraid of this population. In addition, mentally ill persons who have committed crimes may resist psychiatric treatment.
Criminal justice personnel may also believe that mentally ill persons can be served more quickly and efficiently in the criminal justice system. When community mental health services are scarce or criteria for hospitalization are overly stringent, this perception is correct. Police officers often have had frustrating experiences with the mental health system, such as long waits in emergency departments and refused admissions. Thus, even if an officer recognizes that a person has a mental illness, he or she might believe that the person can be more efficiently dealt with in the criminal justice system. Police might even take mentally ill persons who have not committed a crime to jail rather than to a community service site if they believe that no appropriate community alternatives are available. This practice has been referred as "mercy booking."1
Criminal justice personnel can also unwittingly impede access to available community mental health services. Police officers may arrest mentally ill persons rather than transport them to a hospital or other mental health setting because they lack the experience or training to recognize mental illness. Formal training and consultation should be provided to police officers.1,38
INTERVENTIONS FOR MENTALLY ILL OFFENDERS
Interventions for mentally ill detainees include services to prevent arrest and divert offenders, mental health services provided in jails, and linkage to services after conviction and release. Many jurisdictions combine several types of interventions; however, linkage to community services, which is critical to successful outcomes, is used only sparingly.
Prebooking programs, such as police crisis teams, attempt to divert mentally ill offenders to appropriate mental health services before they are arrested. These teams include specially trained mental health officers, mental health professionals employed by the police department, or community mental health professionals who provide consultation to police officers. They respond to calls involving mentally ill persons and make assessments and referrals. For example, the mobile crisis unit in Fairfax County, Virginia, works with families, police, and the courts to divert mentally ill persons from the jail.37 Evaluations of this approach have been promising, but no controlled studies have been identified.38'39
Another type of prebooking diversion program is a crisis or drop-off center that police can use instead of bringing mentally ill arrestees to jail. Such centers provide assessment, crisis intervention, short-term treatment, and referral, saving police officers the time of booking mentally ill arrestees or waiting around in emergency departments. Police departments in 194 cities were surveyed regarding their strategies for obtaining input from the mental health system about dealing with mentally ill persons.40 Of the 174 cities that responded, most (68%) reported using crisis or drop-off centers. These departments were significantly more likely to perceive themselves as highly effective in responding to individuals with mental illness in crisis than were other departments. Other strategies identified by the survey included using mobile crisis teams from the local community mental health service system (30%), mental health consultants (10%), and officers with mental health training (3%).
Postbooking programs provide services to mentally ill offenders in court, in jail, or in the community, are designed to reduce incarceration days and recidivism, and are the most prevalent kind of diversion program in the United States. Two innovative types of postbooking diversion programs are court liaison programs and mental health courts. The article by Lerner-Wren and Appel in this issue discusses this topic further.
Court liaison programs consist of mental health professionals who work with jail staff, judges, prosecutors, defense attorneys, and families to identify detainees with mental illnesses and alternatives to incarceration. For example, in Pinellas County, Florida, court liaisons conduct evaluations and work to move detainees out of the criminal system by securing civil commitments and having criminal charges dismissed. Communication and cooperation by all parties involved is key to the success of court liaison programs.37 The use of mental health consultation in a municipal court was evaluated in a 1-year follow-up of 100 randomly selected defendants who were referred by the court for psychological evaluation.41 Services included evaluation, treatment planning, and referral. More than half (58%) were mandated to judicially monitored treatment. A significantly larger proportion of subjects mandated to treatment had positive outcomes, compared with those who were not mandated (59% vs 29%).
Mental health courts handle cases involving mentally ill offenders exclusively. The judge, prosecutor, defense attorney, and other court staff have special training in and are familiar with community mental health services. Defendants can have their charges or jail sentences deferred if they agree to participate in services such as medication management, substance abuse treatment, or psychosocial rehabilitation. No evidence regarding the effectiveness of mental health courts is available, but related research on drug courts shows promise for this model.42-43
Jail-based services include intake screening and mental health evaluation, crisis intervention, and short-term treatment that can include suicide prevention, case management, counseling, psychotropic medication, and discharge planning. (The articles by Freeman and Alaimo and Kravitz et al. in this issue discuss suicide prevention and psychotropic medication, respectively, further.) In a national survey of service provision, Steadman and Veysey37 found that most jails provided screening (83%), evaluation (60%), and suicide prevention (73%). However, fewer than half provided crisis intervention (43%), psychiatric medications (42%), special housing areas (36%), inpatient care within jail (24%), inpatient care outside of jail (48%), or therapy or counseling (27%). Also, despite the importance of discharge planning, only 21% of the jails provided this service.
Jail Diversion Program Surveys
Steadman et al.44 conducted a national study of jail diversion programs, defined as programs that screen detainees for mental disorders, use mental health professionals to evaluate those identified, and negotiate with other parties to produce a mental health disposition outside of the jail. They estimated that only 52 true jail diversion programs for mentally ill offenders exist nationwide. Most (84%) were funded by mental health departments, and the majority (75%) were located in mental health agencies. All programs served misdemeanants. Most (71%) also served nonviolent felons, and almost half (48%) served a subset of violent felons. There was an even distribution of prearraignment, postarraignment, and combination programs. Most (85%) had staff specifically assigned to them. High rates of recidivism among detainees and difficulty operating in the jail environment were cited as factors that lowered effectiveness.
Veysey et al.7 studied 379 mentally ill inmates in 7 U.S. jails. Regardless of the way services were organized, fewer than half (43%) actually received services after release, suggesting major problems with discharge planning. Steadman et al.36 suggested that discharge planning and follow-up are the key components of jail mental health programs, although these are the weakest elements of programs nationwide. They attributed the lack of adequate discharge planning to the belief held by the staff of most jails that their responsibility ends when inmates are released. Yet, "in terms of long-term gain, institution-based correctional mental health services are doomed to failure without effective linkages to communitybased services."36 Attaining treatment goals for mentally ill offenders can be accomplished only if these detainees are identified while in jail, linked with mental health services before discharge, and, for many, have their subsequent linkage to community services monitored.7
Programs that do address discharge planning begin early in the detainee's stay and follow through to ensure that linkages to appropriate services are maintained subsequent to release. Released offenders have a variety of service needs that must be addressed. Therefore, discharge planning to identify needed services must begin prior to release. Case management that begins in the jail and continues into the community can provide linkages to community services.
Case management involves engaging clients in a system of services by an individual case manager or a team, and also advocacy on the client's behalf.45 Case managers can facilitate mentally ill persons' living safely in the community by limiting the risks that these individuals pose to themselves and to the community and teaching them to recognize and respond to high-risk situations.46 Effective programs must have extremely low caseloads (8 to 15 clients) and must be available 24 hours a day. Case managers must be familiar with social services, mental health agencies, medical providers, and criminal justice agencies and must facilitate communication and cooperation among these agencies.46
Evaluations of case management programs have reported mixed results. Although uncontrolled studies have produced fairly positive findings» the only available controlled study did not. In this study,47 the assertive case management condition was positively associated with jail recidivism; however, after client demographics and the availability of services were controlled for, this relationship disappeared. Nonetheless, jail recidivism was related to receiving fewer services for developing independent living skills, when clients reported that they needed such services. The results are consistent with an extensive review of 75 evaluations of assertive case management and intensive case management for mentally ill persons.48 Both types of programs were effective in terms of reducing hospital time and improving housing stability, but had little or no impact on arrests and time spent in jail, or on social and vocational functioning.
Findings from a review of 3 uncontrolled studies suggest that intensive case management can be effective in reducing violent behavior by mentally ill clients in the community.46 Two of the 3 studies also reported reducing jail days and recidivism. In a recent, uncontrolled, follow-up study, case management while in jail was offered to 261 mentally ill detainees.49 Although services received in jail did not reduce recidivism directly, receipt of these services predicted receiving community case management. Community case management, in turn, was associated with a lower probability of rearrest and a longer period before rearrest, A similar program in Massachusetts observed mentally ill offenders briefly (for 3 months) and reported a fairly low rate of recidivism (10%).50
These studies suggest that expanding access to case management services can improve the ability of mentally ill offenders to live in the community and stay out of the hospital and possibly reduce jail time. However, to be effective, existing models of case management need to be modified to address the particular needs of mentally ill offenders in the community. The low voluntary participation rate was discouraging and suggests that greater efforts at engagement need to be made and court-mandated treatment considered.49
Survey research also provides some directions for program development. As an additional phase of a larger study of the nation's jails, 18 of 115 telephone survey respondents were selected for site visits.36 Among postbooking programs, 6 factors were identified from the most effective ones: integrated services, regular meetings of key agency representatives, strong leadership, early identification, distinctive case management services, and boundary spanners (liaisons that directly manage interactions among correctional, mental health, and judicial staff). Few of the programs visited had specific follow-up procedures designed to ensure that initial linkages with community-based services were maintained. The most effective diversion programs included a comprehensive array of jail services that were integrated with community-based mental health, substance abuse, and housing services. The authors view these linkages to community-based services as the essence of effective programs. They further suggest that staff whose specific role is to integrate services and span service boundaries are crucial.
Substance Abuse Treatment
Despite an extremely high prevalence of comorbidity, no studies of postdischarge treatment for inmates with mental illness and substance abuse disorders were located. Therefore, we must examine related research on appropriate treatment for this vulnerable population. Patients with co-occurring mental illness and substance abuse disorders were traditionally served by two separate treatment systems, if they were fortunate enough to receive treatment for both disorders. The poor outcomes associated with separate treatment approaches led to the development of integrated dual-disorder treatment programs that combine substance abuse and mental health interventions into one clinical program.
In the most extensive review available, Drake et al.51 examined 36 research studies of integrated treatment for clients with a dual diagnosis. Although noting that the studies reviewed had various méthodologie limitations, Drake et al. concluded that patients with dual disorders can be effectively treated and that integrated treatments are superior to nonintegrated treatments. Comprehensive integrated programs can result in significant reductions of substance abuse and rates of remission, reductions in hospital use, and improvements in other outcomes, especially when delivered for 18 months or longer. They stressed that programs must be comprehensive and include assertive outreach, case management, and stage-wise motivational interventions for substance abuse for extended periods of time.
IMPLICATIONS FOR SERVICE SYSTEMS AND MODEL PROGRAMS
Poor coordination of service points to a need for models of community mental health care that address noncompliance and the potential for violence, and include better communication with the airninal justice system. A complete database, including arrest reports, criminal histories, hospital records, psychiatric evaluations, and probation reports, must be complied for mentally ill offenders so that effective and comprehensive care is delivered.35 Moreover, continuing contact between community treatment staff and criminal justice staff must be maintained. Each must respect the other's points of view and agree on shared goals. Given the multitude of problems facing mentally ill offenders, linkage should be made to the following kinds of programs and services: entitlements such as SSI and Medicaid, money management and representative payee programs, integrated substance use and psychiatric treatment, psychosocial rehabilitation, housing, and medical care. Two programs exemplify many of these characteristics.
Milwaukee Community Support Program
A model program that includes many of these services for mentally ill offenders is the Community Support Program (CSP) in Milwaukee, Wisconsin.52 The program, run by the Wisconsin Correctional Service (WCS), has been serving this population since 1978. Formal legal authority is used to initially get offenders into the program, which consists of medical and therapeutic services, money management, housing and other support services, day reporting and close monitoring, and client participation.
Clients are referred by other WCS programs, probation and parole, and private attorneys and through self-referral and active canvassing of local jails by the CSP staff. If referrals are suitable, the courts are notified, and the program can become an alternative to incarceration, or a condition of probation. The program is the legal recipient of the client's Social Security and other disability benefits (representative payee). Fixed expenses are paid directly by the program and the remainder is given to the client in a daily allowance, on the condition that the client take his or her prescribed medication. The CSP has received support from criminal justice professionals and groups, and county officials have funded 3 other similar programs. Central to its success has been the CSP's ability to provide service at a low cost of $3,000 per year, per client.
Approximately 250 clients are served at any one time. The typical CSP client is male, single, and in his mid-30s and has been diagnosed as having a major mental illness. Most have at least 2 prior arrests and average approximately 75 days in psychiatric hospitals in the prior 2 years. Program staff have reported an increase in mentally ill offenders who also use drugs.
Although no formal evaluation has been conducted, data are available on persons discharged in 1992. Recidivism was fairly low; only 18% were discharged because they were jailed for new offenses or violations of the terms of their release. Almost half either fulfilled their legal obligations and left (24%) or completed their legal obligations and were referred to less-structured programs (24%). More than 10% were lost at followup or disappeared, whereas another 10% moved out of state, died, or both. Referral to treatment facilities was necessary for a relatively small proportion (15%).
Chicago LInkCM Project
The Illinois Department of Human Services and Cook County Jail in Chicago have initiated an innovative pilot program that integrates their respective data systems, allowing for better linkage and case management (LInkCM). To facilitate communication, recent legislation was passed in Illinois that allows for the sharing of records between community mental health centers and jails throughout the state. The Office of Mental Health (OMH) receives daily downloads of jail census data and cross matches this information with active OMH cases. Thresholds, a comprehensive community mental health agency, provides linkage services to OMH clients who are identified in the jail and facilitates their reintegration into the community and reentry to services at the appropriate community agency. If the pilot is a success, the OMH hopes to expand this program citywide.53
Individuals with serious mental illness have multiple service needs that must be addressed for successful community adjustment. Unfortunately, due to many factors, including aspects of their illnesses, inadequate community resources, and lack of coordination of existing services, many of these individuals are unable to access appropriate care. The evidence indicates that many of them are ending up in our jails, which are becoming (in many cases reluctantly) mental health service providers of last resort. Jails have the obligation to meet the basic needs of mentally ill detainees, which include medical, psychiatric, and social services. Failure to do so constitutes cruel and unusual punishment. Part of meeting this population's basic needs includes effective linkage to community services that begins prior to release from jail. This is being recognized in a pending lawsuit against the City of New York charging that inmates treated for mental illness while in jail were released without any provisions for continuing care in the community.54
Additionally, community mental health systems must recognize that individuals with serious mental illness who become involved with the criminal justice system are still part of the community for which they are responsible to provide services. Outreach, intensive case management, integrated substance abuse, and housing programs must be developed to engage even the most difficult and resistant individuals, regardless of whether they are involved in the criminal justice system.
We can no longer view individuals with mental illness in the criminal justice system as a population separate from those to be served in the community, for they are the same, not some other system's problem. The criminal justice and mental health systems both must take responsibility and work together. Coordinated planning and information systems are necessary. There is also a need to devise and fund appropriate liaison and linkage programs that facilitate engagement in community treatment at discharge. Mental health courts offer a promising tool to accomplish this. Further research is needed to identify under what conditions different types of interventions and programs are effective for this population.
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