To community mental health practitioners, correctional facilities and forensic hospitals can seem remote and mysterious. When a patient is arrested, community clinicians are often left wondering: “What happened to my patient? Where did he go, and what kind of treatment is he receiving?” This knowledge gap is surprising, considering how many psychiatric patients are involved with the criminal justice system. Approximately 16% of prisoners suffer from mental illness,1 and psychiatric patients are arrested at high rates after discharge from the hospital.2 Given this substantial degree of overlap, why don't we understand more about the treatment of psychiatric patients in the criminal justice system?
In this article, we aim to provide community mental health practitioners with essential knowledge about correctional facilities and forensic hospital settings. We discuss the key features of psychiatric treatment in high-security environments, using an illustrative case to highlight important principles. We conclude by discussing the vital role that community mental health providers can play in the primary prevention of criminal justice involvement for people with mental illness.
The Mental Health-Criminal Justice Interface
Many people think of prisons and forensic hospitals as closed systems of care that have little interaction with the community. In reality, prisons, jails, forensic hospitals, and community mental health centers are all part of the same continuum of care for people with mental illness who are involved with the criminal justice system. Figure 1 illustrates how and why a person may move through the different criminal justice settings.
An illustration of how and why people move between criminal justice settings.
As Figure 1 illustrates, transfers between criminal justice and hospital settings occur for a variety of clinical, legal, and administrative reasons. A detailed explanation of these movements is beyond the scope of this article, but the general psychiatrist should understand that correctional facilities and forensic hospitals (hereafter referred to as forensic settings) are dynamic, with patients moving in and out daily.
It is also important to understand that not all patients in forensic hospitals are involved with the criminal justice system. Most patients in forensic hospitals have been arrested and found incompetent to stand trial, or they have been found not guilty by reason of insanity. However, some patients have never been arrested or charged with a crime. They are psychiatric patients whose behavior was too dangerous or violent to handle in a general psychiatry setting, and they require temporary placement in a higher-security facility.
Thus, forensic settings can be understood to treat three distinct (but overlapping) groups of people: those with mental illness, criminal justice involvement, and serious violence risk. Figure 2 illustrates these groups and their overlap.
The intersection of violence, mental illness, and the criminal justice system.
In the illustrative case, the patient was arrested and taken to jail, where he stayed until appearing in court for arraignment. At the arraignment, the patient's defense attorney noticed that he appeared confused and was talking to himself, so the attorney asked the court to assess his competence to stand trial (ie, his ability to understand the legal proceedings and assist in his defense (see the article on competency in this issue). A forensic mental health professional (MHP) completed his assessment and advised the court, which then determined that he was incompetent. He was sent to the state forensic hospital for treatment to restore his competence, where he spent 2 months. After the court determined that he was restored to competency, he was returned to jail and sentenced to 3 months in jail; he received credit toward that sentence for the 2 months spent in custody at the forensic hospital. He was then released from custody, and he returned to his original treating psychiatrist at the mental health center.
During his involvement with the criminal justice system, the patient received treatment in both the correctional system and a forensic hospital. Much of the treatment in these settings is similar to that which occurs in general psychiatric settings, including diagnostic evaluation, suicide and violence risk assessment, medication management, and psychotherapy. However, some aspects of treatment in correctional facilities and forensic hospitals are unique to those settings, posing additional challenges to MHPs.
Unique Challenges of Treatment in the Forensic Setting
The initial entry into a forensic setting is a high-risk time. Often, people have just been arrested or arraigned, and they may have serious difficulty adjusting to the new circumstances. Additionally, many people have used drugs and alcohol in the community,3 creating a risk of withdrawal without access to illicit substances. Some people with psychotic illnesses have not taken psychiatric medication in months, and they exhibit florid symptoms of psychosis upon entering a forensic facility.
Because of these risks, some of which are life-threatening, psychiatric assessment is initiated expeditiously upon entry into a forensic setting. Patients are screened for high-risk symptoms such as suicidal ideation, drug and alcohol withdrawal, and psychosis. They are closely monitored during the first few days after admission, particularly because suicide rates in inmates are substantially higher than in the general population, and they are highest during the first week of confinement.4 Elopement is also a risk, and staff must be vigilant about monitoring patients as they adjust to their new environment.
Some patients in forensic settings stay just a few hours or days (for example, before being released from jail on bond), but others spend decades in custody. Depending on patients' length of confinement, diagnosis, and treatment needs, their initial assessments and treatment plans could vary significantly. Ideally, staff from the forensic hospital or correctional facility will contact the patient's community providers to obtain clinical information and collaborate on a treatment plan that will serve the patient's needs even after release from custody. However, in practice, this collaboration sometimes does not occur. The patient may refuse to allow contact with outpatient providers, or may not remember past treatment facilities. In addition, some correctional facilities are substantially understaffed, and phone calls to community providers become a low priority, particularly when the patient may be incarcerated for only a short time.
Despite the logistical difficulties, collaboration between community providers and treatment teams in forensic facilities is always advisable. For example, in the illustrative case, the forensic hospital staff could have called the outpatient psychiatrist to see what medications had helped the patient in the past and whether he was taking them consistently around the time of his arrest. The community and inpatient providers could have discussed whether a long-acting antipsychotic injection would be indicated. The community providers could also have informed the forensic hospital team about the patient's past history of violence, substance use, medical problems, family supports, and other information that would be helpful in formulating an initial treatment plan.
Adapting Treatment to the Forensic Setting
Correctional facilities and forensic hospitals treat people who are considered dangerous, and they must therefore employ enhanced security measures to provide mental health treatment safely (in addition to their responsibility for maintaining secure custody of the individual). In practice, this often means using metal detectors, property and movement restrictions, and uniformed security personnel within the treatment milieu. Balancing security and treatment needs of patients can be difficult; at times, treatment methods must be adapted for the higher-security setting. For example, patients participating in group therapy sessions in correctional facilities may be shackled to a bench or desk, making it difficult for them to write in a workbook or on a chalkboard. In forensic hospitals, patients may be placed on constant observation status and restricted to their rooms during periods of acute risk, and so treatment must be administered individually rather than in groups. In both settings, patients may be prohibited from having items, such as personal music players or certain video games, that patients in general psychiatry settings are accustomed to using for self-soothing and recreation.
In addition to adapting psychiatric treatment for a high-security environment, the needs of the unique patient population in forensic settings must be considered. Patients in these settings frequently suffer from refractory mental illnesses, severe personality disorders, and cognitive and intellectual disabilities. In addition, forensic patients are exposed to trauma at remarkably high rates, likely even higher than the rate of 90% that has been reported for general psychiatric patients.5 Sometimes early traumatic experiences are further compounded by experiences in criminal justice settings, where people are again exposed to violence and traumatic events.6 These complex factors must be considered when developing effective treatment plans for forensic patients.
To the extent that it is possible, an environment that is trauma-sensitive should be developed and maintained by staff in forensic settings. Such environments can help to calm patients during periods of agitation and decrease the potential for violence. Elements of a trauma-sensitive environment include careful attention to the style of interaction between patients and staff, the availability of quiet spaces or rooms with sensory modulation equipment, the physical environment of the milieu (such as paint colors, artwork choices, and lighting), and avoidance of overcrowding.
Sensitivity to trauma may seem incompatible with high-security environments, but the two can co-exist. In fact, some elements of high-security settings, such as clear rules, schedules, and high staff-to-patient ratios, have been shown to foster a therapeutic milieu by reassuring staff and patients of their safety.7 However, excessive rigidity in the application of rules can induce anxiety in patients and provoke a negative response. Mental health staff in forensic settings should be alert to the danger of developing a “guard mentality,” when excessive attempts to control behavior negates the therapeutic effect of maintaining a safe milieu.7 Particularly in correctional facilities, mental health staff must be careful to maintain a therapeutic role and appropriate boundaries between themselves and corrections officers. For optimal outcomes, there should be a fine balance of security and treatment in forensic settings, which can be achieved through a collaborative relationship between treatment and security staff.8
Dual Agency for Mental Health Professionals
MHPs working in forensic inpatient settings may be called upon to fulfill both treatment and evaluative roles; this is known as “dual agency.” For example, treating psychiatrists may be asked by courts or administrative bodies to comment upon a patient's competency to stand trial, readiness to return to a correctional facility, or violence risk in the community. Performing these assessments places the MHP in the challenging position of being both the treating clinician and forensic evaluator, potentially creating an ethical tension between truth-telling to the court and advocating for the patient. Although MHPs in all settings encounter these tensions to some extent (eg, completing disability paperwork for a patient or testifying in a civil commitment proceeding), the frequency with which the situations arise is greater in the forensic setting. Most patients in forensic hospitals are involved with the criminal justice system, and so they have frequent court appearances and forensic evaluations. For example, in the illustrative case, when the patient was hospitalized for competency restoration, the treatment team would have been asked to report periodically on the status of his competency to the court. In doing so, the treatment providers may have been placed in a position of dual agency, with obligations both to the patient and to the court.
Clinicians working in correctional institutions must also contend with a different type of “dual agency” tension: loyalty to the prison system and loyalty to the patient. MHPs in prisons and jails are frequently faced with situations in which their therapeutic role is tested.9 For example, if the patient in the illustrative case had assaulted a corrections officer while in jail, a MHP would likely have been asked during the adjudication of the disciplinary infraction whether the patient's psychiatric illness contributed to the assault. The clinician's opinion could have a significant impact upon the outcome of a disciplinary hearing. If the clinician opined that mental illness played a substantial role in the assault, he may not have faced any consequence for his actions, potentially angering the assaulted officer and many others. Under these circumstances, MHPs may fear retribution from the security staff if they do not “hold the inmate accountable,” creating a tension between their loyalty to the patient and to the correctional institution.
Because of the difficulty of managing these tensions, dual agency is best avoided. However, most forensic facilities do not have adequate personnel resources to avoid placing their staff in dual agency situations, as this would require hiring additional staff to serve separately as treaters and as evaluators. When faced with dual-agency conflicts, mental health clinicians and administrators in forensic settings should develop clear guidelines for working with patients. For example, patients should be informed about the limits of confidentiality upon admission and periodically thereafter. They should be informed that the clinician may have an obligation to discuss their behavior, diagnosis, and treatment in court proceedings or administrative hearings. Although this disclosure does not eliminate the ethics tension created by dual agency, it does convey respect for patients by keeping them informed about potential conflicts by a clinician's disclosures in an open court proceeding.
Management of Violence Risk
Community-based MHPs, especially those practicing in the public sector, are generally quite familiar with the task of managing risk of violence in their patients. In forensic settings, the immediacy of this task becomes more obvious, as they have high concentrations of people who are at high risk of violence because of their past violent actions, age, gender, history of substance abuse, and antisocial personality and associations. The orderly and safe functioning of the facility requires attention to risk management, whether risk is driven primarily by acute mental illness or criminogenic factors.10 The former may require involuntary medication procedures, some of which are specific to correctional settings.11 The latter may involve a variety of cognitive-behavioral approaches now widely used in the criminal justice system.10
Secure forensic hospitals are established primarily for managing violence risk due to mental illness, for both criminal and civil patient populations. Hospital settings manage this risk via milieu management (including contraband and environmental controls, and staff training in de-escalation and physical management techniques), medication (involuntary when needed), group and individual therapies, education, rehabilitation and recreational activities, and restraint and seclusion in emergencies. Therapies are predicated on a thorough individual assessment of violence risk and protective factors, including extensive history gathering, psychological testing, assessment of patient preferences for coping with difficult situations, the opportunity for 24-hour observation of behavior, and interdisciplinary treatment planning.12 Forensic hospitals often use a system of multi-layered hierarchical review of risk when making decisions about the advancement of a patient's privileges or movement to a lower-security treatment setting.
In correctional facilities, management of violence is generally approached as a security matter. Aggressive acts by inmates are handled by corrections officers using different tools, such as pepper spray, shields, and metal shackles, than would be used in a hospital setting, However, MHPs are frequently asked to assist with deescalating inmates to avoid the use of force, particularly when the inmate has a known history of mental illness. In those cases, MHPs may talk to the inmate to help him or her calm down, or they may decide that the circumstances warrant the emergency administration of psychotropic medication. The MHP may also choose to transfer an inmate to a more intensive treatment setting, such as the prison infirmary or a specialized mental health unit, for additional monitoring and assessment. MHPs functioning in this role (as part of the facility's crisis management team) can be integral to maintaining an orderly institution and decreasing the use of force by corrections officers.
Challenges of Discharge Planning
When people enter a correctional facility or a high-security hospital, they acquire a new and highly stigmatizing label: “forensic.” At the time of discharge, the forensic label can frighten community providers away from working with these patients, as the providers believe that the patients are now too dangerous to manage in their previous outpatient settings. When this stigma is added to the enormous logistical burden of arranging appropriate community services for the more than 11 million inmates who leave prisons and jails each year,13 it is easy to see why discharge planning in forensic settings is such a challenge.
Some states have risen to this challenge by creating partnerships between mental health agencies and correctional systems that aim to create comprehensive discharge plans for high-risk forensic patients well in advance of their release to the community. These partnerships can include “in-reach” services, where community clinicians meet with patients in forensic facilities for several months, or even years, prior to their release as a way of easing the transition.14 Criminal justice agencies sometimes provide funding for community mental health services for people to use upon release from a correctional facility. In addition, some states have created a mechanism for formal risk assessments to be conducted prior to a person's community release, thereby ensuring another layer of careful review in high-risk or controversial cases.
This type of intensive, collaborative discharge planning only occurs in cases where serious risk or mental health treatment needs have been identified; discharge planning is unfortunately minimal or nonexistent for many inmates leaving correctional facilities. Situations like the illustrative case, in which the patient left prison without any warning to the outpatient psychiatrist, are not uncommon. The patient would be fortunate to be accepted back into treatment and residential services by his former team, but many patients who find themselves labeled “forensic,” particularly when they have assaulted a community provider, are denied services after release from incarceration. This lack of adequate treatment provision can have serious downstream consequences, including clinical decompensation, socioeconomic instability, and even re-arrest. Because of these potential bad outcomes, community clinicians should strive to ensure continuity of care with forensic setting clinicians and advocate for the additional resources they need to treat justice-involved patients safely.
Applying Recovery Principles in the Forensic Context
Recovery has become a dominant model for service delivery in public mental health systems.15 Until relatively recently, the recovery model, with its principles of autonomy and choice, was regarded as inconsistent with forensic services and their focus on security and safety.16,17 However, authors have described various approaches to the incorporation of recovery principles into forensic mental health services. An early approach to this integration used the concept of citizenship (“a strong connection to the rights, responsibilities, roles, resources, and relationships that society offers to its members”18) to address the community reintegration needs of justice-involved persons with mental illness.19 Another approach advanced as a bridge between recovery and forensic care is the use of narrative to help the patient adopt a new identity that is reconnected to the social values of the larger community.20 A related approach focuses on the identification and creation of a meaningful life in the community with enhanced quality and safety.21
In order for forensic patients to achieve their recovery goals, they must develop therapeutic relationships with caregivers in which they feel respected and understood;21 this emphasis on mutual respect matches well with the narrative approach noted above.20 Other encouraging research has demonstrated that therapeutic relationships in mandated community treatment for people involved in the criminal justice system are most often characterized as affiliative and autonomy-granting.22 Currently, it appears that forensic treatment, even when mandated by courts or other administrative bodies, is not entirely incompatible with recovery principles. However, for many people with mental illness living in the community, avoiding the criminal justice system altogether is still preferable, as discussed in the next section.
Community Treatment and Primary Prevention of Criminal Justice Involvement
Criminal justice system involvement (CJSI) is a challenging adverse sequela of serious mental illness (SMI) for many clients managed in the community. A public health approach to CJSI emphasizes the importance of prevention and conceptualizes the use of primary, secondary, and tertiary prevention strategies to address it.23 The Sequential Intercept Model24 describes various stages of the criminal justice system at which interventions can either divert an individual from justice involvement to treatment or limit the adverse consequences of justice involvement. In this conceptualization, programs such as jail diversion, drug and mental health courts, assertive community treatment, correctional re-entry, and specialized mental health probation or parole can limit the negative impact of CJSI, thus constituting tertiary prevention. With law enforcement officers trained in the crisis intervention team25 approach to people in mental health distress in the community, they can be brought to treatment locations rather than arrested. CJSI is thus stopped at an early stage before significant further adverse consequences result, constituting secondary prevention.
The most effective public health strategy is primary prevention. In this context, primary prevention involves interventions that prevent CJSI for people with serious mental illness. Best clinical practices are a necessary starting point,23 but even the best clinical care fails to prevent CJSI for some people. Primary prevention requires a different level of attention to the work, including ongoing risk assessment and management, and a different set of tools to address the criminogenic factors that create a risk for CJSI.26 These factors include antisocial behavior, personality, cognitions, and associates.
Traditionally, MHPs reflexively consider criminogenic risk factors to be outside the scope of treatment, but addressing them proactively is crucial for effective management of patients with SMI and CJSI. Direct care staff should be trained to recognize criminogenic factors and to address them through cognitive-behavioral approaches. Examples of approaches familiar to most clinicians include dialectical behavioral therapy and motivational interviewing. Other approaches developed in the criminal justice system include Thinking for a Change, Moral Reconation Therapy, Interactive Journaling, Reasoning & Rehabilitation, and Schema-Focused Therapy.10 Deficits in interpersonal and cognitive skills (eg, problem solving, planning, future thinking) are the targets of a workbook-based intervention called START NOW27 that can be used in correctional facilities, forensic hospitals, and community settings. To provide more definitive assistance to clients as described in the illustrative case, community providers must develop the capacity to use such programs for clients who are not currently involved in the criminal justice system as a way of breaking down the cycle illustrated in Figure 1. Collaborations among community, correctional, and forensic hospital colleagues can be foundational to such developments.23