Integrating Criminal Justice,Community Healthcare,and Support Services for Adults with Severe Mental Disorders

Persons with severe mental disorders are overrepresented in our nation's jails and prisons. Factors including cooccurring substance use disorders, homelessness, and lack of access to community services have contributed to this problem, as have gaps between criminal justice, healthcare, and community support systems. In order to address these issues, Project Link was developed by the University of Rochester Department of Psychiatry in collaboration with five local community agencies. Project Link is designed to prevent involvement of individuals with severe mental illness from entering the criminal justice system. While many models of diversion programs exist, they are all dependent on access to appropriate community-based services. This paper will describe the steps that Project Link has taken towards integrating criminal justice, healthcare, and community support services for individuals with severe mental disorders involved in the criminal justice system.     

Violence prevention and safety training for case management services

Violence inflicted by individuals with mental illness towards healthcare workers has received significant media attention. Though such incidents are relatively infrequent, they inspire reactive responses and contribute to further stigmatization of the mentally ill. Prevention of violence is an important challenge for those who train and supervise mental health workers. Project Link is an outpatient treatment program designed to reduce jail and hospital recidivism among severely mentally ill adults with histories of criminal justice system involvement. Utilizing a Safety and Violence Education (SAVE) curriculum, Project Link has successfully transitioned high-risk mentally ill individuals from the criminal justice system into the community since 1995. The SAVE curriculum uses a preventative strategy to train case managers to identify warning signs of impending violence, and to safely engage patients in community settings. This paper will present an overview of the SAVE curriculum and its development, as well as results from a preliminary evaluation of trainee satisfaction.     

Project back-on-track at 1 year: a delinquency treatment program for early-career juvenile offenders

OBJECTIVE: This study assessed the effectiveness of Project Back-on-Track, an after-school diversion program that uses a multimodal approach for the treatment of early-career juvenile offenders. METHOD: Project Back-on-Track completers (30 of 41 enrollees; 73%), aged 9 to 17 years, 63% female, participated in a 4-week cycle of treatment consisting of group and family therapies, parent groups, educational sessions, community service projects, and empathy-building exercises. These youths attended the program 2 hours per day, 4 days a week, allowing for 32 hours of contact with the program per cycle; parents attended the program for 15 hours per cycle. Most youths were referred for violent offenses and met criteria for conduct disorder. RESULTS: Project Back-on-Track completers were significantly less likely than matched controls to have committed subsequent criminal offenses at 12 months. In addition, they had significantly fewer subsequent criminal charges at 9- and 12-month follow-up intervals than the control group. By decreasing the frequency of criminal recidivism, it is estimated that Project Back-on-Track resulted in savings to society of approximately $1,800 per youth enrolled after 1 year. CONCLUSION: At 1-year follow-up, findings suggest that treatment through Project Back-on-Track was effective in reducing criminal recidivism and costs in a population of early-career juvenile offenders.     

Offenders with intellectual disability: a prospective comparative study

BACKGROUND: Intellectually disabled offenders (IDO) are a poorly served and under-recognized group, who are likely to require long-term specialist treatments and interventions. METHOD: This prospective study investigated the characteristics and factors that influence outcome in this group, with particular reference to therapeutic interventions. Sixty-one individuals were identified from contact with either (1) specialist health and social services for people with intellectual disability (ID) or (2) nonspecialist services in the criminal justice or (forensic) mental health/social service systems. The participants were assessed at baseline and after a mean of 10 months in order to compare recidivism rates and the impact of therapeutic interventions. RESULTS: The findings suggest that IDO start offending at an early age, that they frequently have a history of multiple offences, and that sex offending and arson are over-represented offence types. Those participants recruited from nonspecialist ID services had significantly higher IQs and were less likely to have had contact with community social and health support agencies. Despite the high rates of psychopathology, there was little evidence for efficacy of therapeutic interventions, which, where offered, appeared to be of a nonspecific nature. At second interview, approximately half of the sample had re-offended.     

Comparison of offenders with mental illness only and offenders with dual diagnoses

OBJECTIVE: The study compared offenders who had severe mental illness only and offenders who had severe mental illness and substance abuse problems-dual diagnoses-to determine whether these groups differed. Offenders with dual diagnoses who were involved with the criminal justice system at different levels were compared to explore their profiles and experiences after release. METHODS: Secondary data collected on offenders who had diagnoses of severe mental illness and of substance abuse in Massachusetts were used to examine sociodemographic, clinical characteristics, and criminal justice characteristics, service needs, and community reentry experiences in the first three months postrelease of 265 offenders with major mental illness and 436 with dual diagnoses. RESULTS: Offenders with dual diagnoses were more likely to be female and to have a history of being on probation and of using mental health services. On release from correctional custody, they had more immediate service needs than offenders with mental illness alone, including a need for housing and sex offender treatment, and they were more likely to require an assessment for dangerousness. They were also more likely to return to correctional custody. CONCLUSIONS: The data do not suggest that offenders with dual diagnoses have a distinct clinical background, but rather that substance abuse is an important feature that affects their real or perceived level of functioning, engagement with the criminal justice system, and dependence on social service institutions in the community.     

Understanding and preventing criminal recidivism among adults with psychotic disorders

The high prevalence of adults with psychotic disorders in the criminal justice system has received much attention recently, but our understanding of this problem is marked by diverging opinions. Mental health professionals point to deinstitutionalization and our fragmented mental health system as primary causes. Criminologists minimize the role of mental illness and contend that persons with and without mental illness are arrested for the same reasons. Meanwhile, practice guidelines offer little guidance to clinicians about how to address the problem. Drawing upon contemporary crime prevention principles as well as current knowledge of psychotic disorders and their treatment, this article presents a conceptual framework for understanding and preventing criminal recidivism. The framework highlights the importance of individual and service-system risk variables and emphasizes the central role of treatment nonadherence as a mediator between modifiable risk variables and recidivism. On the basis of the conceptual framework described in this article, three necessary elements of intervention are presented for preventing recidivism among adults with psychotic disorders: competent care, access to services, and legal leverage. Research is needed to further define and test these intervention elements as foundations for future service delivery efforts.     

Justice résolutive de problèmes : efficacité des tribunaux en santé mentale aux États-Unis et présentation du dispositif lyonnais

People with mental disorders are over-represented in the criminal justice system. Mental Heath Courts are problem-solving oriented courts developed as a means of providing treatment to individuals with mental illness involved in the criminal justice system in order to avoid recidivism and to improve access to community mental health care services. MHCs are an alternative to the incarceration and the innovation behind his model is the collaboration between the judiciary and mental health services. The first MHC was created in 1997 in Florida; there are now more than 300 such courts in the United States. In Lyon, France, thought work with Canadian team at the Montreal Mental Health court, a new program called Contrainte Pénale Justice Thérapeutique was created in 2016. CPJT is also based on the collaboration of legal, social and pre-existing mental health services in order to treat recidivist offenders suffering from psychiatric and/or addictive disorder. The aim of this interview with Constance Baheux and Dr Sabine Mouchet–Mages is to present the results of American mental health court in terms of effectiveness and to introduce the French program Contrainte Pénale Justice Thérapeutique in Lyon according to French law.     

Service Referral for Juvenile Justice Youths: Associations with Psychiatric Disorder and Recidivism

Secondary multiple regression analyses related disorder profile, probation officers’ mental health/substance use service referrals, and recidivism in 361 juvenile justice youths. Those with externalizing (disruptive behavior or substance use) disorder or substance offenses were most likely to receive service referrals. Substance disordered youths with service referrals had lower recidivism risk compared to counterparts without referrals; referral lowered the recidivism odds to approximately that for youths without a substance use disorder. Providing juvenile justice youths with systematic mental health assessment and linking those with substance use disorder to mental health and substance use services likely reduces recidivism risk.     

Risk factors for criminal recidivism -- a prospective follow-up study in prisoners with substance abuse

ABSTRACT: BACKGROUND: Substance use in general has been shown to predict criminal recidivism. The present study aimed to examine potential predictors of criminal recidivism, including substance-specific substance use patterns, in prisoners with substance use. METHODS: A cohort of prisoners with substance use problems (N = 4,152) were assessed with the Addiction Severity Index (ASI) in the Swedish criminal justice system. Clients were followed for an average of 2.7 years. Criminal recidivism was defined as any return to the criminal justice system. RESULTS: During follow-up, 69 percent (n = 2,862) returned to the criminal justice system. Recidivism was associated with amphetamine and heroin use, with an additive risk for injectors, and with polysubstance use. Also, recidivism was negatively associated with alcohol, other opioids than heroin/methadone and with hallucinogenic drugs, and positively associated with previous psychiatric in-patient treatment, violent behaviour, and with a shorter index sentence. Associations remained when controlling for type of crime. CONCLUSIONS: Even when controlling for type and severity of crime, and for psychiatric problems, risk of criminal relapse was increased by substance use variables, including amphetamine, heroin and polysubstance use, and an additional risk was shown for injection drug users. These findings have implications for the need for substance abuse treatment after release from prison.     

Forensic assertive community treatment: preventing incarceration of adults with severe mental illness

OBJECTIVE: Persons with severe mental illness are overrepresented in jails and prisons in the United States. A national survey was conducted to identify assertive community treatment programs that have been modified to prevent arrest and incarceration of adults with severe mental illness who have been involved with the criminal justice system. METHODS: Members of the National Association of County Behavioral Health Directors (NACBHD) were surveyed to identify assertive community treatment programs serving persons with criminal justice histories and working closely with criminal justice agencies. Programs were identified that met three study criteria: all enrollees had a history of involvement with the criminal justice system, a criminal justice agency was the primary referral source, and a close partnership existed with a criminal justice agency to perform jail diversion. Senior representatives of each program were subsequently contacted, and a telephone survey was administered to gather information about the design and operation of the programs. RESULTS: A total of 291 of 314 NACBHD members (93 percent) responded to the survey. Sixteen programs that met the study criteria were identified in nine states. The primary referral sources for 13 of these programs (81 percent) were local jails. Eleven programs (69 percent) incorporated probation officers as members of their assertive community treatment teams. Eight programs (50 percent) had a supervised residential component, with five providing residentially based addiction treatment. Eleven of the 16 programs have begun operating since 1999. Only three programs have published outcome data on program effectiveness. CONCLUSIONS: Forensic assertive community treatment is an emerging model for preventing arrest and incarceration of adults with severe mental illness who have substantial histories of involvement with the criminal justice system. Further research is needed to establish the structure, function, and effectiveness of this developing model of service delivery.     

Commentary: older offenders--no place to go?

For offender groups, difficulties in definition of 'elderly' and 'older' are considerable. Adoption of chronological age cutoffs gives little indication of service need. Contrary to popular belief, there has been no upsurge of offending among people of 60 and over, but there has been an increase in their representation in the prison population. Older prisoners tend to have more mental and physical health care needs than younger prisoners and than their similarly aged peers in the community. Their needs may be more appropriately met in health care rather than criminal justice services. Neither health care nor criminal justice services, however, have yet made adequate specific provision for this group. Our commentary reviews current evidence for more appropriate and safer service responses.     

Alternatives to custodial remand for women in the criminal justice system: A multi‐sector approach

Throughout the world, women involved in criminal justice systems often present with substantial needs and vulnerabilities. Diverting vulnerable people away from prison is government policy in England and Wales, but full psychiatric and social assessments are expensive and hard to access. A screening and quick response initiative ‐ alternatives to custodial remand for women (ACRW) ‐ was implemented across three areas of London (West, South and East) to supplement existing court liaison and diversion services, to assess the feasibility of a supplementary custodial remand service as part of a women's specialist service pathway in the criminal justice system in England. Three mental health trusts and two voluntary sector providers offered this service enhancement – a screening and service link provision in three London boroughs between 2012 and 2014. We conducted a service evaluation using routinely collected service use record data. The service made 809 contacts, of whom 104 had contact on multiple occasions. Many were identified as at risk of self‐harm (46%) or had histories of hospital admission for mental disorder (36%), but few were referred either to the liaison and diversion service or specialist mental health services. The largest group of referrals was to women's community services outside the health service (e.g. counselling, domestic violence or sexual abuse services). 180 women had dependent children and 22 were pregnant, increasing the urgency to find non‐custodial alternatives. As well as confirming high levels of need amongst women entering the criminal justice system, this evaluation confirms the feasibility of working across sectors in this field, providing an extra layer of service that can complement existing liaison and diversion service provision. The service was responsive and most women using it were kept out of custody. Research is now required to understand the appropriateness of the referrals, the extent to which women follow them through and the impact on their mental health and desistance from offending.     

Effectiveness of a mental health court in reducing criminal recidivism and violence

OBJECTIVE: In response to the large-scale involvement of people with mental disorders in the criminal justice system, many communities have created specialized mental health courts in recent years. However, little research has been done to evaluate the criminal justice outcomes of such courts. This study evaluated whether a mental health court can reduce the risk of recidivism and violence by people with mental disorders who have been arrested. METHOD: A retrospective observational design was used to compare the occurrence of new criminal charges for 170 people who entered a mental health court after arrest and 8,067 other adults with mental disorders who were booked into an urban county jail after arrest during the same interval. A matching strategy based on propensity scores was used to adjust analyses for nonrandom selection into mental health court. RESULTS: Propensity-weighted Cox regression analysis, controlling for other potential confounding variables (demographic characteristics, clinical variables, and criminal history), showed that participation in the mental health court program was associated with longer time without any new criminal charges or new charges for violent crimes. Successful completion of the mental health court program was associated with maintenance of reductions in recidivism and violence after graduates were no longer under supervision of the mental health court. CONCLUSIONS: The results indicate that a mental health court can reduce recidivism and violence by people with mental disorders who are involved in the criminal justice system.     

Targeting Criminal Recidivism in Mentally Ill Offenders: Structured Clinical Approaches

Decreasing criminal recidivism in justice-involved individuals with mental illness, is among the most consistently desired outcomes by programs, policy makers and funding agencies. Evidencebased practices with track records of effectiveness in treating mental illness and co-occurring substance abuse, while important clinically, do not necessarily address criminal recidivism. Addressing recidivism, therefore, may require a more targeted criminal justice focus. In this paper, we describe recent challenges to decriminalization approaches and review factors associated with recurrent criminal behavior. In particular, we focus on structured clinical interventions which were created or adapted to target the thoughts and behaviors associated with criminal justice contact.     

Violent recidivism among mentally disordered offenders in Japan

Background A new forensic mental health law was enacted in Japan in 2003, enabling development of specialist services. Before their establishment, it is important to determine the nature, frequency and correlates of the problems they are designed to ameliorate. Aims To establish rates of violent recidivism among mentally disordered offenders before the new legislation, and examine associated risk factors. Method Data were extracted from one complete annual (1980) national cohort of people judged by the Court or prosecutor to be without responsibility for a criminal offence, or of sufficiently diminished responsibility for it to be diverted for psychiatric treatment. The outcome measure was violent recidivism after community discharge and before 1991. Results Fifty‐two (10%) of 489 in the cohort were arrested or convicted of further violent offences. Violent recidivism was most strongly associated with a substance‐related disorder, but histories of violence, homelessness and short index admissions were independently related. Conclusions Violent recidivism was so unusual that, on this outcome, it could take many years to show any effect of the new service. Desistance from substance use, compliance with treatment and maintenance of stable housing may be better indicators of success, and their achievement a good preventive strategy. Copyright © 2007 John Wiley & Sons, Ltd.     

Criminal Justice Involvement,Behavioral Health Service Use,and Costs of Forensic Assertive Community Treatment: A Randomized Trial

Jail diversion and forensic community treatment programs have proliferated over the past decade, far outpacing evidence regarding their efficacy. The current study reports findings from a randomized clinical trial conducted in California for frequent jail users with serious mental illness that compares a forensic assertive community treatment (FACT) intervention with treatment as usual (TAU). Outcomes are reported at 12 and 24 months post-randomization for criminal justice outcomes, behavioral health services and costs. At 12 months, FACT vs. TAU participants had fewer jail bookings, greater outpatient contacts, and fewer hospital days than did TAU participants. Results of zero-inflated negative binomial regression found that FACT participants had a higher probability of avoiding jail, although once jailed, the number of jail days did not differ between groups. Increased outpatient costs resulting from FACT outpatient services were partially offset by decreased inpatient and jail costs. The findings for the 24 month period followed the same pattern. These findings provide additional support for the idea that providing appropriate behavioral health services can reduce criminal justice involvement.     

Use of the Sequential Intercept Model as an approach to decriminalization of people with serious mental illness

The Sequential Intercept Model provides a conceptual framework for communities to use when considering the interface between the criminal justice and mental health systems as they address concerns about criminalization of people with mental illness. The model envisions a series of points of interception at which an intervention can be made to prevent individuals from entering or penetrating deeper into the criminal justice system. Ideally, most people will be intercepted at early points, with decreasing numbers at each subsequent point. The interception points are law enforcement and emergency services; initial detention and initial hearings; jail, courts, forensic evaluations, and forensic commitments; reentry from jails, state prisons, and forensic hospitalization; and community corrections and community support. The model provides an organizing tool for a discussion of diversion and linkage alternatives and for systematically addressing criminalization. Using the model, a community can develop targeted strategies that evolve over time to increase diversion of people with mental illness from the criminal justice system and to link them with community treatment.