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.     

The Client–Caseworker Relationship and Its Association with Outcomes Among Mental Health Court Participants

A portion of people with mental illnesses who are arrested are diverted to mental health courts (MHC) where they work with teams of treatment and court staff rather than serving time in custody. This study investigated the association between the relationship with caseworkers and outcomes. MHC participants were recruited to participate in structured interviews on their perceptions of the bond and conflict with their MHC caseworkers. Regression models tested associations between relationships with caseworkers and program retention, service use, and number of days spent in jail. Perceived conflict with caseworkers was higher among participants who were terminated or missing from the MHC. Participants who perceived less conflict with caseworkers utilized more services and spent fewer days in jail. The perceived bond was significantly associated with service use. Caseworkers with clients who are in the criminal justice system should be mindful as conflict arises and implement strategies to effectively manage conflict.     

The Impact of Criminal Justice Involvement and Housing Outcomes Among Homeless Persons with Co-occurring Disorders

The relationship between criminal justice involvement and housing among homeless persons with co-occurring disorders was examined. Program participants assisted in moving to stable housing were interviewed at baseline, six months, and discharge. Those who remained homeless at follow-up and discharge had significantly more time in jail in the past month than those who were housed. However, criminal justice involvement was not significantly related to housing status at the six month follow-up or discharge. Findings suggest that housing people with complex behavioral health issues reduces the likelihood of further criminal justice involvement.     

The Mentally Ill in Jails and Prisons: Towards an Integrated Model of Prevention

Jails and prisons have become a final destination for persons with severe mental illness in America. Addiction, homelessness, and fragmentation of services have contributed to the problem, and have underscored the need for new models of service delivery. Project Link is a university-led consortium of five community agencies in Monroe County, New York that spans healthcare, social service and criminal justice systems. The program features a mobile treatment team with a forensic psychiatrist, a dual diagnosis treatment residence, and culturally competent staff. This paper discusses the importance of service integration in preventing jail and hospital recidivism, and describes steps that Project Link has taken towards integrating healthcare, criminal justice, and social services. Results from a preliminary evaluation suggest that Project Link may be effective in reducing recidivism and in improving community adjustment among severely mentally ill patients with histories of arrest and incarceration.     

The treatment and care of mentally ill offenders in Victoria,Australia

This article explains, examines and evaluates the effectiveness of the legislative scheme for the provision of psychiatric services to forensic patients in Victoria.¹ The term “forensic patients” is used to describe people who have mental illness and who have come into contact with the criminal justice system.² This includes people who receive treatment for mental illness in jail, in psychiatric in‐patient services, or in the community. New initiatives were introduced by Victoria's Mental Health Act in 1986 and 1990, and in the Sentencing Act 1991.³ The aims of the reforms are to provide the best possible care and treatment for people with mental illness, and to give sentencing judges and magistrates a range of dispositional options when dealing with mentally ill people who appear before the criminal courts. This encompasses the often conflicting aims of providing treatment and care, and protecting the public. It also involves a number of agencies whose roles are explained and examined.     

Parent coaching intervention for children with suspected autism spectrum disorder: Cost analysis

BackgroundParent coaching interventions for young children suspected of having autism spectrum disorder (ASD) have shown promise. The objectives were to measure the costs of parent coaching and the pre-diagnosis utilization of services and treatments related to autism and to compare costs between families who received parent coaching (PC) and those who received enhanced community treatment (ECT).MethodsThis analysis was conducted prospectively alongside a randomized comparative effectiveness trial of a PC intervention in British Columbia, Canada. Twenty-four participants were randomly assigned to the PC group and received 24 weeks of coaching support and 25 participants were assigned to the ECT group. Families in both groups also received health, education and community services. Parent-reported service utilization was collected for the 6 months prior to initiation of parent coaching and for the period coinciding with receipt of one of the two interventions. Services were costed from the public payer (i.e., provincial government) and societal perspectives; the latter included out-of-pocket family costs, parental time losses due to caregiving, and public payer costs.ResultsFamilies in the PC group used fewer services than did those in the ECT group. The estimated incremental mean cost per family over two time periods for PC compared to ECT was $2515 CAD (95% CI: − 1302, 5071) from the public payer perspective and $6994 CAD (95% CI: − 4395, 19,299) from the societal perspective.ConclusionsThe findings can be used to inform funding and policy decision-making to enhance the treatment options available for young children awaiting an ASD diagnosis.     

Health status,service use,and costs among veterans receiving outreach services in jail or community settings

OBJECTIVE: This study compared client characteristics, service use, and health care costs of two groups of veterans who were contacted by outreach workers: a group of veterans who were contacted while incarcerated at the Los Angeles jail and a group of homeless veterans who were contacted in community settings. METHODS: Between May 1, 1997, and October 1, 1999, a total of 1,676 veterans who were in jail and 6,560 community homeless veterans were assessed through a structured intake procedure that documented their demographic, clinical, and social adjustment characteristics. Data on the use and costs of health services during the year after outreach contact were obtained from national databases of the Department of Veterans Affairs (VA). Chi square and t tests were used for statistical comparisons. RESULTS: The veterans who were contacted in jail obtained higher scores on several measures of social stability (marital status and homelessness status) but had higher rates of unemployment. They had fewer medical problems but higher levels of psychiatric and substance use problems, although the rate of current substance use was lower among these veterans than among the community homeless veterans. One-year service access for the jailed veterans was half that of the community homeless veterans. No differences were observed in the intensity of use of mental health services among those who used services, but the jailed outreach clients used fewer residential, medical, and surgical services. Total health care expenditures for the veterans who received outreach contact in jail were $2,318 less, or 30 percent less, than for those who were contacted through community outreach. CONCLUSIONS: Specialized outreach services appear to be modestly effective in linking veterans who become incarcerated with VA health care services. Although it is clinically challenging to link this group with services, the fact that the rate of current substance use is lower during incarceration may provide a window of opportunity for developing linkages between inmates and community rehabilitative services.     

Predictors of general and violent recidivism among SMI prisoners returning to communities in New York State

Correctional and forensic mental health systems throughout the country are routinely called on to manage and provide treatment for mentally ill prison inmates. This study identifies criminal justice and mental health predictors of general re-arrest and re-arrest for violence in seriously mentally ill (SMI) persons leaving prison in New York State. Both length and diversity of criminal history predicted general re-arrest, as did substance abuse diagnoses, participation in community mental health treatment, parole supervision, and coordinated parole and mental health services. Only demographics and criminal justice measures were predictive of re-arrest for violence. The rate of re-arrest for violence in this SMI sample was lower than that of general prison release populations.     

'Forensic' labelling: an empirical assessment of its effects on self-stigma for people with severe mental illness

Increasingly, specialized ‘forensic’ mental health services are being developed to address the criminogenic and clinical needs of people with mental illness who are involved in the criminal justice system. Theoretically, the construction of such specialized services can produce simultaneous positive benefits and negative consequences. This mixed methods study examined and compared the level of self-stigma that was experienced by people who receive compulsory community-based treatment services in the forensic (n = 52) and civil (n = 39) mental health systems of British Columbia, Canada. The quantitative findings indicate that ‘forensic’ labelling was not associated with elevated levels of self-stigma. Quantitative level of self-stigma was significantly associated with psychiatric symptom severity, history of incarceration, and history of homelessness. The qualitative findings suggest that access to high-quality, well-resourced forensic mental health services may, for some service users, come at the risk of increased exposure to social and structural stigma. Together, these findings reveal some of the strengths and weaknesses that are associated with organizing forensic mental health services using a specialized service delivery model.     

A peer-support, group intervention to reduce substance use and criminality among persons with severe mental illness

OBJECTIVE: This study compared the effectiveness of two interventions in reducing alcohol use, drug use, and criminal justice charges for persons with severe mental illnesses: first, a community-oriented group intervention with citizenship training and peer support that was combined with standard clinical treatment, including jail diversion services, and second, standard clinical treatment with jail diversion services alone. METHODS: A total of 114 adults with serious mental illness participated in a 2 x 3 prospective longitudinal, randomized clinical trial with two levels of intervention (group and peer support for the experimental condition and standard services for the control) and three interviews (baseline, six months, and 12 months). Self-report questionnaires assessed alcohol and drug use, and program databases assessed criminal justice contacts. The authors used a mixed-models analysis to assess alcohol and drug use, repeated-measures analysis of covariance to assess criminal justice charges, and correlational analyses to assess the relation between intervention participation and outcome variables. RESULTS: The experimental group showed significantly reduced alcohol use in comparison with the control group. Further, results showed a significant group-by-time interaction, where alcohol use decreased over time in the experimental group and increased in the control group. Drug use and criminal justice charges decreased significantly across assessment periods in both groups. CONCLUSIONS: Of the outcomes, only decreased alcohol use was attributable to the experimental intervention. Although this may be a chance finding, peer- and community-oriented group support and learning may facilitate decreased alcohol use over time.     

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.     

The role of Medicaid enrollment and outpatient service use in jail recidivism among persons with severe mental illness

OBJECTIVE: This study sought to determine whether having Medicaid benefits and receiving behavioral health services are associated with a reduction in recidivism for jail detainees with severe mental illness. METHODS: A quasi-experimental design with linked administrative data was used. All persons released over a two-year period from jails in King County, Washington (N=5,189), and Pinellas County, Florida (N=2,419), who had severe mental illness were followed for 12 months after jail release. Those who were receiving Medicaid benefits at release and those who were not were compared on three indicators: how many subsequent arrests occurred, how soon the arrest occurred, and how serious the associated offense was. The data were analyzed with negative binomial, Cox proportional hazards models and logistic regression with adjustments for dependent observations. RESULTS: In both counties, having Medicaid at release was associated with a 16% reduction in the average number of subsequent detentions (p<.001 and p<.01, respectively). After the analysis controlled for demographic and clinical variables, more days on Medicaid were associated with a reduced number of subsequent detentions in King County (p<.001) and more days in the community before subsequent arrest in both counties (p<.01 and p<.05, respectively). No association was found between Medicaid status and the seriousness of the subsequent offense in either county. CONCLUSIONS: Although Medicaid benefits and behavioral health services were associated with fewer rearrests and more time in the community, the observed differences were relatively small. Further research is needed to determine how greater reductions in jail recidivism can be achieved for this target population.     

Cost-effectiveness of critical time intervention to reduce homelessness among persons with mental illness

OBJECTIVES: Cost-effective programs are needed to assist homeless persons with severe mental illness in their transition from shelters to community living. The authors investigated the cost-effectiveness of the critical time intervention program, a time-limited adaptation of intensive case management, which has been shown to significantly reduce recurrent homelessness among men with severe mental illness. METHOD:S: Ninety-six study participants recruited from a psychiatric program in a men's public shelter from 1991 to 1993 were randomly assigned to the critical time intervention program or to usual services. Costs and housing outcomes for the two groups were examined over 18 months. RESULTS: Over the study period, the critical time intervention group and the usual services group incurred mean costs of 52,374 dollars and 51,649 dollars, respectively, for acute care services, outpatient services, housing and shelter services, criminal justice services, and transfer income. During the same period, the critical time intervention group experienced significantly fewer homeless nights than the usual care group (32 nights versus 90 nights). For each willingness-to-pay value--the additional price society is willing to spend for an additional nonhomeless night--greater than 152 dollars, the critical time intervention group exhibited a significantly greater net housing stability benefit, indicating cost-effectiveness, compared with usual care. CONCLUSION:S: Although difficult to conduct, studies of the cost-effectiveness of community mental health programs can yield rich information for policy makers and program planners. The critical time intervention program is not only an effective method to reduce recurrent homelessness among persons with severe mental illness but also represents a cost-effective alternative to the status quo.     

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.     

One-year follow-up of persons discharged from a locked intermediate care facility

OBJECTIVES: This study examined outcomes during a one-year follow-up for persons who were discharged from a locked intermediate care facility in an urban area in California. The purpose of this study was to determine the extent to which persons with severe mental illness can be successfully transferred from an intermediate care facility to lower levels of care. METHODS: A total of 101 persons consecutively discharged were studied by record review and by obtaining information from facility staff members, therapists, case managers, and other community caretakers. RESULTS: During the follow-up period 56 percent of the patients who were discharged from the intermediate care facility were not able to demonstrate even minimal functioning in the community. These persons spent 90 or more days in locked or highly structured institutions that provided 24-hour care (including jail) or had five or more acute hospitalizations. However, 44 percent spent less than 90 days in these institutions and had fewer than five acute hospitalizations. Thirty-three percent were not known to have spent any time in an institution or hospital. CONCLUSIONS: The high rate of recidivism shown in this cohort suggests that the current emphasis on transferring patients from more structured, intermediate inpatient services to lower levels of care is not effective for a majority of patients. Furthermore, the poor clinical outcomes found in this cohort did not seem to be offset by any reduction in overall governmental costs because of the high use of acute and intermediate hospitalization and the costs of the criminal justice system.     

Integrated care for co-occurring disorders: psychiatric symptoms, social functioning, and service costs at 18 months

OBJECTIVE: Persons with severe mental illness have high rates of comorbid substance use disorders. These co-occurring disorders present a significant challenge to community mental health services, and few clinical trials are available to guide the development of effective services for this population. The study aimed to evaluate the effectiveness of a program for case managers that trained them to manage substance use disorders among persons with severe mental illness. METHODS: A cluster-randomized controlled trial design was used in South London to allocate case managers either to training or to a waiting list control condition. Outcomes and service costs (health care and criminal justice) over 18 months of 127 patients treated by 40 case managers who received training were compared with those of 105 patients treated by 39 case managers in the control condition. RESULTS: Brief Psychiatric Rating Scale scores for the intervention group indicated significant improvements in psychotic and general psychopathology symptoms. Participants in the intervention group also reported fewer needs for care at follow-up. No significant differences were found between the two groups in levels of substance use at 18 months. At follow-up both groups reported increased satisfaction with care. Service costs were also similar for the two groups. CONCLUSIONS: Compared with standard care, integrated treatment for co-occurring disorders provided by nonspecialist mental health staff produced significant improvements in symptoms and level of met needs, but not in substance use or quality of life, at no additional cost.     

The effects of a jail diversion program on incarceration: a retrospective cohort study.

The objective of this retrospective cohort study was to determine whether a jail diversion program significantly reduced the number of days of incarceration over the year following arrest in a sample of seriously mentally ill (SMI) people who had been arrested for a minor crime. Methods: A group of 314 SMI detainees were diverted out of jail and into mental health treatment. They were compared with a sample of 124 people who would have been eligible for diversion but were not diverted. For each group, the authors compared the total days incarcerated in the year after index arrest. Analyses indicated that jail diversion significantly reduced incarceration time during the next year (40.51 versus 172.84 days, p = .0001). However, the effect of diversion differed depending upon the level of criminal charge: diversion significantly reduced jail time only among those who were arrested for more serious offenses. Those arrested for Class D felony and Class A misdemeanor charges and diverted into mental health treatment spent significantly less time in jail in the next year than those not diverted (260 and 110 fewer days, respectively; p = .0001 for both). Those arrested for Class B or C misdemeanors had similar days incarcerated regardless of diversion. These results remained after adjusting for age, race, gender, and diagnosis. This study presents the first evidence that jail diversion may produce positive longitudinal criminal justice outcomes for SMI people. It also suggests that diversion may not reduce incarceration in all sub-groups of SMI people who are arrested for minor crimes.     

A Comparison of Treatment Outcomes Among Chronically Homelessness Adults Receiving Comprehensive Housing and Health Care Services Versus Usual Local Care

Service use and 2-year treatment outcomes were compared between chronically homelessness clients receiving comprehensive housing and healthcare services through the federal Collaborative Initiative on Chronic Homelessness (CICH) program (n = 281) a sample of similarly chronically homeless individuals receiving usual care (n = 104) in the same 5 communities. CICH clients were housed an average of 23 of 90 days (52%) more than comparison group subjects averaging over all assessments over a 2-year follow-up period. CICH clients were significantly more likely to report having a usual mental health/substance abuse treater (55% vs. 23%) or a primary case manager (26% vs. 9%) and to receive community case management visits (64% vs. 14%). They reported receiving more outpatient visits for medical (2.3 vs. 1.7), mental health (2.8 vs. 1.0), substance abuse treatment (6.4 vs. 3.6), and all healthcare services (11.6 vs. 6.1) than comparison subjects. Total quarterly healthcare costs were significantly higher for CICH clients than comparison subjects (4,544 vs.4,544 vs. 3,326) due to increased use of outpatient mental health and substance abuse services. Although CICH clients were also more likely to receive public assistance income (80% vs. 75%), and to have a mental health/substance provider at all, they expressed slightly less satisfaction with their primary mental health/substance abuse provider (satisfaction score of 5.0 vs. 5.4). No significant differences were found between the groups on measures of substance use, community adjustment, or health status. These findings suggest that access to a well funded, comprehensive array of permanent housing, intensive case management, and healthcare services is associated with improved housing outcomes, but not substance use, health status or community adjustment outcomes, among chronically homeless adults.