Mental Health and Criminal Charges: Variation in Diversion Pathways in Australia

Mental health and criminal justice legislation must provide the appropriate mechanisms for ensuring the assessment and care of mentally ill individuals. It must also balance the right to justice of these individuals with the rights of the community. In Australia, each jurisdiction has its own legislative provisions related to mental health, criminal legislation and sentencing, with variation in the mental health diversion options that are available. This article uses a national survey of court liaison services and mental health courts in Australia and a review of the relevant legislative frameworks to compare jurisdictional approaches to mental health diversion. Despite calls from the National Mental Health Commission for consistency, the Australian approach to the provision of mental health services to people in the criminal justice system is heterogeneous and piecemeal. Variation in the diversion pathways available to individuals with mental illness exists across Australia. The presence of problem-solving courts in some, but not all, jurisdictions results in differences in access to legal and treatment options.     

Horizons of context: understanding the police decision to arrest people with mental illness

The criminalization hypothesis assumes that deinstitutionalization coupled with inadequate police training has led to the increased arrest of people with mental illness. Arrest is viewed as a means to manage the troublesome behavior that often results from mental illness. Supporting research has emphasized the contributing role that illness plays in the arrest decision. This assumption largely ignores an extant criminal justice literature on the factors that influence arrest. On the basis of a review of this criminal justice literature, beginning with Bittner's 1967 seminal work, a framework is proposed that incorporates three contexts -- manipulative, temporal, and scenic -- surrounding the police encounter and the relationship of these contexts to mental illness. These three "horizons" incorporate the characteristics of the community, the offender, and the incident, all of which are recognized as influential in shaping police discretion. The scenic horizon is indicative of the features of the community. The temporal horizon includes police knowledge that stretches beyond the specific incident and officer characteristics. The manipulative horizon involves the current incident from the standpoint of the officer and includes considerations of safety for the community as well as the immediate concerns of the officer. Implications of this framework are then explored with respect to both police and mental health service mandates.     

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.     

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.     

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.     

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.     

Mentally Ill Persons in the Criminal Justice System: Some Perspectives

There is an increasing number of severely mentally ill persons in the criminal justice system. This article first discusses the criminalization of persons with severe mental illness and its causes, the role of the police and mental health, and the treatment of mentally ill offenders and its difficulties. The authors then offer recommendations to reduce criminalization by increased coordination between police and mental health professionals, to increase mental health training for police officers, to enhance mental health services after arrest, and to develop more and better community treatment of mentally ill offenders. The necessary components of such treatment are having a treatment philosophy of both theory and practice; having clear goals of treatment; establishing a close liaison between treatment staff and the justice system; understanding the need for structure; having a focus on managing violence; and appreciating the crucial role of case management, appropriate living arrangements, and the role of family members.     

Are jails replacing the mental health system for the homeless mentally ill?

The author explores the process of how homeless mentally ill persons become involved with the criminal justice system. The unique demands of homelessness and chronic mental illness were specifically examined in this naturalistically based study. The author concludes that a combination of severe mental illness, a tendency to decompensate in a nonstructured environment, and an inability or unwillingness to follow through with aftercare contributed to involvement with the criminal justice system. Changes in the mental health system that would prevent the criminalization of the homeless mentally ill are suggested.This paper is based in part on research supported by grant #717632 from the Office of Program Evaluation and Research, Ohio Department of Mental Health.     

People with an Intellectual Disability in the Australian Criminal Justice System

Intellectual disability (ID) is not accurately identified early enough in the criminal justice system. The extent to which each jurisdiction addresses the needs of persons with ID is inconsistent. Magistrate Court diversion programmes aiming to identify defendants with ID needs vary throughout Australia. This article argues the need for a national approach for the diversion of persons with ID from the criminal justice system. This will be important for persons with and without coexisting mental illness and will affirm international developments protecting the rights of persons with ID (including those in the criminal justice system) to improved and accessible health care.     

'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 SAMHSA research initiative assessing the effectiveness of jail diversion programs for mentally ill persons

For nearly 30 years jail diversion programs have had wide support as a way to prevent people with mental illnesses and substance use disorders from unnecessarily entering the criminal justice system by providing more appropriate community-based treatment. Although these programs have had wide support, very few systematic outcomes studies have examined their effectiveness. This paper discusses findings on rates of incarceration of persons with serious mental illness and co-occurring substance use disorders in U.S. jails, summarizes recently completed research on jail diversion programs, and describes a three-year research initiative begun in 1997 by the Substance Abuse and Mental Health Services Administration that uses a standardized protocol to examine the characteristics and outcomes of various types of jail diversion programs in nine sites throughout the U.S.     

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.     

Contesting Mad versus Bad: The Evolution of Forensic Mental Health Services and Law at Toronto

We analyze relevant aspects in the history of forensic mental health services in the Toronto area, which offers a well-documented historical record for contextualizing current public debates and controversies. Spanning the late 18th century to the present, we trace the development of common and statute law, and service responses in the forensic and criminal justice systems, through the evolution of asylums to latter-day psychiatric facilities and services. Addressing themes of evolving interfaces between the practices of law and mental health care reveals that the balance, as enacted in law and interpreted by the courts, has generally favoured legal interpretations of mental illness, despite psychiatry's steadily-increasing claim to superior insights and evidence on what constitutes mental illness in juridical contexts. The experience of forensic psychiatry over this 200-year period points to relevant implications for continued refinement of legal, court and clinical provisions for this service, and directions for future research.     

Examining the Impact of Mental Illness and Substance Use on Time till Re-incarceration in a County Jail

This paper examines the role that substance use and serious mental illness play in criminal justice recidivism by examining the time to return to jail for a cohort of people admitted to jail in 2003 (N = 16,434). These analyses found that people with serious mental illness alone experienced the longest time in the community before returning to jail and were found to have a risk of re-incarceration that did not differ significantly from individuals with no psychiatric or substance use diagnoses. People with co-occurring disorders had a risk of re-incarceration that was over 40 % higher than that of individuals with no diagnosis.     

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.     

Clinical characteristics of community forensic mental health services

OBJECTIVE: Community forensic mental health teams are a new service within the widening range of specialized community mental health services. The characteristics of these novel services are poorly defined. Two commonly described service models in the United Kingdom are the integrated model (forensic specialists working within community mental health teams) and the parallel model (forensic specialists working on a separate specialist team). The study reported here aimed to establish clear definitions of these service models. METHODS: A literature review and a focus group of ten service professionals were conducted to identify candidate characteristics of services in community forensic mental health teams. A total of 31 characteristics were identified and used to prepare the first-round questionnaire for the two rounds of a modified Delphi consultation, which is an expert opinion and consensus method, with a multidisciplinary panel of 32 mental health professionals experienced in community forensic work. RESULTS: Twenty-nine staff (91 percent) completed the two rounds of consultation. Thirteen service characteristics differentiated the integrated and parallel models. Key characteristics of parallel teams included having their own team base, separate referral meetings, a specialist management line, specialist supervision, protected funding, forensic psychology, good links with criminal justice systems, and capped caseloads. Integrated teams were distinguished by their close links with community mental health services and acceptance of more referrals from primary care. CONCLUSIONS: Integrated and parallel models of community forensic mental health teams differ on many service characteristics. Defining these characteristics will help in researching the pros and cons of each model in the treatment and risk management of mentally ill offenders in the community.     

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.     

Adapting evidence-based practices for persons with mental illness involved with the criminal justice system

The overrepresentation of persons with mental illnesses in the criminal justice system is well documented. As more communities attempt to offer appropriate evidence-based practices in diversion and reentry programs, a major issue that has become apparent is that adaptations to the standard practices are often required because of the legal predicaments faced by clients. The associated question is how extensive can adaptations be before fidelity to the proven practice is compromised. To better understand these pressing issues, the National GAINS Center for Evidence-Based Programs in the Justice System held a series of six meetings focused on evidence-based practices (assertive community treatment, housing, trauma interventions, supported employment, illness self-management and recovery, and integrated treatment) and their applicability for persons involved in the criminal justice system. This Open Forum integrates the results of those meetings and proposes future steps to establish relevant evidence-based practices that can influence both behavioral health and public safety outcomes for persons involved with the criminal justice system.