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.     

The use of the insanity defense as a jail diversion mechanism for mentally ill persons charged with misdemeanors

Heightened awareness and concern regarding the large number of mentally ill misdemeanants in jails has led to a search for alternatives to jail and to the development nationwide of jail diversion programs for offenders with mental illness. Two such mechanisms-diversion to civil commitment and the use of mental health courts-are briefly reviewed. In Oregon, however, a rather unique mechanism is used to defer mentally ill misdemeanants (in addition to felons) from the criminal justice system: the insanity defense, with subsequent placement of the individual under Psychiatric Security Review Board jurisdiction. Statistics regarding such use from 1978 to 2001 are provided. The authors compare and contrast this jail alternative with both mental health courts and diversion to civil commitment, and discuss questions related to the feasibility of larger-scale use of this mechanism.     

Planning to meet the needs of offenders with mental disorders in the United Kingdom

During the last decade the planning of services for offenders with mental disorders in the United Kingdom has been geared toward diverting them from the criminal justice system to appropriate levels of psychiatric and social care. Although a seamless service system is yet to be developed, the central government has made a concerted effort to promote a better understanding of the needs of offenders with mental disorders and encourage collaboration between the relevant agencies. A major program of research has been initiated, and local health authorities have been encouraged to use a consortium approach to planning and delivery of specialist services. The authors discuss the activities of the Wessex consortium, composed of five local health authorities and a social services department serving a catchment area with a population of 2.5 million in southern England. The consortium has commissioned needs assessments for all offenders with mental illness from the catchment area and a survey of the resources for secure residential treatment in the region. Based on data from this research, the consortium is planning the development of two long-stay secure units to accommodate offenders with a history of repeated inpatient and prison stays and poor response to previous treatment and rehabilitation efforts.     

The forensic psychiatric aspects of schizophrenia.

This review of the literature does seem to reveal an association between schizophrenia and a variety of antisocial behaviors that include violent crime, and even homicide, especially in North America. The literature consistently shows that since the 1950s, schizophrenics have been involved in crime and arrested more frequently than the general population, they are overrepresented in correctional settings, and they represent the majority of those found not guilty by reason of insanity. Many authors cite changes in mental health policies, particularly de-institutionalization, as one of the major causes of these phenomena. It is important to note that a history of prior arrests and of being male, poor, unskilled, uneducated, and unmarried are perhaps the best predictors of antisocial behaviors in the mentally ill and in the general population alike. Schizophrenic drift and increased family pathology in schizophrenic families, however, may predispose people suffering from schizophrenia to these demographic variables. Interestingly, these variables do not seem as relevant in the emergency room or inpatient wards where violence seems to be mainly affected by the severity of psychopathology, substance abuse, neurologic signs, and the environment within the mental health setting. The implications for the practice of psychiatry are diverse. Clearly clinicians in both hospitals and community mental health settings must have experience, training, and an awareness of the literature relating to the prevention, causes, and management of violence. It behooves us in the mental health field, having vociferously supported the community mental health movement, to assist police in the management of the mentally ill who are now in the community, perhaps by the use of mobile crisis intervention teams and by a considerably increased amount of effort and cooperation. Correctional services require urging to develop resources for identifying and tracking the mentally ill so as to be able to provide programs and continuity of care. Community mental health and criminal justice systems need to cooperate in planning the transition of mentally abnormal offenders from prisons into the community and then providing support and after-care for them. One exemplary program that has developed and benefited from the coordination and planning at the interministerial level is the Inter-ministerial Project (IMP) program in Vancouver. This program identified the people whose histories revealed repeated admissions to both correctional and mental health facilities, bouncing between one and the other. Using a case management approach with a limited caseload, clinicians were able to reduce the number of admissions to both types of facilities. This program should serve as a model for other jurisdictions.(ABSTRACT TRUNCATED AT 400 WORDS)     

Psychiatry,Stigma and Courts

Stigma causes significant handicap to people with mental illness. The mentally ill in the criminal justice system are an extremely marginalised group. This article examines stigma, mentally ill offenders and the role of court liaison services in managing these issues. Western Australia has some unique factors including legislation and geography, which have significant impact on the mentally ill offender.     

Criminalization of the mentally ill: Part I. Police perceptions

This paper reports the findings from Phase I of an ongoing prospective, longitudinal study of mentally ill offenders. The study documents the nature, extent and location of mentally ill offenders in the criminal justice system in Southern Alberta, evaluates mechanisms which are used to identify mentally ill offenders in need of treatment, identifies existing psychiatric services available within the criminal justice system and documents their psychiatric service utilization patterns. A study cohort of 611 was identified at their time of arrest and followed through the justice process from initial detention until final release. Part I on this study focuses on the period of arrest. More specifically, police perceptions of disturbed behaviour are examined. The prevalence of police-identified offenders is reported and police judgments regarding possible causes of disturbed behaviour (that is, mental illness, drugs, alcohol) and recommendations for psychiatric treatment are examined. Discrepancies between official recommendations made by police to a bail magistrate (and recorded on the arrest report) and unofficial recommendations collected as part of the study are explained in terms of differing decision-making models; clinical versus legal. Finally, the importance of police perceptions concerning the presence of mental illness as opposed to substance abuse are identified as important factors which influence the decision to recommend psychiatric examinations.     

Review of psychiatric services to mentally disordered offenders around the Pacific Rim

This article was commissioned to collate and review forensic psychiatric services provided in a number of key Pacific Rim locations in the hope that it will assist in future dialogue about service development. The Board of the Pacific Rim College of Psychiatrists identified experts in forensic psychiatry from Australia, Canada, China, Hong Kong, Japan, Russia, Singapore, Taiwan, and the US. Each contributor provided an account of issues in their jurisdiction, including mental health services to mentally disordered offenders in prison, competence or fitness to stand trial, legal insanity as a defense at trial, diminished responsibility, and special forensic services available, including forensic hospitals and community forensic mental health services. Responses have been collated and are presented topic by topic and country by country within the body of this review. The availability of mental health screening and psychiatric in‐reach or forensic liaison services within prisons differed considerably between countries, as did provisioning of community forensic mental health and rehabilitation services. Diversion of mentally disordered offenders to forensic, state, or hybrid hospitals was common. Legal constructs of criminal responsibility (insanity defense) and fitness to stand trial (“disability”) are almost universally recognized, although variably used. Disparities between unmet needs and resourcing available were common themes. The legislative differences between contributing countries with respect to the mental health law and criminal law relating to mentally disordered offenders are relatively subtle. The major differences lie in operationalizing and resourcing forensic 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.     

Legal coercion and retention in drug abuse treatment

The criminal justice system is increasingly referring offenders who have mental health problems to the community mental health system for treatment. The effects of such referrals on treatment outcome and on the mental health and criminal justice systems are not well understood. Because the length of time an individual remains in a drug abuse treatment program is an important indicator of treatment effectiveness, this paper assesses the impact of court referrals by examining the relationship between a drug abuser's length of stay in treatment and his referral by legal and nonlegal sources. Regression analyses on data for more than 2,200 individuals indicate that clients who are legally induced to seek treatment stay in treatment longer than, and do at least as well as, those who seek treatment voluntarily. The implications of these findings for drug abuse treatment and policy are discussed.     

An evaluation of a mental health program for homeless men

The authors report the results of a before-and-after evaluation of an on-site mental health day treatment program for homeless men. Thirty-two subjects were interviewed 6 or more months after placement from a crisis shelter to community housing in order to probe housing stability, aftercare treatment compliance, employment, rehospitalization, and criminal justice contacts. In the after phase, living on the street was virtually eliminated, use of shelters decreased sevenfold, aftercare utilization tripled, and contacts with the criminal justice system were halved. Psychiatric hospitalizations and unemployment were higher in the after phase. Findings are discussed in relation to the need to conduct controlled experiments of new psychosocial treatments for the homeless mentally ill.     

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.     

The behavior of mentally disordered criminals in civil mental hospitals

Because of changes in Ohio mental health legislation in 1978, mentally disordered criminal offenders can now be turned over to the civil probate court for civil commitment procedures. In part because many officials in the civil hospital system fear the admission of dangerous criminals into their hospitals, the authors conducted a statewide research project to compare civil and criminal patients on demographic, diagnostic, and behavioral variables. There were no differences between the two groups on some indices of dangerousness, but on other variables the two groups differed. Sometimes it was not the forensic but the civil patients who appeared more threatening. In all, the forensic patients did not constitute a unique class of patients who are clearly and categorically more dangerous than civil patients. The findings suggest a more open-door policy toward forensic clients in the civil mental health system.     

Federal Demonstration Funds at the Interface of Mental Health and Criminal Justice

A jail diversion program was implemented for offenders with co-occurring mental health and substance abuse disorders (COD) in Lane County, Oregon. This paper discusses whether the program resulted in any sustained community service systems change. Interviewees were asked questions about any systems-level changes that interviewees were aware of in corrections, criminal justice, or treatment where offenders with COD were involved. Results showed evidence of system-level changes in corrections, criminal justice, and treatment that were attributed to various aspects of our "boundary spanning" jail diversion approach with the COD population. The researchers also interpreted the results as evidence of the efficacy of using research to promote change.     

Impact of Winko on absolute discharges

In Canada, case laws have had a significant impact on the way mentally ill offenders are managed, both in the criminal justice system and in the forensic mental health system. The Supreme Court of Canada's decision with respect to Winko has set a major precedent in the application of the test of significant risk to the safety of the public in making dispositions by the Ontario Review Board and granting absolute discharges to the mentally ill offenders in the forensic health system. Our study examines the impact of the Supreme Court of Canada's decision before and after Winko. The results show that the numbers of absolute discharges have increased post-Winko, which was statistically significant, but there could be other factors influencing this increase.     

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.     

Community treatment of severely mentally ill offenders under the jurisdiction of the criminal justice system: a review.

OBJECTIVE: Very large numbers of severely mentally ill persons now fall under the jurisdiction of the criminal justice system. A number of conditions are placed on those who are returned to the community, including specific ones related to treatment. This paper reviews the principles and practice of forensic outpatient mental health treatment. METHODS: MEDLINE, Psychological Abstracts, and the Index to Legal Periodicals and Books were searched from 1978, and all pertinent references were obtained. RESULTS AND CONCLUSIONS: Community treatment of severely mentally ill offenders who fall under the jurisdiction of the criminal justice system has important differences from treatment of nonoffenders, which focuses on alleviation of symptoms. Patients must comply with legal restrictions on their behavior, and treatment first addresses a patient's risk of harm to the community. Mentally ill offenders are often resistant to treatment. The mental health system may be disinclined to treat them due to their resistance and their criminal history, especially a history of violence. It is critical to identify a treatment philosophy that strikes a balance between individual rights and public safety and includes clear treatment goals, a close liaison between treatment staff and the criminal justice system, adequate structure and supervision, treatment staff who are comfortable with using authority, interventions for managing violence, incorporation of the principles of case management, appropriate and supportive living arrangements, and a recognition of the role of family members and significant others in treatment.     

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.     

Recidivism and use of services among persons with mental illness after release from prison

OBJECTIVE: Despite large numbers of mentally ill offenders in prisons, few studies of mentally ill offenders released from prison have been conducted. This study describes such a population of mentally ill offenders, the postrelease services they received, new offenses they committed, and factors associated with recidivism. METHODS: The authors reviewed electronic files and archived medical charts from the state corrections department to identify mentally ill offenders who left Washington state prisons in 1996 and 1997. Data on the individuals identified were then provided by several public agencies. Summary statistics were computed on subjects' characteristics and postrelease outcomes, and logistic regression analysis was used to identify variables that predicted convictions of new felonies and new crimes against persons. RESULTS: A total of 337 mental ill offenders were identified. Men and women differed with regard to offenses, diagnoses, rates of drug abuse, and use of mental health resources. Although most subjects (73 percent) received postrelease social or mental health services, few received clinically meaningful levels of service during the first year after release. Charges for new crimes or supervision violations were common (70 percent of subjects), but only 10 percent committed new felonies against persons, and 2 percent committed very serious crimes. Youth, frequency of past felonies, and variables such as misbehavior in prison were associated with new offenses. CONCLUSIONS: Whether community mental health treatment affects recidivism cannot be assessed fairly in the absence of higher levels of service during the first months after release. This study also identifies actuarial risk factors that predict new offenses at a level comparable to that of published risk assessment instruments. Commission of less serious offenses that usually precede felonies may provide an early warning of risk for new felonies and an opportunity for strategic intervention. The low rate of serious violence in the community by mentally ill offenders released from prison suggests that the risk of violence may be a weak and potentially counterproductive rationale for community support and mental health treatment of mentally ill offenders.     

The shift of psychiatric inpatient care from hospitals to jails and prisons

Far-reaching structural changes have been made in the mental health system. Many severely mentally ill persons who come to the attention of law enforcement now receive their inpatient treatment in jails and prisons, at least in part, because of a dramatic reduction of psychiatric inpatient beds. While more high-quality community treatment, such as intensive case management and assertive community treatment, is needed, the authors believe that for many, 24-hour structured care is needed in the mental health system for various lengths of time to decrease criminalization. Another central theme of this article is that when a mentally ill individual is arrested, that person now has a computerized criminal record, which is easily accessed by the police and the courts in subsequent encounters. This may influence their decisions and reinforce the tendency to choose the criminal justice system over the mental health system.