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.     

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.     

Psychiatric emergency service use and homelessness, mental disorder, and violence

OBJECTIVE: This study examined relationships between homelessness, mental disorder, violence, and the use of psychiatric emergency services. To the authors' knowledge, this study is the first to examine these issues for all episodes of care in a psychiatric emergency service that serves an entire mental health system in a major city. METHODS: Archival databases were examined to gather data on all individuals (N=2,294) who were served between January 1, 1997, and June 30, 1997, in the county hospital's psychiatric emergency service in San Francisco, California. RESULTS: Homeless individuals accounted for approximately 30 percent of the episodes of service in the psychiatric emergency service and were more likely than other emergency service patients to have multiple episodes of service and to be hospitalized after the emergency department visit. Homelessness was associated with increased rates of co-occurring substance-related disorders and severe mental disorders. Eight percent of persons who were homeless had exhibited violent behavior in the two weeks before visiting the emergency service. CONCLUSIONS: Homeless individuals with mental disorders accounted for a large proportion of persons who received psychiatric emergency services in the community mental health system in the urban setting of this study. The co-occurrence of homelessness, mental disorder, substance abuse, and violence represents a complicated issue that will likely require coordination of multiple service delivery systems for successful intervention. These findings warrant consideration in public policy initiatives. Simply diverting individuals with these problems from the criminal justice system to the community mental health system may have limited impact unless a broader array of services can be brought to bear.     

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.     

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.     

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.     

Persons with Severe Mental Disorders in the Criminal Justice System: Challenges and Opportunities

Persons with schizophrenia and other severe mental disorders are at risk for falling through the cracks between the criminal justice and mental health systems. This article is based on a panel discussion between representatives from both systems that recently convened at a regional conference to discuss integration of services. The purpose of the panel discussion was to identify challenges and opportunities related to integrating mental health and criminal justice services at each phase of the criminal justice process. A synopsis of the discussion is presented, along with new models of service delivery designed to prevent the inappropriate arrest and incarceration of persons with severe mental disorders.     

Screening and Access to Services for Individuals with Serious Mental Illnesses in Jails

High rates of serious mental illnesses (SMI) among jail inmates pose challenges for the criminal justice system and risks for the individual with SMI. Research has identified actions to address these issues; it is unclear to what extent they have been operationalized. This study examines jails in one state, exploring how individuals with SMI are identified and treated, and comparing these with research-based recommendations. Results indicate that jails are not using evidence-based screenings, staff require training in SMI, access to services and medications for jailed individuals with SMI is often slow, and coordination between community providers and jails is limited.     

Reaching a Balance Between Privacy,Privilege and Planning: A Look at Barriers to Obtaining Information for Patients with Criminal Involvement

Persons with serious and persistent mental disorders present unique problems for the criminal justice system. The challenges are tremendous as courts venture into problem solving models, attempting to integrate mental health services with the criminal justice system. Gathering and accessing confidential information is often difficult. This article will identify and explore the legal issues related to obtaining such information.     

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.     

Evolving systems of care: Individuals found not criminally responsible on account of mental disorder in custody of civil and forensic psychiatric services

Following psychiatric deinstitutionalization and changes in involuntary civil commitment laws, many individuals with severe mental disorders have been receiving mental health services through the back door, that is, the criminal justice system. Significant changes to the section of Criminal Code of Canada dealing with individuals with mental disorders have led to significant annual increases in the number of individuals declared Not criminally responsible on account of mental disorder (NCRMD), many of whom are directed to civil psychiatric settings. The goal of the present study was to describe the psychosociocriminological and risk characteristics of individuals found NCRMD remanded to civil psychiatric hospitals (CPH) compared to a forensic psychiatric hospital (FPH). This study was conducted between October 2004 and August 2006 in the sole FPH of the province of Québec and two large CPH in the Montréal metropolitan area. The final sample for the current study consisted of 96 men: 60 from the FPH and 36 from the two CPH. Results indicate that individuals in both settings have similar psychosociocriminal profiles, including PCL-R scores, but that individuals in CPH have higher scores in the Risk subscale of the HCR-20 than do their counterparts in the FPH. This difference is due to a higher score on two items: exposure to destabilizing factors and noncompliance with remediation attempts. Results are discussed in terms of the need for civil psychiatric settings to implement risk assessment and management programs into their services, and the need for further research into forensic mental health services.     

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.     

A Critical Review of Mental Health Court Liaison Services in Australia: A first national survey

Mental health Court Liaison Services have emerged in Australia as a key part of the response to the over-representation of people with mental illness in the criminal justice system. These specialist services aim to intervene early in the criminal justice process by identifying mentally ill individuals at the post-charge, pre-sentence stage, providing timely advice to courts and linkage with treatment providers. To date there has been no systematic comparison of the various models of court liaison in each of the Australian jurisdictions, and little is known about their effectiveness. This article presents the findings of the first national survey of Court Liaison Services. In the absence of clear national guidelines, services have formed independently of each other, shaped by the jurisdictional legislation and health services. While services were found to have similar aims, variation exists in their human resources, clinical processes, geographic coverage, and their ability to provide equitable access.     

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.     

Juvenile justice mental health services

As the second century of partnership begins, child psychiatry and juvenile justice face continuing challenges in meeting the mental health needs of delinquents. The modern juvenile justice system is marked by a significantly higher volume of cases, with increasingly complicated multiproblem youths and families with comorbid medical, psychiatric, substance abuse disorders, multiple family and psychosocial adversities, and shrinking community resources and alternatives to confinement. The family court is faced with shrinking financial resources to support court-ordered placement and treatment programs in efforts to treat and rehabilitate youths. The recognition of high rates of mental disorders for incarcerated youth has prompted several recommendations for improvement and calls for reform [56,57]. In their 2000 annual report, the Coalition for Juvenile Justice advocated increased access to mental health services that provide a continuum of care tailored to the specific problems of incarcerated youth [58]. The specific recommendations of the report for mental health providers include the need for wraparound services, improved planning and coordination between agencies, and further research. The Department of Justice, Office of Juvenile Justice and Delinquency Prevention has set three priorities in dealing with the mental health needs of delinquents: further research on the prevalence of mental illness among juvenile offenders, development of mental health screening assessment protocols, and improved mental health services [59]. Other programs have called for earlier detection and diversion of troubled youth from juvenile justice to mental health systems [31,56]. Most recently, many juvenile and family courts have developed innovative programs to address specific problems such as truancy or substance use and diversionary or alternative sentencing programs to deal with first-time or nonviolent delinquents. All youths who come in contact with the juvenile justice system should be screened and, when necessary, assessed for mental health and substance abuse disorders. The screening should occur at the youth's earliest point of contact with the juvenile justice system and should be available at all stages of juvenile justice processing. Whenever possible, youth with serious mental health disorders should be diverted from the juvenile justice system [58]. If delinquent youths do not receive the necessary evaluation, treatment, and rehabilitation, they face the real prospect of further incarceration in adult correctional facilities. Improved screening and treatment require better interagency collaboration, established standards of care, and continuing research on the mental health needs of youth in the juvenile justice system. Better mental health care for youth in the juvenile justice system supports the goal of rehabilitation. Mental health professionals should support these efforts as the appropriate response to meet the challenges of the new century.     

Adequacy of Help Received by Individuals with Severe Mental Disorders After a Major Healthcare Reform in Quebec: Predictors and Changes at 5-Year Follow-Up

This study assessed predictors and changes in adequacy of help received (AHR), as perceived by 204 individuals with severe mental disorders (SMDs) transferred from a mental health institution to the community following a key healthcare reform. Adjusted perceived AHR remained stable after 2 years (T1), but decreased at 5-year follow-up (T2). Predictors of higher adjusted perceived AHR are age, severity of needs, help received from services and relatives, and number of health professionals consulted. Community mental health services need to address the two major predictors of adjusted perceived AHR: severity of needs among individuals with SMDs and level of help from services.     

The police and mental health

With deinstitutionalization and the influx into the community of persons with severe mental illness, the police have become frontline professionals who manage these persons when they are in crisis. This article examines and comments on the issues raised by this phenomenon as it affects both the law enforcement and mental health systems. Two common-law principles provide the rationale for the police to take responsibility for persons with mental illness: their power and authority to protect the safety and welfare of the community, and their parens patriae obligations to protect individuals with disabilities. The police often fulfill the role of gatekeeper in deciding whether a person with mental illness who has come to their attention should enter the mental health system or the criminal justice system. Criminalization may result if this role is not performed appropriately. The authors describe a variety of mobile crisis teams composed of police, mental health professionals, or both. The need for police officers to have training in recognizing mental illness and knowing how to access mental health resources is emphasized. Collaboration between the law enforcement and mental health systems is crucial, and the very different areas of expertise of each should be recognized and should not be confused.     

The involvement of schizophrenic insanity acquittees in the mental health and criminal justice systems.

This article described the mental health and criminal justice involvement of a large group of schizophrenic insanity acquittees and the program designed to manage and treat these individuals. Most insanity acquittees in our system are chronically mentally ill individuals who fit well into the psychosocial rehabilitation models that have developed over the past 15 years. In addition, the use of conditional release and monitored care in the community appears to be the most realistic approach to this group of individuals who show a high degree of involvement with the mental health and criminal justice service systems. This research has continued implications for the development of outpatient civil commitment and for the attempt to give people as much liberty as they are capable of handling while being realistic about their capacities to survive in the community.