(Aug. 1, 2017) The United States incarcerates more individuals with mental illness than any other nation on earth, a result of both our incarceration rate and the disproportionate prevalence of mental illness in our inmate population. Based on the most recent prevalence estimates, an estimated 213,780 state and federal prisoners and 163,800 jail inmates had psychiatric symptoms or had previously been diagnosed with a serious mental health condition in 2011-12 - 377,580 men and women altogether.*
Most of these individuals do not receive treatment behind bars, and many are released from incarceration under conditions that all but guarantee they will not succeed in the community. As just one example, the US Inspector General recently reported that 13% of prisoners in a sample of individuals with mental illness in solitary confinement were released directly from an isolation cell to the community with no transition through the general prison population and with no outside support put in place.
In a new paper now online in Behavioral Sciences and the Law, Drs. H. Richard Lamb, a research pioneer on the criminalization of mental illness, and Linda E. Weinberger examine the issues surrounding the release of individuals with serious mental illness and practices that would reduce their risk of re-incarceration and over adverse consequences.
"Throughout, a pragmatic ethics is advocated," they write, "that which is good is that which works."
"Formidable" Problems
The authors identify several challenges to implementing "that which works" for this population.
- The successful use of mental health courts to divert people from incarceration after arrest is contingent on the availability and quality of local services (e.g., therapy, housing, rehabilitation), which may be lacking.
- Clinicians in correctional settings find that post-release supports their clients need for success in the community may not be available.
- Mental health professionals trained to treat non-forensic patients can feel overwhelmed, fearful and unprepared to work with clients who have been incarcerated and may be at risk for violence.
- Coordination between the criminal justice system (e.g., parole and probation officers, court personnel) and mental health system is essential but not guaranteed.
- Structured living can be critical to success for individuals leaving the institutional setting of jails or prisons but may not be not available.
- Community housing and treatment options are often not equipped to manage and treat patients who are resistant to treatment, with symptoms that are difficult to control, or who are at risk for violence.
- Involuntary options such as assisted outpatient treatment (AOT) reduces the risk of re-arrest and re-incarceration for individuals with a history of negative consequences from not adhering to treatment but are not universally available.
"The list of problems is formidable," the authors write, "but they can be resolved."
What Works
Noting that individuals with mental illness are a heterogeneous group, Lamb and Weinberger call for better recognition that diverse needs require more diverse resources and interventions. "Outpatient treatment and services for persons placed in the community should be for those who are the most likely to succeed and the least likely to fail and as a result need costly, lengthy hospitalizations and/or be at risk of re-arrest for serious offences," they say. At the same time, there is a substantial minority, "who need the structure and support found in acute, intermediate or long-term care in a hospital setting or a highly structured, locked 24-hour care community facility."
To reduce criminalization and promote the success of individuals with mental illness re-entering the community from jail or prison they propose:
- A very large increase in the number of community mental health services, including forensic assertive community treatment teams and intensive case management
- Treatments for the co-occurring substance disorders that are common in the population
- Practices that assure administration of prescribed medications after release
- Crisis response teams
- Appropriate structured, monitored and supportive housing
- Vocational and rehabilitation therapies
- Provision for acute care in the community and for acute, intermediate and long-term inpatient care when needed
- Less restrictive civil commitment laws to facilitate emergency intervention sooner
- The use of AOT and conservatorships/guardianships when indicated.
"Many of these interventions are evidence-based practices," the authors conclude. "With a sufficient amount of all of these services being made available, the number of persons with (serious mental illness) being criminalized should fall significantly, and many more should be able to make progress toward wellness and live more enriched lives in the community."
In its entirety, the paper covers the issues of asylum and sanctuary; the need for structure; various forms of involuntary treatment; an assessment of the capabilities and limitations of outpatient treatment; appropriate treatment goals; liaison between treatment and criminal justice staff; and management of violence.
* Based on survey data released by the US Department of Justice, Bureau of Justice Statistics, June 2017.
Doris A. Fuller
Chief of Research and Public Affairs
References:
- Lamb, H.R. & L. Weinberger. (July 2017). Understanding and treating offenders with serious mental illness in public sector mental health. Behavioral Sciences and the Law.
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Research Weekly is a summary published as a public service of the Treatment Advocacy Center and does not necessarily reflect the findings or positions of the organization or its staff. Full access to research summarized may require a fee or paid subscription to the publications.
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