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Mental illness and the criminal justice system: Reducing the risks
NEW YORK – The overrepresentation of people with serious mental illness (SMI) in the criminal justice system has led to creation of a resource from the Judges’ and Psychiatrists’ Leadership Initiative (JPLI) aimed at helping psychiatry and law enforcement address the problem.
The resource, “Supporting People with Serious Mental Illnesses and Reducing Their Risk of Contact with the Criminal Justice System: A Primer for Psychiatrists,” released last year, was designed to provide psychiatrists with specific knowledge and tools, according to Michael Champion, MD, forensic chief at the Hawaii State Department of Health, Adult Mental Health Division, Honolulu, and a member of the JPLI executive leadership team.
In developing the primer, the JPLI, which was created about 10 years ago by the American Psychiatric Association Foundation in partnership with the Council of State Governments Justice Center in response to the growing problem of such overrepresentation, sought to teach psychiatrists about what the criminal justice literature has dubbed “criminogenic risk” and to explore strategies to address those risks in community treatment settings, Dr. Champion said at the annual meeting of the American Psychiatric Association.
“The fact is that one in three Americans has a criminal record, and people with serious mental illness and criminal justice involvement are frequently part of our patient population – particularly in the public mental health sector,” Dr. Champion said. “Part of the challenge is that psychiatrists ... aren’t typically trained in these principles ... so the JPLI saw that this as an area that we could try to make some traction in and try to make a difference.”
The JPLI’s goals in publishing this resource are to reduce the risk of patient involvement in the criminal justice system, and to improve clinical and recovery outcomes by educating community psychiatrists about Risk-Need-Responsivity (RNR) principles. The JPLI also seeks to provide strategies for collaborating with criminal justice partners, incorporating criminal justice history into screening and assessment, and integrating criminogenic risk needs of patients into comprehensive treatment plans, Dr. Champion said.
Criminogenic risk and RNR
Many factors contribute to the involvement of people with serious mental illnesses in the criminal justice system, including higher rates of arrest, longer stays, recidivism, and limited access to health care, said Fred C. Osher, MD, former director of health systems and services policy for the Council of State Governments Justice Center.
“We used to think that ... if we could just get folks the health care that they need, they wouldn’t get involved with the criminal justice system. It turns out that that’s a gross oversimplification, in that their needs are terribly complex, and while treatment is a necessary component, it isn’t often sufficient for a large number of individuals,” said Dr. Osher, now a member of the JPLI executive leadership team.
Criminogenic risk – the likelihood that a person who has been arrested and jailed will commit a new crime after release or return to custody – helps explain why that is the case, he said, adding: “We have ways in which we can understand those risks.”
The risks are measured via static factors (unchanging conditions such as criminal history, age at first arrest, current age, and gender) and dynamic factors, he explained.
he said, noting that the research has shown there are eight specific criminogenic risk factors: substance abuse, history of antisocial behavior, antisocial personality pattern, antisocial cognition, antisocial associates, family and/or marital discord, poor school and/or work output, and having few leisure/recreation outlets.
Notably, mental illness is not a part of that list, he said.
“The reason for that is it’s not explanatory in and of itself,” he added.
However, research shows that people with mental illness have more of these dynamic risk factors, and research by Jennifer L. Skeem, PhD, and others shows that those with mental illness were coming back to jail not for new criminal activity, but for failing to comply with their conditions of release.
“These risks, then, have been brought into a paradigm that is central to our criminal justice operations, and it’s called the Risk-Need-Responsivity model,” Dr. Osher said. “This paradigm is what allows a criminal justice system to think about how to prioritize the resources – to think about who really needs to be wrapped tight, who needs to have close supervision, frequent reporting, lots of contact.”
The risk principle in the RNR model says that resources should be focused on high-risk cases, with limited supervision in lower-risk cases. This is based on experience demonstrating that recidivism is lower in high-risk individuals with close supervision but higher in low-risk individuals with close supervision.
The needs principle suggests that dynamic needs are “the issues that get folks in trouble,” he said.
“So, if we’re going to intervene, if we’re going to provide programming, if we’re going to try and help that individual stay out of jail or prison, we need to address these criminogenic needs,” he said, adding that the “big four” are related to their antisocial thinking and personality and friends.
Targeted interventions can help those individuals make better choices going forward, he noted.
The responsivity principle is an acknowledgment that individuals have different ways of learning, different cultural factors and backgrounds that influence them, and social determinants that are important to understand if they predict the ability to stay out of trouble.
“This is where mental illness fits in,” Dr. Osher said. “It’s absolutely important that we understand that.”
Examples would be patients with severe major depressive disorder who need their depression treated before they can participate in a group treatment setting designed to address criminogenic risks.
Dynamic risk factors are best treated with cognitive-behavioral interventions, Dr. Osher said, noting that the most effective interventions provide opportunities for participants to practice new behavior patterns and skills with feedback from program staff.
In many states, those interventions are being provided by criminal justice personnel, including probation officers, partly because of “an absence of [psychiatrists’] understanding, willingness, or ability to step forward.” The JPLI primer is designed to “really amp up our own excitement about, and willingness to learn how to develop interventions to help that individual stay out of trouble,” and it includes detailed descriptions of numerous well-researched, standardized, manualized interventions that people can access that make it less likely for them to have criminal justice access going forward, he said.
Those include programs such as “Thinking for a Change,” “Reasoning and Rehabilitation,” “Moral Reconation Therapy,” and “Interactive Journaling.”
A focus on the Sequential Intercept Model, which describes how individuals move through the criminal justice system, illustrates multiple points where psychiatrists can “do things better and differently to intervene,” he said, noting that the primer includes a framework for prioritizing the target population, and validated screening and assessment tools, including tools to help corrections officers identify mental health/substance abuse/criminogenic issues at the time individuals are booked into jail so they can be referred for appropriate interventions.
Achieving positive public health and safety outcomes requires changes to policy and practice, Dr. Osher said.
The JPLI primer is a step toward making such changes, and with it comes a set of four principles:
1. Conduct universal risk, substance use, and mental health screening at booking, and full assessments as appropriate, he said, noting that “13 million times this year (9 million unduplicated count), 2 million folks with serious mental illness are going to be arrested and brought to jail. Let’s make sure they get assessed, identified, and then a plan can be made.”
2. Get relevant information into the hands of decision makers in time to inform pretrial release decisions. For example, knowing if someone is eligible for a mental health court could lead to that person’s receiving necessary support and supervision, he said.
3. Use assessment information to connect people to appropriate jail-based services and post-release services and supervision, and ensure that there is communication between the two.
4. Ensure services and supervision are evidence based and hold systems accountable by measuring outcomes.
In addition, the goal is to partner with the criminal justice system through information-sharing agreements and integrating dynamic criminogenic risk factors into treatment plans, he said.
The intercepts
To demonstrate ways in which psychiatrists can intervene over the course of a patients’ journey toward involvement in the criminal justice system, Stephanie Le Melle, MD, provided a case example involving a 30-year-old African American man diagnosed with schizophrenia at age 18 years.
As a child, “Joe” was neglected and abused; both parents had a history of mental illness and substance use. He experienced homelessness, never finished high school, and was hospitalized or visited the emergency department more than 15 times after going off medications or because of intoxication.
His history with the legal system involved a first arrest at age 14 years for gang-related fighting and assault (after being bullied as a child and seeking safety in a gang), followed by 3 years in juvenile detention. He was released with supervision at age 17 years, was arrested several times after that for public intoxication and loitering, and was held for several days or weeks each time – then released with time served or summons paid. His first hospitalization occurred at age 18, when he was diagnosed with psychosis.
Subsequent experiences included treatment in a community mental health program at age 25 for heroin use and drinking. However, he was denied admission to a substance abuse program because of his history of psychosis and violence. After stopping his medications because of side effects, he tried to buy heroin, got into a fight, and was arrested for assault with a pocket knife. He resisted arrest and was tasered, handcuffed, and taken to prison, where he was held because he could not afford bail. Involvement in gang activity while in prison led to sanctions, including time in solitary confinement.
During all of his time in the criminal justice system, Joe refused treatment, because he was afraid he’d be considered “crazy” and would be preyed upon even more by other inmates. After about 3 years, he was released to a Forensic Assertive Community Treatment team for 2 years and completed that program, and is now receiving treatment in the community. He lives alone in supported housing and has Supplemental Security Income. He does not engage in clinic-related activities and has a lack of trust in the clinical team. He often is agitated and disruptive in the clinic. Staff members have concerns about his history of violence and drug use, and were reluctant to bring him into the program.
“Going back to ... the sequential intercept model, we can think about things, as psychiatrists, that we could have done for Joe all along the way to help him not get into the criminal justice system in the first place,” said Dr. Le Melle, director of public psychiatry education at Columbia University/New York State Psychiatric Institute, New York.
This is a framework for thinking through treatment for a patient like Joe:
Intercept 0 (community services). At this early stage, Joe would have been screened for adverse childhood experiences, and that could have led to trauma treatment, substance abuse treatment, and educational and vocational services. Awareness of his family illness, discord, and poverty would have led to parenting interventions, early school involvement, and promotion of meaningful activities, she said.
“These are things, again, that we can address as clinicians ... to intervene with families and with schools and communities to try to give young people an opportunity to not get into the criminal justice system,” she said, adding that providing early co-occurring treatment for mental health and substance use is particularly important.
Intercept 1 (law enforcement) also is a stage during which a psychiatrist can intervene by giving pertinent information when 911 is called by providing police or corrections with contact information for follow-up. For Joe, psychiatrist involvement at this intercept could have allowed for treatment recommendations or assessment for diversion programs, and in fact, at some point during his care, did allow for communication about his treatment needs, Dr. Le Melle said.
In general, psychiatrists also can participate at this stage through provision of crisis intervention team training for first responders or by being part of a co-response team, she said.
Intercept 2 (initial detention/initial court hearings). Attending court on behalf of a patient can make a real difference in outcomes, she noted.
“Judges want to know that someone is out there who can help, and they want to know that there’s a team of people who can intervene and try to get someone out of the criminal justice system,” she said.
At this stage, psychiatrists can help by recommending a treatment plan for a diversion program, and – within HIPAA guidelines – can share pertinent information about treatment needs and preferences.
Intercept 3 (jails/courts). At this in-the-system stage, information shared between corrections and community behavioral health would have led to Joe’s transfer to a mental health/observation unit; he would have been offered mental health treatment and been started on substance use treatment; and he would have participated in motivational treatment and cognitive-behavioral therapy targeting his criminogenic needs, she said.
Meeting with individuals while they are incarcerated can be helpful for “keeping them grounded.”
This also is a stage where psychiatrists could help individuals prepare for release by getting them into a GED program or other training.
Intercept 4 (reentry). With appropriate intervention at this stage, Joe would have his benefits, such as Medicaid and Supplemental Security Income, reinstated prior to reentry to the community. Also, his psychiatrist and treatment program would be contacted. He would be welcomed back into treatment, and he would have assistance finding a permanent place to live with services provided in the community.
Intercept 5 (community corrections). At this stage, community behavioral health clinicians would maintain awareness of their biases and fears about people involved in the criminal justice system and avoid making assumptions about Joe. His risks, needs, and priorities would be assessed and addressed, and he would be asked about his experiences with the system and about what could be done to help him avoid incarceration in the future.
He would receive help in incorporating alternative behaviors and thinking to address dynamic criminogenic risk, and evidence-based practices would be used in treatment.
The sequential intercept model reflects the fact that the criminal justice system and the people it serves are part of the community, Dr. Le Melle said.
“The community and the behavioral health system and the criminal justice system are partners in our shared mission of public safety and public health, so we are one and we can’t expect that our responsibility for providing people with the best care and services ends if someone is in the criminal justice system,” she said.
Dr. Champion, Dr. Osher, and Dr. Le Melle reported having no disclosures.
NEW YORK – The overrepresentation of people with serious mental illness (SMI) in the criminal justice system has led to creation of a resource from the Judges’ and Psychiatrists’ Leadership Initiative (JPLI) aimed at helping psychiatry and law enforcement address the problem.
The resource, “Supporting People with Serious Mental Illnesses and Reducing Their Risk of Contact with the Criminal Justice System: A Primer for Psychiatrists,” released last year, was designed to provide psychiatrists with specific knowledge and tools, according to Michael Champion, MD, forensic chief at the Hawaii State Department of Health, Adult Mental Health Division, Honolulu, and a member of the JPLI executive leadership team.
In developing the primer, the JPLI, which was created about 10 years ago by the American Psychiatric Association Foundation in partnership with the Council of State Governments Justice Center in response to the growing problem of such overrepresentation, sought to teach psychiatrists about what the criminal justice literature has dubbed “criminogenic risk” and to explore strategies to address those risks in community treatment settings, Dr. Champion said at the annual meeting of the American Psychiatric Association.
“The fact is that one in three Americans has a criminal record, and people with serious mental illness and criminal justice involvement are frequently part of our patient population – particularly in the public mental health sector,” Dr. Champion said. “Part of the challenge is that psychiatrists ... aren’t typically trained in these principles ... so the JPLI saw that this as an area that we could try to make some traction in and try to make a difference.”
The JPLI’s goals in publishing this resource are to reduce the risk of patient involvement in the criminal justice system, and to improve clinical and recovery outcomes by educating community psychiatrists about Risk-Need-Responsivity (RNR) principles. The JPLI also seeks to provide strategies for collaborating with criminal justice partners, incorporating criminal justice history into screening and assessment, and integrating criminogenic risk needs of patients into comprehensive treatment plans, Dr. Champion said.
Criminogenic risk and RNR
Many factors contribute to the involvement of people with serious mental illnesses in the criminal justice system, including higher rates of arrest, longer stays, recidivism, and limited access to health care, said Fred C. Osher, MD, former director of health systems and services policy for the Council of State Governments Justice Center.
“We used to think that ... if we could just get folks the health care that they need, they wouldn’t get involved with the criminal justice system. It turns out that that’s a gross oversimplification, in that their needs are terribly complex, and while treatment is a necessary component, it isn’t often sufficient for a large number of individuals,” said Dr. Osher, now a member of the JPLI executive leadership team.
Criminogenic risk – the likelihood that a person who has been arrested and jailed will commit a new crime after release or return to custody – helps explain why that is the case, he said, adding: “We have ways in which we can understand those risks.”
The risks are measured via static factors (unchanging conditions such as criminal history, age at first arrest, current age, and gender) and dynamic factors, he explained.
he said, noting that the research has shown there are eight specific criminogenic risk factors: substance abuse, history of antisocial behavior, antisocial personality pattern, antisocial cognition, antisocial associates, family and/or marital discord, poor school and/or work output, and having few leisure/recreation outlets.
Notably, mental illness is not a part of that list, he said.
“The reason for that is it’s not explanatory in and of itself,” he added.
However, research shows that people with mental illness have more of these dynamic risk factors, and research by Jennifer L. Skeem, PhD, and others shows that those with mental illness were coming back to jail not for new criminal activity, but for failing to comply with their conditions of release.
“These risks, then, have been brought into a paradigm that is central to our criminal justice operations, and it’s called the Risk-Need-Responsivity model,” Dr. Osher said. “This paradigm is what allows a criminal justice system to think about how to prioritize the resources – to think about who really needs to be wrapped tight, who needs to have close supervision, frequent reporting, lots of contact.”
The risk principle in the RNR model says that resources should be focused on high-risk cases, with limited supervision in lower-risk cases. This is based on experience demonstrating that recidivism is lower in high-risk individuals with close supervision but higher in low-risk individuals with close supervision.
The needs principle suggests that dynamic needs are “the issues that get folks in trouble,” he said.
“So, if we’re going to intervene, if we’re going to provide programming, if we’re going to try and help that individual stay out of jail or prison, we need to address these criminogenic needs,” he said, adding that the “big four” are related to their antisocial thinking and personality and friends.
Targeted interventions can help those individuals make better choices going forward, he noted.
The responsivity principle is an acknowledgment that individuals have different ways of learning, different cultural factors and backgrounds that influence them, and social determinants that are important to understand if they predict the ability to stay out of trouble.
“This is where mental illness fits in,” Dr. Osher said. “It’s absolutely important that we understand that.”
Examples would be patients with severe major depressive disorder who need their depression treated before they can participate in a group treatment setting designed to address criminogenic risks.
Dynamic risk factors are best treated with cognitive-behavioral interventions, Dr. Osher said, noting that the most effective interventions provide opportunities for participants to practice new behavior patterns and skills with feedback from program staff.
In many states, those interventions are being provided by criminal justice personnel, including probation officers, partly because of “an absence of [psychiatrists’] understanding, willingness, or ability to step forward.” The JPLI primer is designed to “really amp up our own excitement about, and willingness to learn how to develop interventions to help that individual stay out of trouble,” and it includes detailed descriptions of numerous well-researched, standardized, manualized interventions that people can access that make it less likely for them to have criminal justice access going forward, he said.
Those include programs such as “Thinking for a Change,” “Reasoning and Rehabilitation,” “Moral Reconation Therapy,” and “Interactive Journaling.”
A focus on the Sequential Intercept Model, which describes how individuals move through the criminal justice system, illustrates multiple points where psychiatrists can “do things better and differently to intervene,” he said, noting that the primer includes a framework for prioritizing the target population, and validated screening and assessment tools, including tools to help corrections officers identify mental health/substance abuse/criminogenic issues at the time individuals are booked into jail so they can be referred for appropriate interventions.
Achieving positive public health and safety outcomes requires changes to policy and practice, Dr. Osher said.
The JPLI primer is a step toward making such changes, and with it comes a set of four principles:
1. Conduct universal risk, substance use, and mental health screening at booking, and full assessments as appropriate, he said, noting that “13 million times this year (9 million unduplicated count), 2 million folks with serious mental illness are going to be arrested and brought to jail. Let’s make sure they get assessed, identified, and then a plan can be made.”
2. Get relevant information into the hands of decision makers in time to inform pretrial release decisions. For example, knowing if someone is eligible for a mental health court could lead to that person’s receiving necessary support and supervision, he said.
3. Use assessment information to connect people to appropriate jail-based services and post-release services and supervision, and ensure that there is communication between the two.
4. Ensure services and supervision are evidence based and hold systems accountable by measuring outcomes.
In addition, the goal is to partner with the criminal justice system through information-sharing agreements and integrating dynamic criminogenic risk factors into treatment plans, he said.
The intercepts
To demonstrate ways in which psychiatrists can intervene over the course of a patients’ journey toward involvement in the criminal justice system, Stephanie Le Melle, MD, provided a case example involving a 30-year-old African American man diagnosed with schizophrenia at age 18 years.
As a child, “Joe” was neglected and abused; both parents had a history of mental illness and substance use. He experienced homelessness, never finished high school, and was hospitalized or visited the emergency department more than 15 times after going off medications or because of intoxication.
His history with the legal system involved a first arrest at age 14 years for gang-related fighting and assault (after being bullied as a child and seeking safety in a gang), followed by 3 years in juvenile detention. He was released with supervision at age 17 years, was arrested several times after that for public intoxication and loitering, and was held for several days or weeks each time – then released with time served or summons paid. His first hospitalization occurred at age 18, when he was diagnosed with psychosis.
Subsequent experiences included treatment in a community mental health program at age 25 for heroin use and drinking. However, he was denied admission to a substance abuse program because of his history of psychosis and violence. After stopping his medications because of side effects, he tried to buy heroin, got into a fight, and was arrested for assault with a pocket knife. He resisted arrest and was tasered, handcuffed, and taken to prison, where he was held because he could not afford bail. Involvement in gang activity while in prison led to sanctions, including time in solitary confinement.
During all of his time in the criminal justice system, Joe refused treatment, because he was afraid he’d be considered “crazy” and would be preyed upon even more by other inmates. After about 3 years, he was released to a Forensic Assertive Community Treatment team for 2 years and completed that program, and is now receiving treatment in the community. He lives alone in supported housing and has Supplemental Security Income. He does not engage in clinic-related activities and has a lack of trust in the clinical team. He often is agitated and disruptive in the clinic. Staff members have concerns about his history of violence and drug use, and were reluctant to bring him into the program.
“Going back to ... the sequential intercept model, we can think about things, as psychiatrists, that we could have done for Joe all along the way to help him not get into the criminal justice system in the first place,” said Dr. Le Melle, director of public psychiatry education at Columbia University/New York State Psychiatric Institute, New York.
This is a framework for thinking through treatment for a patient like Joe:
Intercept 0 (community services). At this early stage, Joe would have been screened for adverse childhood experiences, and that could have led to trauma treatment, substance abuse treatment, and educational and vocational services. Awareness of his family illness, discord, and poverty would have led to parenting interventions, early school involvement, and promotion of meaningful activities, she said.
“These are things, again, that we can address as clinicians ... to intervene with families and with schools and communities to try to give young people an opportunity to not get into the criminal justice system,” she said, adding that providing early co-occurring treatment for mental health and substance use is particularly important.
Intercept 1 (law enforcement) also is a stage during which a psychiatrist can intervene by giving pertinent information when 911 is called by providing police or corrections with contact information for follow-up. For Joe, psychiatrist involvement at this intercept could have allowed for treatment recommendations or assessment for diversion programs, and in fact, at some point during his care, did allow for communication about his treatment needs, Dr. Le Melle said.
In general, psychiatrists also can participate at this stage through provision of crisis intervention team training for first responders or by being part of a co-response team, she said.
Intercept 2 (initial detention/initial court hearings). Attending court on behalf of a patient can make a real difference in outcomes, she noted.
“Judges want to know that someone is out there who can help, and they want to know that there’s a team of people who can intervene and try to get someone out of the criminal justice system,” she said.
At this stage, psychiatrists can help by recommending a treatment plan for a diversion program, and – within HIPAA guidelines – can share pertinent information about treatment needs and preferences.
Intercept 3 (jails/courts). At this in-the-system stage, information shared between corrections and community behavioral health would have led to Joe’s transfer to a mental health/observation unit; he would have been offered mental health treatment and been started on substance use treatment; and he would have participated in motivational treatment and cognitive-behavioral therapy targeting his criminogenic needs, she said.
Meeting with individuals while they are incarcerated can be helpful for “keeping them grounded.”
This also is a stage where psychiatrists could help individuals prepare for release by getting them into a GED program or other training.
Intercept 4 (reentry). With appropriate intervention at this stage, Joe would have his benefits, such as Medicaid and Supplemental Security Income, reinstated prior to reentry to the community. Also, his psychiatrist and treatment program would be contacted. He would be welcomed back into treatment, and he would have assistance finding a permanent place to live with services provided in the community.
Intercept 5 (community corrections). At this stage, community behavioral health clinicians would maintain awareness of their biases and fears about people involved in the criminal justice system and avoid making assumptions about Joe. His risks, needs, and priorities would be assessed and addressed, and he would be asked about his experiences with the system and about what could be done to help him avoid incarceration in the future.
He would receive help in incorporating alternative behaviors and thinking to address dynamic criminogenic risk, and evidence-based practices would be used in treatment.
The sequential intercept model reflects the fact that the criminal justice system and the people it serves are part of the community, Dr. Le Melle said.
“The community and the behavioral health system and the criminal justice system are partners in our shared mission of public safety and public health, so we are one and we can’t expect that our responsibility for providing people with the best care and services ends if someone is in the criminal justice system,” she said.
Dr. Champion, Dr. Osher, and Dr. Le Melle reported having no disclosures.
NEW YORK – The overrepresentation of people with serious mental illness (SMI) in the criminal justice system has led to creation of a resource from the Judges’ and Psychiatrists’ Leadership Initiative (JPLI) aimed at helping psychiatry and law enforcement address the problem.
The resource, “Supporting People with Serious Mental Illnesses and Reducing Their Risk of Contact with the Criminal Justice System: A Primer for Psychiatrists,” released last year, was designed to provide psychiatrists with specific knowledge and tools, according to Michael Champion, MD, forensic chief at the Hawaii State Department of Health, Adult Mental Health Division, Honolulu, and a member of the JPLI executive leadership team.
In developing the primer, the JPLI, which was created about 10 years ago by the American Psychiatric Association Foundation in partnership with the Council of State Governments Justice Center in response to the growing problem of such overrepresentation, sought to teach psychiatrists about what the criminal justice literature has dubbed “criminogenic risk” and to explore strategies to address those risks in community treatment settings, Dr. Champion said at the annual meeting of the American Psychiatric Association.
“The fact is that one in three Americans has a criminal record, and people with serious mental illness and criminal justice involvement are frequently part of our patient population – particularly in the public mental health sector,” Dr. Champion said. “Part of the challenge is that psychiatrists ... aren’t typically trained in these principles ... so the JPLI saw that this as an area that we could try to make some traction in and try to make a difference.”
The JPLI’s goals in publishing this resource are to reduce the risk of patient involvement in the criminal justice system, and to improve clinical and recovery outcomes by educating community psychiatrists about Risk-Need-Responsivity (RNR) principles. The JPLI also seeks to provide strategies for collaborating with criminal justice partners, incorporating criminal justice history into screening and assessment, and integrating criminogenic risk needs of patients into comprehensive treatment plans, Dr. Champion said.
Criminogenic risk and RNR
Many factors contribute to the involvement of people with serious mental illnesses in the criminal justice system, including higher rates of arrest, longer stays, recidivism, and limited access to health care, said Fred C. Osher, MD, former director of health systems and services policy for the Council of State Governments Justice Center.
“We used to think that ... if we could just get folks the health care that they need, they wouldn’t get involved with the criminal justice system. It turns out that that’s a gross oversimplification, in that their needs are terribly complex, and while treatment is a necessary component, it isn’t often sufficient for a large number of individuals,” said Dr. Osher, now a member of the JPLI executive leadership team.
Criminogenic risk – the likelihood that a person who has been arrested and jailed will commit a new crime after release or return to custody – helps explain why that is the case, he said, adding: “We have ways in which we can understand those risks.”
The risks are measured via static factors (unchanging conditions such as criminal history, age at first arrest, current age, and gender) and dynamic factors, he explained.
he said, noting that the research has shown there are eight specific criminogenic risk factors: substance abuse, history of antisocial behavior, antisocial personality pattern, antisocial cognition, antisocial associates, family and/or marital discord, poor school and/or work output, and having few leisure/recreation outlets.
Notably, mental illness is not a part of that list, he said.
“The reason for that is it’s not explanatory in and of itself,” he added.
However, research shows that people with mental illness have more of these dynamic risk factors, and research by Jennifer L. Skeem, PhD, and others shows that those with mental illness were coming back to jail not for new criminal activity, but for failing to comply with their conditions of release.
“These risks, then, have been brought into a paradigm that is central to our criminal justice operations, and it’s called the Risk-Need-Responsivity model,” Dr. Osher said. “This paradigm is what allows a criminal justice system to think about how to prioritize the resources – to think about who really needs to be wrapped tight, who needs to have close supervision, frequent reporting, lots of contact.”
The risk principle in the RNR model says that resources should be focused on high-risk cases, with limited supervision in lower-risk cases. This is based on experience demonstrating that recidivism is lower in high-risk individuals with close supervision but higher in low-risk individuals with close supervision.
The needs principle suggests that dynamic needs are “the issues that get folks in trouble,” he said.
“So, if we’re going to intervene, if we’re going to provide programming, if we’re going to try and help that individual stay out of jail or prison, we need to address these criminogenic needs,” he said, adding that the “big four” are related to their antisocial thinking and personality and friends.
Targeted interventions can help those individuals make better choices going forward, he noted.
The responsivity principle is an acknowledgment that individuals have different ways of learning, different cultural factors and backgrounds that influence them, and social determinants that are important to understand if they predict the ability to stay out of trouble.
“This is where mental illness fits in,” Dr. Osher said. “It’s absolutely important that we understand that.”
Examples would be patients with severe major depressive disorder who need their depression treated before they can participate in a group treatment setting designed to address criminogenic risks.
Dynamic risk factors are best treated with cognitive-behavioral interventions, Dr. Osher said, noting that the most effective interventions provide opportunities for participants to practice new behavior patterns and skills with feedback from program staff.
In many states, those interventions are being provided by criminal justice personnel, including probation officers, partly because of “an absence of [psychiatrists’] understanding, willingness, or ability to step forward.” The JPLI primer is designed to “really amp up our own excitement about, and willingness to learn how to develop interventions to help that individual stay out of trouble,” and it includes detailed descriptions of numerous well-researched, standardized, manualized interventions that people can access that make it less likely for them to have criminal justice access going forward, he said.
Those include programs such as “Thinking for a Change,” “Reasoning and Rehabilitation,” “Moral Reconation Therapy,” and “Interactive Journaling.”
A focus on the Sequential Intercept Model, which describes how individuals move through the criminal justice system, illustrates multiple points where psychiatrists can “do things better and differently to intervene,” he said, noting that the primer includes a framework for prioritizing the target population, and validated screening and assessment tools, including tools to help corrections officers identify mental health/substance abuse/criminogenic issues at the time individuals are booked into jail so they can be referred for appropriate interventions.
Achieving positive public health and safety outcomes requires changes to policy and practice, Dr. Osher said.
The JPLI primer is a step toward making such changes, and with it comes a set of four principles:
1. Conduct universal risk, substance use, and mental health screening at booking, and full assessments as appropriate, he said, noting that “13 million times this year (9 million unduplicated count), 2 million folks with serious mental illness are going to be arrested and brought to jail. Let’s make sure they get assessed, identified, and then a plan can be made.”
2. Get relevant information into the hands of decision makers in time to inform pretrial release decisions. For example, knowing if someone is eligible for a mental health court could lead to that person’s receiving necessary support and supervision, he said.
3. Use assessment information to connect people to appropriate jail-based services and post-release services and supervision, and ensure that there is communication between the two.
4. Ensure services and supervision are evidence based and hold systems accountable by measuring outcomes.
In addition, the goal is to partner with the criminal justice system through information-sharing agreements and integrating dynamic criminogenic risk factors into treatment plans, he said.
The intercepts
To demonstrate ways in which psychiatrists can intervene over the course of a patients’ journey toward involvement in the criminal justice system, Stephanie Le Melle, MD, provided a case example involving a 30-year-old African American man diagnosed with schizophrenia at age 18 years.
As a child, “Joe” was neglected and abused; both parents had a history of mental illness and substance use. He experienced homelessness, never finished high school, and was hospitalized or visited the emergency department more than 15 times after going off medications or because of intoxication.
His history with the legal system involved a first arrest at age 14 years for gang-related fighting and assault (after being bullied as a child and seeking safety in a gang), followed by 3 years in juvenile detention. He was released with supervision at age 17 years, was arrested several times after that for public intoxication and loitering, and was held for several days or weeks each time – then released with time served or summons paid. His first hospitalization occurred at age 18, when he was diagnosed with psychosis.
Subsequent experiences included treatment in a community mental health program at age 25 for heroin use and drinking. However, he was denied admission to a substance abuse program because of his history of psychosis and violence. After stopping his medications because of side effects, he tried to buy heroin, got into a fight, and was arrested for assault with a pocket knife. He resisted arrest and was tasered, handcuffed, and taken to prison, where he was held because he could not afford bail. Involvement in gang activity while in prison led to sanctions, including time in solitary confinement.
During all of his time in the criminal justice system, Joe refused treatment, because he was afraid he’d be considered “crazy” and would be preyed upon even more by other inmates. After about 3 years, he was released to a Forensic Assertive Community Treatment team for 2 years and completed that program, and is now receiving treatment in the community. He lives alone in supported housing and has Supplemental Security Income. He does not engage in clinic-related activities and has a lack of trust in the clinical team. He often is agitated and disruptive in the clinic. Staff members have concerns about his history of violence and drug use, and were reluctant to bring him into the program.
“Going back to ... the sequential intercept model, we can think about things, as psychiatrists, that we could have done for Joe all along the way to help him not get into the criminal justice system in the first place,” said Dr. Le Melle, director of public psychiatry education at Columbia University/New York State Psychiatric Institute, New York.
This is a framework for thinking through treatment for a patient like Joe:
Intercept 0 (community services). At this early stage, Joe would have been screened for adverse childhood experiences, and that could have led to trauma treatment, substance abuse treatment, and educational and vocational services. Awareness of his family illness, discord, and poverty would have led to parenting interventions, early school involvement, and promotion of meaningful activities, she said.
“These are things, again, that we can address as clinicians ... to intervene with families and with schools and communities to try to give young people an opportunity to not get into the criminal justice system,” she said, adding that providing early co-occurring treatment for mental health and substance use is particularly important.
Intercept 1 (law enforcement) also is a stage during which a psychiatrist can intervene by giving pertinent information when 911 is called by providing police or corrections with contact information for follow-up. For Joe, psychiatrist involvement at this intercept could have allowed for treatment recommendations or assessment for diversion programs, and in fact, at some point during his care, did allow for communication about his treatment needs, Dr. Le Melle said.
In general, psychiatrists also can participate at this stage through provision of crisis intervention team training for first responders or by being part of a co-response team, she said.
Intercept 2 (initial detention/initial court hearings). Attending court on behalf of a patient can make a real difference in outcomes, she noted.
“Judges want to know that someone is out there who can help, and they want to know that there’s a team of people who can intervene and try to get someone out of the criminal justice system,” she said.
At this stage, psychiatrists can help by recommending a treatment plan for a diversion program, and – within HIPAA guidelines – can share pertinent information about treatment needs and preferences.
Intercept 3 (jails/courts). At this in-the-system stage, information shared between corrections and community behavioral health would have led to Joe’s transfer to a mental health/observation unit; he would have been offered mental health treatment and been started on substance use treatment; and he would have participated in motivational treatment and cognitive-behavioral therapy targeting his criminogenic needs, she said.
Meeting with individuals while they are incarcerated can be helpful for “keeping them grounded.”
This also is a stage where psychiatrists could help individuals prepare for release by getting them into a GED program or other training.
Intercept 4 (reentry). With appropriate intervention at this stage, Joe would have his benefits, such as Medicaid and Supplemental Security Income, reinstated prior to reentry to the community. Also, his psychiatrist and treatment program would be contacted. He would be welcomed back into treatment, and he would have assistance finding a permanent place to live with services provided in the community.
Intercept 5 (community corrections). At this stage, community behavioral health clinicians would maintain awareness of their biases and fears about people involved in the criminal justice system and avoid making assumptions about Joe. His risks, needs, and priorities would be assessed and addressed, and he would be asked about his experiences with the system and about what could be done to help him avoid incarceration in the future.
He would receive help in incorporating alternative behaviors and thinking to address dynamic criminogenic risk, and evidence-based practices would be used in treatment.
The sequential intercept model reflects the fact that the criminal justice system and the people it serves are part of the community, Dr. Le Melle said.
“The community and the behavioral health system and the criminal justice system are partners in our shared mission of public safety and public health, so we are one and we can’t expect that our responsibility for providing people with the best care and services ends if someone is in the criminal justice system,” she said.
Dr. Champion, Dr. Osher, and Dr. Le Melle reported having no disclosures.
REPORTING FROM APA 2018