Mental Health Disorders and the Criminal Justice System: A Continuum of Evidence-Informed Practices

Alysson Gatens  |  Updated: April 23, 2019  |  
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Mental health disorders (MHD) are between three and six times more common among individuals involved in the criminal justice system compared to the general population.[1] In the United States, 24 percent of individuals who are incarcerated reported receiving a clinical diagnosis or treatment for a MHD within the past year and 49 percent reported experiencing symptoms of a MHD.[2] Research estimates 1 million individuals with a MHD are on probation or parole in the United States.[3]

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Despite the disproportionately high prevalence of MHDs in the criminal justice system, many individuals do not receive treatment while incarcerated.[4] Nationally, sixty-three percent of individuals with a history of a MHD received treatment in prison from 2011 to 2012, and only 45 percent of those jailed received treatment.[5] In addition, individuals with a MHD spend significantly more time in jail compared to those without a MHD.[6]

Upon release from prison, individuals with a MHD on parole are nearly twice as likely to be reincarcerated within one year of release than those without mental health disorders.[7] This creates a problematic cycle where individuals with MHDs are released into the community, only to likely be returned to the justice system in the future.[8] These issues, among others, have led to the development of interventions targeted to justice-involved individuals with a MHD.

A very small proportion of the crimes committed by individuals with mental health disorders are a direct result of their mental health symptoms; researchers estimate about 1 in 10 arrested individuals with a MHD are involved with the justice system due to mental health symptoms.[9] Moreover, the idea that MHDs are a primary cause of criminality does not align with the fact that the vast majority of individuals with a MHD (treated or untreated) do not commit crimes.[10] This flaw in the rationale for providing interventions that mainly emphasize provision of mental health treatment may in part explain why such programs and practices have failed to reduce the overrepresentation of individuals with MHDs in the criminal justice system.[11] Research has shown individuals with MHDs have largely the same predictors and risk factors for criminal justice involvement as individuals without MHDs.[12]

Evidence-based practices or programs (EBPs) have demonstrated consistently positive outcomes through empirical research and evaluation. Promising programs and practices are associated with positive outcomes but need further research to support them as EBPs.[13] There are many EBPs for treating MHDs and there are several EBPs for preventing/reducing criminality. However, EBPs addressing mental health outcomes often have little to no impact on public safety outcomes.[14] There is markedly little empirical research on EBPs from the mental health field tailored for the justice-involved population or on criminal justice practices adapted to the abilities of individuals with a MHD.[15] More research is needed to gauge outcomes from adapted models relative to the expected outcomes from an EBP implemented with high levels of fidelity.[16]

This continuum was created to present the current state of research regarding programs and practices targeted to individuals with mental health disorders at various stages of the criminal justice system following the sequential intercept model (SIM). The SIM is a way to conceptualize points throughout the criminal justice system where individuals with MHD can be diverted to mental health treatment; or if the individual is already in the criminal justice system, programs and practices aim to help individuals avoid future involvement with the justice system (e.g. reentry).[17] Interventions at each intercept can be evaluated on measures in the following domains:

  • Criminal justice outcomes.
  • Mental health (clinical) outcomes.
  • Costs and savings.
  • Client and staff perceptions and satisfaction.[18]
References

  1. Note: Mental Health Disorders (MHDs) are diagnosed by clinicians using the criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).Blandford, A. & Osher, F. (2012). A checklist for implementing evidence-based practices and programs (EBPs) for justice-involved adults with behavioral health disorders. Delmar, NY: SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation.

  2. James, D. J., & Glaze, L. E. (2006). Mental health problems of prison and jail inmates (Bureau of Justice Statistics Report NCJ-213600). Washington, DC: U.S. Department of Justice, Office of Justice Programs. Retrieved from https://www.bjs.gov/content/pub/pdf/mhppji.pdf

  3. Louden, J. E., Manchak, S., O’Connor, M., & Skeem, J. L. (2015). Applying the sequential intercept model to reduce recidivism among probationers and parolees with mental illness. In P.A. Griffin, K. Heilbrun, E.P. Mulvey, D. DeMatteo, & C.A. Schubert (Eds.). The sequential intercept model and criminal justice: Promoting community alternatives for individuals with serious mental illness (pp. 118-136). USA: Oxford University Press.

  4. Note: There are limited data available on the proportion of probationers and parolees that receive mental health treatment while under community supervision; this is due, in part, to the more decentralized system of community mental health services, relative to the provision of treatment while incarcerated.DeMatteo, D., LaDuke, C., Locklair, B. R., & Heilbrun, K. (2013). Community-based alternatives for justice-involved individuals with severe mental illness: Diversion, problem-solving courts, and reentry. Journal of Criminal Justice, 41(2), 64-71.

  5. Bronson, J., & Berzofsky, M. (2017). Indicators of mental health problems reported by prisoners and jail inmates, 2011-12. (Bureau of Justice Statistics Report NCJ-250612). Washington, DC: U.S. Department of Justice, Office of Justice Programs. Retrieved from https://www.bjs.gov/content/pub/pdf/imhprpji1112.pdf

  6. Haneberg, R., & Watts, K. “Stepping Up” to beat the mental health crisis in U.S. jails. Criminal Justice/Corrections. New York, NY: Council of State Governments Justice Center. Retrieved from http://knowledgecenter.csg.org/kc/system/files/Haneberg Watts 2016.pdf

  7. Eno Louden, J., & Skeem, J. (2011). Parolees with mental disorder: Toward evidence-based practice. Bulletin of the Center for Evidence-Based Corrections, 7(1), 1-9.

  8. Baillargeon, J., Binswanger, I. A., Penn, J. V., Williams, B. A., & Murray, O. J. (2009). Psychiatric disorders and repeat incarcerations: The revolving prison door. American Journal of Psychiatry, 166(1), 103-109.

  9. Skeem, J. L., Manchak, S., & Peterson, J. K. (2011). Correctional policy for offenders with mental illness: Creating a new paradigm for recidivism reduction. Law and Human Behavior, 35(2), 110-126.

  10. Louden, J. E., Manchak, S., O’Connor, M., & Skeem, J. L. (2015). Applying the sequential intercept model to reduce recidivism among probationers and parolees with mental illness. In P.A. Griffin, K. Heilbrun, E.P. Mulvey, D. DeMatteo, & C.A. Schubert (Eds.). The sequential intercept model and criminal justice: Promoting community alternatives for individuals with serious mental illness (pp. 118-136). USA: Oxford University Press.

  11. Epperson, M. W., Wolff, N., Morgan, R. D., Fisher, W. H., Frueh, B. C., & Huening, J. (2014). Envisioning the next generation of behavioral health and criminal justice interventions. International Journal of Law and Psychiatry, 37(5), 427-438.; Osher, F. C., & Steadman, H. J. (2007). Adapting evidence-based practices for persons with mental illness involved with the criminal justice system. Psychiatric Services, 58(11), 1472-1478.

  12. Bonta, J., Law, M., & Hanson, K. (1998). The prediction of criminal and violent recidivism among mentally disordered offenders: a meta-analysis. Psychological Bulletin, 123(2), 123.; Epperson, M. W., Wolff, N., Morgan, R. D., Fisher, W. H., Frueh, B. C., & Huening, J. (2014). Envisioning the next generation of behavioral health and criminal justice interventions. International Journal of Law and Psychiatry, 37(5), 427-438.

  13. Blandford, A., & Osher, F. (2012). A checklist for implementing evidence-based practices and programs (EBPs) for justice-involved adults with behavioral health disorders. Delmar, NY: SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation.

  14. Osher, F. C., & Steadman, H. J. (2007). Adapting evidence-based practices for persons with mental illness involved with the criminal justice system. Psychiatric Services, 58(11), 1472-1478.

  15. Heilbrun, K., DeMatteo, D., Yasuhara, K., Brooks-Holliday, S., Shah, S., King, C., ... & Laduke, C. (2012). Community-based alternatives for justice-involved individuals with severe mental illness: Review of the relevant research. Criminal Justice and Behavior, 39(4), 351-419.

  16. Heilbrun, K., DeMatteo, D., Yasuhara, K., Brooks-Holliday, S., Shah, S., King, C., ... & Laduke, C. (2012). Community-based alternatives for justice-involved individuals with severe mental illness: Review of the relevant research. Criminal Justice and Behavior, 39(4), 351-419.

  17. Munetz, M. R., & Griffin, P. A. (2006). Use of the sequential intercept model as an approach to decriminalization of people with serious mental illness. Psychiatric Services, 57(4), 544-549.

  18. DeMatteo, D., LaDuke, C., Locklair, B. R., & Heilbrun, K. (2013). Community-based alternatives for justice-involved individuals with severe mental illness: Diversion, problem-solving courts, and reentry. Journal of Criminal Justice, 41(2), 64-71.

Intervention at Criminal Justice Intercepts

Pre-arrest: Law Enforcement and Emergency Services
Police officers are often called on to respond to incidents in which an individual is experiencing a mental health crisis. Many police departments have developed specialized responses for the incidents to divert individuals away from the criminal justice system and connect them to mental health treatment.

Intercept 1

Post-arrest: Initial Detention and Initial Hearings
Individuals with mental health disorders (MHDs) are less likely to be able to afford monetary bail, and more likely to remain in custody for longer periods of time if not diverted.

Intercept 2

Jail and Courts: Adult Mental Health Court
Mental health courts are problem-solving courts that provide alternative sanctions aimed at reducing behaviors that may lead to incarceration.

Intercept 3

Reentry from Institutions: Jails, Prisons, and Forensic Hospitals
Reentry programs aim to improve the continuity of care for individuals as they exit a correctional facility or hospital to return to the community. During the first hours, days, and weeks following release, individuals may experience a heightened need for mental health services.

Intercept 4

Community Corrections and Community Support
Individuals with mental health disorders (MHDs) under community supervision (probation or parole) by the criminal justice system are at higher risk for violating the terms of their supervision and are nearly twice as likely to have their probation or parole revoked than those without an MHD.

Intercept 5

Additional Evidence-Based Practices
The following are evidence-based programs and practices (EPBs) for individuals with mental health disorders (MHDs) that span multiple intercepts.

Intercepts 1-5

Behavioral Interventions
Behavioral interventions work to change the behavior of individual clients, teaching self-monitoring to reinforce new coping skills to handle stressful situations. Cognitive behavioral therapy and dialectical behavior therapy are examples of effective behavioral intervention techniques. These therapies can be used across intercepts.

Intercepts 1-5

Trauma-Informed Therapies
The following are evidence-based programs and practices (EPBs) for individuals with mental health disorders (MHDs) that span multiple intercepts.

Intercepts 1-5

Points to Consider

  1. What is included under the term “mental health disorders” (MHDs) is defined differently by many programs, policies, and in various research studies.[1] Clinical diagnostic criteria for specific disorders are available in in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).[2]
  2. Individuals with MHDs have largely the same predictors and risk factors for criminal justice involvement as individuals without MHDs.[3]
  3. Individuals with MHDs in the justice system share many of the same treatment needs as individuals with MHDs who are not involved in the justice system.[4]
  4. The criminal justice system has the primary goal of promoting public safety, whereas the primary goal of the mental health system is to improve mental health symptoms.[5]
  5. A number of evaluations of programs and practices found no association between criminal justice outcomes and mental health outcomes (i.e. many interventions impact one group of factors but not the other).[6]
  6. The availability and capacity of mental health resources in a community may impact the ways in which the criminal justice system and the mental health system are able to collaborate.[7]
  7. Mental health treatment and services should be provided by a practitioner with appropriate training, and in some cases, the necessary professional licenses.[8]
  8. Receipt of mental health treatment in the community may be impacted by the consumer’s insurance status or ability to pay out of pocket.[9] In Cook County, individuals are screened for Medicaid eligibility and offered assistance with the application for enrollment during the jail intake process.[10] For more information on facilitating access to publicly funded behavioral healthcare benefits for justice-involved individuals, see Critical Connections: Getting People Leaving Prison and Jail the Mental Health Care and Substance Use Treatment They Need.
  9. Illinois state law and federal law require that insurance plans provide equal coverage for behavioral health and physical health benefits; under the Affordable Care Act, mental health and substance use disorder treatment are categorized as essential health benefits, which requires at least a minimum level of coverage in these areas for many employer-sponsored plans.[11] For more information, see Mental Health and Addiction Parity in Illinois.
  10. If an individual is receiving mental health treatment in the community, involvement with the criminal justice system has the potential to interrupt receipt of care, with possible negative effects.[12]
  11. Strict criteria for voluntary or involuntary psychiatric hospitalization may lead to arrests or revocations of supervision with the intention of providing access to treatment.[13]
  12. Any change (or lack of change) in future outcomes due to treatment is dependent in part on the quality of mental health treatment services received, which is often beyond the control of the justice system.[14]
  13. Involvement with the criminal justice system as well as having an MHD can cause an individual to feel stigmatized, which can impact their willingness to seek services, including mental health treatment.[15]
  14. Participants may view treatment mandated by the criminal justice system as coercive, which has the potential to impact the effectiveness of the treatment.[16]
  15. Studies should control for a participant’s level of risk for recidivism when evaluating interventions.[17]
  16. Individuals with co-occurring disorders can also benefit from EBPs for substance use disorders. For more information, see Reducing Substance Use Disorders and Related Offending: A Continuum of Evidence-Informed Practices in the Criminal Justice System.
  17. Community-based providers tend to employ more evidence-based practices compared to practices used in institutional settings.[18]
  18. Improvements in technology have increased the use of “telemedicine” which allows mental health professionals to provide treatment remotely; this practice has been beneficial in increasing access to mental health treatment for individuals in correctional facilities, while eliminating some issues that arise from either transporting individuals or bringing mental health professionals into secure facilities for consultation.[19] In some departments, law enforcement officers are also able to consult with mental health professionals regarding crisis incidents while in the field.[20]
  19. Information about an individual’s mental health may be subject to the protections of HIPAA and should be treated with all necessary protections to confidentiality.[21] For more information, see Information Sharing in Criminal Justice-Mental Health Collaborations: Working with HIPAA and Other Privacy Laws.[22]
  20. The Substance Abuse and Mental Health Services Administration’s working definition of recovery from MHDs is “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.”[23] Recovery support can be offered through long-term services that aim to promote improved individual functioning and reductions in symptoms through ongoing treatment and community-based programming.[24]

Additional Resources

Principles of Community-based Behavioral Health Services for Justice-involved Individiuals: A Research-based Guide

Sheriffs Addressing the Mental Health Crisis in the Community and in the Jails

References

  1. Cross, B. (2011). Mental health courts effectiveness in reducing recidivism and improving clinical outcomes: A meta-analysis (Doctoral disseration). Retrieved from University of South Florida, Graduate School Theses and Dissertations.http://scholarcommons.usf.edu/cgi/viewcontent.cgi?article=4247&context=etd

  2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

  3. Bonta, J., Law, M., & Hanson, K. (1998). The prediction of criminal and violent recidivism among mentally disordered offenders: a meta-analysis. Psychological Bulletin, 123(2), 123.; Epperson, M. W., Wolff, N., Morgan, R. D., Fisher, W. H., Frueh, B. C., & Huening, J. (2014). Envisioning the next generation of behavioral health and criminal justice interventions. International Journal of Law and Psychiatry, 37(5), 427-438.

  4. Rotter, M., & Carr, A. (2013). Reducing criminal recidivism for justice-involved persons with mental illness: Risk/needs/responsivity and cognitive-behavioral interventions. Delmar, NY: SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation. Retrieved from http://forensiccounselor.org/images/file/ReduceCrimRecidMIRiskNeedsResponCogBehavInter.pdf; Osher, F. C., & Steadman, H. J. (2007). Adapting evidence-based practices for persons with mental illness involved with the criminal justice system. Psychiatric Services, 58(11), 1472-1478.

  5. DeMatteo, D., LaDuke, C., Locklair, B. R., & Heilbrun, K. (2013). Community-based alternatives for justice-involved individuals with severe mental illness: Diversion, problem-solving courts, and reentry. Journal of Criminal Justice, 41(2), 64-71.; Osher, F. C., D’Amora, D. A., Plotkin, M., Jarrett, N., & Eggleston, A. (2012). Adults with behavioral health needs under correctional supervision: A shared framework for reducing recidivism and promoting recovery. New York, NY: Council of State Governments Justice Center. Retrieved from https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=261662; Skeem, J. L., Manchak, S., & Peterson, J. K. (2011). Correctional policy for offenders with mental illness: Creating a new paradigm for recidivism reduction. Law and Human Behavior, 35(2), 110-126.

  6. Epperson, M. W., Wolff, N., Morgan, R. D., Fisher, W. H., Frueh, B. C., & Huening, J. (2014). Envisioning the next generation of behavioral health and criminal justice interventions. International Journal of Law and Psychiatry, 37(5), 427-438.

  7. Lamberti, J. S. (2016). Preventing criminal recidivism through mental health and criminal justice collaboration. Psychiatric Services, 67(11), 1206-1212.; Council of State Governments. (2002). Criminal justice/mental health consensus project. New York, NY: Author. Retrieved from https://csgjusticecenter.org/wp-content/uploads/2013/03/consensus-project-full-report.pdf

  8. Lurigio, A. J., & Swartz, J. A. (2000). Changing the contours of the criminal justice system to meet the needs of persons with serious mental illness. In J. Horney (Ed.) Criminal justice 2000 (Vol. 3) policies, processes, and decisions of the criminal justice system (pp. 45-108). Washington, D.C.: U.S. Department of Justice, National Institute of Justice.; Mental Health America. (n.d.) Types of mental health professionals. Retrieved from http://www.mentalhealthamerica.net/types-mental-health-professionals

  9. Boutwell, A. E., & Freedman, J. (2014). Coverage expansion and the criminal justice–involved population: Implications for plans and service connectivity. Health Affairs, 33(3), 482-486.; Slate, R. N., & Usher, L. (2014). Health coverage for people in the justice system: The potential impact of Obamacare. Federal Probation, 78, 19.; Winkelman, T. N., Kieffer, E. C., Goold, S. D., Morenoff, J. D., Cross, K., & Ayanian, J. Z. (2016). Health insurance trends and access to behavioral healthcare among justice-involved individuals—United States, 2008–2014. Journal of General Internal Medicine, 31(12), 1523-1529.

  10. National Association of Counties. (2015). Addressing mental illness and medical conditions in county jails. NACo Why Counties Matter Series. Washington, DC: Author. Retrieved from https://www.naco.org/sites/default/files/documents/09.16.15_Cook County - Healthcare and Jails Case Study.pdf

  11. The Kennedy Forum Illinois. (2015). Mental health and addiction parity in Illinois. Chicago, IL: Author. Retrieved from http://thekennedyforumillinois.org/wp-content/uploads/2015/12/Summary-of-HB-1-Parity-Provisions.pdf

  12. Heilbrun, K., DeMatteo, D., Brooks-Holliday, S., & Griffin, P.A. (2015). Intercept 2: Initial detention and initial hearings. In P.A. Griffin, K. Heilbrun, E.P. Mulvey, D. DeMatteo, & C.A. Schubert (Eds.). The sequential intercept model and criminal justice: Promoting community alternatives for individuals with serious mental illness (pp. 57-77). USA: Oxford University Press.

  13. Skeem, J. L., Manchak, S., & Peterson, J. K. (2011). Correctional policy for offenders with mental illness: Creating a new paradigm for recidivism reduction. Law and Human Behavior, 35(2), 110-126.; Solomon, P., Draine, J., & Marcus, S. C. (2002). Predicting incarceration of clients of a psychiatric probation and parole service. Psychiatric Services, 53(1), 50-56.

  14. Skeem, J. L., Manchak, S., & Peterson, J. K. (2011). Correctional policy for offenders with mental illness: Creating a new paradigm for recidivism reduction. Law and Human Behavior, 35(2), 110-126.

  15. Lamb, H. R., Weinberger, L. E., & Gross, B. H. (2004). Mentally ill persons in the criminal justice system: Some perspectives. Psychiatric Quarterly, 75(2), 107-126.; Lamb, H. R., & Weinberger, L. E. (1998). Persons with severe mental illness in jails and prisons: A review. Psychiatric Services, 49(4), 483-492.; Phan, S. V. (2012). Mental illness and the criminal justice system: Where are we now?. Mental Health Clinician, 1(8), 180-181.

  16. Osher, F. C., & Steadman, H. J. (2007). Adapting evidence-based practices for persons with mental illness involved with the criminal justice system. Psychiatric Services, 58(11), 1472-1478.

  17. Blandford, A. & Osher, F. (2012). A checklist for implementing evidence-based practices and programs (EBPs) for justice-involved adults with behavioral health disorders. Delmar, NY: SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation.

  18. Friedmann, P. D., Taxman, F. S., & Henderson, C. E. (2007). Evidence-based treatment practices for drug-involved adults in the criminal justice system. Journal of Substance Abuse Treatment, 32(3), 267-277.

  19. Morgan, R. D., Patrick, A. R., & Magaletta, P. R. (2008). Does the use of telemental health alter the treatment experience? Inmates' perceptions of telemental health versus face-to-face treatment modalities. Journal of Consulting and Clinical Psychology, 76(1), 158.; Kip, H., Bouman, Y. H., Kelders, S. M., & van Gemert-Pijnen, L. J. (2018). eHealth in treatment of offenders in forensic mental health: A review of the current state. Frontiers in Psychiatry, 9, 42.

  20. Gatens, A. (2018). Law enforcement response to mental health crisis incidents: A survey of Illinois police and sheriff’s departments. Chicago, IL: Illinois Criminal Justice Information Authority.

  21. Coffey, R. M., Buck, J. A., Kassed, C. A., Dilonardo, J., Forhan, C., Marder, W. D., & Vandivort-Warren, R. (2008). Transforming mental health and substance abuse data systems in the United States. Psychiatric Services, 59(11), 1257-1263.; Petrila, J. (2007). Dispelling the myths about information sharing between the mental health and criminal justice systems. CMHS National GAINS Center for Systemic Change for Justice-Involved People with Mental Illness. Tampa, FL: Department of Mental Health Law & Policy, University of South Florida.

  22. Petrila, J., & Fader-Towe, H. (2010). Information sharing in criminal justice-mental health collaborations: Working with HIPAA and other privacy laws. New York, NY: Council of State Governments Justice Center.

  23. Substance Abuse and Mental Health Services Administration. (2012). SAMHSA’s working definition of recovery. Rockville, MD: Author. Retrieved from https://store.samhsa.gov/product/SAMHSA-s-Working-Definition-of-Recovery/PEP12-RECDEF

  24. Osher, F. C., D’Amora, D. A., Plotkin, M., Jarrett, N., & Eggleston, A. (2012). Adults with behavioral health needs under correctional supervision: A shared framework for reducing recidivism and promoting recovery. New York, NY: Council of State Governments Justice Center. Retrieved from https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=261662; Substance Abuse and Mental Health Services Administration. (2018). Recovery and recovery support. Rockville, MD: Author. Retrieved from https://www.samhsa.gov/recovery.