While expanding treatment availability to incarcerated individuals with SMI is important, developing intensive community-based treatment and after-care services are important resources to make easily accessible. This is the bottom line of a recently published article in International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.
Featured Article | International Journal of Forensic Mental Health | 2017, Vol. 16, No. 2, 104-116
Community-Based Mental Health Treatment Preceding Jail Detention Among Adults with Serious Mental Illness
James A. Swartz, Jane Addams College of Social Work, University of Illinois at Chicago
Suhad Tabahi, Jane Addams College of Social Work, University of Illinois at Chicago
This study examined the lifetime and past-year community mental health treatment use of 282 male and 149 female jail detainees with SMI. Although most participants reported high lifetime rates of mental health treatment they believed effective, only a minority accessed treatment in the year and month before arrest. Women were less likely to receive treatment than men and more often left treatment against medical advice. Both substance use and post-traumatic stress disorder were significantly undertreated and care was provided predominantly by psychiatrists. The implications for expanding treatment availability and access to critical services such as housing and employment are discussed.
Serious mental illness, criminal offenders, community mental health treatment
Summary of the Research
“People with one or more serious mental illness (SMI) such as schizophrenia spectrum disorder, bipolar disorder, and major depression are overrepresented in the criminal justice system (CJS) … Moreover, offenders with SMI are more likely than their non-mentally ill peers to be rearrested and reincarcerated and remain in the CJS for extended periods. The over-representation is such that those with SMI are estimated to be three times less likely to be placed in a psychiatric hospital than in a jail or prison” (p. 104).
“[T]his study examined highly detailed information on pre-detention community-based mental health treatment use in a sample of jail detainees with SMI. Specifically… lifetime and past-year use of community-based mental health treatment for adult jail detainees with SMI by diagnostic category and gender. (p. 105).
“[The authors] used the service questions from the diagnostic sections of the WMH-CIDI [World Mental Health Composite International Diagnostic Interview] to determine, by diagnostic category: if a respondent had ever talked to a medical doctor or other professional about the symptoms related to each diagnosis for which they met DSM-IV diagnostic criteria; the age they first talked to a medical doctor or other professional; if they had ever been hospitalized for diagnosis-related symptoms; whether they had ever received community treatment they considered effective; the age they first received effective community treatment; and whether they had received treatment for a given diagnosis/diagnostic category in the year prior to detention” (p. 106).
“A large majority of participants reported having received mental health treatment services from at least one provider type during their lifetime. However, psychiatrists were the predominant service providers as the percentage of participants reporting ever receiving treatment from any provider falls … when psychiatric treatment is excluded. Moreover, whereas just under 80% reported they had ever seen a psychiatrist, the next closest provider type was psychologists followed by social workers, and mental health counselors. The emphasis on psychiatric treatment or treatment by a physician or other practitioner with prescription privileges is underscored by the fact that 71.2% of participants reported taking prescription medications related to their mental health symptoms in the past year” (p. 109).
“The predominance of psychiatric treatment was also evident in the year and month prior to detention. For instance, just over one-third of men and about one-fourth of women reported seeing a psychiatrist within a month prior to their arrest and detention… Additionally, as with hospitalization rates, mental health treatment use dropped considerably in the year and month prior to arrest and detention. Fewer than half of the men and just over one-third of the women reported seeing any kind of provider for mental health treatment including psychiatrists in the month prior to arrest” (p. 109).
“In spite of the frequency of care and perceived effectiveness, however, there were clearly identifiable gaps such as a fairly large drop in service use in the year and month preceding arrest as well as relatively lower rates of care by mental health service providers other than psychiatrists”(p. 114).
Translating Research into Practice
“This study found high proportions of adult jail detainees with SMI access and use a broad array of community-based mental health treatment services, including psychiatric hospitalization over their lifetimes. Moreover, in the year prior to their arrest and detention a substantial minority of participants, about 40–45%, report seeing one or more mental health treatment providers an average of twice a month for 30- to 45- min. Most participants accessing treatment thought the treatment was effective and expressed satisfaction with the services they received. Assessed against these findings, it is unclear why, for this group of participants at least, there has been a lifelong pattern of criminal justice involvement despite what appears to be access to care they deem effective… In addition, [they] found a relatively sharp drop-off in access to care in the month prior to arrest. This suggests that dropping out of treatment might precede or be indicative of psychiatric decompensation that then leads to a re-involvement in the CJS. If this is correct, then improving treatment retention for this population, most of whom have received treatment at some time, could be paramount to reducing CJS involvement” (p. 112).
“Majorities of both male and female participants that received treatment believed the treatment to have been effective. In spite of the frequency of care and perceived effectiveness, however, there were clearly identifiable gaps such as a fairly large drop in service use in the year and month preceding arrest as well as relatively lower rates of care by mental health service providers other than psychiatrists. Women in particular had lower rates of recent service use and a higher probability of leaving treatment” (p. 114).
“While medication management and psychotherapy are critically important components of mental health care, provision of ancillary psychosocial services such as literacy training and education, employment and housing services, and care coordination are also critical. Moreover, given there is presently an acute shortage of psychiatrists in the United States broadening access to and the use of different types of mental health service providers might be a cost-effective way of expanding treatment access for the population of offenders with SMI, thereby supporting the care provided by psychiatrists” (p. 114).
Other Interesting Tidbits for Researchers and Clinicians
“[R]esearch has, with some consistency, indicated that community-based mental health treatment has a measurable but limited impact on criminal recidivism, a possible alternative explanation is that the intensity or effectiveness (or both) of the services received are simply lacking. There is ample evidence, for instance, that mental health treatment, especially publicly funded treatment, is delivered with poor fidelity and is rarely in accordance with recommended evidence-based practice” (p. 105).
“[W]hereas women had lifetime treatment rates comparable to men, women were much less likely to access mental health treatment in the month and year prior to arrest. Those women who did have treatment in the past year were also more likely to leave against medical advice suggesting either a higher degree of dissatisfaction with the treatment received or some other issue that resulted in the women… discontinuing treatment prematurely” (P. 112).
“A strong emphasis on increased use of psychiatric hospitalization as some have advocated (e.g., Torrey, 2015) is [not] warranted because such care is expensive, of limited duration, and does not facilitate community reintegration… [H]ospitalization deters crime only during the time-limited period of incapacitation (and often forced medication) and that upon release, unless a strong linkage is made with effective community-based treatment (and other services such as housing), the crime-deterring effects of hospitalization rapidly diminish” (p. 114).
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Authored by Eliza Kopelman
Eliza Kopelman is a first year master’s student in the Forensic Psychology program at John Jay College. She graduated in 2015 with her B.A. in psychology and English from Brandeis University, and then went on to work as a community residence counselor at McLean Hospital in Belmont, MA before coming back to school. Eliza’s research experience is on levels of psychopathy in sex offenders, and her professional interests include crime scene analysis and violent risk assessment.