According to a consensus of recently convened corrections experts, a confluence of concerning trends is exacerbating a mental health crisis in correctional environments. These trends are straining already limited institutional resources. In some cases, seriously mentally ill (SMI) incarcerated persons may face longer periods of confinement than others, while they often require more staff attention and cause more disruption. And, importantly, individuals who are SMI may struggle when they return to their communities. In general terms, individuals with SMI may not fit the traditional standard of corrections, a fact that complicates the task of fully addressing their needs.
The dissolving of community-based mental health resources means that, for some of these individuals, the primary way to connect with necessary physical and mental health care is to engage with the justice system. Many individuals with SMI often struggle with substance abuse issues, making criminal justice encounters more likely. Meanwhile, a sharp rise in serious mental health problems afflicting adolescents suggests that some of these individuals are likely to enter the adult justice system with complex issues going forward.
The growth of the SMI segment of the incarcerated population can stress and weaken corrections institutions. A critical challenge facing criminal justice agencies generally, and corrections professionals specifically, is understanding how to manage this ever-growing population and its needs.
The RAND Corporation (RAND), on behalf of the National Institute of Justice (NIJ), convened a workshop of national experts to discuss diverse aspects of managing seriously mentally ill persons in the justice system. The workshop experts were select prison, jail, probation, and parole administrators as well as researchers and mental health care professionals.
A core goal of the workshop was to inform future research endeavors by NIJ, a primary federal funder and manager of corrections-focused research. The experts’ findings are presented in a report, “Managing the Seriously Mentally Ill in Corrections,” prepared for the Priority Criminal Justice Needs Initiative — a project of RAND, the Police Executive Research Forum, RTI International, and the University of Denver.
Among the key needs identified by the experts are:
- A need to prioritize mental illness and dedicate sustainable treatment resources, with the justice system advocating for better access to treatment in the community.
- A greater emphasis on the prevention of mental illness, early detection, and intervention, particularly for children.
- Training of law enforcement agencies for improved responses to individuals with SMI.
- An infusion of resources into criminal justice institutions, enabling them to address both the mental health needs of incarcerated persons and the traits that inform their criminal tendencies (i.e., criminogenic needs).
- Discharge planning coordinated to ensure continuity of care in the community.
- Bridging the gap between the criminal justice system and the mental health system to provide better care to the seriously mentally ill.
The priority needs assessment was informed by growing recognition of the difficult plight of the mentally ill in corrections and its adverse impact on the justice system. The NIJ workshop report noted that more than 18% of adults in the United States have some type of mental illness. Although an estimated 4.2% of the general adult population suffers from SMI, a disproportionate number of individuals involved with the justice system — specifically, 20-26% of the jail population, 15% of individuals incarcerated in state prison, 9% of those on probation, and 7% of those on parole — are diagnosed with SMI.
The pervasive and growing presence of SMI in correctional institutions can be highly problematic for those institutions. Individuals with SMI tend to remain in confinement longer and impose higher costs of care on the institutions housing them, and they are at high risk of stress and suicide. In general, they are harder to manage than other persons who are incarcerated, the NIJ experts reported. Often denied time outside their cells and opportunities for communication with others, the SMI population endures conditions that can be harsh for any person who is incarcerated. In the end, the typically noisy and claustrophobic conditions of confinement can exacerbate pre-existing mental illness issues. The conditions and needs of the mentally ill behind bars represent just one element of a systemic challenge.
Research managers tasked the expert workshop participants with identifying priority needs across six areas:
- community-based treatment;
- policing and public safety;
- specialty courts and jail diversion;
- institutional programming;
- reentry coordination and relapse prevention; and
- data-driven accountability
Over the course of two days, experts identified and prioritized a total of 47 needs across the six subject areas that can inform future research and practice. In assessing the relative importance of each of the six areas, they identified two needs areas as having the highest importance: community-based treatment and reentry coordination and relapse prevention.
Community-based treatment needs
Experts agreed that many individuals with SMI do not receive adequate care in the community. Some are undiagnosed, others fail to recognize they have a disorder, and some fear they will be stigmatized if they engage in treatment. Moreover, resource shrinkage has been acute: states cut $5 billion in mental health services and trimmed 4,500 available public psychiatric beds —10% of total beds — between 2009 and 2012. The cuts have disproportionately hurt the poor and disenfranchised, who lack the wherewithal to pay for treatment. Those cuts speak to a growing need for focused research on community mental health care.
Community-based needs should inform research priorities
In terms of research priorities, the workshop experts noted a need for better empirical data to make the case for more community-based mental health resources. They also called for research to establish the optimal number of mental health services beds in each community and urged more public advocacy in favor of optimal mental health services.
Merely identifying the optimal level of community services would be insufficient in itself to address the need. The experts noted that the recommended services must be fully resourced, sustainable, and grounded in evidence-based practices — and performance metrics should be in place to gauge the effectiveness of service delivery and receipt.
An acute need to support juveniles with mental health challenges
As with adults, addressing mental health symptoms and needs of juveniles is crucial. Actions urged by the NIJ expert group included assessing the costs and benefits of conducting early school assessments and teaching life skills at a very early age. Individuals with mental illness often lack the basic social and survival skills to manage daily challenges. The lack of coping skills may leave them less prepared to manage the disorders and related challenges that may steer them toward the justice system. Intervention earlier in life can help reduce that skill deficit and any related negative outcomes.
America’s youth are experiencing mental illness at “astounding rates,” the workshop report noted. Specifically, almost half of all adolescents aged 13 to 18 have had a mental disorder, and more than 22% have suffered severe impairment. Early identification of mental health symptoms and difficult childhood experiences could help many young people avoid later involvement with the justice system. The experts called for more research to identify the most effective intervention points.
Some of the SMI lack motivation to seek treatment. Left untreated, however, they may pose a threat to themselves as well as others. On that point, the experts observed a need to assess the benefits of “Mental Health First Aid Training” and to create ways to mandate care for high-risk SMI individuals, before they harm themselves or others. Workshop participants strongly urged coordinated comprehensive case management for SMI individuals in the community.
The question of forced treatment, however, divided the expert panelists. Mental health advocates firmly oppose mandated treatment and medication for individuals not involved with the justice system, while others maintain that waiting to treat individuals until they pose a danger to themselves or others may be inappropriate. As the report noted, “A balance is required between an individual’s legal right to refuse care and society’s desire to preserve the safety of both the individual and those around him or her. Research is needed to explore the practical, effective, and ethical responses to this dilemma.”
Needs related to reentry coordination and relapse prevention
In the area identified as second in relative importance, needs related to reentry coordination and relapse prevention, the experts called for the development of best practices to ensure continuity of care for incarcerated persons after discharge, as well as a “warm hand-off” between agencies, i.e., an informative, face-to-face briefing on the individual’s condition and needs at discharge. Among other priority needs identified in this area, the experts urged the development of best practices for contracting with community providers to improve the provision of services post-release.
The experts emphasized that preservation of Medicaid eligibility can be vital to successful transition, especially in the critical period immediately following release, when the risk of recidivism and health problems is often highest.
One set of reentry challenges for the mentally ill involves the attitude or preparedness of community providers. The report stated, “Some providers do not want to work with the justice-involved population, while other organizations in the community that are willing to serve the SMI population often are unaware of what is required to provide service for particularly violent individuals.” To address these issues, experts agreed on the need to identify best practices for contracting with community providers and develop a model curriculum for mental health providers that delivers a background in justice-related issues.
Policing and public safety
Another area of high importance identified by the experts is policing and public safety. Individuals with SMI account for 10% of all police calls for service and are two to three times more likely to be arrested than the general population, yet many of these encounters are relatively minor and nonviolent. First responders often lack training in how to interact with the SMI population.
One approach to policing the mentally ill that was endorsed by the workshop experts, but not by other authorities in the field, is the expanded use of a Crisis Intervention Team (CIT) model. The CIT model is designed to facilitate collaboration between mental health professionals and law enforcement. CIT comprises specialized, police-led, pre-booking jail diversion responses to individuals with mental illness. The goals are to reduce police officers’ injuries and use of force and to reduce arrests of individuals with mental illness.
NIJ’s CrimeSolutions program-evaluation resource concluded, however, after reviewing a 2016 meta-analysis, that CIT has not been shown to be more effective than conventional law enforcement interventions with mentally ill individuals.
With respect to the CIT model, CrimeSolutions states, “The practice is rated No Effects for reducing arrests of individuals with mental illness and reducing trained police officers’ use of force in situations involving mentally ill individuals.”
The workshop experts, on the other hand, called for assessments of the costs and benefits of CIT training, along with assessments of cultural sensitivity training and de-escalation training.
A key conclusion from the workshop speaks to the need for specialized training to equip law enforcement professionals to interact more effectively with individuals exhibiting symptoms of mental illness. CIT programming provides law enforcement with essential “knowledge about the nature of mental illness and strategies to better handle interactions with this population,” the report explained.
Even with adequate law enforcement training, however, individuals with SMI may find themselves in jail absent appropriate alternatives. In many cases and when available, hospitals, acute care drop-offs, and crisis intervention centers are far better options. In that vein, the expert group identified a need to assess benefits and best practices for alternatives to jail and to leverage synergies between the justice and mental health systems.
Specialty courts and jail diversion
The expert group discussed the emergence of mental health specialty courts that make court-mandated treatment — coordinated with community provider agencies — the core of the court’s disposition of the defendant’s case. However, the experts pointed out there is often a disconnect between mental health courts and community-based mental health approaches. The report noted that some studies indicate no relationship between court-ordered treatment and recidivism or jail days. Nonetheless, there is ample evidence supporting the view that, overall, mental health courts have a positive impact on their participants. In that respect, the report stated, “Research on mental health courts has documented generally favorable outcomes. When compared with those processed through regular court, mental health court participants are more likely to be connected with treatment services, are rearrested less frequently during and after the program, and spend less time in jail. Furthermore, program completers have more favorable outcomes than dropouts.”
To enhance the effectiveness and sustainability of specialty courts, and the professionals engaged by them, the experts encouraged the following steps:
- Development of educational resources and risk assessment tools related to the management of mental illness, for judges, prosecutors, public defenders, and case managers.
- Development of model policy and training, for probation and parole handling of compliance related to mental health courts.
- Assessment of the amount of resources needed to allow mental health courts to function well.
- Provision of tools to conduct sustainability assessments for specialty courts.
Although many individuals with SMI may end up in custody due to a lack of community mental health resources, some violent individuals with SMI may need to be incarcerated, as they pose a threat to public safety. Institutions are challenged to address and cope with the array of issues presented by this population. The report suggests that the mentally ill tend to “require more resources, create more behavioral management problems, experience longer periods of confinement, be more likely to self-harm and die by suicide, and be more likely to be victimized.”
Court decisions, statutes, and professional organization standards make it clear that institutions have a legal duty to treat those with SMI, but the provision and delivery of treatment can be uneven. The report observed “that many correctional agencies simply are not resourced or best suited to provide this level of care.”
The inability to attract and retain treatment staff is also part of the problem. With that in mind, one need identified by the experts is the development of best practice guides to help agencies leverage programs such as loan forgiveness, tuition reimbursement, partnerships with academic institutions and other incentives and partnerships. The experts also urged the identification of best practices to keep individuals with mental illness engaged with treatment programs while in custody.
Another key need is involvement of correctional staff who have the appropriate training, temperament, and personal traits as well as the desire to work with incarcerated persons who are mentally ill. Officers are at risk of effects of exposure to traumatic incidents, such as suicides, attempted suicides and self-mutilation. Generally, working with this population can cause high levels of stress among correctional staff, warranting observation and treatment. The development of trauma-based care for staff is a critical need as well, the experts reported.
Data-driven accountability and overarching needs
A final area considered by the experts, data-driven accountability and overarching needs, focused on filling problematic information gaps between various agencies. A particular difficulty, the experts noted, is the institutional hesitancy of many health and other organizations to share sensitive health records — a disservice to the individual and the entity, the report concluded. “At a minimum, service provision can be hampered,” the experts’ report said. “In extreme cases, lack of information-sharing can have immediate and irreversible implications,” such as a deadly encounter when a law enforcement officer lacks critical information on the mental health of an individual. The pervasive institutional tendency to withhold health information, while individuals bounce between inadequately informed agencies, does further harm to mentally ill individuals. In that regard, the experts warned, “As individuals churn through the system, they often fall through the cracks, which can result in medication lapses, relapses, decompensation, and interruption of services.” The expert group identified a need for legislative mandates of information-sharing among providers.
Among other needs related to research and uniform practices, the NIJ-supported experts urged an increased emphasis on evidence-based research to support informed strategies with the goal of improving convicted person and public safety outcomes. The experts called for organizing groups of academics, practitioners, and policymakers to operationalize and engage in evidence-based research.
This article selectively addressed key needs identified by the expert workshop for managing seriously mentally ill individuals in the justice system across six subject areas. This article does not include a discussion of all 47 identified needs, but the critical takeaways from the expert workshop included:
- The prioritization of the needs of the seriously mentally ill.
- The need for early detention and intervention for children at risk for or exhibiting mental illness.
- The improvement of community-based mental health services.
- A focus on treatment rather than prevention.
- Barriers to collaboration between the justice system and the mental health system that continue to disrupt care for the mentally ill.
As public resources become more and more scarce, the SMI population will continue to grow. Those individuals’ engagement with the criminal justice system will likely increase as well. That reality necessitates focused dialogues driving research priorities and commitments related to SMI needs in corrections. Individuals with serious mental illness, the institutions tasked with managing them, and society itself will pay a steep price if SMI challenges are unmet.