Crime and Mental Health Disorder Essay Paper: Goals & standards

Mental Health Disorder Week 2 Assignment

Week 2 – Crime and Mental Health Paper: Goals & standards

Make sure assignment aligns with the below questions as well as the assignment content. THANK YOU!
· Describe possible causes of mental health issues in the criminal justice system.

· Identify the behavioral criteria of common mental health disorders seen in the criminal justice system. Crime and Mental Health Disorder Essay Paper: Goals & standards.

· Describe possible causes for common mental health disorders seen in the criminal justice system.

· https://medlineplus.gov/mentaldisorders.html

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Week 2 – Crime and Mental Health Paper

Assignment Content

Write a 550- to 700-word paper on the connection between crime and mental health. Include the following:

o Describe the prevalence and causes of mental health issues in the criminal justice system.

o Describe the behavioral symptoms for three of the most common mental health disorders present in the criminal justice system Crime and Mental Health Disorder Essay Paper: Goals & standards.

o Describe the relationship between these mental health issues and crime.

Include a minimum of three sources.

Format your paper consistent with APA guidelines.

Submit your assignment.

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CPSS410 Overview of Mental Health in Criminal Justice Crime and Mental Health Disorder Essay Paper: Goals & standards

Week 2 Mental Health Issues in the Criminal Justice System

Readings:

Ringhoff, D., Rapp, L., & Robst, J. (2012). The criminalization hypothesis: Practice and policy implications for persons with serious mental illness in the criminal justice system. Best Practice in Mental Health, 8(2), 1-19.

Searches:

mental health disorders AND behavioral criteria

mental health disorders AND criminal justice system

Videos

Week 2 – Crime and Mental Health Paper Readings:

Films Media Group (1998). Criminal Justice and Brain Impairment (06:03) From Title: Mind Talk: The Brain’s New Story.

The term criminalization has been used to describe the overrepresentation of persons with serious mental illness in the criminal justice system. Public policy responses have focused on simply linking individuals with treatment. Crime and Mental Health Disorder Essay Paper: Goals & standards. Although treatment is important to minimizing symptoms, evidence indicates that nonclinical variables are greater pre- dictors of arrest than clinical variables and that risk factors for arrest are similar for persons with and without mental illness. This article reviews the literature on the link between severe mental illness (SMI) and criminal behavior; considers whether treat- ment has been effective at reducing criminal behavior among individuals with SMI; and discusses practice, policy, and crime prevention implications Crime and Mental Health Disorder Essay Paper: Goals & standards.

Keywords: criminal justice system; criminalization; risk factors; serious mental illness

Introduction

The disproportionate number of persons with severe mental illness (SMI) involved in the criminal justice system is widely recognized as a significant social problem (Lamberti, Weisman, & Faden, 2004; More & Hiday, 2006; Steadman, Osher, Robbins, Case, & Samuels, 2009; Torrey, 1995). Research estimates that 8 percent of the nation’s 13 million annual arrests involve persons with SMI (McNeil & Binder, 2007; Morrissey, Cuddeback, Cuellar, & Steadman, 2007; Steadman & Naples, 2005), although others have argued that this may represent a significant underestimation (Steadman et al., 2009). Although people with diagnosable mental illnesses often spend brief periods of time in jail (Morrissey et al., 2006), rearrest is common and poses safety risks for both law enforcement

The Criminalization Hypothesis: Practice and Policy Implications for Persons with Serious Mental Illness in the Criminal Justice System

Daniel Ringhoff, Lisa Rapp, and John Robst

Daniel Ringhoff, LCWS, is a doctoral student in the School of Social Work at the University of South Florida. Lisa Rapp, PhD, is associate professor in the School of Social Work at the Univer- sity of South Florida. John Robst, PhD, is research assistant professor in the Department of Men- tal Health Law and Policy at the University of South Florida.

and arrestees (Cox, Morschauser, Banks, & Stone, 2001; Hartwell, 2003; Lamb & Weinberger, 2001; Lamb, Weinberger, & Gross, 2004). Inmates with SMI may cause considerable management and financial problems for state and local correctional authorities (Clark, Ricketts, & McHugo, 1999; Domino, Norton, Morrissey, & Thakur, 2004). They also generally receive inadequate mental health treatment while incarcerated (Veysey, Steadman, Morrissey, & Johnsen, 1997). Additionally, persons with SMI are more likely to be arrested (McNeil & Binder, 2007; Teplin, 1983, 1984, 1990; Teplin, Abram, & McClelland, 1996), and to have their community supervision revoked as the result of a technical vio- lation or new offense (Skeem & Louden, 2006).

Consequently, many policy makers and practitioners have labeled this phe- nomenon as the criminalization of mental illness or the criminalization of the mentally ill, and point to inadequacies in the mental health treatment system as its primary cause (Engel & Silver, 2001; Fisher, Silver, & Wolff, 2006; Lamb et al., 2004; Teplin, 1983). Mental health advocacy groups (National Alliance for the Mentally Ill, 2001), research institutes (Soros Foundation, 1996), government related entities and committees (Council of State Government’s Criminal Justice/ Mental Health Consensus Project, 2002; Florida Supreme Court, 2007; New Free- dom Commission on Mental Health, 2003), and lawmakers (Fisher et al., 2006) have all used such terms to describe the extent of the problem. Because of the widespread influence of perceived criminalization on public policy, it is important to assess the construct’s ability to explain the current problem so that researchers, policy makers, and practitioners can have confidence they are formulating and implementing the most effective policies and interventions. The purpose of this review, therefore, is to examine the construct of criminalization and the assump- tion that it is a significant cause of the overrepresentation of persons with SMI in the criminal justice system. In addition, this article will discuss the concept of mental illness as a cause of crime and criminogenic risk factors. Finally, promising models in the criminal justice literature that policy makers and practitioners may consider when planning and implementing interventions for individuals with mental illness and criminal justice histories will be reviewed.

Deinstitutionalization and the Criminalization Construct

Criminalization has long been viewed as an unanticipated side effect of deinsti- tutionalization (Aderibigbe, 1997; Fisher et al., 2006). Rather than referring to one event or policy decision, deinstitutionalization describes a confluence of events that closed many state hospitals and indelibly changed the mental health system between the 1950s and 1990s. Salient factors that caused these changes included statutory reforms, the advent of revolutionary psychotropic drugs such as Thora- zine, state budget constraints, and exposés of deplorable conditions in state hospi- tals, as well as the Community Mental Health Centers Act of 1964, which provided an avenue for community treatment (Fisher et al., 2006; Steadman, Monahan, Duffee, Hartsone, & Robbins, 1984; Teplin, 1983, 1984; Torrey, 2008). During this time, psychiatric beds in state mental and general hospitals were significantly

2 Best Practices in Mental Health

reduced—from 559,000 in 1955 to 68,000 in 1990—as patients were released to families and facilities in the community (Aderibigbe, 1997).

To provide for these persons, funding for community mental health services increased through the creation and expansion of Medicaid and Supplemental Security Income (SSI). Funding, however, remained inadequate (Frank, Goldman, & Hogan, 2003; Petrila, 2001). Increased funding also had the unintended effect of speeding up deinstitutionalization and creating what has been called the corol- lary phenomenon of transinstitutionalization, whereby psychiatric patients are transferred back and forth between community inpatient facilities and jails (Fisher et al., 2006; Frank et al., 2003; Steadman et al., 1984; Teplin, 1983, 1984; Torrey, 2008). As a result, many persons with mental illness entered the community with inadequate housing and community supports (Torrey, 1988). Statutory reforms and more stringent civil commitment criteria further limited psychiatric disposi- tions, making it more difficult to hold and treat persons in the mental health sys- tem, and presumably shifting persons with mental illness to the criminal justice system, as communities grappled with how to manage persons exhibiting undesir- able behavior (Fisher et al., 2006). In addition, as homelessness and incarceration increased among persons with mental illness, so did the perception that the men- tal health system was failing in its mission to provide adequate services for persons with mental illness (Fisher et al., 2006; McNeil, Binder, & Robinson, 2005).

In 1972, as these events were unfolding, one California psychiatrist (Abram- son, 1972) described the disproportionate number of persons with mental illness in the criminal justice system as “the ‘criminalization’ of mentally disordered behavior” (Fisher et al., 2006, p. 545). Although many use the term criminaliza- tion to refer simply to the prevalence of persons with SMI in the criminal justice system, in particular to their overrepresentation and increased likelihood of arrest, the term has specific connotations. Most broadly, it implies that jails became substitutes for state mental hospitals, presumably because persons who were previously state hospital patients were refusing treatment in the community or unable to access treatment in the community (Fisher et al., 2006). Fisher et al. (2006) provides more detail, describing criminalization as:

a process whereby behaviors that in one era had been managed by involun- tary transport and psychiatric hospitalization became less easily managed in that way as a result of the new restrictions placed on civil commitment. With the mental health disposition less available, but still faced with a need to man- age situations involving undesirable behaviors, agents of social control— police and judges—would impose a criminal, rather than psychiatric, defini- tion of an individual’s deviant behavior. The individual would then be arrested, often on a trivial charge such as trespassing or disorderly conduct, rather than civilly committed, and in some cases detained in jail. (p. 546)

In other words, judicial professionals, such as police and judges, began using crim- inal sanctions to manage persons with SMI in the community because other men- tal health options were unavailable (Engel & Silver, 2001; Fisher et al., 2006; Teplin, 1983).

The Criminalization Hypothesis 3

Junginger, Claypoole, Ranilo, and Crisanti (2006) provided more clarification regarding criminalization and the role that symptoms might play in the arrest of people with mental illness:

Why persons with serious mental illness are more likely to be arrested and incarcerated is unclear, but a literal and popular interpretation of the crimi- nalization hypothesis implies two possibilities. First, symptoms of serious mental illness have become de facto criminal offenses; that is, person with serious mental illness are arrested and incarcerated for displaying psychiatric symptoms. Second, symptoms of serious mental illness motivate or otherwise cause actual criminal offenses. (p. 879)

This nuanced definition is important because it helps clarify how mental health symptoms have become criminalized and distinguishes between arrests resulting from the display of mental health symptoms, and those resulting from criminal behaviors that are directly or indirectly caused by mental health symptoms. Crim- inalization therefore occurs when persons with mental illness are arrested, either for displaying symptoms of mental illness or for committing minor crimes that are a direct or indirect result of mental illness, instead of being treated in the mental health system.

Assessing the Validity of Criminalization

Although there is a great deal of anecdotal evidence supporting the criminal- ization hypothesis, it is a widely understood principle that policy should be driven by rigorous research (Morrissey et al., 2006). Criminalization therefore must be found to be an important cause of the problem before policy makers rely on it to inform decisions, even though there are a disproportionate number of persons with SMI in jails and prisons. Specifically, research must show that deinstitution- alization and inadequate community resources have caused individuals with SMI to have greater involvement with the criminal justice system. However, if other nonclinical factors are found to be important to the high rates of arrest, then pub- lic policy can address the problem only through a more comprehensive treatment plan that addresses both clinical and nonclinical factors.

Are Individuals with SMI Targeted for Arrest?

Junginger et al. (2006) stated that the criminalization hypothesis implies that legal professionals, such as police and judges, treat mental illness as a crime and target mentally ill persons in the community with criminal sanctions. Several studies have examined this question using: (1) prevalence data of persons with mental illness in jails and prisons, (2) arrest rates of discharged hospitalized men- tal health patients, and (3) comparisons of arrest rates for person with and with- out mental illness (Engel & Silver, 2001; Lamb & Weinberger, 1998; Rabkin, 1979; Teplin, 1984).

4 Best Practices in Mental Health

Some researchers have suggested that mental illness may be associated with an increased risk of arrest. For example, Teplin’s (1983) literature review focus- ing on (1) archival studies, (2) police decision making, and (3) prevalence data, found mixed evidence that persons with mental illness were being targeted for arrest. Arrest rates were higher among offenders with previous hospitalizations than for persons with no prior arrests, but persons previously admitted to psy- chiatric hospitals had arrest rates that were higher than those of the general pop- ulation. Furthermore, persons with mental illness and no prior arrests had arrest rates similar to those of the general population. Teplin (1984) analyzed arrest rates between persons with and without mental illness. Although there was an increased probability of arrest for those showing symptoms of mental illness as compared to those who did not, the findings were based on cross-tabulation analysis absent of statistical controls for legal factors and other important vari- ables known to affect police decision making (Engel & Silver, 2001). In support of criminalization, Teplin (1983) found a majority of studies investigating police decision making provided some evidence that persons with mental illness may be targeted for arrest.

Other studies investigating police decision making, however, appear to contra- dict Teplin’s findings. When the problem of the increasing incarceration rates of persons with mental illness was first becoming evident, Bittner (1967) found that police were “reluctant to take any official action (including arrest) ‘on the basis of the assumption or allegation of mental illness’ and that officers often chose to resolve such encounters informally” (Engel & Silver, 2001, p. 229). In addition, police were not found to arrest noncommittable persons with mental illness involved in nondangerous incidents simply out of expediency (Bonovitz & Bonovitz, 1981), nor were they more likely to arrest persons with SMI or to use arrest to manage persons with mental illness (Engel & Silver, 2001). In summary, there is no conclusive answer to the question of whether persons with SMI are tar- geted for arrest.

Does Mental Illness Cause Crime?

The second interpretation of the criminalization hypothesis by Junginger et al. (2006) is that symptoms of SMI indirectly or directly cause crime. Assessing the causal link between mental illness and crime is difficult for two reasons. First, mental illness is correlated with factors that cause crime, such as criminal think- ing; and second, mental illness elevates risk factors that lead to crime, such as sub- stance abuse (Frank & McGuire, 2010). A full review of the causal link between mental illness and crime is beyond the scope of this article. However, research thus far has found convincing evidence that there is a small connection between men- tal illness and crime, although the connection is specific for certain subsets of per- sons with mental illness (Frank & McGuire, 2010). Given the link, albeit a small one, between mental illness and crime, access to community resources and treat- ment is often seen as important to reducing criminal activity. The question of the

The Criminalization Hypothesis 5

extent to which improved access and use of mental health treatment would sig- nificantly reduce crime will be addressed below.

Does Access to Mental Health Treatment Reduce Crime?

Medicaid is the principal funding source for persons with SMI and accounts for 24 percent of total revenues for the community mental health centers that pro- vide many of the specialized programs for persons with SMI (Domino et al., 2004; Frank et al., 2003; Koyanagi & Stine, 2009; McAlpine & Mechanic, 2000; Morrissey et al., 2006; National Alliance for the Mentally Ill, 2001; Petrila, 1992, 2001). Morrissey et al. (2007) examined the association between Medicaid enroll- ment upon release from jail and time in the community (i.e., time until rearrest). The study compared two groups of individuals with SMI who had been enrolled in Medicaid prior to entering jail. One group remained enrolled in Medicaid at the time of release from jail whereas the other had been disenrolled due to incarcera- tion. Morrissey and colleagues found a small association between a combination of enrollment in Medicaid benefits and service utilization and reduction in arrests in a twelve-month period following release.

While Morrissey et al. (2007) focused on disenrollment of Medicaid recipients, Domino et al. (2004) examined whether reductions in mental health services due to managed mental health care led to indirect cost shifting from insurance plans to jails and state hospitals. By analyzing pre- and postmanaged care periods and comparing the difference in jail costs, state hospital costs, and county outpatient mental health costs between these periods, they found that managed care led to indirect cost shifting, most likely through poorer access to services, resulting from a greater probability of arrest. This study highlights the importance of cross- system outcomes. By seeking to control Medicaid costs, the implementation of managed care had the unintended consequence of increasing criminal justice expenditures.

The relationship between access to treatment and arrests has also been exam- ined by following a sample of people with SMI over time and by comparing arrest rates in communities with different levels of available care. Constantine et al. (2011) followed a sample of individuals with SMI and criminal justice contacts over a four-year period. Inpatient and emergency room contacts were positively related to the number of arrests, whereas outpatient treatment was negatively associated with arrests. Outpatient visits were associated with a reduced number of felony and misdemeanor arrests, whereas inpatient/emergency room contacts were associated with felony arrests. Fisher, Packer, Simon, and Smith (2000) com- pared incarceration rates of two regional communities in Massachusetts with sig- nificantly different levels of community mental health services and found no sig- nificant difference in arrest rates. The differing service levels were the result of a federal lawsuit, which doubled the per capita mental health funding in one county as compared to other counties in the state. This resulted in greater per capita fund- ing of residential programs and case management services as well as the creation of new services such as a mobile crisis team.

6 Best Practices in Mental Health

Current Responses and Risk Factors for Crime

The mixed findings discussed above do not provide strong support for the crim- inalization hypothesis. Such inconsistent findings have also caused several to sug- gest that criminal justice outcomes are not strongly related to clinical factors (Case, Steadman, Dupis, & Morris, 2009; Erickson et al., 2009; Fisher et al., 2006; Frank & McGuire, 2010; Lamberti et al., 2004). For example, Frank and McGuire (2010) wrote:

A small fraction [Skeem et al. (2009) judge it to be one in ten] of criminals with mental illness commit crimes because of their current illness, but the elevated risk is small. Current treatment can ameliorate current illness and symptoms, but cannot reverse the past effects of illness on the accumulation of other risk factors over a person’s lifetime. (p. 4)

Indeed, other nonclinical risk factors may be just as important if not more important than current mental health symptoms. Case et al. (2009) found that prior criminal history, a risk factor for persons with and without mental illness, rather than clinical variables, predicted subsequent arrests. The importance of these findings as noted by Case et al. is that “the lack of significance of clinical variables compared with criminal history variables suggests that programs must target changeable risk factors, not just improved symptomatology and service connectedness” (p. 670).

This notion that clinical factors such as diagnosis are weak predictors of crime and recidivism is not new (Bonta, Hanson, & Law, 1998; Case et al., 2009; Erickson et al., 2009; Lamberti et al., 2004; Philips et al., 2005). In a meta- analysis of predictors of criminal or violent recidivism among offenders with mental disorders, Bonta et al. (1998) found that “clinical or psychopathological variables were either unrelated to recidivism or negatively related” (p. 139). In addition, Junginger et al. (2006) found that mental illness was unlikely to be a direct cause of arrest among persons with SMI.

Despite this evidence, public policy continues to focus on treatment and the reduction of symptoms in order to address the problem of the overrepresentation of persons with SMI in the criminal justice system. According to Fisher et al. (2006), this notion of the mentally ill offender who has been managed in the crim- inal justice system because of perceived inadequacies in the mental health system has shifted the focus of the problem from “individual psychopathology to the socio-legal/system context in which deviant behavior is exhibited” (p. 546). Responses therefore have focused on fixing the system by connecting persons to treatment in order to mediate the effects of deinstitutionalization. Consequently, mental health policy has focused on jail diversion and substituting treatment for incarceration, based on the belief that incarceration is unnecessary (Fisher et al., 2006; GAINS Center, 2010; Morrissey, Fagan, & Cocozza, 2009).

Since 1992, jail diversion programs have grown from 52 to approximately 560 (Case et al., 2009). Outcomes, however, have been mixed. Steadman and Naples (2005) found that a wide variety of pre- and postbooking diversion programs

The Criminalization Hypothesis 7

operating within the parameters of the typical judicial system reduced days spent in jail without increasing public safety risks, but did not find significant reductions in arrests during the twelve-month follow-up. On the other hand, in addition to a reduction in days spent in jail, Case et al. (2009) found that persons diverted to post- booking programs experienced fewer arrests during a twelve-month follow-up.

Prebooking programs typically involve crisis intervention teams (CIT), which consist of specially trained police officers who attempt to prevent arrest through de-escalation and/or by transporting persons to mental health centers for assess- ment rather than to jail. Compton, Bahora, Watson, and Oliva (2008) provide an overview of the research evaluating CIT programs. They found that CIT training had a positive effect on police officers’ attitudes, beliefs, and knowledge relevant to interactions with individuals with mental illness, and officers reported feeling bet- ter prepared to handle calls involving individuals with mental illnesses. Although CIT may reduce arrests and lower associated criminal justice costs, this requires that, by definition, CIT diversion must occur at prebooking.

Mental health courts (MHCs) are a specific type of postbooking diversion pro- gram that have a specialized docket and use ongoing court status reviews and sanctions to motivate treatment compliance (Marlowe, Festinger, Dugosh, & Lee, 2005). As such, MHCs provide a gateway for offenders to access treatment and community resources. Studies have found mixed results for the effectiveness of these courts. Mental health courts in Seattle, Washington, led to increased treat- ment engagement and reduced crime (Trupin & Richards, 2003), as did those in Clark County, Washington (Herinckx, Swart, Ama, Dolezal, & King, 2005). Men- tal health courts in Broward County, Florida, increased access to care (Boothroyd, Poythress, McGaha, & Petrila, 2003), but such treatment did not lead to symptom reduction (Boothroyd, Mercado, Poythress, Christy, & Petrila, 2005), and rates of rediversion after a new charge were not lower than typical recidivism rates (Boccaccini, Christy, Poythress, & Kershaw, 2005). More recent studies (McNeil & Binder, 2007; More & Hiday, 2006) have shown promise in reducing recidivism, perhaps because MHC participants receive and observe encouragement and/or sanctions during court status reviews.

Although diversion programs have been popular and may provide specific ben- efits to individuals with mental illness, there are additional factors to consider when evaluating their effectiveness. First, individuals with mental illness make up a larger percentage of persons who are at higher risk for arrest, and therefore would be expected to comprise a greater proportion of arrests (Draine, Salzer, Culhane, & Hadley, 2002). Another issue to consider is the association between conduct disorder, the precursor to antisocial personality disorder, and mental ill- ness. Research has found there is an elevated risk for children with conduct disor- der to develop adult mental disorders and that there are higher rates of childhood conduct disorder in adults with schizophrenia (Frank & McGuire, 2010; Morgan, Fisher, Duan, Mandracchia, & Murray, 2010). That said, mental illness may, indeed, play a role in other risk factors for arrest, but the other risk factors may be easier and more cost effective to manage than the mental illness itself. Managing

8 Best Practices in Mental Health

such amenable factors may make an important difference in criminal justice out- comes. Consequently, some mental health researchers have emphasized the importance of addressing nonclinical risk factors for recidivism in addition to treatment.

The Risk-Needs-Responsivity Model

The risk-needs-responsivity (RNR) model is a correctional model that may pro- vide a useful framework for developing interventions that address clinical and nonclinical risk factors for offenders with SMI (Case et al., 2009; Erickson et al., 2009; Lamberti, 2007). Developed from general personality and cognitive-social- learning theories of criminal behavior, RNR consists of a set of principles for devising crime prevention strategies that target risk factors for offending and matching services with offender characteristics (Andrews & Dowden, 2007). As its name implies, the three main principles are the risk, needs, and responsivity principles. The risk principle states that services should target offenders who pose a higher risk of recidivism because lower risk offenders, even with an absence of services, have a low probability of recidivism. The needs principle states that ser- vices should target criminogenic needs, or needs that are strong predictors of crime and can be changed, whereas the responsivity principle states that services should match offender characteristics, such as personality, learning styles, and motivational level (Andrews & Dowden, 2007).

Risk factors for crime can be dynamic or static. Dynamic risk factors, such as employment, can change, while static risk factors, such as race or gender, do not change. Other factors typically considered static include the presence of a crimi- nal history or a mental illness. One strategy of RNR is to target the offender’s dynamic risk factors. Dynamic risk factors are considered criminogenic needs as a matter of emphasis to imply that meeting the specific need that produces or pre- dicts crime should result in a reduction of crime. Matching services with the offender’s risk factors is crucial in this process. Indeed, research in correctional settings has found that mismatching low-risk offenders with intensive services increases the risk of recidivism (Andrews & Bonta, 2003).

Monahan et al. (2005) developed a model of risk assessment for violence among individuals being released from psychiatric facilities after arrest. The top ten risk factors included seriousness of arrest, drug or alcohol abuse, type of psy- chiatric diagnosis, anger control, violent fantasies, childhood abuse, previous vio- lence, age, and gender. Perhaps in contrast to studies that show clinical variables to be unimportant, psychiatric diagnosis was found to be an important factor, and both static and dynamic factors were important predictors of violence.

Several dynamic risk factors that are common among individuals with SMI are important predictors of arrest. Homelessness increases the risk of arrest among individuals with SMI (Constantine et al., 2010; Lamberti et al., 2004; McNeil, Binder, & Robinson, 2005). Substance abuse is also a clear risk factor for individ- uals with SMI. Constantine et al. (2010) found that 66 percent of a sample of

The Criminalization Hypothesis 9

individuals with SMI and criminal justice contacts in Pinellas County, Florida, had a substance abuse diagnosis, and more than 90 percent had a diagnosis or service (e.g., detox) consistent with substance use. These factors often work together: McNeil et al. (2005) found that 78 percent of inmates with SMI who were home- less at the time of arrest also had substance related disorders. In addition, they found that individuals who are homeless with substance use had longer jail dura- tions than other individuals charged with similar crimes.

Individuals with SMI often have low levels of education, and consequently, poor job prospects, both dynamic risk factors for crime (Mocan & Tekin, 2006). For example, individuals with SMI were more likely to drop out of high school and those who did graduate from high school were less likely to graduate from college (Breslau, Lane, Sampson, & Kessler, 2008). Rylance (1997) found high school dropout rates reached 50 percent among a sample of youth with serious emo- tional disturbance. Given their lower levels of education, individuals with SMI face limited labor market opportunities. Indeed, unemployment rates among individu- als with SMI were reported to be as high as 90 percent (New Freedom Commission on Mental Health, 2003). Kessler et al. (2008) found that among employed work- ers, those with SMI earn lower wages. In addition, they determined that individu- als with other less serious mental illness have earnings similar to those of workers without mental illness, suggesting that people with SMI have fewer opportunities than those with less serious mental illness. Crime and Mental Health Disorder Essay Paper: Goals & standards.

Overall, nonclinical factors may be greater predictors of recidivism than men- tal health symptoms. In addition to the studies discussed above, there is substan- tive evidence that the major predictors of recidivism include: (1) history of antiso- cial behavior, (2) antisocial cognition, (3) antisocial attitudes, (4) antisocial associates, (5) family and/or marital problems, (6) school and/or work issues, (7) lack of leisure/recreation activities, and (8) substance abuse (Andrews, Bonta, & Wormith, 2006; Andrews & Dowden, 2007). Indeed, Bonta et al. (1998) con- cluded, “the major correlates of crime are the same regardless of race, gender, class, and the presence or absence of a mental illness” (p. 139). Crime and Mental Health Disorder Essay Paper: Goals & standards.

Crime Prevention Programs

A number of mental health researchers have argued that crime prevention programs for persons with SMI should target criminogenic needs in addition to mental health treatment. There is also a growing recognition that effective, com- prehensive programs should address issues such as substance abuse and home- lessness. Specialized treatment programs such as Assertive Community Treatment (ACT) teams provide services designed specifically for high-risk individuals, which arguably offer the best access to treatment for high-risk persons with SMI in the community (Lamberti et al., 2004). Services include case management, initial and ongoing assessments, psychiatric services, employment and housing assis- tance, family support and education, and substance abuse services Crime and Mental Health Disorder Essay Paper: Goals & standards. However, whereas such comprehensive programs reduce hospitalizations, they have little

10 Best Practices in Mental Health

or no effect on incarceration rates (Erickson et al., 2009; Fisher et al., 2006; Lamberti, 2007; Lamberti et al., 2004). Unfortunately, ACT programs have not been effective at reducing arrests, perhaps in part due to their focus on mental health and only a few of the above mentioned predictors of recidivism.

As a result, forensic ACT (FACT) programs specific to reducing criminal behav- ior have been modeled after the RNR model (Erickson et al., 2009; Lamberti, 2007). Several features differentiate FACT programs from ACT programs, includ- ing the targeting of individuals involved with the criminal justice system, taking referrals from criminal justice agencies, working with criminal justice agency partners, use of court sanctions, use of probation officers, and identifying preven- tion of rearrest as the primary goal (Lamberti et al., 2004). In a limited number of studies, FACT programs have been found to reduce criminal behavior (Cusack, Morrissey, Cuddeback, Prins, & Williams, 2010; Lamberti, 2004). Crime and Mental Health Disorder Essay Paper: Goals & standards. However, only Cusack et al. (2010) used a randomized study design, and although arrests were reduced, the costs of the program were only partly offset by criminal justice and inpatient savings.

One challenge is the variation among FACT programs, which differ in the ser- vices they offer, clients they serve, and staffing (Cuddeback, Morrissey, Cusack, & Meyer, 2009). For example, some programs offer residential services whereas oth- ers do not (Erickson et al., 2009). Cuddeback et al. (2009) examined the services offered by FACT programs, and found that only 36 percent of the programs had a housing specialist on staff. In addition, although 93 percent of programs had a psychiatrist on staff and 79 percent had a registered nurse, Cuddeback et al. did not report on how many programs had psychologists, social workers, and/or men- tal health counselors on staff. Thus, it remains unclear whether FACT programs address the antisocial traits that are such important predictors of criminal behav- ior. Indeed, the focus on intensive services may be useful to stabilize untreated individuals, but long-term success may hinge on effective therapy as well as med- ication. For example, Lamberti et al. (2004) discussed the limitations of tradi- tional interventions when treating offenders with SMI in FACT programs, sug- gesting that highly structured cognitive-behavioral interventions used with correctional populations may assist with nonclinical risk factors: Crime and Mental Health Disorder Essay Paper: Goals & standards.

Implicit in FACT’s design to promote engagement of clients in psychopharma- cology, addiction treatment, and community support services is the notion that such interventions will reduce criminal recidivism. Although intensive services may reduce recidivism among persons who are arrested as a result of untreated psychosis, drug addiction, or homelessness, such services are prob- ably not sufficient for everybody. Individuals with co-occurring psychopathy may also benefit from additional interventions that directly target antisocial attitudes, skills, and cognitions. Research in populations of persons who do not have a mental illness has suggested that the most effective approaches to individuals who are at a high risk of criminal recidivism incorporate highly structured cognitive-behavioral interventions. (p. 1291) Crime and Mental Health Disorder Essay Paper: Goals & standards.

The Criminalization Hypothesis 11

For psychotic offenders, Lamberti (2007) recommended utilizing a conceptual framework that includes three areas of focus: (1) competent care, (2) access to treatment services, and (3) use of legal leverage. Most importantly, competent care requires care providers who are knowledgeable of the criminal justice system in order to utilize legal leverage; familiar with cognitive-behavioral interventions, which have proven effectiveness in correctional settings for persons without men- tal illness; and familiar with strategies that promote treatment adherence such as motivational interviewing.

Discussion

An enormous number of studies have been conducted regarding criminal behavior among individuals with SMI. This article provides an overview of this very complex topic to assist researchers, policy makers, and practitioners in understanding the current evidence. However, it does not represent an exhaustive review of the literature.

This article has examined the evidence that supports and contradicts the crimi- nalization hypothesis in order to evaluate the assumption that it is a significant cause of the overrepresentation of individuals with mental illness in the criminal justice system Crime and Mental Health Disorder Essay Paper: Goals & standards. The evidence suggests that there is only a small correlation between mental illness and crime, and that mental health treatment alone will, at best, play a small role in reducing criminal behavior among individuals with SMI. Thus, there is not strong support for a key assumption of the criminalization hypothesis.

Although treatment alone is unlikely to reduce arrest rates significantly, access to evidence-based mental health services remains a crucial first step in a compre- hensive strategy. Current research suggests crime prevention strategies should also draw from criminology and correctional models to develop interventions that target criminogenic needs in addition to connecting persons to services that treat mental health symptoms (Case et al., 2009; Fisher et al., 2006; Lamberti, 2007; Silver, 2006). For this to happen, mental health policy makers may need to shift their thinking away from criminalization, perhaps to a view that understands that many persons with SMI can be criminal offenders in need of treatment that incor- porates clinical and nonclinical factors, rather than victims of the mental health system as criminalization implies. Even current comprehensive and costly treat- ment programs that focus on medication, substance abuse treatment, and com- munity services may have relatively little effect because they do not address essen- tial factors related to crime. Antisocial traits are consistent predictors of criminal behavior that may be most effectively addressed through cognitive behavioral therapy. As Morrissey et al. (2009) discuss, there has been greater emphasis on collaborations between the criminal justice and mental health treatment systems to address the unique needs of individuals with SMI.

Social workers and human service workers in a case management role should incorporate criminogenic needs into individual treatment plans. Although case managers typically address certain criminogenic needs, such as housing and employment, in individual treatment plans, they often overlook others, such as Crime and Mental Health Disorder Essay Paper: Goals & standards

12 Best Practices in Mental Health

antisocial behavior, antisocial cognitions, antisocial attitudes, and antisocial asso- ciations. However, evidence indicates that antisocial behaviors and thinking are the greatest risk factors for re-offending. Not only should case managers be able to assess for criminogenic needs and incorporate them into individual treatment plans, but they also need to be able to link clients to programs/interventions that specifically target criminogenic needs.

Moreover, social workers and counselors in therapist roles should have knowl- edge of cognitive behavioral therapies used in correctional settings to address anti- social behaviors and thinking. There are many cognitive behavioral therapies, such as Reasoning and Rehabilitation, Moral Reconation Therapy, Aggression Replacement Therapy, Interpersonal Problem Solving Therapy, and Thinking for a Change, that have proven effective in correctional settings and could be modified to work with offenders with SMI (Landenberger & Lipsey, 2005; Rotter & Carr, 2010). Whereas any generic cognitive behavioral therapy approach is likely to show positive effects, those tailored to address specific criminal behaviors are more likely to produce better criminal justice outcomes.

Clearly, there is importance in matching services to risks and focusing on crim- inogenic needs and high-risk offenders. In real world settings, however, there is often a tendency to focus more attention on low-risk clients who are less difficult to work with and more likely to complete treatment. The RNR strategy is a useful approach that social work administrators and practitioners can apply to counter this tendency when designing and implementing interventions for offenders with SMI.

Ultimately, research should inform policy as well as social work practice guide- lines. As evidence suggests, the construct of criminalization may be too simplistic to guide either. Because criminalization may contain incorrect assumptions about the problem and not fully explain the causes of the disproportionate number of persons with SMI in the criminal justice system, it may limit efforts by social work administrators and practitioners to address the problem. Thus far, twenty years of evidence suggests that simply connecting persons to mental health services does not significantly reduce incarceration rates (Bonta et al., 1998; Draine et al., 2002; Fisher et al., 2006; Lamberti, 2007; McNeil & Binder, 2007; Silver, 2006; Steadman et al., 2009). Furthermore, according to Fisher et al. (2006), the focus on treating mental health symptoms not only neglects other approaches to reduc- ing crime, but it also neglects the psychosocial rehabilitation model’s emphasis on the person as separate from the illness and, in doing so, “reinforces the label of ‘person with mental illness as a master status’—that status which above all others defines the individual’s position with the mental health system, the criminal jus- tice system and society in general” (p. 549). Crime and Mental Health Disorder Essay Paper: Goals & standards.

Clearly, there is considerable room for additional empirical study. Rigorous research is needed to determine whether programs meet the standards to be con- sidered evidence-based practices. Many pre- and post-booking programs have either been the subject of little research, or have found only modest support in studies. Issues of cost effectiveness are rarely dealt with in studies. In addition, part of the RNR model is responsiveness. In an era of limited public resources,

The Criminalization Hypothesis 13

research must consider which programs can be cost effective in addressing the needs of people most likely to be responsive. Almost certainly, one inherent chal- lenge in past studies that examine the effectiveness of an intervention is that some subjects will not be receptive no matter how effective the treatment.

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