homeless people with severe mental illnesses every
year.
Participants in the first 2 years of the ACCESS
demonstration project were surveyed to determine
whether or not they had formed a relationship with
their assigned case manager and what, if any, dif-
ferences they experienced in terms of homelessness,
symptom management, and use of substances. A total
of 2,798 participants completed the survey process.
Only 48% reported having a relationship or personal
connection with their case manager, underscoring the
difficulty in establishing a therapeutic relationship
with the homeless mentally ill. Clients reporting such
a relationship described more social support, received
more public support and education, were less psy-
chotic, were homeless fewer days, and were intoxi-
cated fewer days than participants who reported
having no relationship with their assigned case man-
ager. Although engaging this population in a thera-
peutic relationship is difficult, results are positive
when that relationship is established.
The most recent report from the ACCESS project
(2000) found that participants reported multiple fac-
tors that influence their quality of life; managing psy-
chiatric symptoms and receiving social support were
most important. The data from this report suggest
that focusing treatment on the multiple, independent
domains of psychiatric illness; social support net-
works; work and income; housing; and increased ser-
vice use is necessary to maximally improve client’s
self-assessed quality of life (Lam & Rosenheck, 2000).
Prisoners
Clinical studies suggest that 6% to 15% of people in
city and county jails and 10% to 15% of people in state
prisons have severe mental illness (Lamb & Wein-
berger, 1998). The rate of mental illness in the jailed
population is four times greater than in the general
population. Offenders generally have acute and
chronic mental illness and poor functioning, and many
are homeless. Factors cited as reasons why mentally
ill people are placed in the criminal justice system in-
clude deinstitutionalization, more rigid criteria for
civil commitment,lack of adequate community sup-
port, and the attitudes of police and society (Lamb
& Weinberger, 1998). The phrase criminalization of
mental illnessrefers to the practice of arresting and
prosecuting mentally ill offenders, even for misde-
meanors, at a rate four times that of the general pop-
ulation in an effort to contain them in some type of in-
stitution where they might receive needed treatment.
The authors noted that if offenders with mental ill-
ness had obtained needed treatment, some might not
have engaged in criminal activity.
80 Unit I CURRENTTHEORIES& PRACTICE
The public concern about the potential danger of
people with mental illness is fueled by the media at-
tention that surrounds any violent criminal act com-
mitted by a mentally ill person. Although it is true that
people with major mental illnesses who do not take
prescribed medication are at increased risk of being
violent (Lamb & Weinberger, 1998), most people with
mental illness do not represent a significant danger to
others. This fact, however, does not keep citizens from
clinging to stereotypes of the mentally ill as people to
be feared, avoided, and institutionalized. If such peo-
ple cannot be confined in a mental hospital for any pe-
riod, there seems to be public support for arresting
and incarcerating them instead.
People with mental illness who are in the crimi-
nal justice system face several barriers to successful
community reintegration, according to Roskes et al.
(1999) (Box 4-6). Lamb and Weinberger (1998) made
several recommendations to prevent or alleviate the
urgent problem of mentally ill people in the criminal
justice system:- Provide a mental health consultation to
police in the field to provide mental health
treatment, rather than incarceration, for
those who need it. - Provide formal training of police officers to
help them recognize mental illness and to
City and county jails