4 TREATMENTSETTINGS ANDTHERAPEUTICPROGRAMS 81
improve their attitudes toward people with
mental illness.- Perform careful screening of incoming pris-
oners to provide treatment, including med-
ication, when needed. - Encourage the diversion of people with
mental illness who have committed minor
offenses to the mental health system. - Implement ACT programs to provide out-
reach services in the community. - Provide social control interventions, such as
outpatient commitment, court-ordered treat-
ment, psychiatric conservatorship, or 24-hour
structured care, as conditions of probation for
people who do not voluntarily accept treat-
ment or services. - Ensure involvement of and support for
families. - Provide appropriate mental health treatment.
Some programs for people with mental illness who
have committed crimes have been successful. Kravitz
and Kelly (1999) described a mandatory forensic out-
patient program for mentally ill offenders who were
found not guilty by reason of insanity. Since they en-
rolled in the program, 47% were admitted to the hos-
pital at least once and 19% were rearrested or had
committed a new crime. With respect to psychiatric
stability, only 24% were in full remission and 68%
showed at least one indicator of difficulty reintegrat-
ing into the community. The authors suggested that,
although successful outcomes often include decreased
hospital admission rates, inpatient care might be a
positive outcome for this population.
Johnson and Hickey (1999) studied the criminal
justice involvement of offenders with mental illness
who participated in a clubhouse-type psychosocial re-
habilitation program. The extent of criminal justice
involvement diminished but was not completely elim-
inated for clubhouse participants. They had fewer ar-
rests and incarcerations than they had before psycho-
social rehabilitation. In some cases, the reduced in-
volvement with criminal justice did not continue long
after clubhouse participation ended. The study has
positive implications for involving offenders with men-
tal illness in ongoing psychosocial rehabilitation as a
way to decrease involvement in the criminal justice
system.
The Thresholds Collaborative Jail Linkage Proj-
ect in Chicago, Illinois, works with mentally ill of-
fenders caught in the revolving door of homelessness
and incarceration. Threshold staff members visit the
client in jail and begin working with him or her prior
to release. They locate housing, establish relation-
ships with landlords and local police, and may also
secure an early release for the client. The members
of the multidisciplinary team function according to
many of the principles of ACT programs such as 24/7
availability for crises, money management, home vis-
its, and access to a wide variety of community ser-
vices. The program is succeeding in helping clients
avoid arrest or rehospitalization. In addition, the pro-
gram costs about $26 a day per client as opposed to
$70 a day to keep a person in jail or $500 a day in a
public psychiatric hospital (Thresholds, 2001).
Appelbaum, Hickey, & Packer (2001) describe the
role of correctional officer on the multidisciplinary
team to treat incarcerated people with mental illness.
Along with their usual duties involving safety and se-
curity, correctional officers provide therapeutic inter-
ventions to inmates in specialized residential units of
the institution. These officers also provide valuable ob-
servations that they relay to the treatment team to en-
hance the psychiatric care that inmates with mental
illness receive. This approach has improved both the
quality of treatment and the safety of the correctional
environment.Box 4-6
➤ BARRIERS TOSUCCESSFULCOMMUNITYREINTEGRATION
- Double stigma:Individuals are stigmatized as being “cons” as well as enduring the stigma of mental illness.
- Lack of family or social support:Offenders are often estranged from family members even more so than
clients with mental illness who are not in jail, and they have few or no friends to provide social support. - Comorbidity:Substance abuse is a problem for most of the mentally ill offenders in the program sponsored
by the authors, and 50% have severe chronic or subacute medical illnesses. - Adjustment problems:Many offenders report difficulty readjusting to living in the community after a prison
term, including a lack of support in the community. - Boundary issues:Offenders often view any person, including psychiatrists or other health professionals, as
being an extension of correctional staff. This makes trust very difficult.
Roskes, B., Feldman, R., Arrington, S., & Leisher, M. (1999). A model program for the treatment of mentally ill offenders in the
community. Community Mental Health Journal, 35(5), 461– 475.