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«CRIME AND JUSTICE RESEARCH REPORT The Processing and Treatment of Mentally Ill Persons in the Criminal Justice System A Scan of Practice and ...»

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The Processing and Treatment of

Mentally Ill Persons in the Criminal

Justice System

A Scan of Practice and Background Analysis

KiDeuk Kim Miriam Becker-Cohen Maria Serakos

March 2015


The nonprofit Urban Institute is dedicated to elevating the debate on social and economic policy. For nearly five decades, Urban scholars have conducted research and offered evidence-based solutions that improve lives and strengthen communities across a rapidly urbanizing world. Their objective research helps expand opportunities for all, reduce hardship among the most vulnerable, and strengthen the effectiveness of the public sector.

Copyright © March 2015. Urban Institute. Permission is granted for reproduction of this file, with attribution to the Urban Institute. Cover image from Shutterstock.

Contents Acknowledgments iv Executive Summary v I. Introduction 1 II. Research Objective and Focus: Severe Mental Illness among Individuals Involved in the Criminal Justice System 3 III. Data and Methodology 5

1. Scan of Practice 5

2. Research Synthesis 5 IV. Findings 8

1. Scope of the Problem 8

2. Costs Associated with Managing Mentally Ill Individuals in the Criminal Justice System 10

3. Current Practice and Policy 14

4. Criminal Justice Programs and Interventions for Mentally Ill Individuals 26 V. Research and Policy Recommendations 39 VI. Conclusion 41 Appendix. Statutory Sources of Information 42 Notes 44 References 46 About the Authors 50 Statement of Independence 51 Acknowledgments This report was funded by Janssen Pharmaceuticals Inc. We are grateful to our funders, who make it possible for Urban to advance its mission. It is important to note that funders do not determine our research findings or the insights and recommendations of our experts. Janssen Pharmaceuticals had input into the scope but not the content of this report.

Executive Summary Mentally ill offenders possess a unique set of circumstances and needs. However, all too often, they cycle through the criminal justice system without appropriate care to address their mental health.

According to the Bureau of Justice Statistics, individuals with mental health needs make up a large proportion of the US correctional population. An estimated 56 percent of state prisoners, 45 percent of federal prisoners, and 64 percent of jail inmates have a mental health problem. These individuals often receive inadequate care, with only one in three state prisoners and one in six jail inmates having received mental health treatment since their admission (James and Glaze 2006). Offenders with severe mental illness place even more strain on the criminal justice system as a whole, in terms of their unique case-processing requirements and treatment needs and their increased risk of recidivism (Baillargeon et al. 2009; Cloyes et al. 2010; Feder 1991). Housing mentally ill offenders in the criminal justice system is costly. In addition to high health care costs, mentally ill inmates tend to have higher rates of prison misconduct and recidivism (Fellner 2006; Toch and Adams 2002).

Despite the evidence that mental illness in the criminal justice system is a pressing concern, our comprehensive effort to identify cost-effective, evidence-based programs and policies for managing and treating mentally ill persons in the criminal justice system brought to light how limited current knowledge is on this topic. There have been only a few rigorous evaluations of criminal justice programs and policies targeted at mentally ill offenders. This limitation, in and of itself, is a notable finding, as it shows what more needs to be done to better understand how to effectively alleviate the costs and challenges of treating and processing offenders with mental illness in the criminal justice system. Given these challenges and their financial consequences for society and governments, it is important to understand how to identify and provide early intervention for those who suffer from mental illness in the criminal justice system.

This report focuses on the societal and economic costs of holding mentally ill offenders in jails and prisons. It also presents a detailed discussion of how mentally ill offenders are processed in the criminal justice system, highlighting the diversity of protocols and practices outlined in state statutes to address these challenges. Further, it discusses several promising criminal justice interventions and policies for

mentally ill offenders, including the following:

Diversionary mechanisms, such as mental health courts, that route mentally ill offenders to  community-based mental health treatment programs instead of prison or jail

–  –  –

mentally ill offenders transitioning into the community Policies that provide mentally ill offenders with increased access to medical and mental health 

–  –  –

After reviewing these promising interventions, the background analysis finishes with suggestions for future research and a discussion of the implications of our findings.


I. Introduction Individuals with mental illness are overrepresented in the US criminal justice system. Severe mental illness afflicts nearly one-quarter of the US correctional population, including individuals in prisons, in jails, and on probation (Ditton 1999; Lurigio and Fallon 2007). Epidemiological studies place between 15 and 24 percent of prison inmates in this category (Baillargeon et al. 2009; Diamond et al. 2001;

Ditton 1999), and the most recent report from the Bureau of Justice Statistics (BJS) on the mental health of prison and jail populations in the United States indicates that more than 700,000 inmates reported symptoms or a history of a mental health disorder at midyear 2005 (James and Glaze 2006).

These numbers represent a substantial need for mental health treatment in the criminal justice system.

However, given that many prisons and jails are not equipped to handle this growing population with special needs, these numbers raise concerns about the well-being of mentally ill individuals involved in the criminal justice system, as well as the safety in correctional facilities and communities in general.

At the request of Janssen Pharmaceuticals Inc., this background analysis examines how individuals with mental illness are processed and treated in the criminal justice system and discusses the implications of insufficient or inadequate care for these individuals. In particular, the main objectives of this paper are to review current practice in the processing of mentally ill offenders, assess societal and economic costs associated with recidivism and insufficient care for this population, and highlight promising strategies to tackle challenges involved in the reintegration of mentally ill offenders into society.

This paper is organized as follows. First, we review the operational definition of mental illness as used in this paper as well as in the literature and legislative documents. Second, we provide an overview of the methodology used in this study to conduct a comprehensive review of current practice related to the treatment and management of mentally ill individuals in the criminal justice system. The paper outlines procedures used for collecting and synthesizing prior research and legislative documents regarding mental health treatment in the criminal justice system. Third, we present findings on the current landscape of mental health care for criminal justice populations, including a review of the costs associated with managing mentally ill persons in the criminal justice system, followed by a state-bystate scan of relevant statutes and codes that provide a framework for the definition and treatment of mentally ill offenders in each state. On the basis of prior research on reentry and diversionary programs for mentally ill offenders, we also identify evidence-based strategies to manage and treat mentally ill offenders in the criminal justice system. Finally, we identify gaps in empirical research on this topic and


discuss societal and economic implications of inadequate mental health care in the criminal justice system.

Research Questions Presented by Janssen Pharmaceuticals State-by-state analysis: How are mentally ill offenders defined, processed, and treated  differently across states, and what are the implications for recidivism?

National trends: What are the national trends regarding individuals with mental health  problems in the criminal justice system and associated costs related to recidivism?

Costs: What are the societal and economic costs associated with managing and treating  mentally ill persons in the criminal justice system?

Promising criminal justice policies and programs: What does research say about effective  strategies to address mental health needs of individuals involved in the criminal justice system?


II. Research Objective and Focus:

Severe Mental Illness among Individuals Involved in the Criminal Justice System One objective of this background analysis is to shed light on how the criminal justice system recognizes the status of being mentally ill and addresses the mental health needs of individuals diagnosed with mental illness. These findings provide the framework for an analysis of the costs associated with mental illness in the criminal justice system. As such, we are most interested in the extent to which mentally ill individuals are held liable for criminal acts; on what basis claims of mental incompetence can be made;

how the mental health needs of individuals involved in the criminal justice system are addressed; and what criminal justice interventions or policies have proven effective in improving mental health outcomes, as well as in reducing criminal behavior, among known offenders who have mental health issues. Thus, it seems relevant to focus on severe mental illness that significantly impairs mental functioning rather than more minor symptoms such as anxiety or sleep disorders. Severe mental illness is distinct from general mental health maintenance. Nonetheless, it is notable that neither exists in a vacuum, and the two cannot be completely separated from each other. This is especially true in jails and prisons, where many inmates have multiple diagnoses and co-occurring disorders, and where preexisting mental health conditions are often exacerbated by prison environments, causing the escalation of mental illness among those who are predisposed (Angelotti and Wycoff 2010).

Given the vast array of terminology used to describe mentally impaired conditions, we will refer to these impairments collectively as mental illness in this report unless otherwise noted. Also worth noting is that most of the literature examined for this report, explicitly or inexplicitly, focuses on severe mental illness among incarcerated populations.

This working definition of mental illness generally fits the established categories of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as stated below:

A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behavior (e.g.,

–  –  –

Occasionally, criminal justice research examines mental health problems broadly. For example, the most comprehensive correctional mental health data from BJS show “a recent history or symptoms of a mental health problem,” defined as a clinical diagnosis or treatment by a mental health professional (James and Glaze 2006, p. 1). Our report makes a distinction when the focus of prior research is broadly directed at mental health problems.

In addition to distinguishing between serious mental illness by the DSM-5 standards and other definitions of mental illness or mental health problems, we also distinguish between jail and prison populations frequently in this study. Jails are generally short-term city- or county-level facilities housing inmates who are awaiting trial or sentencing, as well as those who are serving relatively brief sentences (usually less than one year). Prisons, in contrast, are generally longer-term correctional facilities operated at the state or federal levels. It is important to note that these two terms are not interchangeable, especially in descriptions of correctional treatment programs, which tend to be more extensive in prisons because of their longer-term nature.


III. Data and Methodology This paper highlights how mentally ill persons are managed and treated in the criminal justice system by synthesizing information about policies and programs in place for such individuals. Recognizing the potential for state-level similarities and differences in the management and treatment of mentally ill offenders, we conducted a thorough review of the current state of policies and practice. Given the extensive body of literature surrounding mentally ill offenders, this study presents two targeted research initiatives: (1) a state-specific scan of practice, identifying how mentally ill offenders are defined and handled by the criminal justice system in each state, and (2) a literature review and synthesis on the treatment of mentally ill offenders and their reentry into society and the costs associated with this treatment or, in some cases, lack of treatment. In the following subsections, we describe the research protocols and procedures used in each of these initiatives.

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