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Perspectives

Psychosis, Mania and Criminal Recidivism: Associations and Implications for Prevention

Lamberti, J. Steven MD; Katsetos, Viki MD; Jacobowitz, David B. MA; Weisman, Robert L. DO

Author Information
Harvard Review of Psychiatry: 5/6 2020 - Volume 28 - Issue 3 - p 179-202
doi: 10.1097/HRP.0000000000000251
  • Open

Abstract

Why are people with mental illness overrepresented throughout the criminal justice system? Research studies have consistently shown that the prevalence of mental illness is substantially higher in jail,1 prison,2 parole,3 and probation4 populations than in community settings. These studies have reported overrepresentation of a range of diagnoses, including attention-deficit disorder, posttraumatic stress disorder, anxiety disorders, mood disorders, and intellectual developmental disorders. Recently, research has suggested that the prevalence of mental illness is especially high among justice-involved women.5,6 How we understand this overrepresentation of people with mental illness within our criminal justice system is critical to developing effective prevention strategies. Unfortunately, our understanding of this problem and our attempts to address it are currently marked by two broadly divergent perspectives.

One view regards mental illness as having little or no relationship to criminal justice system involvement. This view is evident within the field of criminology in the risk-need-responsivity model, the predominant model of offender assessment and treatment in the world.7,8 According to the model’s risk principle, the likelihood of criminal behavior is reliably predicted by criminogenic risk factors that do not include mental illness. Called the central eight, these factors are criminal history, antisocial personality pattern, pro-criminal attitudes, social support for crime, substance use, family/marital problems, school/employment problems, and lack of healthy recreational/leisure pursuits. Beyond being predictive, research has shown that these factors might possibly have a causal relationship to criminal behavior—with the exception of criminal history, which is historical and non-modifiable.8 According to the needs principle of the risk-need-responsivity model, the seven remaining factors (called criminogenic needs) are appropriate and necessary targets of interventions aimed at preventing criminal recidivism. In discussing the risk-need-responsivity model in their influential textbook, The Psychology of Criminal Conduct, D. A. Andrews and James Bonta8(p 321) concluded that “clinical psychopathology is important for the humane treatment of individuals and management of disturbing symptoms, but its presence does not appear to be a significant predictor of criminal behavior.” This viewpoint suggests that mental illness is neither a predictor nor an appropriate target for interventions aimed at reducing criminal justice system involvement among people with mental illness.

In sharp contrast, mental health and criminal justice service providers typically view mental illness as a primary cause of criminal justice system involvement, at least in some cases. Because it is viewed as a possible cause of crime, mental illness is also viewed as an important target of intervention. This view is evident in the widespread practice of jail diversion, which, according to a Department of Health and Human Services website, “provides alternatives to incarceration to people who are arrested and jailed as a result of behaviors caused by their mental illness.”9 Jail-diversion strategies involve active diversion of justice-involved individuals with mental illness into community-based mental health treatments and services.10 Furthermore, assisted outpatient treatment laws in some jurisdictions mandate mental health treatment for people with mental illness who are unlikely to live safely in the community without supervision, including individuals with histories of repeated arrest.11

One source of confusion in understanding why people with mental illness enter the criminal justice system is a failure to fully appreciate the heterogeneity of mental illness. Mental illness is a general term that is analogous to motor vehicles, a term representing everything from scooters to semitrailers. In fact, the latest, fifth edition of the Diagnostic and Statistical Manual of Mental Disorders lists approximately 250 different diagnoses.12 These disorders range in scope from minor and temporary to severe and persistent. Given these differences, it is perhaps not surprising that treating “mental illness” is viewed by many criminologists as unimportant in preventing arrest and incarceration. However, two specific diagnostic categories of mental disorders—schizophrenia spectrum disorders and bipolar I disorder—may provide particularly important targets for interventions aimed at preventing criminal justice system involvement. These disorders are characterized by the presence of psychosis and mania, respectively, which can affect human behavior in especially profound ways.

Psychosis includes a group of symptoms that commonly vary in frequency, duration, and intensity within affected individuals. Examples include persecutory or paranoid delusions, where individuals believe they are being threatened or attacked, and command auditory hallucinations, where individuals hear voices directing them to do things that may include harming themselves or others. Mania likewise includes a range of symptoms that can vary over time. Common examples include significantly increased energy, irritability, impulsivity, and grandiosity, along with excessive involvement in high-risk activities such as reckless driving, unrestrained buying sprees, and sexual indiscretions. When severe, both psychosis and mania can manifest in complete loss of behavioral control that may necessitate the use of physical restraints and sedation for safety.13 The frequency, duration, and intensity of psychotic and manic symptoms are influenced by many variables.14,15 These include illness severity, treatment adherence, treatment effectiveness, substance use, environmental stressors, social supports, and personal coping skills.

Based on review of the current literature, this article will examine the evidence for and against an association between psychosis, mania, and criminal recidivism, and whether this association is predictive or causal in nature. Following that review, implications for developing effective interventions to prevent criminal recidivism among justice-involved adults with schizophrenia spectrum disorders and bipolar I disorder will be discussed.

METHODS

Data Sources

To examine possible associations between psychosis, mania, and criminal recidivism, a literature review was conducted of all studies published since 1998, the year of publication for the first meta-analytic review examining predictors of recidivism among individuals with mental disorders.16 The present review was conducted in two phases. The first phase involved using three search engines: Google Scholar, Ovid MEDLINE, and PubMed. Search terms included mental illness, psychotic disorders, psychosis, thought disorders, pharmacotherapy, antipsychotic, mood stabilizer, lithium, schizophrenia, schizoaffective disorder, bipolar disorder, mania, arrest, incarceration, crime, criminal justice, and criminal recidivism. All articles that appeared to meet the selection criteria based on their titles or abstracts, as well as those requiring closer examination to determine their potential relevance, were reviewed in full text. The second phase of the review involved an examination of citations that appeared in articles identified through the first phase; citations that appeared to meet selection criteria were subsequently reviewed in full text for possible inclusion.

Selection Criteria

This review specifically targeted studies that examined psychosis, mania, or related psychiatric disorders and their association with criminal recidivism. For review purposes, criminal recidivism was broadly defined as repeated offending, arrest, conviction, or incarceration, in order to encompass a range of study outcomes. Of note, studies that focused exclusively on violence or homicide as outcomes were excluded. Several recent reviews have already examined the relationship between major mental disorders and violence.17–22 And while serious violence is difficult to predict or prevent due to its infrequent nature, nonviolent crimes are common and thus may offer practicable opportunities for prevention. Prior to the current systematic literature review, however, no review has focused exclusively on the association between psychosis, mania, and nonviolent crime. Examples of nonviolent crimes include the following: prostitution; disorderly conduct; driving offenses; fraud; property crimes such as shoplifting, theft, burglary, and vandalism; and drug and alcohol-related crimes, including use, possession, and distribution.

This review also includes pharmacotherapy studies that examine whether treatment with medications can affect criminal justice system involvement. The reason for including these studies is that, if psychosis and mania are causally related to criminal recidivism, then treatment with antipsychotic medications and mood stabilizers should reduce criminal recidivism rates.

For inclusion in this review, publications were required to be written in English, to be peer reviewed, and to provide data on adult subjects with schizophrenia spectrum disorders, bipolar disorder, psychosis, or mania. Studies that examined subjects with “mental illness” in general without providing the necessary data were excluded. Only empirical studies were selected—both prospective and retrospective, including meta-analytic reviews. For each study the following information was extracted: study purpose, design, subjects, independent variables, dependent variables, and findings. Independent variable data represent each study’s measures of psychopathology, pharmacotherapy, or related health care expenditures. Dependent variable data represent each study’s criminal justice outcome measures, though not necessarily the study’s primary outcome measures. Likewise, findings relevant to the focus of this review, though not necessarily the main findings of each study, were also extracted. In studies with mixed or uncertain findings, the study authors’ conclusions are presented. Additional data, including time frames, subject numbers, means, and standard deviations, are presented for each study if provided by the authors.

RESULTS

Results are presented in Tables 1, 2, and 3. The studies varied widely in design, target population, and definition of variables related to psychosis or mania. Table 1 presents data from 13 studies reporting that psychosis or mania are unrelated, or inversely related, to criminal recidivism.16,23–34 Of these studies, one (7.7%)32 used a prospective research design, one (7.7%)23 used a cross-sectional evaluation, two (15.4%)16,29 involved meta-analytic reviews of the literature, and the remaining nine (69.2%) involved retrospective reviews of existing data. With regard to study populations, one (7.7%)25 examined veterans, one (7.7%)33 examined psychiatric outpatients on assisted outpatient treatment, two (15.4%)24,30 examined U.S. survey respondents, and the remaining nine (69.2%) examined individuals who were involved in various parts of the criminal justice or forensic systems. The majority of studies on Table 1 examined diagnoses (61.5%)24–28,30,31,34 rather than symptoms (15.4%);32,33 two (15.4%)16,29 examined both; and one (7.7%)23 examined mental health expenditures.

Table 1
Table 1:
Studies Supporting the View That Psychosis and Mania Are Unrelated or Inversely Related to Criminal Recidivism
Table 2
Table 2:
Studies Supporting the View of Psychosis and Mania as Related to Criminal Recidivism
Table 3
Table 3:
Studies Examining the Effect of Pharmacotherapy for Psychosis or Mania on Criminal Recidivism

Table 2 presents data from 25 studies reporting that psychosis or mania is associated with significantly increased criminal recidivism rates.35–59 Of these studies, two (8.0%)48,58 utilized prospective research designs, one (4.0%)50 involved a meta-analytic review of the literature, four (16.0%)37,42,44,54 utilized cross-sectional evaluations, and the remaining 18 (72.0%) involved retrospective studies. With regard to study populations, two (8.0%)51,53 examined U.S. survey respondents, five (20.0%)38,39,41,56,57 examined psychiatric inpatient populations, eight (32.0%)35,42–45,52,55,59 examined psychiatric outpatients, and nine (36.0%)36,37,40,46–49,54,58 examined individuals involved in various parts of the criminal justice or forensic systems. Compared to the studies in Table 1, a larger percentage of the studies in Table 2 examined psychiatric symptoms (20.0%)40,48,51,53,58 or symptoms and diagnoses (24.0%),42,43,50,54,56,57 rather than diagnoses alone (56.0%).35–39,41,44–47,49,52,55,59

Table 3 presents data from 12 studies that examined the effect of pharmacotherapy for psychosis or mania upon criminal recidivism.60–71 Instead of using symptoms or diagnoses as independent variables, these studies employed various measures of pharmacotherapy. Three (25.0%)63,65,67 examined general medication prescription data, four (33.3%)61,62,66,71 examined medication adherence, and five (41.7%)60,64,68–70 examined specific medications. Three studies (25.0%)61,62,68 utilized prospective research designs, and the remaining nine (75.0%) utilized retrospective designs. With regard to study populations, four (33.3%)61,64,69,70 examined individuals in the criminal justice or forensic systems, and the remaining eight (66.7%) involved psychiatric outpatients. Of the 12 pharmacotherapy studies, 11 (91.7%) reported that pharmacotherapy was associated with significantly decreased criminal recidivism, as evidenced by fewer arrests,60,62,65,66 fewer convictions,67,71 delayed time to first arrest or conviction following treatment,68,70 fewer days in prison,61,69 or fewer posttreatment offenses.64

In addition to variations in study design and target populations, the studies in this review used different definitions of criminal recidivism, including violations, arrests, convictions, jail days, and prison days. The types of crimes underlying these events can also vary to include any of the nonviolent crimes previously mentioned. Such variability lessens the likelihood of finding causal pathways, which may differ depending upon the particular criminal behaviors and outcomes being assessed. Because differences in how criminal recidivism is defined and measured should decrease rather than increase the likelihood of finding treatment effects,8 it is noteworthy that robust treatment effects are consistently present in Table 3.

Another feature of the current literature relates to differences in the independent variables used. Because schizophrenia and bipolar I disorder are relapsing and remitting disorders, full expression of their characteristic psychotic and manic symptoms occurs intermittently. As a result, studies examining diagnoses rather than symptoms are confounded by the fact that people with these disorders usually have attenuated symptoms or are otherwise without symptoms. Such individuals are still at risk for committing crimes in the absence of acute psychotic or manic symptoms, which can obscure a relationship between their symptoms and recidivism. Of note, Table 2 includes seven studies (28.0%)40,43,48,49,51,53,54 that specifically examined the time course of events, including symptom emergence and subsequent criminal justice events, through careful record review or interview. These studies enabled a more rigorous assessment of possible relationships between psychosis, mania, and criminal recidivism.

With the exception of pharmacotherapy studies, which examined the effect of medication treatment on criminal justice outcomes, most studies failed to account for the effects of treatment interventions. For example, chemical-dependency treatment can reduce the severity of substance use.72 To the extent that substance use is causally related to criminal justice system involvement, the presence or absence of effective treatment could affect the likelihood of such involvement. Beyond treatment per se, studies in general also failed to control for the effects of support services. For example, the presence of safe and affordable housing can potentially decrease the exposure of people with severe mental disorders to arresting officers.

With few exceptions,51,56 studies in this review also did not account for potentially important variations in the types of symptoms that were present. Research has suggested that certain types of psychotic56,73,74 and manic51 symptoms are especially likely to lead to arrest. These psychotic symptoms include persecutory delusions and command auditory hallucinations to harm others, while the manic symptoms include grandiosity, increased libido, and excessive engagement in pleasurable activities with a high risk of painful consequences. Also, people with schizophrenia spectrum disorders can have prominent “negative” symptoms in addition to psychotic symptoms. Common negative symptoms include apathy, anhedonia, amotivation, anergia, and social withdrawal. As demonstrated by Swanson and colleagues75 in their analysis of data from the national CATIE study, the presence of negative symptoms appears to mitigate the effect of psychotic symptoms. In other words, people with prominent negative symptoms may lack the necessary energy or social engagement to become involved in problematic or criminal activities.

It is noteworthy that two studies in Table 1 that initially found a positive relationship between symptoms or diagnoses and criminal recidivism subsequently found no relationship once they controlled for substance use.24,25 Several of the studies reporting increased recidivism rates in Table 2 also noted the presence of co-occurring substance use disorders. These observations raise the possibility that the apparent associations between psychosis, mania, and recidivism might be fully explained by the presence of co-occurring substance use disorders. Nearly half of the studies in Table 2, however, reported a positive relationship between psychosis, mania, or their related diagnoses and criminal recidivism even after controlling for substance use and other variables.

DISCUSSION

What Conclusions Can Be Drawn from the Literature Regarding the Association Between Psychosis, Mania, and Criminal Recidivism?

It is challenging to draw firm conclusions in light of the substantial inconsistencies present in the current literature. Studies differed widely in terms of their design, target populations, and independent and dependent variables. In addition, they generally failed to account for the time course of illness, symptom types, and effects of treatments and services. These differences likely contributed to the conflicting results found in this literature review. Nonetheless, a substantial majority (36 of 50; 72%) of studies in this review found that the presence of psychotic or manic symptoms is associated with an increased likelihood of criminal recidivism. This evidence suggests that psychosis and mania, depending on a variety of mediating and moderating influences, can function as predictors of criminal recidivism. Even so, the extent to which this association might actually be causal remains unclear.

The strongest evidence to date for a causal relationship between psychosis, mania, and criminal recidivism comes from studies that carefully examined the time course of symptoms and criminal justice events,40,43,48,49,51,53,54 and from pharmacotherapy intervention studies.60–71 As noted by Bonta and Andrews,8 “the causes of crime are most convincingly established not through the determination of correlates and predictors, but through the demonstrations of the effects of deliberate interventions.” Pharmacotherapy studies to date have consistently show both decreased criminal recidivism with initiation of pharmacotherapy and increased recidivism with medication nonadherence.61–70 Similar findings have been reported by studies examining the relationship between pharmacotherapy of psychosis, mania, and violence.21,67,76,77 This empirical evidence is also consistent with firsthand accounts of family members who have described their loved ones with severe mental disorders experiencing behavioral and legal consequences after stopping medications.78–80 However, whether symptoms cause recidivism and whether pharmacotherapy can prevent recidivism may represent different questions. There are multiple mechanisms through which medications may reduce criminal recidivism in persons with severe mental disorders. In addition to reducing psychotic symptoms, for example, antipsychotic medications have been shown to reduce both aggression81–83 and substance use.84,85 It has also been suggested that decreased recidivism may be due to improvements in an individual’s ability to avoid arrest,60,82 or to nonpharmacological benefits such as having regular contact with clinicians.67

In summary, review of the current literature suggests that a predictive and possibly a causal relationship may exist between psychosis, mania, and involvement with the criminal justice system. Given the inconsistencies in the literature to date, however, important questions remain about how symptoms might actually lead to criminal justice system involvement and, ultimately, how such involvement can be prevented. These questions are explored in the following sections.

How Might Psychosis and Mania Lead to Criminal Justice System Involvement?

The relationship between psychosis, mania, and arrest is clearly complex, with several possible mechanisms involved. Based on available evidence, there appear to be five primary pathways through which psychosis, mania, and associated mental disorders might lead to involvement with the criminal justice system:

  • − Psychosis and mania can sometimes directly lead to arrest. As summarized on Table 2, studies of diagnostically mixed groups have consistently shown that approximately 5%–10% of their arrests are due to behaviors that are a direct result of psychosis or mania.43,48,54 However, a study that specifically examined individuals with schizophrenia spectrum disorders and bipolar disorder suggested that 23% and 62% of their crimes, respectively, were completely or mostly related directly to symptoms.54 Because the presence of psychotic and manic symptoms does not always lead to arrest, the prevailing opinion is that the relationship between such symptoms and criminal recidivism is not strong.43,48,54 But it is also not negligible. Although violence is not a focus of this review, it deserves acknowledgment here as a possible causal pathway between symptoms and criminal justice system involvement. As stated by Douglas and colleagues18(p 693) in their meta-analysis examining the relationship between psychosis and violence, “psychosis appears to be intermediate in comparison to other putative risk factors. It is comparable to, or larger than, numerous other risk factors, though tends to be smaller than externalizing disorders, such as antisocial personality or psychopathy.”
  • Schizophrenia and bipolar disorder are associated with high prevalences of established criminogenic needs. For example, the prevalence of substance use disorders excluding nicotine dependence is approximately 10% in the general population.86 It is estimated to be approximately 40%, however, among people with schizophrenia and bipolar disorder.87–89 Likewise, the unemployment rate in the United States is currently 4%, but it ranges from 57% to 97% in people with schizophrenia90 and from 30% to 60% in people with bipolar disorder.91,92 Also, approximately 2% to 3% of the general population meet diagnostic criteria for antisocial personality disorder, a particularly strong predictor of criminal recidivism.93 By contrast, among community samples of people with schizophrenia and bipolar disorder, the rate of antisocial personality disorder is estimated to be 5% to 7%.94,95 To the extent that criminogenic needs may have a causal relationship to criminal behavior, as suggested but not proven by multiwave longitudinal studies,8 their co-occurrence represents another pathway to criminal justice system involvement among people with psychosis or mania.
  • − Psychosis, mania and associated symptoms can function as responsivity factors. While researchers have focused on the question of whether certain symptoms are predictors or causes of criminal recidivism, considerably less attention has been paid to examining whether symptoms can function as responsivity factors. According to the risk-need-responsivity model, responsivity factors are individual characteristics that affect a person’s ability to engage with, and learn from, correctional intervention.7,8 Low-level psychotic symptoms and hypomanic symptoms can potentially present barriers to correctional intervention. For example, paranoid individuals may be less willing or able to trust the advice of judges, probation, and parole officers. Likewise, feelings of grandiosity and euphoria may interfere with an individual’s willingness to follow orders from authority figures. It is also important to note that people with severe mental illness have higher rates of trauma than the general population.96 Research suggests that early exposure to traumatic events may interfere with a person’s ability to respond to correctional intervention.97,98 While responsivity factors may not lead directly to arrest or incarceration, they can make it harder for justice-involved individuals to exit the criminal justice system.
  • − Severe mental disorders and substance use may interact synergistically. Several studies have reported especially high rates of criminal recidivism among individuals with schizophrenia or bipolar disorder and co-occurring substance use disorders.1,26,27,53 Of note, studies by Wilson and colleagues26,27 found that individuals with co-occurring severe mental disorders and substance use had the highest recidivism rates of any group studied. In addition, Valuri and colleagues59 found higher conviction rates among substance users with psychotic disorders than in those with other mental illnesses. It was not reported how adjusting for these covariates altered effect sizes. Nonetheless, such reports suggest that schizophrenia and bipolar disorder might interact with substance use, with the combined effect greater than the cumulative effect of each factor separately.99 Substance use is known to be associated with medication nonadherence, emergence of psychotic and manic symptoms, and worsening of the course of illness among individuals with schizophrenia or bipolar disorder.100–105 Likewise, the presence of severe mental disorders greatly increases the likelihood of substance use, perhaps due to genetic mechanisms and also to self-medication for amelioration of certain symptoms.106–108 In addition, the co-occurrence of severe mental disorders and substance use each complicates treatment of the other.100,101,109 It should also be noted that the high prevalence of co-occurring substance use has occurred within a social and political context of harsh drug laws. This unfortunate situation has contributed significantly to overrepresentation of people with severe mental disorders throughout the criminal justice system,110 especially those who are African American or Hispanic.111
  • − Psychotic and manic symptoms are stigmatizing. Schizophrenia spectrum disorders and bipolar disorder are highly stigmatized conditions, due in part to the presence of symptoms that are bewildering and frightening to the general public. Popular movies and television, along with sensationalistic media coverage of violent acts perpetrated by people with severe mental disorders, further convey the notion that all such individuals are unpredictable and dangerous.112 In reality, most people with severe mental disorders are never arrested, and they are far more likely to become victims rather than perpetrators of crime.113,114 Nonetheless, such implicit beliefs about dangerousness can affect the way that criminal justice professionals interact with individuals with mental disorders. For example, Skeem and colleagues32 found that psychiatric symptoms predicted parole failure and return to prison, but not new offenses, in a group of parolees with schizophrenia and bipolar disorder. In explaining this finding, the authors stated that parole officers “keep offenders with mental illness on a ‘tighter leash’ than those without mental illness, based partially on stigma-based fear and paternalism.”32(p 221) Stigma has also contributed to problematic interactions between people with mental disorders and the police,115 such that stigma reduction is a goal of police-based crisis intervention team training.116 In addition, stigma has influenced public policy decisions about access to treatment, housing, and other services that have brought people with severe mental disorders into closer contact with the criminal justice system.110,117,118 These collective social forces, along with the declining availability of long-term psychiatric hospital care, have resulted in some people with severe mental disorders being jailed when they should have been hospitalized. This regrettable phenomenon has become known as the “criminalization” of people with mental disorders.48,119,120

What Are the Implications for Interventions Aimed at Preventing Criminal Recidivism Among Justice-Involved Adults with Schizophrenia or Bipolar Disorder?

Without definitive research to guide them, mental health and criminal justice service providers are both left facing the question of how to prevent further arrest and incarceration among people with schizophrenia and bipolar disorder who are involved in the criminal justice system. Current best practices for managing justice-involved adults with severe mental disorders are characterized by diversion from the criminal justice system into intensive, community-based mental health treatments and services. Examples of prominent jail-diversion strategies include mental health courts, specialty probation and parole, crisis intervention teams, and pretrial diversion programs.10 In addition, assisted outpatient treatment programs operate under civil law for individuals who have not committed crimes but may be at risk of criminal justice system involvement. Intensive outpatient mental health interventions commonly used with these strategies include assertive community treatment, integrated dual-diagnosis treatment, and intensive case management. For example, all enrollees in New York State’s assisted outpatient treatment programs are required to receive either assertive community treatment or intensive case management (in the form of care coordination adviser).121

To the extent that individuals’ criminal justice system involvement is caused by psychosis, mania, or related issues such as homelessness, intensive mental health treatments and services can reasonably be expected to reduce such involvement because they target these potential drivers. Some studies have even suggested that standard mental health treatment in general is effective at reducing criminal recidivism.66,122–125 However, reviews of the effectiveness of jail diversion interventions126–128 and mandated outpatient treatment129,130 in preventing criminal recidivism have consistently shown mixed results. In a multisite study of who succeeds in jail-diversion programs, Case and colleagues131 found that criminal history rather than clinical factors was the strongest predictor of failure. In addition, research has shown that criminal behaviors beginning before the onset of a mental disorder are more likely to be associated with factors such as antisocial personality and substance use than with psychosis or mania.56,57,132 Such findings suggest that mental health treatments and services, while necessary, may not be sufficient to prevent criminal recidivism among individuals with psychosis and mania who have lengthy criminal histories.

In the absence of conclusive research on the causes of crime, those who seek to prevent criminal recidivism among justice-involved adults with schizophrenia and bipolar disorder may wish to consider addressing a range of factors that might drive that involvement. Based upon the available literature, these factors include psychosis and mania along with the seven criminogenic needs as identified within the risk-need-responsivity model. Community mental health service providers, however, rarely screen for criminogenic needs or incorporate them into treatment plans in a systematic manner, even in assertive community treatment programs that specialize in serving justice-involved patients.133 In contrast to mental health professionals, community corrections professionals routinely utilize standardized “risk/needs assessment” tools, such as the Level of Service Inventory, to identify and address potential drivers of crime.134–136 According to the Council of State Governments Justice Center,137 these tools are used “to guide decision making at various points across the criminal justice continuum by approximating a person’s likelihood of reoffending and determining what individual criminogenic needs must be addressed to reduce that likelihood.” Risk/needs-assessment tools are also becoming more gender informed,138,139 which is important in view of the high prevalence of mental illness among justice-involved women.5,6

Probation and parole officers typically use risk/needs assessments to make decisions about supervision frequency and intensity, assigning the highest levels of oversight to individuals with the highest recidivism risk. Because these tools also identify criminogenic needs, there is a growing emphasis within community corrections on using them to develop targeted interventions to prevent future recidivism. This emphasis is evident in the recent development of the Level of Service/Case Management Inventory, which prompts users to develop service plans to address each individual’s unique criminogenic needs.136 In addition, training programs for probation and parole officers such as Effective Practices in Community Supervision (EPICS) strongly emphasize teaching skills and prosocial behaviors to clients rather than relying upon the use of violations or threats of incarceration.140,141

The current emphases within the field of community corrections on preventing criminal recidivism and promoting socialization now parallels the emphases within the field of community mental health on preventing symptom relapse and promoting recovery. This convergence can provide an important foundation for collaboration between mental health and criminal justice professionals—who serve the same clients in community settings. Collaboration between mental health and criminal justice professionals is widely viewed as essential in serving justice-involved adults with severe mental illness,142–145 and specialized models of community-based care have emerged that emphasize such collaboration.58,146 However, fundamental differences in values, goals, and methods between mental health and criminal justice staff can pose significant barriers to effective collaboration in community settings.147–149 For example, mental health professionals typically value health and utilize person-centered approaches, whereas criminal justice professionals typically value safety and may utilize enforcement-oriented approaches. Attempts at collaboration between mental health and community corrections professionals can potentially result in increased violations and arrests as a result of such differences, particularly if corrections officers are guided by a philosophy of enforcement rather than problem solving.149,150 Although the risk-need-responsivity model strongly emphasizes the use of problem-solving strategies over punishment, barriers to implementing the model remain within community correctional settings. These include burgeoning correctional caseloads, growing financial pressures, and organizational resistance to change.8 Increased violations and arrests can also occur if collaborating mental health professionals begin to function as an arm of the criminal justice system, simply reporting illegal behaviors to their community corrections counterparts rather than engaging them in active problem solving.149

To promote effective collaboration, prospective collaborators should work toward having shared goals and accountabilities, a guiding philosophy that emphasizes problem solving over punishment, clearly defined roles and responsibilities, and clarity around what information will be shared and why.147,151 It should also be recognized that there are potentially important similarities in how outpatient mental health and community corrections professionals work with their respective clients in community settings.147 Both groups must engage their clients, perform individualized assessments, intervene accordingly, and problem solve when problematic behaviors emerge or persist. These functional similarities can provide opportunities for productive collaboration at each step of the process, beginning with engagement. Some people with severe mental disorders and substantial criminal histories will remain unwilling or unable to engage in care despite the availability of mental health services that are culturally competent, trauma informed, and motivationally based. In the absence of the needed treatments and services, such individuals are at increased risk for endangering themselves or others, for poor health outcomes, and for considerable pain and suffering among their family members. Justice-involved individuals who consistently refuse necessary care may accept it, however, if stipulated by probation or parole officers, or by the courts. This acceptance, although legally leveraged, can provide a critical first step in helping people with severe mental disorders become active participants in their own care.152

Following engagement, the client-assessment process can provide an additional opportunity for effective collaboration. In pursuing their respective missions of promoting patient health versus public safety, both outpatient mental health and community corrections professionals have traditionally paid more attention to some of the factors associated with criminal recidivism than to other such factors. Figure 1 illustrates the general focus of mental health versus criminal justice professionals with respect to these factors. Their different foci call to mind the parable of the blind men and the elephant, where each man felt certain that his assessment of the elephant was accurate despite touching only part of the animal. Sharing the results of their respective psychosocial and risk/needs assessments might thus enable mental health and criminal justice service providers to have a more complete understanding of their mutual clients, thereby laying the groundwork for more effective intervention.

Figure 1
Figure 1:
Relative areas of mental health and criminal justice focus on factors associated with criminal recidivism.

The intervention process can potentially provide another opportunity for productive mental health and criminal justice collaboration. Each field has developed effective interventions to address the criminogenic needs within their respective domains.147,153 For example, community mental health service providers routinely utilize evidence-based practices to address psychosis, mania, co-occurring substance use, family problems, and unemployment. They typically lack skills, however, in addressing antisocial personality, pro-criminal attitudes, and social support for crime. Because criminology research has suggested that these criminogenic needs are most strongly associated with crime, they are commonly addressed by community corrections professionals.8,154 For instance, cognitive-behavioral strategies such as Thinking for a Change and Reasoning and Rehabilitation are often used within community correctional settings to address pro-criminal attitudes and antisocial behaviors.155,156 These respective mental health and criminal justice intervention strategies, if combined, could potentially address the full array of possible drivers of criminal behavior that are shown in Figure 1.

Regardless of the intervention approaches used, behavioral problems are likely to occur when serving justice-involved adults with severe mental disorders in community settings. In addressing these problems, collaboration can also provide an opportunity for shared problem solving. By drawing upon their respective knowledge bases, experiences, and resources, collaborating mental health and criminal justice professionals can potentially maximize the likelihood of successful problem resolution. To help people with severe mental illness who straddle two service systems, two heads may be better than one.

Many communities currently lack specialized models of collaborative care such as mental health courts,157 mental health probation,158 and forensic assertive-community treatment.159 However, most communities are served by both mental health and criminal justice service providers—a co-location that provides a natural opportunity for collaboration. Mental health professionals who serve individuals under community correctional supervision should consider the potential risks and benefits of reaching out to their criminal justice counterparts in the interest of establishing working partnerships on behalf of their shared clients.

CONCLUSION

Review of the current empirical literature suggests that psychosis and mania have a predictive and, in some cases, possibly a causal relationship to criminal recidivism. To the extent that causal relationships are present, mental health treatments and services might reasonably be expected to reduce recidivism among symptomatic individuals. Mental health treatment is unlikely to be sufficient, however, for individuals whose recidivism is driven by factors unrelated to their mental disorders. Unfortunately, the current literature does not support a reliable way of determining which individuals’ criminal justice involvement can be reduced through pharmacotherapy or other mental health treatments alone. For optimal prevention, those who serve justice-involved adults with psychosis or mania should consider identifying and addressing the full range of factors that are potential drivers of criminal justice system involvement. These aims can potentially be accomplished through mental health and criminal justice collaboration, which may provide opportunities to promote client engagement, to improve assessment accuracy, and to combine best-practice interventions from each field. The extent to which such collaboration is successful may depend, in part, on the ability of mental health and criminal justice professionals to embrace a shared philosophy and to develop strategies for working together effectively.

In closing, it must be acknowledged that even optimal collaboration among service providers is unlikely to fully address the problem of overrepresentation of people with severe mental disorders throughout the criminal justice system. Advocacy is needed at a public policy level to address stigma, racism, punitive drug laws, access to treatment, lack of affordable housing, and other social factors that likely perpetuate criminal justice system involvement among people with severe mental disorders.

Declaration of interest

Drs. Lamberti and Weisman are owners of Community Forensic Interventions, LLC, a company that provides consultation and technical assistance in the community-based care of justice-involved adults with serious mental illness.

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Keywords:

bipolar disorder; criminal justice; recidivism; risk factors; schizophrenia

Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the President and Fellows of Harvard College.