Improving Outcomes for People with Serious Mental Illness and Co-Occurring Substance Use Disorders in Contact with the Criminal Justice System

Individuals with serious mental illness are over-represented throughout the criminal justice system (1). An effective, accessible mental health system may prevent criminal justice involvement or allow for diversion to more appropriate treatment settings. When contact with the justice system is appropriate, outcomes can be improved and inappropriate expenditures can be reduced. This white paper focuses on policies that can improve outcomes overall. The focus is on local efforts to implement evidence-based practices within both the criminal justice system and the mental health system and on federal policy opportunities to strengthen such efforts.

Although serious mental illness affects up to 5% of the general population, police estimate that 7%–10% of their encounters involve individuals with mental illness (2,3). Individuals with mental illness are more likely than those without mental illness to be arrested for the same behavior (4,5). Two million individuals with serious mental illness cycle through our nation’s jails every year. The rates of serious mental illness among jail inmates is about 17%, and most have a co-occurring substance use disorder (6,7). These numbers are mirrored in prison, probation, and parole populations (8). In addition, half of all justice involved veterans have mental illness or substance use disorders (9).

Inmates with mental illness tend to stay in jail and prison longer than others charged with similar offenses and are less likely to be approved for probation or parole (1,10,11). Upon release, they have a greater chance of recidivating, particularly those with co-occurring illnesses, compared with other offenders (10,12,13). Recidivism is often the result of violating the conditions of probation or parole rather than committing a new crime (13,14). These violations may not be willful but instead the result of the disorganizing effects of the mental illness itself or secondary to housing instability, lack of transportation, or other effects of poverty (12).

Community reentry is especially important for African-American citizens with mental health challenges, who are disproportionately affected by incarceration (13,15,16). Reentry from jail comes with many challenges for individuals returning home, but the experiences of those with mental illness are uniquely difficult. Challenges include arrow windows of release, unpredictable discharges, limited supported housing options, and delayed receipt of general medical and mental health services in the community. Existing data indicate that reintegration efforts that connect returning citizens to treatment and resources such as housing and employment are cost-effective and help reduce recidivism (17). However, mental health treatment, housing, and employment services are often not available to the population in need.

Failure to provide accessible, effective evidence-based treatment along with the necessary support services in community mental health settings also contributes to the over-representation of individuals with mental and substance use disorders in the justice system. Between 2009 and 2011, states cut more than $1.8 billion in mental health funding for children and adults; for 11 states, mental health budget cuts accounted for 12%–35% of their overall state mental health general fund budget (18). These cuts translate into decreased community resources, increased emergency room visits and inpatient hospitalizations, increased homelessness, and premature death. In the absence of effective services, symptoms and secondary effects of mental illness are criminalized and individuals in large numbers end up in the criminal justice system. Although communities need to address the criminogenic risk factors identified among people with mental illness, the expertise and technology developed in the criminal justice system to accomplish this have not been integrated into mental health treatment (19).

There are two theories that provide the foundation for community responses to improve the outcomes of contact between the mental health system and the criminal justice system. Criminal justice professionals have studied the causes of recidivism and use the Risk-Need-Responsivity model to inform treatment and supervision of the system’s population (20). Mental health professionals developed a Sequential Intercept model to identify opportunities for intervention (21).

The Risk-Need-Responsivity model is an evidence-based approach to understanding how a person’s level of recidivism risk determines the intensity of intervention (19). The model explains that justice-involved individuals with serious mental illness score higher than offenders without serious mental illness on criminogenic risk factors that predict recidivism (22). To effectively address the over-representation of individuals with serious mental illness in the criminal justice system, it is critical to assess these criminogenic risk factors and address the corresponding criminogenic needs (19).

The Sequential Intercept Model is a conceptual framework that suggests that each point in the criminal justice system where an individual with mental illness may appear presents a public health opportunity to divert that individual to the treatment system. There are emerging best practices at each intercept point that communities can adopt to reverse the over-representation of people with mental illness in the criminal justice system. These diversion practices require a willingness among leaders and practitioners at all levels of the mental health, addiction, and criminal justice systems to work together and to do things differently (21,23).

Four key outcome measures that can be examined at baseline to characterize the extent of the problem and monitored over time to evaluate the impact of any interventions:

1. Reducing the number of people with behavioral health disorders booked in jail
2. Reducing the length of time people with mental illnesses remain in jail
3. Increasing connections to treatment
4. Reducing recidivism

In recognition of the universal problem, the National Association of Counties, the Justice Center of the Council of State Governments, and the American Psychiatric Association Foundation have started the Stepping Up Initiative. Every U.S. county has been asked to sign on to work together across county systems to reduce the number of people with mental illness in local jails (24). So far 341 of the nation’s 3,142 counties have signed on (25).

Understanding that what is counted is what gets attended to, Stepping Up emphasizes the need to collect data. The initiative targets four key outcome measures that can be examined at baseline to characterize the extent of this problem and monitored over time to evaluate the impact of any interventions, including: 1) reducing the number of people with behavioral health disorders booked in jail, 2) reducing the length of time people with mental illnesses remain in jail, 3) increasing connections to treatment, 4) reducing recidivism.

If these data are not currently available, an essential first step is to establish the processes, policies, and monitoring capacity to collect and track these data elements. County leaders have considerable potential to mobilize change to improve the criminal justice system, reduce unnecessary costs, and protect the public safety while addressing mental health.

Examples of promising practices (26) that are increasingly being adopted include:

Specialized police response programs, such as the crisis intervention team (CIT) program (27)

Use of a validated brief screen at the time of jail booking to identify individuals with serious mental illness and/or substance use disorders (28)

Problem-solving courts, such as mental health courts or specialty dockets for veterans (29)

Jail policies to suspend rather than terminate Medicaid coverage, so that upon release individuals have immediate access to treatment, including prescribed medication (30)

Implementation of the SSI/SSDI Outreach, Assist, and Recovery (SOAR) Program, funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), which provides resources to state and local agencies to increase access to Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) benefits to eligible adults experiencing mental illness, homelessness, medical impairment, and/or a co-occurring substance use disorder (31)

Forensic assertive community treatment teams that integrate probation officers into the interdisciplinary mental health treatment team (32).

Ideally every U.S. county will sign on to Stepping Up. Next, they must convene the group of committed cross-system stakeholders needed to create change. Implementation efforts may be informed by a recent monograph, Reducing the Number of People with Mental Illness in Jail: Six Questions County Leaders Need to Ask (25).

Stepping Up, the Justice Center of the Council of State Governments, the National Alliance on Mental Illness (NAMI), and the SAMHSA GAINS Center (Gather, Assess, Integrate, Network, and Stimulate), among others, offer a great deal of information, guidance, and resources to implement components of Stepping Up. Nevertheless, this work is not easy. States and counties may need expert facilitation to successfully launch efforts such as Stepping Up. The SAMHSA GAINS Center offers training and technical assistance to communities to develop strategies to identify needs and provide services and resources for individuals with co-occurring mental and substance use disorders in the criminal justice system. Sequential Intercept Mapping is a 1.5-day workshop to facilitate collaboration; identify and discuss ways to reduce barriers between the criminal justice, mental health, and substance abuse treatment systems; and begin development of integrated local plans (23). State-level technical assistance centers are more knowledgeable about local systems and laws and may be able to offer continuing technical assistance, resources, and training that national centers cannot provide. For example, in Ohio the Criminal Justice Coordinating Center of Excellence offers Sequential Intercept Mapping to Ohio counties and ongoing technical assistance. This may be a model other states may choose to replicate (23).

States and counties currently have a great opportunity to move this work forward. The 21st Century Cures Act incorporates the Comprehensive Justice and Mental Health Act, which reauthorizes funding for state and local governments to design new approaches to reducing the number of people with mental illness in jail and expand access to veterans treatment courts. The Cures Act also incorporates the Mental Health and Safe Communities Act, which creates the National Criminal Justice and Mental Health Training and Technical Assistance Center and also supports state and local efforts to improve community capacity to recognize and respond to mental illness. The Cures Act offers a variety of funding opportunities to communities to improve their mental health and addiction systems and to develop programs at each of the intercept points. Policy Research Associates has created a template of funding opportunities that the 21st Century Cures Act provides through both the Department of Health and Human Services and the Department of Justice (33).

Counties should convene the necessary stakeholders and take advantage of current funding opportunities through the 21st Century Cures Act.

States should work to increase collaboration across state agencies and consider support of a technical assistance center funded jointly by mental health, addiction, and public safety partners. At the same time, counties should convene the necessary stakeholders and take advantage of current funding opportunities through the 21st Century Cures Act. Implementing Stepping Up in every community is a means to accomplish that end. It will also take sustained advocacy to be certain that the resources in the 21st Century Cures Act are maintained or increased.