Offenders With Mental Disorders: A Call to Action

In the song "Who Killed Davey Moore?" Pete Seeger outlines the death of a boxer. Each verse portrays the excuse of a different party to the match: the referee, the promoter, Davey Moore's manager, the opposing boxer, and the audience.

We are that audience. Instead of watching a boxing match, we watch as hundreds of thousands of mentally ill offenders go untreated or inadequately treated. Mental health professionals, as a group, are reluctant to go into jails and prisons to serve the needs of this population and are perhaps more reluctant to bring such patients into their offices and clinics for treatment. We share the societal fear of this group, no matter the lip service we pay to treating persons with the most serious mental illnesses.

Much attention is paid to the small group of mentally ill offenders adjudicated insane under state or federal law. Although this group is important—particularly as the target of newly developed treatment programs for difficult-to-treat patients—they represent only the tip of the iceberg. Currently in the United States, nearly 6 million people are in jail or prison or on parole or probation on a given day. Most studies estimate the prevalence of mental illness in this population to range between 10 and 15 percent, equivalent to 600,000 to 900,000 individuals. It is time for psychiatry and community mental health to pay attention to this large and challenging patient population.

The papers in this special section contradict the notion that this group of patients is untreatable.

In a study reported in the first paper, Howard M. Kravitz, D.O., M.P.H., and Jonathan Kelly, M.D., examined rates of rehospitalization and criminal recidivism among offenders with mental illness adjudicated as not guilty by reason of insanity and mandated to treatment in a forensic psychiatric outpatient program. They found that even after treatment in the specialized program, the offenders remained impaired and many were rehospitalized, but they point out that rehospitalization is preferable to rearrest for this forensic population.

Susan F. McClanahan, Ph.D., and her colleagues, authors of the second paper, explored relationships among three precursors of prostitution—childhood sexual victimization, running away, and drug use. They found that childhood sexual abuse and running away constitute distinct pathways to prostitution, but drug use did not explain entry into prostitution. They discuss the need for different mental health service interventions for women who wish to leave prostitution, depending on which pathway to prostitution they experienced.

The third paper, which I wrote with Richard Feldman, L.C.S.W., describes a collaborative treatment program developed by a community mental health center and a probation officer of the U.S. federal prison system to serve the mental health needs of offenders on probation, parole, supervised release, or conditional release in the community. Findings on service outcomes for the program's first clients suggest that the intervention may have improved the clients' level of compliance with the conditions of their release.

In the fourth paper, Henry J. Steadman, Ph.D., and his colleagues describe a three-year research initiative begun in 1997 by the Substance Abuse and Mental Health Services Administration that is using a standardized research protocol to systematically study the outcomes of a variety of jail diversion programs in nine sites throughout the U.S.

In the fifth paper, Doug Badger, M.S.W., and his associates report on strategies for planning services in the United Kingdom and conclude that both large-scale epidemiological studies and smaller regional surveys are needed to fully determine mentally ill offenders' characteristics and service requirements.

The sixth paper, by James A. Swartz, Ph.D., and Arthur J. Lurigio, Ph.D., examines the prevalence of psychiatric disorders among male jail detainees in drug treatment and highlights the need for integrated treatment of psychiatric and substance use disorders within criminal justice drug treatment settings.

The papers focus on treatment issues related to a variety of forensic populations, including pretrial detainees, parolees, and offenders found insane, as well as convicted felons and misdemeanants. Treatment programs at various stages of development are discussed, and attention is paid to the treatment of the individual patient-offender as well as to the development of services for populations of offenders. All of these papers highlight the point that mentally ill offenders can be treated. It is time for psychiatry and other mental health disciplines to include these difficult-to-treat but needy clients in their mission.