Preventing Criminal Recidivism Through Mental Health and Criminal Justice Collaboration

Justice-involved individuals should be engaged in each step of the collaborative process (8,23,24). Collaborating mental health and criminal justice staff can begin by engaging their mutual clients around a common goal—to be healthy and free from criminal justice involvement. This approach requires prospective collaborators to embrace public health and public safety as complementary rather than as competing goals. As noted by Matejkowski and colleagues (25), “An approach that pairs evidence-based treatment with accountability under close supervision for offenders with psychiatric or substance use disorders could be more effective at promoting public health and safety than either treatment or supervision alone.”

Rapport with justice-involved clients can be strengthened by informing them of the nature and purpose of the mental health–criminal justice collaboration, including what information about them will be shared and how it will be used. As observed by Draine and Solomon, however, such details often are not provided to justice-involved individuals. In a study of clients on probation and parole, those investigators noted that “client comments to researchers reflected a poor understanding—sometimes an overestimation, other times an underestimation—of the nature or extent of collaboration in their case. Such misunderstandings may undermine client trust in both systems” (11). Given that persons with serious mental illness can have significant cognitive deficits, using written materials or pictures and other visual aids to inform them about collaboration can be helpful (26).

Collaborating mental health and criminal justice staff can further engage their shared clients by treating them with respect and empathy, offering them choices, providing encouragement, and being nonjudgmental (27). Although such strategies may seem contrary to the correctional ethos, using relationship skills to enhance motivation is recognized as a best practice both in correctional rehabilitation (21) and in health care (28). In addition, evidence suggests that when people feel they have been treated fairly by authorities, they are more likely to accept an authority’s decisions (29) and they may have better mental health outcomes (30,31).

Persons with serious mental illness are overrepresented throughout the criminal justice system (32). Many have attributed this problem to deinstitutionalization and lack of access to psychiatric services (33). However, the lack of association between mental illness and crime (34,35) and the failure of standard mental health treatment to prevent crime (36,37) led mental health researchers to seek a criminologically informed understanding of recidivism among adults with serious mental illness (38,39). These efforts drew attention to the importance of targeting risk factors that drive criminal recidivism in this population, which is a basic principle of effective correctional intervention. It is now widely accepted that criminal recidivism is driven by “criminogenic” risk factors of individuals with or without mental illness (9,40,41). The eight central risk factors are history of antisocial behavior, antisocial personality pattern, antisocial cognition, having criminal companions, family/marital problems, work/school problems, lack of healthy leisure/recreational pursuits, and substance abuse (17). Although mental illness in general is not associated with criminality (42), research has also established that psychosis and mania can sometimes directly lead to criminal justice system involvement (43,44).

The process of identifying criminogenic risk factors and what is needed to prevent criminal recidivism is called risk and needs assessment, or simply “risk assessment” (17). Standardized tools for criminogenic risk assessment such as the Level of Service Inventory–Revised and the Wisconsin Risk and Needs have been shown to reliably predict the likelihood of criminal recidivism among diverse offender groups, including individuals with mental illness (17,45). In general, as outlined in Table 1, criminal justice authorities conduct criminogenic risk and needs assessments, which focus on public safety, whereas mental health professionals conduct psychosocial assessments, which focus on client health. However, there is substantial overlap in these assessments. Although the psychosocial assessment process is not designed to assess risk of criminal recidivism, it involves assessment of risk for other adverse outcomes, including violence, homicide, suicide, and relapse. Also, both types of assessments examine substance use, employment status, financial status, family supports, and residential stability. Sharing respective results can thus improve evaluation accuracy and identification of clients at greatest risk of recidivism while laying the groundwork for collaborative planning and treatment.

A recent review examining the applicability of criminogenic risk assessment to persons with mental illness suggests that addressing both mental health problems and criminogenic risk factors together will enhance prevention of criminal recidivism (46). In addressing mental health problems, it is noteworthy that mental health professionals routinely address four of the eight central risk factors (substance abuse, work/school problems, family/marital problems, and lack of healthy leisure/recreation pursuits). This process includes the use of evidence-based practices, such as integrated dual-diagnosis treatment for co-occurring substance use disorders (47), individual placement and support for unemployment (48), and family-based interventions for family and marital problems (49). In addition, mental health professionals routinely apply best practices to address “responsivity factors” that influence how justice-involved individuals respond to correctional intervention. Responsivity factors can include trauma, homelessness, cultural differences, and symptoms of serious mental illness, such as paranoia and impaired cognition (21). However, uncertainty exists concerning who should address the problematic thinking that leads to antisocial behaviors. Although Table 1 suggests that criminal justice professionals have no role in treatment, they sometimes use cognitive-behavioral treatment to address criminal thinking (50). Cognitive-behavioral best practices have been developed with correctional populations to address antisocial cognitions and attitudes (51,52), and they have shown promise for people with mental illness (46). Yet these interventions are rarely used by mental health professionals to address criminal thinking within outpatient treatment settings. Also, new models, such as effective practices in community supervision (the “EPICS” model), have been developed to teach probation and parole officers evidence-based principles of effective behavioral management (53). Unlike cognitive-behavioral therapies for criminal thinking, however, behavioral management principles are often used by mental health professionals within residential and day programs for persons with co-occurring mental illness and substance use disorders (54,55). These observations provide a clear rationale for mental health–criminal justice collaboration in planning and treatment, including deciding who is responsible for providing which treatments and services for each client.

Consistent with principles of effective correctional intervention, collaborating service providers should monitor for both nonadherence and for signs of progress. Because treatment adherence is generally a stipulation of leverage-based intervention strategies, clinicians should submit regular progress reports to their criminal justice partners as part of the monitoring process. Communication is the key to effective monitoring, and it should include face-to-face meetings between representatives of the outpatient mental health team and the supervising criminal justice agency when possible. Such meetings can help build rapport between collaborators while enabling them to better understand and address adherence issues.

Face-to-face meetings also provide a forum for joint meetings with clients. Joint meetings provide collaborators with an opportunity to formally recognize and reinforce clients’ progress. In addition, they can foster both engagement and accountability by directly involving clients in the process of identifying and addressing problem behaviors. However, joint meetings are unlikely to reduce recidivism if based on a philosophy of enforcement and control (11,12,56). Evidence suggests that the most effective approach to monitoring clients involves building a therapeutic alliance while incorporating principles of procedural justice to create an environment that is firm, fair, and caring (29,56–58).

Working with justice-involved clients rarely goes smoothly, especially when multiple criminogenic risk factors and responsivity factors are present. Even clients who make good progress can be expected to take backward steps. Responding to these setbacks should reflect a balance between recognizing that such problems are an inevitable part of the recovery process, and the need for accountability and public safety. This balance can be supported by considering the following three principles when addressing nonadherence and other behavioral issues as part of the collaborative process.

The transition step involves the conclusion of criminal justice oversight. This event marks a significant change for justice-involved individuals, one that can place them at increased risk of relapse into drug use and other problematic behaviors. Collaborating mental health and criminal justice professionals can help their mutual clients prepare for this event by offering transitional services and supports. Providing extra outpatient appointments can give clients transitional support while enabling clinicians to observe them more closely for warning signs of illness exacerbation. Involving supportive family members, friends, and residential service providers can further give clients the physical and emotional resources necessary for a successful transition. As an added benefit, such individuals are generally well positioned to alert care providers to early warning signs of relapse into psychosis, addiction, or both. Another example of transitional support is offering a representative payee for clients who may be tempted to buy illicit drugs and alcohol in the absence of criminal justice oversight. Among persons with serious mental illness and co-occurring substance use disorders, having a representative payee has been associated with decreased substance use and improved quality of life (62). Also, hosting graduation ceremonies and other recognition events may help clients adjust to this major transition (63).