International research evidence has suggested that persons with mental health problems are overrepresented within criminal justice systems. This is a matter of significant concern for professionals and policy makers involved in law enforcement, courts, community supervision of offenders, and the management of correctional institutions. Mental health treatment refers to interventions intended to ameliorate problems in cognitive, emotional, or behavioral functioning. These types of interventions may be offered to persons involved in the criminal justice system to address criminogenic risk factors, facilitate various criminal justice processes, or fulfill basic human rights to essential healthcare. Mental health treatment planning is the process of identifying and prioritizing interventions that correspond to the individual’s particular mental health concerns. This article includes estimates of the extent of the mental health problems faced by criminal justice populations, justifications for and types of mental health treatment, an overview of the basic elements of mental health treatment planning, and unique criminal justice considerations.
Mental Health Problems and Criminal Justice Systems
A number of factors can impede the development of accurate estimates of the number of persons with mental health problems within criminal justice systems. First, mental health problems vary widely along multiple dimensions, including symptomatology (e.g., depressed mood vs. disordered perceptual experiences), severity or degree of functional impairment, and expected course (e.g., remission after a few weeks vs. chronic problems persisting across the life span). Thus, estimates will vary depending on the types of problems included and how they are counted (e.g., a single time-point snapshot vs. counting any historical symptoms). Second, formal diagnoses are imperfect and can be costly to obtain. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition and the International Classification of Diseases and Related Health Problems–10th Revision are widely used and accepted by mental health practitioners. However, use of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition or the International Classification of Diseases and Related Health Problems–10th Revision requires training and thus can be costly in terms of human resources. Finally, in criminal justice contexts, a reliance on formal diagnoses may miss relevant concerns that do not fulfill diagnostic criteria. Thus, arriving at a meaningful estimate of mental health problems is not a straightforward task.
Acknowledging the difficulties associated with measuring rates of mental health problems, existing data can still provide some insight into the extent of these problems in criminal justice settings. In Canada, a 2015 prevalence study indicated that 40% of incoming male federal offenders (i.e., offenders receiving a custodial sentence of 2 years or more) met criteria for a mental disorder (the rate was approximately 70% when antisocial personality disorder and substance use problems were included). The U.S. Department of Justice released a report in 2017 estimating that 68% of female and 41% of male jail inmates, and 66% of female and 35% of male prisoners reported having a history of a mental health problem. High rates of mental health problems have also been observed among criminal justice populations outside North America, including among prisoners in India and police detainees in Australia. Thus, mental health problems among criminally involved persons represent an international issue.
Mental Health Treatment in Criminal Justice Settings
Justifications for the Provision of Mental Health Treatment
For some individuals, mental health treatment is the main focus of the criminal justice interventions they receive. For instance, in many jurisdictions, an offender may be found not guilty by reason of insanity or not criminally responsible if he or she had a mental illness at the time of the offense that impaired his or her ability to understand the nature of the act or that it was morally wrong. In such a case, the individual may receive a legal disposition requiring detention or community supervision, with the expectation that he or she will be provided with treatment to address the mental health problem that contributed to the offenses. Persons found to have impaired legal competencies or a lack of fitness to stand trial as a result of a mental health problem may also receive mental health treatment. One may be found incompetent or unfit to participate in any one of a number of criminal justice processes, from making decisions to waive certain rights during an arrest, to presenting a defense during a trial, to facing execution. Given that criminal justice processes may be paused until the individual’s competence or fitness can be restored, mental health treatment can be offered to restore competence.
For other individuals, mental health treatment is not the primary focus of criminal justice interventions. Nonetheless, mental health treatments may be employed as part of criminogenic interventions to directly reduce risk of recidivism, facilitate participation in other programming, or improve prospects for community reintegration. Mental health treatments for particular problems can also be offered on the grounds that they are considered essential healthcare. In the United States and Canada, for example, correctional inmates are considered to have legal rights to essential and some nonessential mental health services.
Types of Mental Health Treatment Offered in Criminal Justice Settings
Psychotropic Medication
Psychotropic medications are a common form of mental health treatment. Medications vary widely on a number of dimensions, including method of administration (e.g., orally administered pills vs. injections) and intended effects (e.g., increase mood, reduce anxiety, increase concentration). Psychotropic medications are generally prescribed (a) to directly treat mental health symptoms (e.g., hallucinations, delusions) in an effort to restore mental health and reduce symptomatology and/or (b) to behaviorally and emotionally stabilize agitated patients to increase staff and patient safety and institutional security. The net effect of these combined functions is that patients are able to benefit from psychosocial or criminogenic interventions when they are more behaviorally and emotionally stable, and their mental health is less compromised. For instance, antipsychotics (e.g., Risperdal, Seroquel), in addition to treating the symptoms of schizophrenia, may be used to curb impulsivity, aggression, agitation, and angry outbursts. The same may be said for anticonvulsants (e.g., Tegretol, Epival), which have similar stabilizing properties, in addition to being used to treat seizures or to control symptoms of mania.
Psychological or Behavioral Interventions
Other mental health treatments are primarily psychological or behavioral. For instance, some mental health treatment approaches are based on the cognitive behavioral therapy (CBT) model. According to the CBT model, an individual’s thoughts, emotions, and behaviors exert reciprocal influences on one another. Following from these assumptions, CBT interventions might focus on assisting a client to identify and alter irrational or problematic thoughts, develop healthier behaviors, or regulate emotions, in order to address a mental health concern. The relapse prevention model is another approach to mental health treatment that was developed for alcohol and substance use problems. Relapse prevention interventions involve the development of an individualized plan comprised of high-risk situations and corresponding strategies to successfully navigate such situations. It is also common for offenders with diverse mental health problems to demonstrate deficits in social functioning or life skills, which may result from or contribute to their primary concerns. For these individuals, behavioral interventions may be offered to remediate their functional deficits, regardless of the underlying mental health concerns.
What Is Mental Health Treatment Planning and Why Is It Necessary?
As mentioned previously, mental health treatment planning involves identifying and prioritizing treatment targets as well as corresponding interventions. While treatment plans will vary depending on the practitioner’s specific training and skills, they contain some common elements. Broadly speaking, treatment plans involve the application of a structured or systematic approach to interventions, informed by an assessment of problem areas. These plans require practitioners to explicitly identify what they are doing and why are they doing it. In doing so, practitioners allow themselves to monitor the effectiveness of a given intervention at the level of the individual patient and at the level of a patient population more broadly (e.g., through research evaluations).
Effective and evidence-based treatment plans often require mental health practitioners to obtain and synthesize a broad range of information, from general research trends to more specific data from the individual’s personal circumstances. As a result, a case formulation informed by a thorough assessment of the client’s functioning is an important element of treatment planning. For instance, the practitioner might consider and explore factors that cause, maintain, or exacerbate particular mental health difficulties, while also considering how various factors interact with one another. Mental health treatment plans based on poor or incomplete case formulations may not only fail to remedy mental health problems, they may actually make them worse. For instance, consider the case of an offender presenting with the following symptoms: low mood, decreased energy, impaired appetite, insomnia, and thoughts of suicide. A practitioner might reasonably conclude that the offender is experiencing a major depressive disorder, caused or maintained by an organic disturbance in the brain, and prescribe an antidepressant medication to elevate his or her mood. However, if the offender has previously experienced manic symptoms (e.g., elevated mood, inflated self-esteem, risky behavior), it is likely that the depressive symptoms are better understood as part of a bipolar disorder. This additional information would have important treatment implications, given that certain antidepressant medications could exacerbate mental health problems by triggering a manic episode. Thus, an accurate and comprehensive formulation of the individual’s mental health problems is a necessary element of treatment planning.
The selection of appropriate and evidence-based interventions is also a critical component of mental health treatment planning among criminal justice populations. Treatments offered to persons demonstrating psychopathic personality traits represent a good illustration of this concept. In the early 1990s, some researchers arrived at the conclusion that mental health treatment offered to psychopathic offenders increased their probability of criminal recidivism. However, in the mid2000s, a review of the treatment literature suggested that the data were inconclusive in this regard and identified significant problems with the specific intervention approaches that had previously been offered (e.g., the administration of LSD, nude marathon encounter sessions). In contrast, subsequent research studies evaluating treatment programs that target cognitive and behavioral factors that are theoretically and empirically associated with criminal behavior have produced more promising results for reducing recidivism in offenders with psychopathic traits.
Variations in Treatment Planning
Mental health treatment plans can take many forms depending on the mental health practitioners involved in a case, the patient’s mental health problems, and the setting, or the nature of the patient’s involvement in the criminal justice system. For example, a treatment plan for a case of moderate depression developed by an individual CBT practitioner might involve the following: written homework challenging negative thoughts, education regarding sleep hygiene, and instructions to engage in exercise. In contrast, a treatment plan developed by an interdisciplinary team (i.e., comprised of various mental health professions) for a not criminally responsible patient with a psychotic disorder (i.e., characterized by thoughts and perceptions that are inconsistent with reality) could include the following: medication to stabilize severely disordered thoughts and behaviors, education and counselling to encourage commitment to treatment, cognitive and behavioral interventions to develop coping strategies for chronic symptoms (e.g., ongoing voices), vocational rehabilitation to increase employability, and clinical discharge planning to establish stable housing and access to professional supports in the community.
Special Treatment Planning Considerations in Criminal Justice Settings
Treatment planning in criminal justice settings can present unique challenges. The following are a sampling of some of these challenges. First, practitioners must often explicitly consider criminogenic factors in identifying appropriate techniques. For instance, they may prioritize the reduction of symptoms that increase the risk of aggression over symptoms that the client finds more distressing. Second, some interventions could be impractical or even harmful in certain settings. For example, behavioral experiments designed to practice social skills or reduce social anxiety may be contraindicated in settings containing high numbers of aggressive and antisocial individuals. Third, many offenders have alcohol or substance use difficulties. This must be considered in dispensing psychiatric medications, which have the potential to become substances of abuse. Fourth, many individuals involved in the criminal justice system present with multiple and complex difficulties (e.g., mental illness, substance use, trauma, a history of head injury, antisocial personality features), making the development of a treatment plan a complicated and difficult task. Thus, to develop effective treatment plans in criminal justice settings, it is prudent to be mindful of assessment practices, emerging research evidence, and the need for flexibility in approach.
References:
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