Community-based care for people with severe mental illness in Canada

The development of mental health services for people with severe mental illness has in many ways paralleled that in other countries, particularly the United States. As reliance on inpatient psychiatric care has been sharply reduced, a wide range of community supports have been developed. Several distinct institutional and legal features have contributed to shaping the nature of these community supports, which are described herein. At present, the result is a highly fragmented system of care. Key evidence-based practices, notably assertive community treatment, supported employment, and integrated treatment for concurrent severe mental illness and substance use disorder, achieve considerable integration at the clinical level, but remain relatively unavailable in most provinces. The policy of regionalization of services risks inhibiting the development of such practices, which require more centralized technical assistance and monitoring. An evolutionary approach of gradually introducing integrated, evidence-based programs may provide the most feasible strategy for improving the system.     

Short-term outcomes for offenders with mental illness released from incarceration

Using data on 247 offenders with mental illness, this analysis seeks to identify characteristics that distinguish those who are returned to prison or a psychiatric hospital with those who remain in the community. Sociodemographic, mental health, criminal history, and service variables are compared across a range of outcome categories with a focus on those reinstitutionalized and those reincarcerated. Those returning to institutions have somewhat different mental health service and criminal justice histories than the engaged/community group. In particular, the group that is reincarcerated is more likely released from misdemeanor sentences, and the group being released from felony sentences is more likely to be found in a psychiatric hospital after release from correctional custody. These findings have implications regarding the cumulative effects of engagement with the criminal justice system and the process through which persons with mental illness and a criminal history cycle through institutions.     

Treating offenders with mental illness: a research synthesis

The purpose of this research synthesis was to examine treatment effects across studies of the service providers to offenders with mental illness. Meta-analytic techniques were applied to 26 empirical studies obtained from a review of 12,154 research documents. Outcomes of interest in this review included measures of both psychiatric and criminal functioning. Although meta-analytic results are based on a small sample of available studies, results suggest interventions with offenders with mental illness effectively reduced symptoms of distress, improving offender's ability to cope with their problems, and resulted in improved behavioral markers including institutional adjustment and behavioral functioning. Furthermore, interventions specifically designed to meet the psychiatric and criminal justice needs of offenders with mental illness have shown to produce significant reductions in psychiatric and criminal recidivism. Finally, this review highlighted admission policies and treatment strategies (e.g., use of homework), which produced the most positive benefits. Results of this research synthesis are directly relevant for service providers in both criminal justice and mental health systems (e.g., psychiatric hospitals) as well as community settings by informing treatment strategies for the first time, which are based on empirical evidence. In addition, the implications of these results to policy makers tasked with the responsibility of designating services for this special needs population are highlighted.     

The impact of mental health services on arrests of offenders with a serious mental illness

This study examines the impact of mental health services on arrests of offenders with a serious mental Illness (SMI) by assessing changes in associations between receipt of outpatient and emergency room/inpatient services and arrests one, two, and three quarters later. A variety of data sets were used for identifying 3,769 offenders who were in the Pinellas County Florida jail between 7/1/2003 and 6/30/ 2004, and 7,755 offenders who were in the Harris County Texas jail between 10/1/2005 and 9/30/2006. Arrests, out-patient and emergency room/inpatient services were assigned to one of 16 ninety-day periods between 7/1/2002 and 6/10/2006 in Pinellas County and one of 12 such periods between 10/1/2004 and 9/15/2007 in Harris County. Generalized estimating equations were used. Covariates were age, gender, race, diagnosis, and homelessness. The results were also adjusted for exposure to arrests. In Pinellas County, outpatient services significantly reduced the risks of arrests 1 quarter later by 17% (odds ratio [OR] = 0.83, 95% confidence interval [CI]: 0.78-0.87, p < .001), two quarters later by 11% (OR = 0.89, 95% CI: 0.84-0.94, p < .001), and three quarters later by 9% (OR = 0.91, 95% CI: 0.86-0.96, p = .001). In Harris County, these services reduced the risk of arrest 1 quarter later by 5% (OR = 0.95, 95% CI: 0.91-0.99, p = .028), but not two and three quarters later. In Pinellas County, ER/inpatient services increased the risk of arrests by 22% (OR = 1.23, 95% CI: 1.15-1.30, p < .001), 8% (OR = 1.08, 95% CI: 1.02-1.15, p = .010) and 11% (OR = 1.11, 95% CI: 1.02-1.16, p = .001) one, two, and three quarters later. In Harris County, these services increased the risk of arrest only 1 quarter later (OR = 1.16, 95% CI: 1.11-1.22, p < .001). Results suggest that service receipt and its timing may have had some impact on the arrests of adults with a SMI and criminal justice involvement.     

Exposing the myths surrounding preventive outpatient commitment for individuals with chronic mental illness.

Using New York's "Kendra's Law" as an illustrative vehicle, this article addresses the principal criticisms lodged by opponents of preventive outpatient commitment. The authors argue that preventive outpatient commitment is a useful adjunct to conditional release or placement in the least restrictive alternative that has neither produced revolutionary change in psychiatric commitment standards nor will be used inappropriately to assert governmental control over mentally ill citizens. The authors contend additionally that preventive outpatient commitment does not violate federal constitutional norms or represent bad policy making. The authors acknowledge, however, that the coercion inherent in outpatient commitment schemes may produce certain undesirable side effects. Thus, they explore an alternative approach currently in development in Australia that promotes community-based treatment for chronically mentally ill persons without judicial intervention.     

Engagement processes in model programs for community reentry from prison for people with serious mental illness

Linking prisoners with mental illness with treatment following release is critical to preventing recidivism, but little research exists to inform efforts to engage them effectively. This presentation compares the engagement process in two model programs, each representing an evidence-based practice for mental health which has been adapted to the context of prison reentry. One model, Forensic Assertive Community Treatment (FACT), emphasizes a long-term wrap-around approach that seeks to maximize continuity of care by concentrating all services within one interdisciplinary team; the other, Critical Time Intervention (CTI), is a time-limited intervention that promotes linkages to outside services and bolsters natural support systems. To compare engagement practices, we analyze data from two qualitative studies, each conducted in a newly developed treatment program serving prisoners with mental illness being discharged from prisons to urban communities. Findings show that the working relationship in reentry services exhibits unique features and is furthered in both programs by the use of practitioner strategies of engagement, including tangible assistance, methods of interacting with consumers, and encouragement of service use via third parties such as families and parole officers. Nevertheless, each program exhibited distinct cultures and rituals of reentry that were associated with fundamental differences in philosophy and differences in resources available to each program.     

Perceptions and experiences of people with mental illness regarding their interactions with police

This study examined the perceptions and lived experiences of people with mental illness in relation to their interactions with the police. A community-based participatory research approach was used and a procedural justice theoretical perspective guided the study. In-depth, semi-structured interviews were conducted by peer researchers with 60 people with mental illness who had interacted with the police and were living in Metro Vancouver, Canada. Among the study participants, contact with the police was frequent and occurred under a diverse range of circumstances. The majority of participants perceived being treated in a procedurally just manner by the police officer(s) who were involved in their most recent interaction. Almost three-quarters (n = 43, 72%) of participants were generally satisfied with how the police officer(s) had handled their most recent interaction. The slight majority of participants (n = 30, 51%) rated their previous contacts with the police as a positive experience overall, with 32% (n = 19) indicating that their previous interactions with the police were negative life experiences. The findings paint a more balanced picture than that which is often portrayed by the media. Emphasizing a procedural justice framework for police handling of situations involving people with mental illness is a vital step toward improving how these interactions are experienced and perceived.     

Community reintegration of prisoners with mental illness: a social investment perspective

Responding effectively and efficiently to the needs of persons with mental illness returning to the community from prison requires identifying their differences in need and placement difficulties upon return and targeting reintegration investments to reflect these differences. This paper has three parts. The first part profiles the male special needs population in New Jersey prisons. These profiles describe behavioral health and criminal justice characteristics of 2715 male inmates with mental health problems, and are used to identify the scope and nature of the public's investment opportunity. The next part describes the costs associated with possible "investments." The special needs population is classified by need and placement difficulty, and then matched to reentry and community-based treatment programs. Costs are estimated for reentry planning and community-based treatment for the first year post-release. The third part recommends an investment strategy and a set of operational changes that might minimize the loss and maximize the return on the public's investment dollar in mental health.     

Review essay / mental illness and criminal justice

Norval Morris, Madness and the Criminal Law Chicago: The University of Chicago Press, 1982, 235 pp.     

Crisis intervention team training: when police encounter persons with mental illness

Abstract

The Crisis Intervention Team (CIT) model is an established training program used to improve police response to encounters involving persons with mental illness (PwMI). Diversion of PwMI from the criminal justice system to appropriate treatment providers in the community is one of the primary goals of CIT. The present study examines characteristics and outcomes of encounters between citizens experiencing mental health-related crises and CIT-trained patrol officers. Findings of this study indicate encounters involving PwMI and CIT-trained officers often result in diversion to mental health services. Implications for policy and future research are discussed.     

The right of caregivers to access health information of relatives with mental illness

This article reviews the legal, ethical and practical challenges of complying with the Ontario Personal Health Information Protection Act (PHIPA) within the context of a Canadian mental health system that is overburdened and under resourced. The advent of deinstitutionalization has placed significantly increased responsibilities on the families of mentally ill individuals. While research evidences that involving family members in the care of their mentally ill relatives improves treatment outcomes, mental health practitioners constantly face the challenge of engaging family caregivers while also complying with privacy laws. The authors propose an Ontario Caregiver Recognition Act (OCRA) to formally recognize family caregivers as informal health information custodians based on the practice of other jurisdictions which incorporate the rights of family members actively engaged in providing care to their mentally ill relatives.     

TEMPO: A contemporary model for police education and training about mental illness

Given the increasing number of interactions between police and people with mental illnesses (PMI), there has been widespread interest in the development of education for police about how best to interact with PMI. This paper reflects the review of current practice in a variety of jurisdictions across Canada as well as in the United States (U.S.), the United Kingdom (U.K.) and Australia; it proposes a comprehensive model of learning based on the literature that addresses not only the content in the narrow sense but also the importance of broader contextual knowledge and understanding in developing effective education and training. Embedded in the principles articulated in the Mental Health Strategy for Canada, the TEMPO (Training and Education about Mental illness for Police Organizations) model is a multilevel learning strategy for Canadian police personnel. Learning objectives and key principles are articulated in order to ensure the model is applicable to a wide range of police agencies and individual jurisdictional needs. In addition to providing a firm basis of factual knowledge for police personnel, the resultant model embraces a human rights/anti-stigma philosophy, provides for a range of education appropriate to diverse police audiences, emphasizes a systems approach to police/mental health liaison activities and addresses issues related to the delivery and implementation of police education and training.     

Improving police response to persons with mental illness: a multi-level conceptualization of CIT

The large numbers of people with mental illness in jails and prisons has fueled policy concern in all domains of the justice system. This includes police practice, where initial decisions to involve persons in the justice system or divert them to mental health services are made. One approach to focus police response in these situations is the implementation of Crisis Intervention Teams (CIT). The CIT model is being implemented widely, with over 400 programs currently operating. While the limited evidence on CIT effectiveness is promising, research on CIT is limited in scope and conceptualization-much of it focusing on officer characteristics and training. In this paper we review the literature on CIT and present a conceptual model of police response to persons with mental illness that accounts for officer, organizational, mental health system and community level factors likely to influence implementation and effectiveness of CIT and other approaches. By moving our conceptualizations and research in this area to new levels of specificity, we may contribute more to effectiveness research on these interventions.