Addressing the Challenge of Community Reentry Among Released Inmates with Serious Mental Illness

The purpose of the paper is to discuss the formidable challenges to community reentry and reintegration faced by U.S. prison inmates with serious mental illness and to describe various strategies for improving transitional services for these individuals. We review epidemiologic data supporting the high prevalence of severe mental illness in U.S. prisons as well as the historical factors underlying the criminalization of the mentally ill. The importance and challenges of providing adequate psychiatric care for mentally ill prisoners during their incarceration are discussed. We also review the numerous psychosocial and economic challenges confronting these individuals upon their release from prison, such as unemployment and vulnerability to homelessness, as well as specific barriers they may encounter in attempting to access community-based mental health services. We follow with a discussion of some of the more promising strategies for improving the transition of the mentally ill from prison to the community. In the final sections, we review the evidence for a relationship between serious mental illness and recidivism and briefly discuss emerging alternatives to incarceration of the mentally ill.     

Discussion: Reflections from the clinical trenches

This paper involves a series of personal reflections on the deleterious impact of excessive bureaucracy and other institutional forces on the psychosocial treatment of the chronically mentally ill. The writer appeals to three groups of mental-health practitioners—behavior analysts, practicing clinicians, and academic clinicians—to promote cultural change by advocating a restructuring of large-scale bureaucracies with the concurrent establishment of multiple community-based associations.     

Evaluating professionally operated and self-help programs for the seriously mentally ill

Reviewed a study by Bond et al. (1990) that evaluates assertive community treatment (ACT), an intensive community-based program for the seriously mentally ill. Such programs have been developed at a rapid pace in recent years but lack extensive research support. This randomized study supports the effectiveness of ACT and is a significant contribution to the mixed findings from the existing literature. However, its methodological flaws include (a) differential dropout from the ACT and comparison groups, (b) a relatively short follow-up period (12 months), and (c) limitations of the ACT intervention which prevents rehospitalization but lacks impact in other domains (e.g., social relationships, housing stability, employment). Self-help programs, poorly represented by the comparison group in this research, may offer the sorts of societal niches required by the mentally ill. Further research, giving such programs a "fair shake" against professionally controlled programs, is sorely needed.     

JOB DEVELOPMENT FOR THE MENTALLY RESTORED PSYCHIATRIC PATIENT1

The experiences of the placement department of the Mental Health and Manpower Project have demonstrated that an effective team can be created to develop job opportunities for the mentally restored psychiatric patient. Composed of a vocational counselor and a placement counselor, the team is effective in securing meaningful employment and developing re-education programs in the community. While the vocational counselor provides the clinical information concerning the restored patient-client, the placement counselor serves as a more personnel oriented individual in finding the appropriate kind of employment position. The team points to the potential that the mental health center possesses in involving the general community in its programs.     

TRANSITIONAL EMPLOYMENT PROJECT

McLean Hospital is a private, non-profit psychiatric hospital in Massachusetts. It is an extensive treatment facility providing outpatient care, patient hospitalization, and an inpatient bed capacity of 328. The psychiatric modalities used are traditional milieu structuring, individual and group psychotherapy, behavior therapy interventions, family and couples therapy, psychopharmacology, and rehabilitation treatment strategies. As in other psychiatric hospitals, vocational rehabilitation treatment strategies were severely challenged in the 1970s with the Supreme Court decision in the case of Souder versus Brennan. In essence, the findings in this class action suit construed traditional, clinical/vocational programs as forms of employment, not therapy. Thus, the issues of work adjustment and employment preparation for the psychiatrically disabled client needed to be creatively readdressed. Rehabilitation staff were called upon to redefine the activities presented to clients not only from the viewpoint of desired therapeutic interventions but also in terms of the new legal constraints. The shortened length of inpatient hospitalization also highlighted the need for aftercare rehabilitation opportunities. Responding to these needs, the Rehabilitation Services Department of McLean Hospital developed an independent transitional employment corporation called Everywhere Limited.     

Chiarugi and Pinel considered: Soul's brain/person's mind

Pinel and Chiarugi enter the standard histories of psychiatry under the rubric of “psychiatric reformers.” True enough, but insufficient in terms of the complexity and breadth of their thought. Despite Pinel's fame for the “moral,” i.e. psychological treatment of the mentally ill, previous scholarship on Chiarugi and his work would lead one to expect a richer humanity and warmer personal investment in the vagaries of the mentally ill under Chiarugi's auspices. A careful study of Chiarugi's Della Pazzìa and Pinel's Traitésuggest a different portrait. Though conjoined in their humanitarian ideals, these foundational figures in modern psychiatry voiced disparate ideas on the nature, etiology, and treatment of mental disorders, Chiarugi in the context of a biologic or “organicist” theory, Pinel in a psychosocial framework. Their reasoning in support of their opposing perspectives about the centrality of “biologic vs. psychological” determinants and interventions in psychiatry is remarkably congruent with those expressed today. © 1997 John Wiley & Sons, Inc.     

Community treatment for the seriously mentally ill: Is this community psychology?

Community treatment for seriously mentally ill individuals fits well into the philosophy of community psychology. Community psychologists have skills and experiences with other populations that represent assets in improving the ACT service model and producing richer and more useful research results for the future. Maybe we should ask ourselves why community psychologists have obviously avoided this intervention area and the population of seriously mentally ill individuals. Does this represent an adolescent reaction to the parent discipline — clinical psychology? Is the label “mentally ill” as stigmatizing to community psychologists as it is to the general population? Are these individuals written off as not worthy of or capable of benefiting from preventive interventions? Advocates for the seriously mentally ill are mounting a backlash against prevention services. We would be well advised at this time to become involved in community treatment and demonstrate that community psychology is forall vulnerable and at-risk population groups. If the truth of the matter is that “community psychology is not doing much of a job of empowering people” (Berkowitz, 1990), maybe the truth of the matter is also that we need to reach out to more disenfranchised populations with research to show that community psychologycan do the job of empowering some.     

Understanding public opinion relating to the establishment of community mental health facilities: implications of a discourse analytic approach

This paper demonstrates a novel approach to investigating the problem of public opposition to community mental health facilities. With the move towards community care, organizations setting up mental health facilities have encountered public opposition. It has been argued that this is due, in part, to the attitudes held by the public towards mentally ill people. A knowledge and understanding of attitudes towards this client group therefore has the potential to be of practical use to policy makers and practitioners who have a responsibility to consult on, and implement, community care for mentally ill people. The survey approaches and hypothetical situations used in previous British studies of community attitudes towards mentally ill people have, however, failed to take account of the rhetorical richness and complexity of the attitudes likely to be expressed in real‐life community care contexts. By contrast, the study reported in this paper used a discourse analytic approach to explore the views expressed about mentally ill people in a ‘hot situation’. Specifically, people's views were explored in the contexts of the arguments they used to challenge or advocate a supported accommodation project for mentally ill people in their community. This paper examines some of these arguments and discusses the theoretical implications for traditional approaches to attitude research. In conclusion, the potential practical utility of the findings is considered. Copyright © 1999 John Wiley & Sons, Ltd.     

Research Protections for Diverted Mentally Ill Individuals: Should they be Considered Prisoners?

The number of diversion programs for the mentally ill has increased dramatically over the past decade. These programs serve the valuable goal of reducing the growing population of incarcerated mentally ill persons by providing supervised community treatment. Research within these programs, critical for improving outcomes for these vulnerable individuals, is complicated by the fact that participants may have legal statuses which carry significant coercive leverage. In this way their ability to freely consent to research may be limited. In this paper, the authors describe the practice of diversion and review relevant research on coercion, informed consent and decisional capacity among the mentally ill and imprisoned. Current legal protections for prisoners are then discussed in the light of a recent proposal to broaden the legal definition of “prisoner” for research purposes to include community corrections populations, thus including diverted individuals. Copyright © 2011 John Wiley & Sons, Ltd.     

Firearms and the mentally ill: A legislative overview and jurisprudential analysis

This article examines federal and state laws that prohibit the mentally ill from possessing firearms and assesses the jurisprudence that has developed as courts have applied the federal law. It argues that although there is little or no empirical data linking the mentally ill with firearms violence, legislative activity and popular political debate invariably include such restrictions on the mentally ill. Notwithstanding the proliferation of firearms and antecedent violence, this article suggests that legislators and policy-makers must separate this issue from the broader and more emotional issue of “gun control” in order to effectuate better public policy and simultaneously protect the constitutional rights of the mentally ill.     

Rotting with their rights on: why the criteria for ending commitment or restraint of liberty need not be the same as the criteria for initiating commitment or restraint of liberty, and how the restraint may sometimes justifiably continue after its prerequisites are no longer satisfied

That coerced treatment must end when the criteria for initiating coerced treatment cease to apply appears to be universally accepted by courts and commentators.2 Moreover, the consensus appears to be justified by a steel-trap argument. If coercion is justified only when the patient is mentally ill and incapable, because then the patient lacks autonomous capacities, or lacks practical reasoning abilities that undercut autonomous capacities, then these justifications have no force when the patient either is not mentally ill or is capable. A parallel claim holds for civil commitment. This received wisdom, or in = out thesis, rests upon a conceptual confusion: a failure to distinguish the criteria for initiation of intervention, those for cessation of intervention, and the purpose of the commitment or coerced treatment. If the criteria for commitment were mental illness and dangerousness, and the criteria for release were the same, then the purpose of commitment would be to restore persons to the point where they are either just barely not mentally ill, or just barely not dangerous. That is a silly and self-defeating purpose for that large class of patients who, because of lack of insight, or otherwise, do not become treatment compliant until they are substantially healthier than being barely not mentally ill or barely not dangerous. It sets them up to become revolving-door patients. The purpose of commitment is rather to maximize the patient's mental health, and minimize her dangerousness without unduly burdening her liberty. If society is going to violate a patient's liberty, it should do so in a way that will resolve the problem that justified the restriction on liberty in the first place, so long as the restriction of liberty is not too great in relation to the expected gains from the intervention. The criteria for releasing a patient from commitment are in this way responsive to the purpose of the commitment. For some revolving-door patients, this entails that the criteria for their release from commitment should be stricter than the criteria for initiating commitment in the first place. The criteria for release from commitment for revolving-door patients should be that the criteria for initiation for commitment is not met plus it being more likely than not that the patient will be treatment compliant after release, assuming the additional restriction on liberty is less than the gains from the additional restraint, and the restriction is not unduly burdensome. Spelling this out, the criteria for release should be either not mentally ill, or else not dangerous, or capable, and more likely than not to be treatment compliant after release. For those patients for whom such a test is overly optimistic, we might substitute that there is a reasonable probability of treatment compliance after release, or that the probability of treatment compliance has been enhanced. These criteria are to be thought of as rough and ready rules of thumb, and not as analytically precise tests.     

Tonkens on the Irrationality of the Suicidally Mentally Ill

abstract   Ryan Tonkens proposes that my Kantian approach to suicide intervention with respect to the mentally ill (2002) wrongly assumes that the suicidally mentally ill are rational and are therefore rational agents to whom Kantian moral constraints ought to apply. Here I indicate how the empirical evidence concerning the suicidally mentally ill does not support Tonkens' criticism that the suicidally mentally ill are irrational. In particular, that evidence does not support the conclusion that such individuals are systemically practically irrational so as to undermine the attribution of at least minimal rational autonomy to them. A Kantian moral framework, albeit one developed in a non-ideal direction, remains applicable to such individuals.     

Children of Mentally Ill Parents Participating in Preventive Support Groups: Parental Diagnoses and Child Risk

In the Netherlands, preventive support groups are offered to children of mentally ill parents. Given the variety of parental diagnoses it might be questionable if offering a standardized program for all these children is the most effective response. While no overall knowledge exists about the type of parental disorder and varying risk levels and support needs among the participating children, we examined whether there are differences between these children that are related to their parents’ diagnoses. With questionnaires we assessed risk factors in 122 mentally ill parents and their children: high parental illness severity, low perceived parental competence, parent–child interaction problems, poor family functioning, difficult child temperament, and low child competence. We also assessed the children’s psychosocial problems and negative cognitions about their parent’s illness. Results showed that most parents had co-morbidity (multiple diagnoses) and/or personality disorders. Children of parents with either of these conditions were more likely to be exposed to the risk factors: high parental illness severity, low perceived parental competence, problematic parent–child interaction, and low perceived child competence, compared to children of parents without these conditions. They were also faced with more risk factors and had more psychosocial problems and negative cognitions. From these results we may conclude that children of parents with co-morbidity and/or personality disorders require more extensive support than children of parents without these conditions. We suggest strengthening the children’s competence and involving parents as important focuses of preventive interventions for children at high risk. Longitudinal studies should test these assumptions.     

The insanity sentence: Oregon's psychiatric security review board

In response to the dilemma of management of mentally ill persons who commit crimes, Oregon has created the Psychiatric Security Review Board (PSRB) to administrate the supervision and treatment of insanity acquittees. This paper presents an overview of the PSRB structure and examines the quasi-criminal justice features of Oregon's Insanity Sentence. The primary goal of the PSRB is the protection of societý. The maximum sentence, had the individual been found guilty, becomes the PSRB's jurisdictional period for that former defendant. A review of the administrative rules for conditional release and revocation of release that the PSRB is now in the process of adopting are described. The authors conclude that the PSRB is a promising approach which offers better community protection and better treatment for mentally ill offenders (NGRIs) than does the present prison parole system.     

Developmental patterns in the infants and young children of mentally ill mothers

The development of children (ages 2 to 49 months) of mentally ill mothers was compared with that of children of matched “well” mothers. The children of mentally ill mothers scored lower on measures of intelligence and had a less adaptive coping style in the testing situation. The children of “well” mothers were more socially competent; that is, they sought the attention of adults more often, responded more to social initiatives, displayed more positive affect, and sent clearer signals. Clinical data on the children of mentally ill mothers complemented the research data, indicating that these children displayed problems in the areas of interpersonal relationships, verbal-conceptual functioning, attentional skills, and mood and affect.     

Psychosocial Adaptation of Childhood Cancer Survivors and their Siblings

To best use resources in helping childhood cancer survivors, ascertaining the psychosocial adaptation deficit of the survivor is necessary. Psychosocial adaptation comprises a subjective, self-reflective indicator and objective indicators in terms of education, employment, and other achievements. While deficit is possible due to the trauma caused by cancer and its treatment, research evidence for the deficit is required to ascertain its existence. This study represents such a research endeavor based on a survey of 137 childhood cancer survivors and 101 cancer-free siblings of the survivors in Hong Kong, China. Results reveal weak and inconsistent differences in psychosocial adaptation between the survivor and his or her sibling. The effects of cancer treatment and service involvement on psychosocial adaptation were generally sporadic. Age presented the most pervasive influence on psychosocial adaptation. The results imply a justification for current practices in sustaining the psychosocial adaptation of childhood cancer survivors.     

Decreasing Psychiatric Symptoms by Increasing Choice in Services for Adults with Histories of Homelessness

Despite the increase in consumer-driven interventions for homeless and mentally ill individuals, there is little evidence that these programs enhance psychological outcomes. This study followed 197 homeless and mentally ill adults who were randomized into one of two conditions: a consumer-driven “Housing First” program or “treatment as usual” requiring psychiatric treatment and sobriety before housing. Proportion of time homeless, perceived choice, mastery, and psychiatric symptoms were measured at six time points. Results indicate a direct relationship between Housing First and decreased homelessness and increased perceived choice; the effect of choice on psychiatric symptoms was partially mediated by mastery. The strong and inverse relationship between perceived choice and psychiatric symptoms supports expansion of programs that increase consumer choice, thereby enhancing mastery and decreasing psychiatric symptoms.     

The impact of Federal rehabilitation laws on the expanding role of employee assistance programs in business and industry

Federal statutory and case law protecting the rights of individuals with disabilities has had a major impact in expanding the occupational options for mentally and physically impaired employees. One serendipitous result of these protections has been the expansion of job opportunities for psychologists in business and industry. This article examines important federal laws and regulations pertaining to the employment rights of the handicapped worker and emphasizes the intricacies involved for psychologists who work in the employee assistance field or who consult with management. The expansion of vocational options for psychologists working with business is traced, and future prospects for psychologists in this area are explored.     

The Utility of the SASSI‐3 in Early Detection of Substance Use Disorders in Not Guilty by Reason of Insanity Acquittees: An Exploratory Study

Previous studies have shown the Substance Abuse Subtle Screening Inventory‐3 (G. Miller, 1999) to be valid in classifying substance use disorders in forensic and mentally ill populations. The authors found that it also correctly classified substance use disorders in the understudied not guilty by reason of insanity population.     

The Effects of Time Pressure on Controlling Reactions to Persons With Mental Illness

Population surveys suggest that the general public stigmatizes persons with mental illness less than in the past. However, implicit attitude measures find that immediate reactions to mentally ill persons are still negative among both the general public and people diagnosed with mental illness. Time-course data suggest that these reactions may be dynamic, with immediate negative reactions becoming less prejudicial over time. We manipulated time pressures imposed upon social judgments about a mentally ill person. Participants perceived a mentally ill person as dangerous when forced to respond quickly; participants given ample time to respond were less likely to have this perception.