A New Approach to Reduce Recidivism among Incarcerated Adults with Behavioral Health Disorders

Adults with behavioral health disorders are disproportionately represented in the criminal justice system. The Criminogenic Risk and Behavioral Health Needs Framework provides a starting point for corrections, mental health and substance abuse professionals to make better decisions to improve public health and safety outcomes.
 

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About the Author

Nicole Jarrett is a senior policy analyst for the CSG Justice Center.

Warren T. Hansen is a public affairs manager for the CSG Justice Center in the Washington, D.C., office.
 

State correction officials are increasingly concerned about the growing number of incarcerated individuals with mental health or substance abuse issues. Nearly three-quarters of the adults entering jails and half entering state prisons have substance use disorders,1 while 17 percent of adults entering jails and prisons have serious mental illnesses.2 State corrections directors often say their biggest challenge is the record number of people with behavioral health disorders in jails and prisons, or on probation or parole.3 With approximately 650,000 people released from state prisons4 and more than 9 million released from jails5 returning to their communities each year, community-based behavioral health providers also struggle to meet the needs of this significant population.
 
Adults with behavioral health needs involved with the justice system often have poor outcomes. They are incarcerated longer than individuals without behavioral health disorders for the same charges and sentences.6 People with behavioral health disorders also often have difficulty complying with the requirements of incarceration and supervision and are more likely to face disciplinary problems and have their probation or parole suspended or revoked.7
 
As corrections populations have grown, the cost of the health care services correctional facilities are required to provide has stretched their budgets and personnel. As a result, these facilities often lack the resources to provide the kinds of services many of these individuals need to recover and avoid reincarceration.8 Corrections and behavioral health care administrators are recognizing the urgent need to reconsider the best means to facilitate reentry and service delivery to the many people under their care with substance abuse and mental health problems.
 
Addressing the Challenge
To address these challenges, leaders in the corrections and behavioral health fields have increasingly partnered—often through public and private partnerships—to improve outcomes for people with behavioral health problems involved with the criminal justice system. There has been significant progress in advancing collaborative responses to reduce recidivism and promote recovery. In June 2002, The Council of State Governments Justice Center released its landmark “Criminal Justice/Mental Health Consensus Project Report,” which highlighted promising strategies and collaborative efforts backed by corrections and mental health officials.
 
Hearing the joint call for action, local, state and federal governments have allocated resources to respond to this issue. In 2002, the U.S. Department of Health and Human Services’ Substance Abuse and Mental Health Services Administration—also known as SAMHSA—established a jail diversion grant program to support counties across the country that design new and expand existing programs serving people with mental illnesses and co-occurring substance abuse disorders.9 Through the Mentally Ill Offender Treatment and Crime Reduction Act enacted in 2004, Congress established a competitive grant program to promote collaboration between the mental health and criminal justice systems.10 State governments have launched similar grant programs. The Second Chance Act of 2007 increased federal funding available for reentry programs; state and local governments are frequently focusing on the particularly high recidivism rates among people with substance abuse disorders and mental illnesses.11
 
Developing a Shared National Approach
While these and similar investments are crucial, the available resources nationwide do not meet the overwhelming needs of individuals on probation or those returning from prison or jails to the community. Policymakers must ask whether scarce resources are being put to the best use in advancing public safety and personal recovery.
 
Although many corrections and community-based behavioral health agencies have made important advances in allocating the limited resources within their own systems, investments in treatment and supervision traditionally have not been coordinated well and sometimes even work against each other with adverse consequences.
 
In 2010, the CSG Justice Center launched a project to address how these systems can start developing consensus on who should be prioritized for treatment, what services they should receive, and how those interventions should be coordinated with supervision. As a result of 18 months of work, a shared decision-making framework was developed to integrate each system’s independent approaches in ways that improve health and public safety goals.
 
On Sept. 27, 2012, the CSG Justice Center released “Adults with Behavioral Health Needs under Correctional Supervision: A Shared Framework for Reducing Recidivism and Promoting Recovery.” The report was supported by the U.S. Justice Department’s National Institute of Corrections and Bureau of Justice Assistance, and by SAMHSA. It was developed in partnership with the Association of State Correctional Administrators, National Association of State Mental Health Program Directors, National Association of State Alcohol and Drug Abuse Directors, American Probation and Parole Association, and other organizations and national experts.
 
The report introduces an evidence-based framework for prioritizing scarce resources based on assessments of individuals’ risk of committing a future crime and their treatment and support needs. The report also outlines the principles and practices of the substance abuse, mental health and corrections systems, and proposes a structure for state and local agencies to build collaborative responses.
 
The Framework
 
 
The main feature of the report is the Criminogenic Risk and Behavioral Health Framework, which provides a structured approach for agencies to begin building collaborative responses. The framework, presented in the figure above, is based on three dimensions: criminogenic risk (the likelihood of reoffending),12 need for substance abuse treatment, and need for mental health treatment. The framework results in eight possible permutations of varying risk and need groupings. Knowing the size of each group will help system planners understand their supervision and treatment capacity and identify any service gaps. Consistent with research on recidivism reduction, the framework helps to focus resources on higher-risk and higher-need populations. This information can also facilitate tailored interventions for each individual.
 
The framework calls for practitioners to assess a person’s mental health needs separately from their risk of reoffending. Relying on actuarial assessments and best available scientific methodology, the framework helps practitioners match the right person to the right intervention. It also underscores that recovery and rehabilitation are achievable and calls for the reallocation of resources where they will be most efficient and effective. The framework helps professionals in the corrections and behavioral health systems in the following ways:
  • Advance collaboration and communication on challenging issues that each system has traditionally viewed differently by:
  • Developing a shared language around risk of criminal activity and public health needs;
  • Establishing common priorities between criminal justice and behavioral health systems for individuals who are likely to commit future crimes and have treatment needs;
  • Underscoring the need for sharing information across systems;
  • Creating a common starting point and then facilitating cross-systems support for policies, practices and decision-making.
  • Ensure that scarce resources are used efficiently by:
  • Promoting the use of validated assessment tools to gauge individuals’ criminogenic risk and needs—i.e., those associated with the likelihood of committing a future crime—together with substance abuse and mental health needs;
  • Identifying the right people for the right interventions—those most likely to benefit from coordinated supervision and treatment strategies, and those that can do well with fewer interventions;
  • Encouraging collaborative decision-making among system leaders on how scarce treatment slots and intensive supervision services should be allocated to have the greatest impact, and then aligning and developing capacity to meet those needs.
  • Promote effective practices by:
  • Matching individuals’ risk and needs to programs and practices associated with research-based, positive outcomes;
  • Ensuring consistency of coordinated approaches while allowing for individualization of treatment and case management strategies;
  • Refocusing reentry and other efforts for individuals to equip them with the skills and competencies to become law-abiding, healthy members of communities and families.13
 
Applying the Framework
The CSG Justice Center is using the framework to help state and local jurisdictions analyze their systems to maximize the impact of investments in criminal justice and behavioral health.
 
In 2011, New York City Mayor Michael R. Bloomberg launched a Citywide Justice and Mental Health Initiative, with support from the U.S. Department of Justice’s Bureau of Justice Assistance and the Jacob & Valeria Langeloth Foundation, that worked with the CSG Justice Center to understand and address the increased prevalence of individuals with mental health needs in the city’s jails. Using in-depth quantitative analysis of more than 48,000 individual jail admissions, and with input from more than 20 focus groups, the CSG Justice Center distilled different levels of risk of recidivism and mental health needs within the jail population.14
 
The CSG Justice Center worked with New York City leadership to develop different strategies based on assessed risk of pretrial failure to appear, charges, risk of recidivism, and mental health and substance use needs. The city has budgeted almost $10 million over three years to develop the processes and infrastructure to support quick, state-of-the-art assessment on these different dimensions, referral processes, and appropriate options for community-based treatment and supervision. With the framework as a guide, city leaders were able to develop systematic approaches that not only build on existing resources but also make these resources more likely to achieve maximum public safety and public health goals.15
 
To further promote framework-inspired approaches and responses to jurisdictional challenges, the CSG Justice Center is developing resources to assist with system-wide implementation. These tools will include a report examining the strengths and weaknesses of criminogenic risk tools widely used in the United States. In addition, the CSG Justice Center and SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation will release transition planning guidelines in September 2013 to assist behavioral health agencies and corrections and community corrections administrators in developing cross-systems reentry approaches to respond to the multi-dimensional needs of justice-involved clients and the agencies that supervise them.
 
Conclusion
The challenges facing adults with behavioral health needs under correctional supervision are complex and multi-faceted. The framework provides the opportunity for corrections, substance abuse, and mental health professionals to better understand their overlapping populations and to make important decisions on how existing resources should be allocated and how to expand their capacity to better meet public health and safety goals. It is a starting point and touchstone for ongoing dialogue across systems. The path to better outcomes for this population starts here.
 

Notes
1. Mumola, Christopher J., and Jennifer C. Karberg, Drug Use and Dependence, State and Federal Prisoners, 2004 (Washington: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 2006); Karberg, Jennifer C., and Doris J. James, Substance Dependence, Abuse, and Treatment of Jail Inmates, 2002 (Washington: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 2005).
2. Steadman, Henry J., Fred C. Osher, Pamela Clark Robbins, Brian Case, and Steven Samuels, “Prevalence of Serious Mental Illness Among Jail Inmates,” Psychiatric Services 60, no. 6 (June 2009): 761–765; Ditton, Paula, Mental Health and Treatment of Inmates and Probationers (Washington: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 1999).
3. Wilkinson, Reginald A., “Written Testimony on the Criminal Justice System and Mentally Ill Offenders,” (Submitted to The United States Senate Judiciary Committee Hearing, June 11, 2002).
4. Guerino, Paul, Paige M. Harrison, and William J. Sabol, Prisoners in 2010 (Washington: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, December 2011). (The number of releases from state prisons from 2005–2010 ranged from a high of 692,303 in 2006 to 649,677 in 2010.)
5. Solomon, Amy L., Jenny W.L. Osborne, Stefan F. LoBuglio, Jeff Mellow, and Debbie A. Mukamal, Life After Lockup: Improving Reentry from Jail to the Community (Washington: Urban Institute, May 2008). Accessed July 25, 2012.
6. Ditton, Paula, Mental Health and Treatment of Inmates and Probationers (Washington: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 1999).
7. Skeem, Jennifer L., Eliza Nicholson, and Christine Kregg, “Understanding Barriers to Re-entry for Parolees with Mental Disorder,” in D.G. Kroner (Chair), Mentally Disordered Offenders: A Special Population Requiring Special Attention, symposium conducted at the meeting of the American Psychology-Law Society, Jacksonville, FL, March, 2008; Baillargeon, Jacques, Brie A. Williams, Jeff Mellow, Amy J. Harzake, Steven K. Hoge, Gwen Baillargeon, and Robert B. Greifinger, “Parole Revocation Among Prison Inmates with Psychiatric and Substance Use Disorders,” Psychiatric Services 60, no. 11 (November 2009): 1516–1521.
8. Osher, Fred C., David A. D’Amora, Martha Plotkin, Nicole Jarrett and Alexa Eggleston, Adults with Behavioral Health Needs Under Correctional Supervision: A Shared Framework for Reducing Recidivism and Promoting Recovery (New York: The Council of State Governments Justice Center, 2012).
9. SAMHSA’s Center for Mental Health Services (CMHS) Targeted Capacity Expansion (TCE) Grants for Jail Diversion Program was authorized under Section 520G of the Public Health Service Act (Title 42 of the U.S. Code), as amended.
10. Public Law 108-414. MIOTCRA was reauthorized in 2008 through 2014.
11. Public Law 110-119.
12. Criminogenic risk refers to the likelihood that individuals will commit a crime or violate the conditions of their supervision. In this context, risk does not refer to the seriousness of a crime. For more information on the role of criminogenic risk and recidivism reduction see: Andrews, Donald A., “The Risk-Need-Responsivity (RNR) Model of Correctional Assessment and Treatment,” Using Social Science to Reduce Offending, ed. Joel A. Dvoskin, Jennifer L. Skeem, Raymond W. Novaco, and Kevin S. Douglas (New York: Oxford University Press, 2012).
13. Osher, D’Amora, Plotkin, Jarrett, and Eggleston. Adults with Behavioral Health Needs Under Correctional Supervision: A Shared Framework for Reducing Recidivism and Promoting Recovery.
14. Turner, Emily, Improving Outcomes for People with Mental Illnesses Involved with New York City’s Criminal Court and Corrections Systems (New York: The Council of State Governments Justice Center, 2012).
15. Turner, Emily, Improving Outcomes for People with Mental Illnesses Involved with New York City’s Criminal Court and Corrections Systems (New York: The Council of State Governments Justice Center, 2012).
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