VISITING EXPERTSʼPAPERS
CORRECTIONAL SERVICES FOR THE M ENTALLY DISORDERED
OFFENDER:A CHALLENGE THAT M ERITS AN INTEGRATEDRESPONSE
Frank J. Porporino, Ph.D.

“
Ashley Smith was a fourteen-year-old placed in a youth facility for one month in 2003 after
throwing crabapples at the mailman. Smith was placed in solitary confinement after disruptive behavior
on her first day. Her initial one-month sentence would last almost four years, almost entirely inisolation. Often violent and unpredictable, Smith exhibited many attempts at choking herself into
unconsciousness; guards responding were often attacked by Smith, sometimes with weapons she had
manufactured and concealed. The frequent ʻ
use of forceʼreports required to document responses becamea source of concern for facility officials. Eventually, Corrections Canada administrators instructed guards
and supervisors not to respond to the self-strangling attempts by Smith,“ to ignore her, even if she
was choking herself”. Officials kept transferring her to other facilities, preventing the implementation ofa Canadian law requiring mandatory review of prisoners kept in isolation for more than sixty days.
While at Grand Valley Institution for Women in Kitchener, Ontario, on 16 October 2007, Smith
requested transfer to a psychiatric facility; she was placed on a formal suicide watch on 18 October. In
the early hours of 19 October, Smith was videotaped placing a ligature around her neck, an act ofself-harm she had committed many times before. Guards did not enter her cell to intervene; they stoodoutside her cell and watched while 45 minutes passed before she was examined and pronounced dead.
Three guards and a supervisor at the Grand Valley Institution for Women were charged withcriminal negligence causing death in relation to Smithʼs suicide; the warden and deputy warden were
fired. The criminal charges were later dropped.
A coronerʼs jury returned a verdict of homicide in the Ashley Smith case in December of 2013 after
more than a year of testimony and over 12,000 pages of evidence. The verdict supported the conclusionthat the actions of others indeed contributed to her death but stopped short of a finding of criminal orcivil liability. The jury additionally provided 104 recommendations to the presiding coroner, most ofwhich were intended to suggest ways in which the Canadian Correctional System could better serve
female inmates and inmates suffering from mental illness. The jury specifically recommended thatindefinite solitary confinement should be banned.”1

I. INTRODUCTION
The tragic death of Ashley Smith did not occur in an under-developed or under-resourced correctional system. The federal correctional system in Canada is considered to be one of the finest in theworld. That one young woman could immobilize such a system so entirely into in-action and inhumanity in the face of genuine human misery is shocking. The Ashley Smith story received unprecedented
media attention and certainly raised community awareness and calls for action for the treatment ofoffenders with mental health problems in Canada. Our Correctional Investigator declared that this wasa preventable death and the Correctional Service of Canada has since taken significant steps inelaborating its Mental Health Strategy across the system, both in prisons and for aftercare after
Board Member,International Corrections and Prisons Association and Senior Partner T3 Associates Inc.E-mail contact
at fporporino＠rogers.com. A version of this paper was presented in May 2014 to participants of the 157th International
Training Course of the United Nations Asia and Far East Institute for the Prevention of Crime and the Treatment of
Offenders (UNAFEI).
1Adapted from http://en.wikipedia.org/wiki/Ashley Smith inquest>.

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RESOURCE MATERIAL SERIES No. 94
release. But every day all over the world similar tragedies play out in our prisons and correctional
facilities. It is now common in correctional discourse to refer to prisons as theʻ
new asylumsʼ
. Despite
all of our attempts to humanize correctional environments,prisons continue to be primarilyʻschools ofcrimeʼfor young, tough men who can find their place in the ʻschool-yard hierarchyʼand are somehow
able to endure the pains of imprisonment and cope with their circumstances. But for those offenders
who are a little different and donʼt fit in, those who are mentally ill, those who are intellectually or
physically disabled, the elderly and the physically ill, the weak, vulnerable and the emotionally
disturbed, then prison becomes a nightmare.
Correctional staff can sometimes use (or more accurately abuse) the miss-fits in our prisons as
fodder for their entertainment. I remember one of my own incidents of indoctrination into the prison
culture as a young psychologist. I was called upon to visit the segregation cells to intervene with an
offender who was apparently threatening to slash his writs with a razor. As I approached his cell andcaught the foul smell (he had smeared his body and cell walls with his feces),I noticed that two officers
at the other end of the unit were having quite a laugh at my expense. The mentally ill in prisonsbecome the butt of jokes. But much more often,these miss-fits in our prisons irritate and annoy,andquite easily frustrate and anger, both correctional staff, and their fellow offenders. In the absence ofclear policy, early and sensitive assessment of needs and ongoing monitoring, appropriate staff
training, and the availability of a range of programmatic alternatives,correctional practice will tend
to resort to traditional punitive measures such as the removal of privileges and the overuse ofsegregation as a means of managing the challenging behaviors ofmentallydisordered and other special
needs offenders.
The changing demographics and characteristics of offender populations, with a much higher
incidence of a variety of mental disturbance,cognitive deficits,addictions,proneness to violence,poor
education and chronic unemployment,and both community and familial alienation,are posing serious
challenges to modern corrections. It can be overwhelming to outline all of the issues that deserve moredetermined and focused attention. However,in this paper the focus will be on outlining some possible
solutions or responses rather than simply cataloguing the problems. Following a general introductionin Part I of the paper to help us understand and contextualize the issue,especially as it pertains to theorigins and prevalence of the problem of the mentally ill for correctional services,Part II of the paper
will then attempt to sketch out what it would look like in the ideal in corrections if we had:
1. Appropriate and encompassing, evidence-informed policies or strategies for dealing with mentallydisordered and other special needs offenders;
2. A range of programmatic alternatives, before imprisonment as diversionary measures, during
incarceration and after release into the community, aimed to both support these offenders andreduce the likelihood of further exacerbating their mental or physical distress,effectively managing
their conditions and minimizing harm to themselves or others;
3. A systematized approach for assessing needs, monitoring behavior and evaluating impact of ourinterventions;and finally;
4. Training and skills development of staff members both to sensitize them to the unique needs andcharacteristics of these offenders and equip them to better respond.

II. HISTORICAL CONTEXT, PREVALENCE, AND THE MENTAL ILLNESSOFFENDING RELATIONSHIP
A. Deinstitutionalization of the M entally Ill
The ʻ
deinstitutionalizationʼmovement began in America in the mid-1950s. Deinstitutionalizationrefers to the policy of moving severely mentally ill people out of large institutions,ideally in order toreintegrate them back into communities with appropriate psychiatric aftercare. Although undoubtedly
fueled in large measure as a rather straightforward cost-effective practice for reducing public expenditures, there were other well-meaning aspects to this movement. After the Second World War,psychodynamic and psychoanalytic psychiatry emerged in importance with its emphasis on the influ-

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ence of life experiences and social factors. Similarly,advances in pharmacology led to the widespread
introduction of chlorpromazine,commonly known as Thorazine,arguably one of the most well-known
psychotropic medications and the first significantly effective antipsychotic medication. These breakthroughs, together with the introduction of other social and psychological therapies held out thepromise of a more normal existence outside institutions for persons with mental illnesses. It was
believed this could prevent chronicity and the dependency effects of institutionalization (Grob,1991). A
M ental Health Commission under President Jimmy Carter in 1978 summarized the new, progressive
approach as having:“
the objective of maintaining the greatest degree of freedom,self-determination,autonomy,
dignity,and integrity of body,mind,and spirit for the individual while he or she participates intreatment or receives services.”
The deinstitutionalization movement began to spread quickly worldwide. Other than prohibition,
the magnitude of deinstitutionalization of the severely mentally ill perhaps qualifies it as one of thelargest social experiments in American history. In 1955, census estimates indicate there were 558,239
severely mentally ill patients in the nationʼs public psychiatric hospitals. By1994,this number had been
reduced to 71,619, a decrease in institutionalization of the mentally ill of 87% at a time when thenationʼs total population increased by close to 60% (from 164 million to 260 million)(Torrey, 1997).
However,the promised approach ofʻcommunity-basedʼcare and treatment for persons with serious
mental illnesses was never created and it is generally acknowledged that the deinstitutionalization
movement led to a decentralized and uncoordinated mental health system that was not providing
integrated and comprehensive services to those with the greatest needs, namely, persons with severe
and persistent mental illnesses.
In the years following the beginning of the deinstitutionalization movement, despite itʼs wellintentioned aims, some serious unintended consequences emerged, and for many mentally ill persons,
unemployment,poverty,homelessness and community rejection and stereotyping,simply compounded
their suffering and added to their loss of dignity. Another major consequence that is now generally
accepted and deplored is that our prisons and jails have become the ʻ
new asylumsʼfor the mentally ill― surrogate mental hospitals for the severely mentally ill when there is no other apparent alternative
to manage their behavior. This is commonly referred to as the phenomenon of ʻ
criminalization ofmental disorderʼ. It has become perhaps one of the most prevalent and intractable challenges facing
correctional services worldwide.
B. From Prisons to Asylums and Back to Prisons
It is quite interesting to point out that the situation we are facing today,with so many mentally ill
individuals locked up in our prisons and jails,often without receiving appropriate treatment and underconditions that exacerbate their illness,is exactly the situation we faced in the early 1800s,before theadvent of modern psychiatry and before the invention of the psychiatric institution, or mental healthhospital.
Beginning in the mid-1800s, early reformers who visited prisons and jails in America were aghastwith the conditions in those institutions of punishment. Dorethea Dix, for example, one of the mostprominent of these early reformers, reported the following to the legislature in the State of Massachusetts:“
I come to present the strong claims of suffering humanity. I come to place before the Legislatureof Massachusetts the condition of the miserable, the desolate, and the outcast. I come as the
advocate of helpless, forgotten, insane and idiotic men and womenof beings wretched in our
prisons
I proceed, Gentleman, briefly to call your attention to the state of Insane Persons
confined within this Commonwealth, in cages, closets, cellars, stalls, pens: Chained, naked, beatenwith rods, and lashed into obedience!”(taken from Torrey, 19 9 7)
In the 1800s the mentally ill were being picked off the streets and confined in prisons and jails inlarge numbers for minor and nuisance offences such as theft or disorderly conduct. In an interesting5

RESOURCE MATERIAL SERIES No. 94
precursor of history,it was just as it is today. But curiously,and in considerable contrast to today,thesituation of the confined mentally ill in the 1800s spurred government officials into action. The
abhorrent conditions that were documented by a number of early reformers served as at least one
impetus for a wave of construction of what were, for the time, more modern, sanitary and humaneʻinsane asylumsʼ
. The reform efforts of the day were remarkably successful in advocating for theconfined mentally ill. Gradually though quite steadily, mentally ill individuals were moved out ofprisons and jails and placed in public psychiatric hospitals. By 1880,there were 75 public psychiatrichospitals in the United States for the total population of 50 million people. A census of ʻ
insane personsʼwas carried out that year which was perhaps one of the most comprehensive ever carried out. It
included letters to all physicians asking them to enumerate all ʻ
insane personsʼin their communities,
a question about ʻ
insanityʼon the census form that went to every household, and a canvassing of all
hospitals, jails, and public almshouses. A total of 91,959 ʻinsane personsʼwere identified, of which
41,083(44.7%)were living at home,and 40,942(44.5%)were in hospitals and asylums for the insane. The
remainder (9,302)was in public housing of one kind or another and only 397 (or a small 0.7%)were injails.
C. The Scope of the Problem Today“
Deinstitutionalization doesnʼ
t work. We just switched places. Instead of being in hospitals thepeople are in jail. The whole system is topsy-turvy and the last person served is the mentally ill
person.”Jail official, Ohio
There is no doubt that the number of mentally ill in American prisons and jails today is dramatically higher than the rather small 0.7% documented in the 1880 census. Headlines began to appear
routinely in the early 1990s to highlight the extent of the problem. For example, in New York, theestimated population of 10,000 mentally ill inmates in the stateʼ
s prisons was noted as surpassing thatof the stateʼ
s psychiatric hospitals.2 In Seattle it was remarked that ʻquite unintentionally,the jail has
3 And the Los Angeles County Jail,where
become King Countyʼ
s largest institution for the mentally ill.ʼ
approximately 3,300 of the 21,000 inmates ʻ
require mental health services on a daily basisʼ
,was referred
to as the ʻ
the largest mental institution in the countryʼ
.4
A comprehensive survey by the Treatment Advocacy Centre in 2010 estimated that there wereperhaps close to three times more mentally ill confined in prisons and jails in America than in
psychiatric hospitals (Torrey et al., 2010). In 2014, another survey adjusted the estimate to ten times
the number of individuals with serious mental illness in state prisons and county jails compared to thenationʼs remaining mental hospitals (Torrey et al., 2014). It was noted as well that in 44 states in
America, the largest institution housing people with severe psychiatric disease is now a prison or jailand not a mental hospital. Figure 1 below shows the historical increase in concentration of thementally ill in prisons and jails in America in graphic detail.

2Foderaro, L. (1994, Oct. 6). For mentally ill inmates, punishment is treatment. New York Times, p. A1.
3Keene, L. (1993, July 6). A helping hand keeps mentally ill out of jail. Seattle Times, pp. A1, A7.
4Grinfeld, M . J. (1993, July). Report focuses on jailed mentally ill. Psychiatric Times. pp. 13.

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Figure 1
Percentage of Jail and Prison Inmates With Serious M ental Illness

The criminalization of the mentally ill may not be as dramatic in other nations,but it is nonethelesswidely recognized as significant (Salize & Dresing,2005;Knight & Stephens,2009). However,estimating the scope of the problem of the mentally ill within the criminal justice system more precisely isdifficult to do,both because of the issue of diagnostic unreliability and because the population is quite
inconsistently defined from study to study (Cohen & Eastman, 2000). Sometimes researchers restrict
the definition of mental disorder only to major psychotic and manic-depressive or serious depressive
illness. At other times, studies include developmental disabilities (IQ below 70), low functioning (IQ
above 70 with limited adaptive abilities), brain injury (organic or acquired), fetal alcohol effects/
syndrome, other less serious disorders (e.g., anxiety, post-traumatic stress), and quite often, serious
substance abuse disorder. Of course when the latter is included,the prevalence rates rise significantly.
Researchers have also tried to highlight the problem by focusing on different points in the criminal
justice process,or by looking at the issue from different perspectives. For example,we can look simply
at prevalence rates within jail or prison populations, to capture the scope of the problem as an end
result,or we can look at the issue in terms of the experience of the mentally ill individual and ask thequestion of what the likelihood of incarceration might be for that individual over the course of theirlife. In one study,for example,a telephone survey was carried out of 1,401 randomly selected membersof the National Alliance for the M entally Ill, an American advocacy and support group composed
mostly of family members of persons with schizophrenia and manic-depressive illness. It was foundthat 40 percent of the mentally ill in this group had been arrested and incarcerated at some time in theirlives (Steinwachs et al., 1992).
But regardless of definitional issues or where we look to get a sense of the problem,it is indisputably recognized that the mentally ill routinely ʻslip through the cracksʼin health and social support
systems and are at considerably high risk for contact with the criminal justice system. This occurs at
every point in the process;disproportionate numbers of mentally ill come into contact with the police,
are arrested, end up in police cells or on remand, appear in court, and are convicted and imprisoned(Ogloff, 2004).
Beginning in the 1980s,a number of methodologically sound studies using stringent criteria to define
mental disorder began to document substantial prevalence rates among prisoner populations. After
conducting interviews with 3,332 prison inmates in New York State in the late 1980s,Henry Steadman
and his colleagues reported that at least 8% of them had “very substantial psychiatric and functional
disabilities that clearly would warrant some type of mental health service”(Steadman et al.,1987). In
looking at a number of these early prevalence studies, one reviewer (Jemelka et al., 1989) concluded
that it could be safely estimated that at least 10 to 15% of prisoners have a major thought or mood

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RESOURCE MATERIAL SERIES No. 94
disorder and “
need the services usuallyassociated with severe or chronic mental illness.”Steadman andhis colleagues (Steadman et al., 2009) published another methodologically sound survey of mental
illness among jail inmates in 2009. A total of 822 inmates in five jails (three in New York and two in
M aryland)were assessed using a structured diagnostic interview to determine the existence of serious
mental illness during the previous month. Serious mental illness was defined as including schizophrenia, schizophrenia spectrum disorder, schizoaffective disorder, bipolar disorder, brief psychotic disorder,delusional disorder,and psychotic disorder not otherwise specified. A total of 16.6 percent of theprisoners met stringent criteria for a psychotic disorder, more than double what was found ten years
earlier, with the rate among women (31.0%)being much higher than that among men (14.5%).
M ullen, Holmquist, and Ogloff (2003) conducted an extensive review of existing Australian
epidemiological data to arrive at a reliable composite prevalence estimate. They concluded “that theprevalence of major mental illness among male prisoners is significantly greater than in the general
population in the community”(p.2). They noted that 13.5% (1 out of 7)of male prisoners,and 20% (1out of 5)of female prisoners,had reported having prior psychiatric admissions,figures that are clearlymuch higher than the general population.
Reviewing results from 49 worldwide studies of mental illness among incarcerated individuals(19,011 prisoners), Fazel and Danesh (2002) reported an overall prevalence rate of 4% for psychotic
illnesses. Considering that the estimated lifetime prevalence rate for the general population is about
1% (American Psychiatric Association, 1994, 2000),the prevalence for schizophrenia among prisoners
is clearly considerably higher.
Fazel and Danesh (2002)also analyzed 31 studies examining major depression within incarcerated
populations (10,529 prisoners). Because of differences in diagnostic criteria, there was considerable
variation between studies,with reported rates of depression as low as 5% and as high as 14% in someindividual studies. Nonetheless, the prevalence of major depression in the general population isestimated to be 5-9% for females and 2-3% for males (American Psychiatric Association, 2000). The
meta-analytic results of Fazel and Danesh (2002) are 2-3 times higher, in the same range as the fourtimes higher for psychotic illness.
Several consistent findings worth noting are the higher prevalence of mental illness for both female
offenders and prisoners held in remand. The Fazel and Danesh (2002)review,for example,found higher
rates of depression among females (12%) than males (10%), a finding that has been confirmed in a
number of other studies (Brinded et al., 2001). Prins (1995)reviewed numerous studies and concluded
that one third of the population of British prisoners required psychiatric treatment, but that thisnumber would be higher among those on remand. Similarly,in a New Zealand study (Brinded et al.,2001),it was found that male remand offenders had higher rates than the male sentenced offenders for
all categories of mental disorder that were studied. Parsons, Walker, and Grubin (2001)investigatedmental illness among 382 female remand prisoners in the United Kingdom. Theyfound that a veryhigh
59% had at least one current mental disorder (excluding substance use disorders),including 11% withpsychotic disorders.
One large-scale and well-conducted survey by the Correctional Service of Canada (1990), using aquite reliable interview schedule (the D.I.S.), involved a random sampling of more than 2000 maleoffenders sentenced federally across Canada.It was found that there was a lifetime prevalence of10.4%
for psychotic disorders, 29.8% for depressive disorders, and 55% for anxiety disorders. Co-occurring
antisocial personality, drug, and alcohol problems were present in close to 40% of federal prisoners.
M ore recent Canadian research (Boe et al.,2003)looked at the changing profile ofthe federal inmate
population over the years 1997-2002. Over just a few years, there was a significant increase in thenumber of male offenders who were admitted with a past mental health diagnosis (10% to 15%), a
current diagnosis (7% to 10%),or being prescribed medication (9% to 16%). The rates were considerably higher for female offenders, although not showing the same level of increase over the years (forpast diagnosis from 20% to 23%,for current diagnoses from 13% to 16%,and for the percent for which
medication was prescribed from 32% to 34%).

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157TH INTERNATIONAL TRAINING COURSE
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In the US in 2006,the federal Bureau of Justice Statistics (BJS)reported on the findings of perhaps
the single largest survey ever conducted of mental health problems among state,federal and local jailand prison populations throughout the US. Some of the major findings are shown in Table 1.
Table 1
Recent History and Symptoms of M ental Health Problem Among US Prisoners
Category of Mental Health
ProblemState
Prisons

FederalPrisons

Local
Jails

Recent history of mental
health problemsa

56.2%

44.8%

64.2%

Symptoms of mental healthdisorderb

49.2%

Major Depressive Disorder

Corrections
Canada 2000

39.8%
23.5%
15.4%

Psychotic Disorder

60.5%
16.0%

29.7%
23.9%

29.8%
10.4%

10.2%

a In the year before arrest or since admission.
b In the 12 months prior to the interview.

Data from James D.J, and Glaze L.E. (2006). Mental Health Problems of Prison and Jail Inmates.
Bureau of Justice Statistics Special Report. US Department of Justice:NCJ 213600.

Interestingly, the BJS survey differentiated between recent histories of mental health problems
versus actual symptoms of various mental disorders. With both types ofdefinition,the findings showed
quite substantial prevalence rates.5 The figures of prevalence for major depression (16 to 30%) andpsychotic disorders (10 to 24%)were in the same range as was found in the Corrections Canada survey.
This BJS survey also confirmed the trends noted in other research of higher rates of mental healthdisturbance among remand versus sentenced prisoners, and higher rates among females versus males(for example, within State prisons, 73% of females reporting mental health problems versus 55% formales). M oreover,the typical pattern of high co-occurring substance abuse was also highlighted. Over
50% of prisoners with mental health problems were found to have a co-occurring substance abuse
disorder,a prevalence that was much higher than what was identified among prisoners without mental
health problems. As a rather unique aspect of this survey, the backgrounds of mentally ill offenders
were also examined. Quite strikingly,it was found that compared to the non-mentally ill,the mentally
ill population demonstrated both much higher rates of homelessness prior to incarceration,and much
more early experience of physical or sexual abuse.
So in summarizing an answer to the question,how many people with severe mental illnesses are injails and prisons on any given day? Numerous studies of prevalence rates have been carried out over
the years that vary in definition of mental illness and the kinds of populations that are sampled.
However, it is generally agreed that in the extreme, if mental illness is defined to include only
schizophrenia,manic-depressive illness,and severe depression,then 40% or more of all jail and prison
inmates appear to meet these diagnostic criteria,a figure in the range of at least four times that foundin the general population.6 The figures are higher for females than for males and tend to be higher for
offenders held on remand versus sentenced. Finally,ifwe add substance abuse disorder to the mix,thenmore than half of these offenders also have co-occurring substance abuse disorders.

5A recent history of mental health problems included a clinical diagnosis or treatment by a mental health professional.

Symptoms of a mental disorder were based on criteria specified in the Diagnostic and Statistical M anual of M ental
Disorders, fourth edition (DSM -IV).
6An estimated 11% of the U.S. population age 18 or older met criteria for these mental health disorders, based on datain the National Epidemiologic Survey on Alcohol and Related Conditions, 2001-2002 (NESARC), U.S. Department of
Health and Human Services,National Institute ofHealth,National Institute on Alcohol Abuse and Alcoholism,Bethesda,
Maryland.

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RESOURCE MATERIAL SERIES No. 94
D. M ental Illness and Offending:A Complex Relationship
To what extent mental illness is predictive of offending is still very much debated. We know,for
example,that individuals suffering from psychotic illness are at higher risk for violent offending than
the general population. This is exacerbated when there is co-occurring substance abuse and/or
evidence of certain kinds of delusions (Mullen, 1997;2001;Robert et al., 2014;Wallace et al., 2004).7
However,when we look at offenders with mental illness versus those with not,then research has shownthat offenders with mental illness are actually at lower risk of re-offending (e.g.,Porporino & Motiuk,
1995;Quinsey et al., 1998).
In a major Canadian meta-analytic review of 64 studies examining the relationship between mental
illness and offending (Bonta et al.,1998),the authors concluded that:“
the major predictors ofrecidivism
were the same for mentally disordered offenders as for non-disordered offenders”(p. 123). Particularcriminal history factors (e.g., juvenile delinquency) were predictive of offending for both groups.
M oreover,some of the best ʻdynamicʼpredictors (i.e.,criminogenic needs)for both general and violent
recidivism were quite similar for both mentally ill and non-mentally ill offenders (e.g., poor living
arrangements, antisocial personality, substance abuse, relationship instability and employment problems).8
It has been suggested that for some mentally disordered offenders (sometimes referred to as being
both ʻ
badʼand ʻ
madʼ),there are perhaps two separate trajectories or pathways operating simultaneously. The criminal trajectorybegins in earlyadolescence with the emergence ofdisruptive and delinquent
behavior,and then the mental illness trajectory follows in the early to late 20s as the genetic predisposition towards psychotic illness flares up in psychotic episodes (Wallace et al., 2004). This obviously
argues for the treatment of both aspects of risk for mentally ill offenders―managing their illness aswell as addressing the more usual risk factors for offending (e.g., substance abuse; unemployment;
criminal attitudes).
In managing mentally ill offenders so as to avoid further contact with the criminal justice system,
it is also clear that particular dynamic risk factors should be considered. For example, it has been
demonstrated that maintaining psychiatric treatment after release can substantially reduce violent
recidivism among offenders with schizophrenia (Robert et al., 2014). One of the most popular risk
assessment tools used with mentally disordered offenders (The HCR-20 by Webster et al., 1997)
describes five situational factors which should be addressed to avoid re-offending:a lack of feasibleplans, exposure to destabilizers, lack of personal support, non-compliance with remediation attempts, andstress. These contextual factors that can put mentally ill offenders at higher risk for re-offending areclearly crucial for the design of correctional services for the mentally ill that are preventive andprotective in nature (as will be discussed later in the paper).
However, preventing the re-offending of the mentally ill is not the only concern that should
preoccupy correctional services. At the front end, there is a major issue to contend with in terms ofdiverting the mentally ill from contact with the criminal justice system in the first instance.
In contrast to the typical media portrayal of mentally ill serial killers committing heinous crimes,
the reality is that most mentally ill individuals never commit crime, or at least never commit any
serious crime. What we know quite clearly is that most severely mentally ill people we imprison are
there because they have been charged with a variety of rather minor offences. One American study(Valdiserri et al.,1986)reported that compared with the non-mentally ill,mentally ill jail inmates were“four times more likely to have been incarcerated for less serious charges such as disorderly conduct
and threats”. They were also 3 times more likely to have been charged with disorderlyconduct,5 times
more likely to have been charged with trespassing,and 10 times more likely to have been charged withharassment. Another American study tracked a sample of seriously mentally ill individuals discharged
7Examples are persecutory delusions or delusions that ʻ
command violenceʼagainst others and/or that provoke fear.
8In the now predominant ʻ
rehabilitation theoryʼin the field, often referred to as the Risk-Need-Responsivity paradigm(RNR)(Andrews and Bonta, 2003), an important distinction is made between ʻstaticʼrisk factors that are unchangeable(e.g.,background and criminal history factors),and ʻ
dynamicʼrisk factors often referred to as criminogenic needs. Theselatter dynamic factors can be altered and should be the focus of our correctional services and intervention attempts.

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157TH INTERNATIONAL TRAINING COURSE
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from a psychiatric hospital in Ohio (Belcher, 1988). After six months, 32% had been arrested andimprisoned,typically for exhibiting bizarre behavior such as walking in the communitywithout clothes
and talking to themselves. They mostly failed to take their prescribed medications and frequently
abused alcohol or drugs. Significantly, all of these former patients also became homeless during the
6-month follow-up period. The most common charges brought against the mentally ill who end up in
jail are lewd and lascivious behavior (such as urinating on a street corner),defrauding a store owner(eating a meal,then not paying for it),disorderly conduct,panhandling,criminal damage to property,
loitering or petty theft. These are clearly offences that are mostly expressive of mental illness rather
than indicators of any intractable criminality.
Though there is some relationship between mental illness and offending, it is neither straightforward nor inevitable. How we typically manage the mentally ill offender also seems to strengthen
the relationship rather than weaken it. From what we know about which mentally ill individuals we
imprison and why,the risk factors for offending among the mentally ill,and the treatment and support
needs of these individuals, it is clear that an integrated criminal justice and social service response iscalled for. The remainder of this paper will outline what this could like in the ideal.

III. RESPONDING TO THE CHALLENGE OF MENTALLY ILL OFFENDERSIN CORRECTIONS
A. Challenges and Concerns for Correctional Services
Jails and prisons all over the world are inadequatelyresourced to deal with the mentallyill offender.
―

―

―

―
―

Assessment is typically the result of informal observation of unusual behavior rather than theapplication of diagnostic tools for early detection of symptomology or mental health background.
Staff members are poorly trained to deal with the mentally ill offender,especially line prison
officers who have to contend daily with the pressures and difficulties of managing these
individuals.
Psychiatric care is difficult to access, both because forensically trained psychiatrists are few
and far between9, and the few that are available would rather work within psychiatrichospitals (where they are typically in charge) rather than correctional settings (where they
typically are not).
Specialized mental health correctional facilities,where there can be an appropriate balance ofcorrectional supervision and professional mental health intervention, are the exception.
And programs designed and developed specifically to intervene with mentally disordered
offenders are rare;with those that have been evaluated for effectiveness being even rarer.

The National Sheriffs Association in the US,responsible for oversight in the administration of jails
across the country, succinctly outlined some of the key challenges as follows (Torrey et al., 2010):
―
―
―

―
―
―

M entally ill offenders are referred to as ʻ
frequent flyersʼto highlight the fact that they are
regular and repeat offenders, often being arrested and imprisoned dozens of times.
M entally ill inmates cost more to manage.
M entally ill inmates tend to remain in jail or prisons longer than the non-mentally ill, often
because they find it difficult to understand and follow jail and prison rules and are charged
much more frequently for infractions.
M entally ill inmates are often major management problems and end up in administrative
segregation in large numbers.
M entally ill inmates are at much higher risk for committing suicide.
M entally ill inmates are more often abused, both by fellow inmates and staff.

9 Forensics is not a popular specialization within psychiatry and the few forensic psychiatrists who are trained tend towork in forensic psychiatric settings where they focus mostly on assessing individuals for the courts for competence tostand trial. There are variations across jurisdictions around the world, but most acknowledge some variant of a ʻ
notguilty by reason of insanityʼplea which then leads to indefinite civil commitment rather than sentencing and imprisonment in a correctional institution.

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RESOURCE MATERIAL SERIES No. 94
Of course some correctional jurisdictions have few if any resources at all for managing the mentally
ill offender (Agomoh, 2013). But even some fairly advanced correctional agencies point to the limitations in programs and services available for these offenders. Illustrative of this are the findings froma 2004 survey by the Province of British Columbia in Canada of the service and program needs formentally disordered offenders (Oglaff et al., 2004b). The survey included all Canadian Provinces andTerritories, as well as specific international jurisdictions that were similar in population and culture
to British Columbia (i.e.,New Zealand,Scotland,Victoria (Australia),and Maryland,USA). Some of
the findings are shown in Table 2 below,listed in order of how frequently each concern was mentioned.
Additional resources were seen as especially critical in order to improve theʻcontinuum of careʼformentally ill offenders. This included both more and easier access to secure forensic psychiatric beds
to treat acutely disordered offenders, more programs for individuals with co-occurring mental healthand substance abuse,sustainable funding for diversion initiatives,and funding to ensure aftercare upon
return to the community. The enhancement of community-based services was seen as particularly
urgent,especially community-based residential support and programs to support social reintegration of
offenders into the community. This of course is consistent with findings that suggest that re-entry
programs for mentally ill offenders need to emphasize both basic sustainable economic and material
support for these individuals as well as their specific treatment needs (Wilson, 2013).
TABLE 2:M OST URGENT M DO SERVICE/PROGRAM NEEDS10
Area of Need Identified
The need for increased resources for mentally disordered offenders
Increased community services for offenders
Programs for needs of developmentally/cognitively challenged offenders
Diversion programs, such as mental health courts and drug courts
Programs/services for individuals suffering from Fetal Alcohol Effects/Fetal Alcohol Syndrome
Additional services for young offenders with mental disorders
Better collaboration between service providers and criminal justice personnel
Better assessment/diagnostic service to place people in appropriate programs and housing
Increased funding for research and dissemination of information
Need to change public perception of mentally disordered offenders and reduce the stigma of being an MDO
Need for better case management
Coordinating services for dually diagnosed individuals (mental illness and substance abuse) placed in thecommunity
Requirement for high-quality mental health care in prison

Clearly,even well-developed correctional jurisdictions are able to identify a range of service gaps.
But what is encouraging is that they are also able to describe some of their ʻbest practiceʼ. The Stateof Victoria in Australia, for example, has established the Victorian Institute of Forensic M ental
Health, also known as Forensicare, governed by a council that reports to the M inister of Health andincludes representatives from the Attorney General,Corrections Victoria,and the Minister of Health.
It is noteworthy that the State has developed a well recognized and multi-faceted forensic mental
health service that includes court liaison workers (nurses and psychologists) in magistrate courts toassist in diverting mentally ill offenders, formal intake assessments of all offenders entering jails, a
range of psychiatric services in prisons and jails, an acute assessment unit for mentally disordered
offenders in the state remand jail, a secure forensic hospital, a range of community-based forensic
mental health services,and close coordination with regional and local mental health services. As partof a broader provincial ʻmental health planʼ
,the Province of Alberta in Canada has focused on creating
a comprehensive diversion framework for mentally ill offenders (Alberta Health Service,2001). In theUS,the state of M aryland operates an excellent jail-based diversion program that provides social workand psychiatric services to help identify candidates for diversion to mental health treatment in thecommunity. And various Canadian and US jurisdictions have introduced both mental health courts,todivert mentally ill from the criminal justice system in the first instance, and comprehensive re-entry
10 Adapted from Oglaff et al. (2004)

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157TH INTERNATIONAL TRAINING COURSE
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programs to support mentally ill offenders released from prisons. Common to many of these ʻ
bestpracticeʼexamples is the establishment offormal links between law enforcement,the judiciary,forensic
and correctional services and other non-governmental and governmental services and agencies responsible for community mental health, social services,employment,housing and family services,etc.
It is this focus on the development of an integrated and collaborative service delivery model that createscorrectional policies and strategies for managing the mentally ill offender that are ultimately effective(Osher et al., 2012).
B. Innovative Policies and Strategic Direction for Dealing With M entally Disordered Offenders
What focus and underlying principles should underpin an effective, well integrated approach for
dealing with the issue of the mentally ill in corrections?
The American National Sheriffs Association (2010)highlighted a few broad areas as practical andsensible options:―Greater use ofʻM ental Health Courtsʼwhere offenders are essentially given a choice between
either following a treatment plan in the community (including the taking of medication) or
going to jail (Lamb & Wienberger, 2008;Moore & Hiday, 2006).

―

A greater emphasis on assisted outpatient treatment (AOT)for the mentally ill released from
hospitals, jails, or prisons, where there is a court ordered requirement to continue taking
medication as a condition for living in the community. A number ofstudies have demonstrated
that even this rather straightforward change in practice can substantially reduce the likelihood of re-arrest,alcohol or drug abuse,as well as homelessness,risk of suicide,and episodesof violent behavior among individuals with serious mental illnesses (Phelan et al.2010;Swartz
et al., 2009).

―

Change in government funding systems so that departments of mental health pay the local
corrections departments for the treatment costs of all seriously mentally ill inmates.

―

A reform of mental health treatment laws so that treatment interventions can be made basedon ʻ
need for treatmentʼcriteria rather than dangerousness. Typically,it is the dangerousness
standard that necessitates law enforcement involvement. But mentally ill individuals shouldbe able to access treatment before they become dangerous or commit a crime, and not after.

A good example of a significant change in policy direction is the comprehensive Mental HealthStrategy recently adopted by Corrections Canada, developed in collaboration with the M ental HealthCommission of Canada and provincial/territorial correctional jurisdictions across the country (Correctional Service of Canada, 2009). The strategy appropriately highlights the fact that:“Individuals with mental health problems and/or mental illnesses often have previous points ofcontact with multiple systems,including provincial/territorial and federal correctional jurisdictions,health care institutions,and social services. All systems have a shared mandate to provide
an integrated approach of active client engagement,stability,successful community integration,and overall harm reduction in ways that are sensitive to diverse individual and group needs.
Integrated efforts with the “common client”will result in fewer justice system contacts andincrease public safety.”(p. 7)
As guiding principles, the strategy adopts the following:
―

―
―
―

Individuals with mental health problems and/or mental illnesses should be provided access toservices irrespective of race,national or ethnic origin,color,religion,age,sex,sexual orientation,marital status,family status and disability(Canadian Human Rights Act,1977,c.33,s.11);
M ental health services should be client-centered, holistic, culturally sensitive, genderappropriate, comprehensive, and sustainable;
M ental health care should be consistent with community standards;
The role and needs of families in promoting well-being and providing care should be recog-

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RESOURCE MATERIAL SERIES No. 94

―

―
―

―

―

nized and supported;
Prevention,de-escalation of behaviors associated with mental health problems and/or mental
illnesses, interventions, and other mental health activities/services are critical to minimizing
and managing the manifestations of mental health symptoms and promoting optimal mental
well-being;
Promotion of mental health recovery is a grounding philosophy underpinning the continuumof care;M eaningful use of time, including participation in programming for individuals with mental
health problems and/or mental illnesses,is critical to their becoming contributing and productive members of the community;
In addition to their involvement in correctional systems, individuals with mental healthproblems and/or mental illnesses experience a compounded stigma that creates barriers intheir ability to obtain services, and also influences the types of treatment and supports
received, reintegration into the community and their general recovery;and finally,
M echanisms should be established to ensure ongoing evaluation of the effectiveness of mental
health services throughout the continuum of care.

The Corrections Canada strategy details the need for action and the expected results in seven key
areas:M ental Health Promotion;Screening and Assessment;Treatment,Services and Support;Suicideand Self-Injury Prevention and Management; Transitional Services and Support; Staff Education,
Training and Support;and Community Supports and Partnerships.
Beginning in 2007,Corrections Canada enhanced resources significantly in two major ways. First,
an Institutional Mental Health Initiative (IM HI)focused on enhancement of institution-based services
for the mentally ill. This included:―

Development of a computerized M ental Health Intake Screening System to identify offenders
who could be experiencing significant psychological distress at intake. Follow-throughassessments then try to develop a more precise picture of an offenderʼs mental health needs,
which is in turn incorporated into the offenderʼs overall correctional plan;―

Primary Multi-Disciplinary M ental Health Care teams in institutions work to provide
offenders with access to comprehensive mental health care,and focus as well on mental healthpromotion, mental illness prevention, and early intervention, treatment and support (e.g.,suicide prevention);―

Design of a mental-health training package delivered to all correctional staff to increase staff
awareness of mental health issues and enhance their skills in working with these offenders;―Development of intermediate care units for male offenders with mental health issues ininstitutions;―

Consistency in standards at Corrections Canadaʼs Regional Treatment Centers.

Approximately 125 new positions were created to fulfill the staffing complement for the IMHI
including nurses, psychologists, social workers, and behavioral counselors.
Secondly, a comprehensive Community Mental Health Initiative (CMHI)was introduced to ensure
effective discharge planning for mentally ill offenders and appropriate,supportive community supervision. Approximately 50 new positions were created across Canada as a part of this CMHI,including:

14―

Clinical Social Workers as ʻdischarge plannersʼ
;―Community M ental Health Specialists to work directly with offenders with mental healthdisorders at selected parole sites. These professionals also participate in multidisciplinary
teams, provide training for front-line staff and develop partnerships with local agencies;

157TH INTERNATIONAL TRAINING COURSE
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Coordinators to manage the initiative in each region,and to help new staff work with existing
community-based services to enhance mental health support for offenders in the community.

The CMHI also provides funding to local agencies and organizations, for example, for personal
support workers for some offenders and to address the unique needs of mentally disordered Aboriginal
and women offenders.
Corrections Canada is in the early phase of implementation of this rather ambitious strategy.
However,some key indicators of success are currently being monitored that are intended to help adjust
the strategy over time for greater impact. It will hopefully not remain as comprehensive onlyon paper.
Another impressive, comprehensive and well-integrated Policy Framework for dealing with thementally ill within criminal justice was developed by the Stare of Victoria in Australia,as previously
mentioned (Thomas, 2010). The document ʻ
Diversion and support of offenders with a mental illness:
Guidelines for best practiceʼis required reading for any correctional jurisdiction wishing to embark ona similar course. Not only is there a thoughtful presentation of some key principles for managing thisissue at the systemic level,in partnerships with other stakeholders,but the evidence-base in support ofthese principles is reviewed,how policy and program development should proceed is outlined,including
for special groups such as female offenders, young offenders and offenders from culturally diverse
backgrounds,and finally,a set ofʻ
best practiceʼexamples,both from Australia and internationally,isoutlined and discussed.
The Victoria Justice strategic framework takes as its point of departure the fact that there is alogical sequence of interventions that should take place in order to reduce the chance that people witha mental illness will penetrate deeper into the criminal justice system. This concept is nicely captured
in the Sequential Intercept Model developed by M unetz and Griffen (2006) (see Figure 2 below). It
describes a series of possible interception points that are critical for a truly integrated response formanaging the mentally ill within the criminal justice system.
Worthy to review in some detail is both this Sequential Intercept Model (see Figure 2 below)as wellas the principles underpinning the Victoria Justice strategy (as shown in Table 3).
Figure 2
The Sequential Intercept M odel For Managing M entally Ill Offenders

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RESOURCE MATERIAL SERIES No. 94
Table 3
Victoria Justice Framework For M anaging the Mentally Ill Within Criminal Justice16

157TH INTERNATIONAL TRAINING COURSE
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C. Programmatic Interventions and Services for Dealing with the Mentally Disordered OffenderM entally disordered offenders are both ʻmentally illʼand prone to ʻ
criminal offendingʼat some levelof severity. As we have seen,often the offending is of a minor nature,fueled and exacerbated by thesymptoms of mental illness. But clearly as well, serious violence is also possible. Many mental
illnesses are chronic or relapsing conditions where acute phases or relapses may trigger offending
behavior. What is clear is that regardless of level of risk for offending,treatment for the mentally illoffender should balance both a focus on the ʻmental illnessʼand on the ʻ
criminal propensityʼ
. Criminal
justice and mental health outcomes can be significantly affected if there is a judicious and mutually
supportive convergence of interventions and services that can address both dynamic criminologicalrisk factors as well as appropriate management of the mental illness. One recent meta-analytic reviewof 26 program evaluations that met criteria of methodological soundness concluded that interventions
with offenders with mental illness can effectively reduce symptoms of distress,improve the offenderʼsability to cope with their problems,improve behavioral markers such as institutional adjustment andbehavioral functioning and produce significant reductions in both psychiatric and criminal recidivism(Morgan et al., 2012).
Of course the ʻ
howʼand the ʻ
whenʼprograms should deliver services is critical, as is the emphasis
on a number of other key factors such as co-occurring substance abuse disorders,a history of trauma(especially with female offenders),the severity of the psychopathology and whether there are multiple
forms of mental impairment, physical health problems (chronic illness or disability), and various
practical issues like housing or accommodation problems and employment. Table 4 lists a range ofindividual and demographic characteristics that clearly should be considered as programs are designed
and delivered.
Table 4
Individual characteristics impacting on program design for MDOs
Age
Comorbid health issues
Concurrent drug and alcohol abuse
Cultural background
Disability, including intellectual disability
Educational attainment
Employment

Family circumstances, including children
Forensic and/or psychiatric history
GenderHousing circumstances
Indigenous status
Language and literacy
Socio-economic status

One particular consideration for program design merits special emphasis,namely gender (Leschied,2011). It is now commonly accepted that gender-responsive strategies are needed to deal with female
offenders (Blanchette, 2000), and this clearly applies as well to management of mentally disorderedfemale offenders, where some specific approaches such as Dialectic Behavior Therapy have beenshown to lead to significantly improved outcomes (Linehan et al., 2007). Important to remember inallocating treatment resources for dealing with women with mental health issues in criminal justice aresome of the following points highlighted recently by the World Health Organization (2008):
―
―
―

―
―

Gender is a critical determinant of mental health and mental illness;
Gender influences the rates of depression and anxiety (e.g., unipolar depression, predicted tobe the second leading cause ofglobal disabilityburden by2020,is twice as common in women);
Gender specific risk for common mental disorders that disproportionally affect women include
gender-based violence, socioeconomic disadvantage, low income and income inequality, andlow or subordinate social status;
Lifetime prevalence rates of violence against women range from 16% to 50%;High prevalence of sexualized violence to which women are exposed and the correspondingly
high rate of Post Traumatic Stress Disorder (PTSD) following the violence renders such
women the single largest group affected by this disorder.

Gender and other characteristics of the individual should obviously drive the specifics of theintervention approach that is adopted,but more generally,creating correctional services and environ-17

RESOURCE MATERIAL SERIES No. 94
ments that are responsive to the needs of the mentally disordered requires adherence to some minimum
standards of practice (Livingston, 2009). These should include:
―
―
―
―
―

Providing a comprehensive and balanced continuum of services;
Integrating services within and between systems;
M atching services to individual need;
Responding to population diversity;andUsing evidence to make system-wide improvements.

On the side of treatment of mental illness per se,the treatment of choice in the mental health field
for mentally disordered individuals is commonly referred to as psychosocial rehabilitation (Corrigan
et al., 2007). The ultimate goal of this multi-faceted approach is to enable mentally ill individuals,asmuch as possible, to live independently by compensating for, or eliminating, functional deficits. The
focus is on a range of social and educational services and supportive community interventions (e.g.,
intensive case management, supportive housing, social and vocational rehabilitation,substance abuse
treatment, family support services). Deployed in an interconnected fashion, a number of particulartreatment strategies have shown effectiveness and are widely considered evidence-based (M ueser et al.,2003).
―

Collaborative psychopharmacology―where individuals are included in the medication
decision-making formula.

―

Assertive community case management and treatment―where provision of services occurs in
the natural environment (e.g.,community)rather than a clinical setting such as an outpatient
clinic or psychiatric hospital.

―

Family psycho-education―where family members are educated about the effects of mental
illness, and assisted in maintaining positive interpersonal relations and creating a supportiveʻfamilialʼenvironment.

―

Supported employment―to help the individual gain competitive employment and provide
assistance as needed, regarding skill development and employment maintenance for job
security.

―

Illness management and recovery―so that the individual assumes responsibility for theirrecovery, managing their illness, and seeking assistance as needed to obtain personally
meaningful and satisfying life goals.

―

Integrated dual disorders treatment―where service providers target issues of mental illness
and substance abuse simultaneously in an integrated fashion rather than treating these issues
as separate disorders.

The adaptation of psychosocial rehabilitation and Assertive Community Treatment (ACT) to
forensic populations has been successful in improving a host of indicators such as future psychiatrichospitalizations, quality of life and symptom severity (MacKain & M ueser, 2009). However someevidence suggests that that ACT has been generally less successful in reducing re-offending or rates ofarrest and incarceration,possibly in part because ofthe limited emphasis on criminological risk factors(Morrisey et al., 2007). It has been noted (Hodgins et al., 2007) that in order to reduce re-offending,community-based programs should:――――

Be highly structured, intense and make use of multiple problem-specific interventions;
Encourage clinicians to go beyond their clinical focus and accept an active role in preventing
offending and guiding program participants through their personalized program;
Allow for rapid hospitalization when necessary;and
Employ court orders for some patients to support compliance.

Project Link in New York is a good example of an ACT-based approach with a simultaneous

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157TH INTERNATIONAL TRAINING COURSE
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structured emphasis on criminological risk factors. Project Link is a multi-site consortium of fivecommunity agencies that provide a mobile treatment team to service people with mental illness andpast convictions,people diverted from current charges or transitioning out of prison. Within an ACT
out-reach model of wrap-around services, the program incorporates a supervised residential programfor people with mental health and substance use problems. Evaluations have demonstrated significant
reductions in arrests, days in jail, hospitalizations and average hospital days. A follow up of clientsenrolled in the first year in Project Link found a reduction in both the average number of days in jail(from 104 to 45)and hospital (114 to 8)and the average cost of care per individual fell from US$74,500
one year prior to enrolment to US$14,500 one year after enrolment. The programʼs success has been
attributed more particularly to a combination of effective service coordination and culturally sensitive
service delivery (Weisman et al., 2004). M any similar ACT-based programs have been developed
throughout America (see http://www.nami.org) as well as in the UK (Fiander et al., 2003), Europe(Burns et al., 2001), Canada (Wilson et al. 1995), Australia and elsewhere (Ogloff et al., 2004b).11
Although not as broad in scope as the psychosocial rehabilitation approach adopted by Project Link
and other similar programs, a number of innovative, curriculum-based interventions for use withpeople with mental illness also deserve mention.
The first is the Illness Management Recovery (IM R) program, a standardized, curriculum-based
intervention that has been translated into ten languages and is supported by considerable evaluative
research (McGuire et al.,2014). The program can be delivered in a variety of settings (e.g.,community
mental health center,correctional facility)by trained behavioral health practitioners in either one-toone or group format in 40―50 weekly or twice weekly sessions over a period of 6―12 months(Gingerich & Mueser,2011). Essentially,the program adopts motivational,educational,and cognitivebehavioral techniques to help individuals set personal goals and learn more effective strategies for
dealing with their own psychiatric disorder. The curriculum is organized so that specific informationand skills related to illness management are taught in a set of modules that includes: Recovery
Strategies; Basic Facts About Mental Illness; The Stress-Vulnerability Model; Building Social Support;
Using Medication Effectively; Drug and Alcohol Use; Reducing Relapses; Coping with Stress; Copingwith Persistent Symptoms; Getting Your Needs Met in the Behavioral Health System; and HealthyLifestyles.
A number of randomized controlled studies,conducted in the U.S.,Sweden,and Israel,have shownthat IM R improves illness management outcomes significantly more than traditional services(M cGuireet al., 2014). IM R has been implemented extensively in America and elsewhere with individuals
involved in the criminal justice system. In order to make the program more accessible for persons withboth intellectual disability and a psychiatric disorder,an adapted version that appropriately condenses
and simplifies the curriculum has also been developed,the Happy and Healthy Life Class,(Gingerich etal., 2009).
The second curriculum-based intervention worth noting is an adaptation of the Reasoning &Rehabilitation Program (R&R), one of the earliest (Porporino et al., 1991) and perhaps most wellresearched and widely applied correctional interventions adopting cognitive-behavioral principles toteach offenders a variety of new skills for ʻ
thinking and behavingʼmore pro-socially.12 Evaluations
with heterogeneous groups of offenders in different countries have shown that R&R can reduce risk of
11 The ACT approach that originated in America is of course heavily driven and managed by mental health professionals.

In contrast to this,many European jurisdictions focus much more deliberately on laycommunityinvolvement and support
for reintegration of the mentally ill. A world-renowned example is the oldest continuous community mental healthprogram in the Western world in Gheel, Belgium, a small town of 35,000 located in the province of Antwerp. Gheel isinternationally known for the centuries old tradition of foster family care for the mentally ill associated with the legendof St. Dymphna, the patron saint of the mentally ill. Gheel and other similar initiatives in Belgium and elsewhere inEurope promote the concept of ʻ
community recoveryʼwhere communities should strive to live with rather than fear therealities of mental illness. Hundreds of mentally ill individuals live their daily lives in Gheel without any stigmatizationof any kind, and with broad based community acceptance and ongoing support.
12 Among the skills the program tries to teach are to problem solve and consider the consequences of their actions,think
more critically and avoid biased or unfounded assumptions, assess the impact of their behavior on others, make better
decisions, and learn more socially skilled ways of interacting with others.

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RESOURCE MATERIAL SERIES No. 94
re-offending by up to more than 20% (Antonowicz, 2005;Tong & Farrington, 2006).
R&R has been adapted recently to be more particularly responsive to the needs of mentallydisordered offenders (R&R2 MHP;Young & Ross,2007). At only 16 sessions (rather than the original38), the program has been modified so as to maintain engagement with individuals who commonly
present with cognitive deficits (e.g., in attention and memory). It also incorporates guided individual
mentoring between group sessions to consolidate the material introduced in the group and transfer
acquired skills into daily activities. A recent multi-site controlled trial of the program with a sample
of 121 adult males drawn from 10 forensic mental health sites in the UK showed significant improvement across a number of measures from baseline to post-treatment (Reese-Jones et al.,2012). Close to80% of group participants completed the program and in contrast to controls, there were significant
treatment effects on self-reported measures of violent attitudes, rational problem solving and anger
cognitions. Importantly,improvements were endorsed byinformant ratings ofsocial and psychological
functioning within the establishments.
The final curriculum-based intervention worth noting deals with only one, but one particularly
critical issue for the mentally ill, assisting them to access meaningful employment. As part ofcommunity-based vocational rehabilitation efforts, the Ready Set Go program takes an innovative
approach to motivate mentally ill individuals to find and hold on to employment. Delivered in about
thirty 3-hour group sessions, interspersed with one-on-one work, Ready Set Go adopts a three-staged
strategy to vocational rehabilitation. Participants are initially guided in evaluating and committing totheir own goals for self-sufficient living. The program then helps them understand their own selfsabotaging thinking and learn new problem solving and coping skills. Finally,using key principles ofmotivational theory, the focus turns to building intrinsic motivation to seek and retain employment.
Recent evaluations of the program in a number of community settings in the US and Canada haveshown that more than 70% of participants actually gain employment within 30 days of program
completion and the length of job retention more than doubles compared with usual practice (Fabiano,2012).
Particular interventions can make a significant difference in the lives of mentally disordered
offenders. Applied singly or in combination,life outcomes can be affected quite substantially for these
individuals. As a summary, the findings from a recent comprehensive review are instructive. The
review identified at least six evidence-based practices for their potential in reducing both risk of
re-offending and improving mental-heath outcomes for mentally disordered offenders (Osher & Steadman, 2007). These are outlined in Table 5 below.
Table 5What we can conclude,therefore,is that based on the treatment evidence we have to date,we canbe effective in dealing with mentally disordered offenders when we attend to both mental health needs

20157TH INTERNATIONAL TRAINING COURSE
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and what are commonly referred to as ʻ
criminogenicʼneeds.13 For example, integrating drug andalcohol treatment with mental health services (and thereby targeting an important ʻcriminogenicʼneed)is generally considered not only best practice but also essential practice (Clearly et al., 2008). The
emphasis should be on early intervention,as well as relapse prevention and support,and should adopt
an approach that promotes engagement but also challenges drug taking and its link with offending
behavior. Unstable accommodation and/or homelessness and lack of access to the labor force forstable employment are several other key ʻ
criminogenicʼfactors that significantly increase risk ofoffending, including among mentally disordered offenders (M ullen & Ogloff, 2009).
Quite interesting to note as well, however, is that the emphasis on the recovery model and illness
self-management within the mental health field,strongly agrees with another emerging rehabilitation
theory within criminal justice ― the “Good Lives”model of offender rehabilitation, which seeks to
reduce recidivism by equipping individuals with “the tools to lead more fulfilling lives”(Ward &Brown, 2004).14
Another comprehensive overview of treatment alternatives with mentally disordered offenders
makes the point that many of the strategies that have been applied to date have been borrowed fromuse with other populations (Knabb et al.,2011). Of the ten treatment options found in the literature,it
was concluded that only five have been empirically validated with mentally disordered populations(i.e.,behavior therapy,cognitive behavioral therapy,dialectical behavior therapy,assertive community
treatment, and therapeutic communities). Others may be of some value as adjunctive therapies but
evidence has not been accumulated (e.g., music therapy, art therapy, analytical therapy, attachment
theory). In dealing with mentally disordered offenders there are a variety of clinical problems that canemerge quite regularly(e.g.,including aggression,criminal tendencies,institutional management,poor
life skills,substance abuse,social isolation,and psychotic and mood symptoms)(Rice & Harris,1997).
Future treatment integration efforts should combine the strengths of existing interventions,address theplethora of clinical concerns presented by mentally disordered offenders, and more reliably measureefficacy with well-designed randomized controlled trials.
D. Assessment Issues in Managing Mentally Disordered Offenders
Treatment planning and effective delivery of services hinges on proper assessment. You canʼt treatwhat you donʼt identify,and you canʼt monitor how well your treatment might be doing without someclear indicators of outcome. As we have already seen,in dealing with mentally disordered offenders,
there is the prerequisite to assess both risk for offending, so as to address some of the criminogenic
factors that can reduce that risk,as well as to screen for mental health needs and/or diagnosis ofactual
disorder.
Over the last several decades,a number of state-of-the-art assessment tools have been developed toassess the risk/needs of offenders. Andrews and Bonta (2003)have popularized reference to what havebeen coined as the central eight ʻrisk factorsʼfor offending. These include four considered as high inpredictive ability (history of antisocial behavior, antisocial personality pattern, antisocial cognition,
antisocial associates) and another four considered as moderate (family, school, leisure/recreation,
substance abuse). Other than the history factor which follows the old adage that past behavior predicts
future behavior, the remaining set of risk factors are seen as ʻchangeableʼin some fashion;that is,programs and services can do something to minimize their influence on possible future offending (seeTable 6 below for an elaboration of these factors). Although with some different emphasis on one or
13 The wellaccepted RNR ʻ
rehabilitation theoryʼframework for reducing re-offending is based on three key principles:

Some offenders are at higher risk to reoffend than others and so we should try to give them more intensive and/or
enhanced levels of service. (Risk Principle);Some areas of need in offenders are more important than others to attend
to because they relate more reliably and predictively to risk for re-offending (e.g.,substance abuse)(Need Principle);and
finally,though a principle that still remains relatively under-developed,the concept ofʻ
responsivityʼ
points to the fact that
offenders,like people more generally,will respond better in receiving certain kinds of support or help,and certain types
and styles of intervention. In other words, one size will not fit all. (Responsivity Principle).
14 Tony Wardʼs Good Lives M odel suggests that offending continues (regardless of how it originated)because offenders:
1.Apply inappropriate and shortsighted means to secure their needs,2.Lack scope or coherence in their overall life plan,
3. Experience conflict among goals that they are not aware of,and 4.Lack the capacities or skills to adjust in achieving
their needs in some other ways.

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RESOURCE MATERIAL SERIES No. 94
other of these eight factors,most risk/needs assessment tools that have been developed and validated
over the years include some detailed analysis of one or more of these eight dimensions.15
Table 6
Major ʻCriminogenicʼ(Dynamic Risk) Factors

References for some of the most popular risk/needs assessment tools in the field of criminal justice
are shown in Table 7, including the Level of Service/CM Inventory (LS/CMI), the Violence Risk
Appraisal Guide (VRAG), and the Structured Assessment of Violence Risk in Youth (SAVRY).

15 For example,the wellrespected Psychopathy Checklist (PCL,Hare,2003)mostly emphasizes a set of personality traits

that have been related to antisocial personality disorder (e.g., narcissism, callousness, manipulativeness).

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Table 7:References to Standard Risk/Needs Assessment Instruments
Adult instruments
Level of Service Inventory Revised (LSI-R)

Andrews, D.A. & Bonta, J. (2001). The Level ofService Inventory―Revised userʼs manual. North
Tonawanda, NY:Multi-Health Systems.

Risk Assessment for Sex Offender Recidivism(RRASOR)

Hanson, R.K. (1997). The development of a brief
actuarial risk scale for sexual offense recidivism. Ottawa, Ontario, Canada: Department of the Solicitor
General of Canada.
Harris, G.T., Rice, M.E., & Quinsey, V.L. (1993).
Violent recidivism of mentally disordered offenders:
The development of a statistical prediction instrument. Criminal Justice and Behavior 20: 315-335.
SORAG:

Violence Risk Appraisal Guide (VRAG)

Quinsey,V.L.,Harris,G.T.,Rice,M .E.,& Cormier,C.
(2005). Violent offenders: Appraising and managing
risk (2nd ed.). Washington,DC:American Psychological Association.

HCR-20;Assessing Risk for Violence

Webster, C. D., Douglas, K. S., Eaves, D., & Hart, S.
D. (1997). HCR-20: Assessing risk for violence (Version 2).Vancouver,British Columbia,Canada:M ental
Health, Law, and Policy Institute, Simon Fraser
University.

PCL-R;Hare Psychopathy Checklist

Hare, R. D. (2003). M anual for the Revised
Psychopathy Checklist (2nd ed.). Toronto, ON,
Canada:Multi-Health Systems.

Juvenile instruments
Structured Assessment of Violence Risk in Youth(SAVRY)

Borum, R., Bartel, P., & Forth, A. (2006). Structured
Assessment of Violence Risk in Youth (SAVRY).
Oxford, United Kingdom:Pearson Education.

Youth Level of Service/Case M anagement Inventory(YLS/CM I)

Hoge,R.D.& Andrews,D.A.(1995).The Youth Levelof Service/Case Management Inventory: Description
and evaluation. Ottawa, Ontario, Canada: Carleton
University, Department of Psychology.

An effective risk and needs assessment tool should obviously have several key theoretical andpsychometric qualities (e.g.,Bonta,2002). It should sample a number of factors that research shows are
predictive of criminal behavior,assess dynamic factors that can be used to guide treatment decisions,and demonstrate satisfactory reliability and validity across a number of independent studies. Importantly, there should always be some attempt to locally validate both the relevance and accuracy of
selected risk assessment tools since information from these tools can lead to inaccurate classificationof all or part of the local population. Subsequent ʻ
best practiceʼtreatment decisions based on thoseclassifications could actually be quite misdirected. This has been referred to as the ʻvalidation
problemʼwhere many jurisdictions simply adopt tools but are unable to speak to the accuracy of theassessment and classification schemes they use with their local populations (Byrne & Pattavina,2006).
When we turn to the other key aspect of assessment for mentally disordered offenders,the obvious
goal is to identify, for the purposes of treatment, the nature and extent of any mental-health issues
and/or any possible ʻdiagnosableʼdisorder. The most reliable sources of information for this come23

RESOURCE MATERIAL SERIES No. 94
from structured interview schedules in the hands of a competent clinician. A good example is the
Diagnostic interview Schedule which has been used extensively in epidemiological studies of theprevalence of mental illness (Robins et al., 1981). However, on practical grounds, reliance on theseinterview-based measures can be unrealistic. It has been noted that “budgets could never afford enoughpsychiatrists or psychologists to meet the demand［for correctional mental health assessment］”(Grisso, 2006, p. 5). The design of tools for use by non-mental health professionals has consequently
been a major concern in the field. We know that measures are needed as well for screening early inthe correctional process,preferably in the first few days in custody,and “self-report measures offer abetter alternative to lengthy clinical interviews given the large number of prisoners”(Krespi-Boothby,et al., 2010, p. 93).
A number of brief, reliable and relevant tools to screen for offender mental health have beendeveloped. Several of these are briefly summarized below.
Brief Jail Mental Health Screen (BJMHS): This rather brief assessment form (which takes anaverage of 2.5 minutes to administer) is considered a practical and efficient screening tool that
correctional officers can give detainees on intake screening (Steadman et al., 2005).
Jail Screening Assessment Tool (JSAT):The JSAT is a brief, semi-structured interview developedin Canada to identify mental health problems and risk for suicide, self-harm, violence, and victimization among new admissions to jails and pretrial facilities (Nicholls et al., 2005).
Offender Assessment System (OASys):As part of a more comprehensive assessment protocol forassessing the risk/needs of offenders (OASys), the Home Office in the UK has included some mental
health screening indicators that provide a preliminary analysis of mental health risk, which can thenbe examined further with other tools (Fitzgibbon & Green, 2006).
General Health Questionnaire (GHQ):Twelve items from the GHQ formed this self-report inventory
developed to assess for clinically significant emotional distress with offenders. The instrument has
been shown able to detect risk for self-harm and suicide and/or mental health problems requiring longterm care (Krespi-Boothby, et al., 2010).
Computerized Mental Health Screening: Developed by Corrections Canada as a 30 to 40 minutecomputer-assisted assessment of mental health indicators adopted from the Brief Symptom Inventoryof mental health along with a depression,hopelessness and suicide scale,developed within Corrections
Canada. The information is collated into a report that goes to the offenderʼs confidential medical fileand if the score exceeds a certain threshold,there is an automatic referral to a psychologist for a morethorough assessment (Correctional Service of Canada, 2008).
It is worth noting that specialized assessment tools may also be required for assessment of mental
health issues in female offenders, for example, in order to focus on trauma and trauma-relateddisorders like PTSD (Weathers et al., 1994).
Before concluding this section of the paper, there is one particular mental health assessment toolthat merits some brief description both because of its rather innovative approach and the extensive
validation studies that have been conducted to support its use. The Massachusetts Youth Screening
Instrument-Version 2 (M AYSI-2) (Grisso & Barnum, 2006) was designed specifically as a self-report
15-minute screening (triage)tool to be administered,often by non-clinical personnel,to all youth at thetime of intake (within 1-3 hours after admission) in juvenile probation offices, juvenile pre-trial
detention centers, and juvenile justice corrections and residential facilities. Its primary purpose is to
identify symptoms (represented by thoughts,feelings and behaviors)that are found in many psychiatricdiagnostic conditions of youth, but as well in adults. In a set of seven key areas (see Table 8 below),
the tool provides information for whether individuals might require an immediate mental healthresponse (e.g., suicide precautions, need for further evaluation, referral for clinical consultation).
Importantly,through the use of specific cut-off scores,the tool also differentiates whether the individual is in theʻcaution rangeʼof clinical significance for symptoms,or in theʻwarning rangeʼof very highlevel of disturbance.

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Released 12 years ago, the MAYSI-2 is now registered for use in over 2,000 sites in 47 states in
America, including statewide use in all intake probation, detention and/or corrections facilities in 44
American states. Researchers have also translated the MAYSI-2 into 13 languages.
Table 8
Scales in the M AYSI-2

In both the fields of criminal justice and mental health,the design of assessment tools to determine
the risk and needs of individuals has proliferated in the last several decades. But assessment processes
should aim to collect more than initial baseline information. Methods are needed as well to track
individual progress and response to our interventions,both to determine program effectiveness and toplan further interventions to address emerging and outstanding needs. This is where structured Case
M anagement procedures come into play where there should be vigilant and continuous monitoring of
a whole variety of life indicators. For managing mentally disordered individuals,this should include
at a minimum the monitoring of a whole range of criminal justice,mental health and broader health/social indicators (as briefly described in Table 9 below).
Important to capture as well are early signs of disruptive behavior (e.g., whether the person isdifficult to manage;if they are verbally aggressive or attention seeking)and any deterioration in socialand psychological functioning (e.g., insight into behavior, feelings of guilt, social interactions withothers). It goes without saying that issues that are caught early are easier to manage and less likely
to exacerbate. The very successful Assertive Case Management model for managing the mentally ill isbased on this fundamental assumption (Ziguras & Stewart, 2000).

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RESOURCE MATERIAL SERIES No. 94
Table 9Key Indictors for Monitoring Intervention Outcomes
Criminal justice indicators― Arrests and police contacts― Nature and seriousness of offending― Frequency and duration of incarceration
Mental health indicators― Status of diagnosis― Severity of symptoms― Service utilization (e.g., hospitalizations)― M edication compliance

Health and social indicators― Active substance use― Current health status― Housing status― Family relations― Employment participation― Social and emotional wellbeing― Participation in community and cultural life
― Pro-social associates― Quality of life
― Experiential indicators

E. Training and Development of Staff in Managing M entally Disordered Offenders:
In both community and institutional settings staff training is key to affect a more appropriate
response to the challenges presented by mentally disordered offenders. The first point of contact withan individual who is displaying bizarre or disruptive behavior because ofmental health reasons is often
not a professional mental health worker. In the community, it is typically law enforcement officers,
and in prisons or jails it is prison officers. In both types of settings,training of these on-the-line staff
needs to focus:first,on recognizing the various behavioral manifestations of mental illnesses;second,on how to manage and de-escalate as necessary, and finally, on how to appropriately respond toincidents, including to ensure that timely access to professional, clinical intervention will occur.
Considerable success has been shown in various community programs where specialized training of
law enforcement officers encourages diversion of the mentally ill towards mental health care rather
than further criminal justice involvement. One excellent example is the New South Wales Police
Mental Health Intervention Team (M HIT) model in Australia (Laing et al., 2009) based on the Crisis
Intervention Team approach that emerged in America in Memphis,Tennessee (Steadman et al.,2000).
The MHIT program involves four-days of intensive training for police officers on how to work withmentally ill or disordered people in a sensitive,safe and efficient manner. Training gives participants
an understanding of mental health legislation applying in NSW and provides them with an array ofcommunication strategies they can employ, as well as risk assessment, de-escalation and crisis intervention techniques. The overall aims of the program are to reduce the risk of injury to both police andmentally ill individuals, improve collaboration with agencies in the response to, and management of,mental health crisis incidents,and finally,increase the likelihood and reduce the time taken by police
in the handover of individuals to the mental health care system. It has been demonstrated that thesekinds of training approaches to alter police response can lead to significant reductions in arrest rates
for mental-health crisis incidents;to as low as 2% (Steadman et al., 2000).
Within institutional correctional settings, there should be by the very nature of incarceration, agreater likelihood of close observation and supervision of the mentally ill. Unfortunately, the prison
officer ʻcultureʼin these settings is often unsupportive of intervention with the mentally ill,other thanfor punitive reactions to misbehavior (Kropp et al., 1989;Rotter et al., 2005). The control of these
individuals consequently becomes more ʻ
punitive controlʼrather than ʻcaring controlʼ. It is axiomatic
in prison settings that the more active and involved correctional staffare with a program,and the more
input they are encouraged and allowed to have on the development of policies and programs,the more
successfully the program will be implemented. When the advantages of providing professional intervention and programming for the mentally ill are couched in terms of the benefits for line staff(i.e.,lessstressful day-to-day interactions),prison officers will be much more likely to get on board. Interestingly, even relatively brief exposure to appropriate training seems able to alter prison officer behavior
quite dramatically. For example, in one study it was found that a ten-hour mental health training
program developed by the National Alliance on M ental Illness (NAM I-Indiana) for correctional
officers on a prison (ʻsupermaxʼ) special housing unit significantly reduced the frequency of ʻuse offorceʼwith mentally disordered prisoners (Parker, 2009).

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157TH INTERNATIONAL TRAINING COURSE
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Strong arguments have been made to include correctional officers as essential and fully participating members of multidisciplinary treatment teams for offenders with mental illness,rather than simply
relegating them to the role ofʻturn key guardsʼ(Applebaum et al.,2001). Dvoskin & Spiers (2004)quite
accurately describe the culture of the community inside prison walls and argue that correctional
officers can play a vital role in the provision of specialized mental health services to offenders, forexample, by learning to talk with offenders in a therapeutic manner, informing the mental healthconsultation process with their observations, and observing medication effects and side effects.
A number of jurisdictions have developed standardized training curricula to educate prison officers
on the basics of mental illness and strategies for improved management of these individuals. Some
excellent examples include the Correctional Service of Canada and their recent development of a
two-day mental health awareness-training package tailored to the specific needs of various front line
groups including case management staff, institutional health care nurses, and correctional officers.
Another is the State of Coloradoʼs M ental Health Training Course for Law Enforcement and Corrections Officers (Sherman, 2001).
There is certainly no magic bullet curriculum that can make law enforcement or correctional staff
members do what they should do in dealing with the mentally ill offender. Undoubtedly,if there is a
key ingredient to success,it is to allow these line staff to become core members of a multidisciplinary
team,not to remain peripheral to it. Some of the basic tenets of the Assertive Case M anagement model
are a good way to conclude what this should involve:
―
―
―
―

―

―

―

A clear focus on those individuals who require the most help from the service delivery system;
An explicit mission to promote the mentally ill offenderʼs rehabilitation and recovery;Aʻ
total team approachʼwhere all of the staff work with all of the mentally ill clients,under
the supervision of a qualified mental health professional who serves as the teamʼs leader;An interdisciplinary assessment and service planning process that typically should involve a
psychiatrist or psychologist and one or more nurses,social workers,substance abuse specialists,vocational rehabilitation specialists,occupational therapists,and where possible certified
peer specialists (individuals who have had personal, successful experience with the recovery
process);
A willingness on the part of the team to take ultimate professional responsibility for thementally ill individualʼ
s well-being in all areas of institutional or community functioning,
including most especially the “nitty-gritty”aspects of everyday life;
A conscious effort to help people avoid crisis situations in the first place or, if that proves
impossible, to intervene at any time of the day or night to keep crises from turning into
unnecessary incidents;andA commitment to work with people on a time-unlimited basis, as long as they continue todemonstrate the need for this unusually intensive and integrated form of professional help.

IV. CONCLUSION
The effective management of mentally disordered offenders raises a host of interconnected andcomplicated issues. It stretches the expertise of corrections to its limits and exposes the reality thatthe criminal justice system does not really function as a ʻ
systemʼ, much less connect very well withother social service and health care systems. A focused and integrated strategy is needed to divert
mentally disordered offenders away from the experience of imprisonment as much as possible,lessen
the harm of the experience for those who must be incarcerated,and ensure there is adequate after-carepost-release to prevent reoffending. ʻ
Primum non nocereʼ(first do no harm) should be a motto forcorrectional services worldwide and not just the Hippocratic oath of the medical profession. M any
offenders enter prisons with pre-existing mental health issues that are then exacerbated. For others,
imprisonment itself serves as the catalyst for igniting mental disorder. Though it is not just a
correctional problem, but a community and broader social problem, corrections should aspire to do
more in managing these special needs offenders with determined and innovative evidence-informed
approaches.

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