What factors are related to success on conditional release/discharge? Findings from the New Orleans forensic aftercare clinic: 2002-2013.

The conditional release of individuals detained in jails and forensic hospitals reflects a growing trend in state policies toward community-based forensic mental health programming (McDermott, Scott, Bosse, Andrade, Zozaya & Quanbeck, 2008; Vitacco, Vauter, Erickson, & Ragatz, 2013). When individuals are released from a secure forensic setting, it is important to demonstrate that treatment in the community is effective and that public safety is not compromised. In addition, factors that influence whether an individual is likely to be successful on conditional release are important to understand so that clinicians and legal decision-makers have an empirical basis to guide release evaluations and placement decisions. Conditional release into the community is predicated on individuals meeting specific conditions of the release agreement. If an individual violates the conditions of his or her release, the person is subject to revocation of release and return to incarceration or inpatient treatment. Owing to the important public safety and policy implications involving the release of individuals into the community from secure forensic facilities, recent research has focused on the success of individuals placed on conditional release. The majority of the empirical research on conditional release programs has considered whether individuals on conditional release are able to be maintained in the community safely and successfully. Research demonstrates that conditional release programs are effective on key variables, such as reducing recidivism, minimizing arrests and revocations (Bloom, Williams, & Bigelow, 1991, 1992; Vitacco et al., 2013; Wiederanders, 1992; Wilson, Tien, & Eaves, 1995). Early studies demonstrated the success of conditional release programs (i.e., arrest on new charges and revocation), although revocation rates among not guilty by reason of insanity (NGRI) acquittees across studies tended to hover between 35% and 49% (Callahan & Silver, 1998). More recent research has demonstrated improvement in revocation rates and the maintenance of individuals on conditional release in the community over longer durations, perhaps due to the evolution of conditional release programming and responsiveness to behavioral changes in individuals (Vitacco et al., 2013). Much of the extant research investigating conditional release focuses on identifying the factors associated with its successful maintenance; however, differences among programs, participants, and jurisdictions make comparisons difficult. The majority of studies focus on the conditional release of NGRI acquittees (Callahan & Silver, 1998; Monson, Gunnin, Fogel, & Kyle, 2001; Parker 2004; Vitacco et al., 2008, 2011, 2013), although Bertman-Pate and colleagues (2004) and Wilson and colleagues (1995) evaluated conditional release in a mixed sample of mentally disordered offenders. Wilson and colleagues (1995) reported a 35% revocation rate for male mentally disordered offenders released to an intensive assertive case management program. Individuals released from jail to an intensive forensic case management program spent fewer post-release days in jail and were maintained longer in the community than a comparison sample released from jail without follow-up. Callahan and Silver (1998) examined conditional release across four states. The average revocation rate was 31%, indicating that most participants are successful on conditional release. Several variables were related to success on conditional release. Individuals with a substance abuse history were more likely to be revoked. Being White, employed, and married is associated with a lower likelihood of revocation. Race percentages were not listed. Callahan and Silver (1998) also found a trend for individuals with a history of prior hospitalizations to have greater rates of revocation. Consistent with the results found by Callahan and Silver (1998), Monson, Gunnin, Fogel, & Kyle (2001) demonstrated that minority status, substance abuse diagnosis, and prior criminal history predicted revocation in a random sample of 125 NGRI acquittees. Thirty-eight percent of the Monson and colleagues sample was African-American. In a study similar to the one conducted by Wilson and colleagues (1995), examining treatment outcome, Parker (2004) evaluated conditional release success in an assertive community treatment (ACT)-based program over a five year period. Arrest or hospitalization (not revocation) was the primary outcome measure used to determine success on conditional release. Parker (2004) demonstrated that 83% of NGRI acquittees in an assertive case management program were maintained in the community during the five year study period. He reported a 1.4% arrest rate with only one arrest for violent behavior. The primary factor associated with failure on conditional release was a diagnosis of paranoid schizophrenia. Length of time in the community also significantly predicted maintenance on conditional release. Overall, Parker (2004) demonstrated a low arrest rate, moderate hospitalization rate, and high community tenure. Bertman-Pate and colleagues (2004) reviewed the factors associated with successful conditional release in a sample of individuals at the New Orleans Forensic Aftercare Clinic (FAC). The original study examined the conditional release system as it operated in Louisiana from 1995 to 2002. In that study, no significant differences between individuals who were discharged on conditional release from long-term hospitalization and those diverted from jail were found. For both jail-diverted and hospital-discharged clients, success on conditional release was significantly related to fewer previous hospitalizations, fewer prior arrests and a lower number of in- program incidents. Individuals who had their conditional release revoked were more likely to have a diagnosis of schizophrenia and less likely to have a diagnosis of mental retardation. Sixty-five percent of the sample maintained their conditional release over the seven year follow-up period. A 10% rearrest rate was noted with only two arrests for violent charges. The sample in the Bertman-Pate et al. study was a largely minority cohort (81.5% African-American), in contrast to most other published reports. Most recently, Vitacco and colleagues (2008, 2011, 2013) conducted a series of robust studies examining factors related to the maintenance of conditional release. Vitacco and colleagues (2008) demonstrated in a large sample (n = 363) of NGRI acquittees that 66% maintained conditional release for 3.7 years. A diagnosis of substance abuse, previous revocation of conditional release, and mental health symptoms requiring inpatient hospitalization were all positively related to revocation of conditional release. In the only study examining conditional release in female NGRI acquittees, Vitacco and colleagues (2011) demonstrated that 68.4% maintained conditional release for an average of 4 years. There were no revocations due to violent behavior. Emerging symptoms of mental illness requiring hospitalization were related to revocation. Vitacco and colleagues (2013) examined a racially diverse sample of 127 NGRI acquittees in Virginia who were on conditional release from 2007 to 2010. The sample was described as racially diverse and consisted of 38% African-Americans and 56% Caucasian Americans. Previous failure on conditional release, non-adherence to treatment, dangerousness, and prior violent charges predicted revocation. A multivariate survival analysis indicated that criminal behavior (i.e., number of previous charges, number of violent charges) and previous failure on conditional release predicted time to revocation. The authors note that although they relied on a list of standard risk factors, they did not employ an empirically based measure of violence risk. Research on conditional release has focused on the identification of individual factors associated with success on conditional release. Studies employing primarily demographic and standardized risk data demonstrate that individuals are able to be maintained safely in the community, although there exists a subset of individuals who do not respond favorably to community-based treatment programs (Bieber, Pasewark, Bosten, & Steadman, 1988). The conditional release of individuals is predicated on making informed decisions regarding which factors impact success on conditional release, such as the presence and severity of an individual’s mental illness, criminogenic factors related to recidivism and potential dangerousness (McDermott et al., 2008; McDermott & Thompson, 2006). Identifying factors related to conditional release revocation can inform conditional release programming and aid in the development of successful risk management and risk reduction strategies for individuals in community-based treatment.