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Individuals With Serious Mental Illness in the Criminal Justice System The Case of Richard P. Arthur J. Lurigio Loyola University Chicago, Illinois John Fallon Thresholds This paper presents a case study that illuminates the clinical and practical challenges that accompany the treatment of people with serious mental illness (SMI) and criminal involvement. We discuss the historical conditions that led to the influx of a large number of people with SMI into the criminal justice system. We discuss the case history of Richard P., which illustrates the use of Assertive Community Treatment (ACT) to care for criminally involved people with SMI. We focus on the ACT model that was employed by Thresholds to treat Richard P. It was known as the Thresholds Jail Program. We track his progress in the program and explicate the case management considerations that are most salient in treating offenders with SMI. Keywords: criminalization, mental illness, crime, deinstitutionalization, mental health services, probation, ACT 1 Theoretical and Research Basis Fundamental changes in mental health policies and laws have brought criminal justice professionals into contact with the seriously mentally ill at every stage of the justice process: police arrest people with serious mental illness (SMI) because few other options are readily available to handle their disruptive public behaviors; jail and prison administrators strain to attend to the care and safety of the mentally ill; judges grapple with limited sentencing alternatives for individuals with SMI who fall outside of specific forensic categories (e.g., guilty but mentally ill); and probation and parole officers scramble to obtain scarce community services and treatments for people with SMI and attempt to fit them into standard correctional programs or monitor them with traditional case management strategies. When mentally ill inmates are released from prison, their disorders complicate and disrupt their reentry into the community (Council of State Governments, 2002). The current paper presents a case study that highlights the clinical and practical challenges attendant with treating people with SMI who are involved in the criminal justices system. Estimates suggest that nearly 20% of the nation’s correctional population have SMI, including individuals in prisons, jails, and on probation supervision (Ditton, 1999). Clinical Case Studies Volume 6 Number 4 August 2007 362–378 © 2007 Sage Publications 10.1177/1534650106299158 http://ccs.sagepub.com hosted at http://online.sagepub.com Lurigio, Fallon / Serious Mental Illness 363 The majority of prison inmates and jail detainees with SMI eventually return to the community, and mentally ill offenders on probation and parole are already living there. Jails and prisons are legally required to provide mental health care that meets accepted standards of practice, and probationers and parolees can be mandated to receive mental health care as a condition of their release. Hence, clinicians are more likely, now than ever, to treat individuals with SMI and criminal justice involvement (Lurigio & Swartz, 2000). This paper addresses the case management and care of offenders with SMI. First, we discuss the factors that contributed to the large numbers of people with SMI in the criminal justice system. Second, we present the case study of Richard P., which illustrates the use of Assertive Community Treatment (ACT) to care for criminally involved people with SMI. Richard’s symptoms were managed with an ACT model employed by Thresholds, which was known as the Thresholds Jail Program (TJP). Thresholds delivers a wide array of treatment and rehabilitative services for people with chronic psychiatric disabilities. Third, we track Richard’s progress in the program in terms of arrests and days in the hospital and jail. Fourth, we explicate the general clinical and case management considerations that are most salient in treating offenders with SMI. Pathways into the Criminal Justice System Nearly 35 years ago, Abramson (1972) noted that more and more people with SMI were being routed through the criminal justice system instead of the mental health system. Since then, data have suggested that the mentally ill are arrested and incarcerated in numbers that surpass their representation in the general population and their tendencies to commit serious crimes or be arrested (Council of State Governments, 2002). In light of these data, mental health advocates and researchers have asserted that people who have been treated in mental health agencies and psychiatric hospitals are more frequently being shunted into jails and prisons (Teplin, 1983). People with SMI enter the criminal justice system, and people involved in the criminal justice system enter the mental health system, through a variety of pathways, including “crisis services, departments of social services, human services agencies, educational programs, families, and self-referrals” (Massaro, 2003, p. 2). For most mentally ill offenders, SMI complicates rather than causes their involvement in the criminal justice system (Draine, 2003). The disproportionately high number of people with SMI in correctional facilities is associated with the rising number of discharges from state hospitals, the passage of restrictive commitment laws, the splintering of treatment systems, the war on drugs, and the deployment of order-maintenance policing tactics (Lurigio & Swartz, 2000). Deinstitutionalization A fundamental change in mental health policy, known as deinstitutionalization, shifted the locus of care for patients with SMI from psychiatric hospitals to community mental health centers. Deinstitutionalization is the first major contributor to the processing of the 364 Clinical Case Studies mentally ill through the criminal justice system (Grob, 1991). After World War II, state mental hospitals nationwide began to release thousands of psychiatric patients to communitybased facilities for follow-up treatment and services. As a result, the number of patients in state mental hospitals nationwide was substantially reduced from 559,000 in 1955 to 72,000 in 1994 to fewer than 60,000 in 2000 (Center for Mental Health Services, 2004). The length of the average stay in psychiatric hospitals and the number of beds available also declined sharply (Kiesler, 1982). The deinstitutionalization movement was fueled by media accounts of patient abuse and neglect, the development of effective medications to treat SMI, federal entitlement programs that paid for community-based mental health services, insurance coverage for inpatient psychiatric care in general hospitals, and antipsychiatry polemics written by researchers and academic scholars (Sharfstein, 2000). Deinstitutionalization, however, was never properly implemented. Although the policy provided for appropriate outpatient treatment for a large percentage of the mentally ill, it failed to care adequately for individuals who had limited financial resources or social support, especially those with the most severe and chronic mental disorders (Shadish, 1989). The failed transition to community mental health care had the most tragic effect on patients who were least able to handle the basic tasks of daily life. Public psychiatric hospitals became treatment settings for the indigent. Patients became younger because new medications obviated the need for extended periods of hospitalization. Before these medications were discovered, psychiatric patients could remain in the state hospital for decades and be released when they were elderly. New cost-saving measures and hospital policies shifted the costs of care from state budgets, which paid for hospitalization, to federal budgets, which paid for community-based mental health services. Unlike earlier generations of state mental patients, those who were hospitalized during and after the 1970s were more likely to have criminal histories, to be addicted to drugs and alcohol, and to tax the patience and resources of families and friends (Draine, 2003; Lurigio & Swartz, 2000). Lack of affordable housing compounds the problems of people with SMI and interferes with the provision of mental health treatment. An estimated 20 to 25% of the adult homeless population is afflicted with SMI (Council of State Governments, 2002). The characteristics of the mentally ill, therefore, resemble those of many criminally involved persons: poor, young, and estranged from the community (Draine, 2003; Silver, Mulvey, & Swanson, 2002; Steadman, Cocozza, & Melick, 1978). As the Council of State Governments (2002) noted, “Without housing that is integrated with mental health, substance abuse, employment, and other services, many people with mental illness end up homeless, disconnected from community supports, and thus more likely to decompensate and become involved with the criminal justice system” (p. 8). In short, many persons with SMI fall into the lap of the criminal justice system because of the dearth of mental health treatment and other community services (Grob, 1991). Links between the criminal justice and mental health systems have always been tenuous, and the mentally ill who move from one system to the other frequently fail to receive enough treatment or services from either. As a result, their mental health deteriorates and they become both chronic arrestees and psychiatric patients (Lurigio & Lewis, 1987). Lurigio, Fallon / Serious Mental Illness 365 Legal Restrictions Reforms in mental health laws have made it difficult to admit the mentally ill involuntarily into psychiatric hospitals and are the second major contributor to the influx of mentally ill persons into the criminal justice system (Torrey, 1997). Serious restrictions on the procedures and criteria for involuntary commitment sorely limit the use of psychiatric hospitalizations. Most state mental health codes require psychiatric hospital staff to adduce clear and convincing evidence that patients who are being involuntarily committed are either a danger to themselves or others, or are so severely debilitated by their illness that they are unable to care for themselves. In addition, mental health codes strengthened patients’rights to due process, according patients many of the constitutional protections granted to defendants in criminal court proceedings. Thus, only the most dangerous or profoundly mentally ill are ever hospitalized resulting “in greatly increased numbers of mentally ill persons in the community who may commit criminal acts and enter the criminal justice system” (Lamb & Weinberger, 1998, p. 487). Fragmented Services The third major factor that explains the increased presence of mentally ill persons in the criminal justice system is the compartmentalized nature of the mental health and other treatment systems (Laberge & Morin, 1995). The mental health system consists of fragmented services for predetermined subsets of patients. Most psychiatric programs, for example, are designed to treat “pure types” of clients who can be placed into clear-cut categories for clinical services. By the same token, vast majorities of drug treatment staff are unwilling or unable to serve persons with mental disorders, and frequently refuse to accept such clients. Furthermore, offenders with co-occurring disorders are difficult to engage in treatment and are often resistant to efforts to confront their addiction to alcohol and illicit drugs (Drake, Rosenberg, & Mueser, 1996). Abstinence from substance abuse can be a prerequisite for acceptance into mental health treatment programs. Therefore, persons with co-occurring disorders, who constitute a large percentage of the mentally ill in the criminal justice system, might be deprived of services because they fail to meet stringent admission criteria (Abram & Teplin, 1991). When persons with co-occurring disorders—most of them with SMI and substance abuse and dependence disorders—come to the attention of the police, officers might have no other choice but to arrest them given the lack of available referrals within narrowly defined treatment systems (Brown, Ridgely, Pepper, Levine, & Ryglewicz, 1989). Drug Enforcement The fourth major factor associated with the pervasiveness of mentally ill offenders is the arrest and conviction of millions of persons for drug-law violations. The highly significant growth in the volume of drug arrests and convictions stems largely from the war on drugs. Offenders convicted of the use, sale, and possession of drugs constitute one of the fastestgrowing subpopulations in correctional facilities (Beck, 2000). A fairly large proportion of these offenders have co-occurring mental illnesses, adding to the number of mentally ill individuals in the criminal justice system (Swartz & Lurigio, 1999). 366 Clinical Case Studies Police Tactics The fifth major factor that contributed to the processing of people with SMI through the criminal justice system is the recent adoption of law enforcement strategies that emphasize quality-of-life issues and zero tolerance policies in response to public-order offenses: loitering, aggressive panhandling, trespassing, disturbing the peace, and urinating in public (Fagan & Davies, 2000). These crime-control strategies have netted large numbers of the mentally ill for publicly displaying the symptoms of an untreated SMI. The implementation of public-order policing tactics has outpaced the development of diversionary programs for persons with SMI, which has exacerbated the problem of criminalization (Ditton, 1999). 2 Case Introduction Richard P. is a 49-year-old African American man who has never married. He is slender and slightly built, with specks of gray in his hair. He has several missing teeth, and those in his mouth are visibly discolored or decaying making him look somewhat older than his recorded age. Richard was appropriately dressed in a clean jogging suit and running shoes. He moved somewhat slowly and spoke in deliberate, often inaudible, whispers. He was compliant with requests and often looked to his TJP caseworker for direction (e.g., where to sit for the interview). He seemed comfortable from the outset of the interview, displaying no signs of anxiety and appearing unconcerned when his caseworker left the room before the start of the assessment. Throughout the interview, Richard was friendly, made eye contact, and appeared relaxed. His affect was somewhat flat and his emotionality was immature. At the time of the interview, he was adhering to medications and living in a board-and-care facility. Richard reported that his life in the facility was very “safe and nice,” compared with his many stays in the hospital and jail, which left him filled with “bad memories.” 3 Presenting Complaints An independent assessment was conducted to determine the course of Richard P.’s continued involvement with the TJP. 4 History Richard P. grew up on Chicago’s West Side—a highly impoverished and crime-ridden area of the city—with his parents and 12 siblings: 8 sisters and 4 brothers. He is the youngest in the family and no longer has contact with any of his siblings. Richard’s mother died in September 1985, and his father died a year later. However, Richard has refused to believe that his parents are dead and talked longingly about contacting his mother “to see if she’s all right.” In addition, he has maintained that his parents still live at the residence where he spent his childhood and adolescence. He has occasionally harassed the current residents of Lurigio, Fallon / Serious Mental Illness 367 his former home, especially during times when he was homeless. The fragmented nature of Richard’s psychiatric records and the speed at which he moved between systems and institutions caused discharge planners to believe mistakenly that his mother’s home was a place where Richard could stay when he had no other housing options. No reported history of mental illness was found in Richard’s family. Psychiatric records state that one of his brothers was engaged in illegal drug use and other criminal activities. Richard had little to say about his childhood except that his parents were married and he “got along well” with his siblings. He reported that he attended high school but was often truant and “got into trouble” with his friends. He dropped out in the 11th grade. Richard has a long history of substance use, starting in high school with LSD and alcohol. Richard reported that his first hospitalization occurred shortly after he dropped out of high school. He indicated that he earned his GED at one of the state’s psychiatric hospitals. Richard reported that he has held “at least” four jobs—as a dye cutter, a filer in a clothing warehouse, a factory worker, and a mail clerk. Richard’s earliest psychiatric hospitalization occurred in 1976. From 1978 to 1998, he was hospitalized 27 times in state facilities, including numerous transfers between facilities. Richard’s longest period of hospitalization was 5.5 years. His early hospitalizations resulted from incidents of threatened violence and uncontrollable behaviors in the presence of his family members. He was admitted to one state facility following a verdict of not guilty by reason of insanity that stemmed from a charge of criminal trespass to property. Between 1978 and 1998, he was hospitalized a total of 11.5 years. Since 1985, the majority of his hospitalizations have followed the commission of petty crimes or public displays of disruptive, psychotic behaviors. In 1980, Richard stabbed his mother six times with a pair of scissors and threatened to kill the young children who resided at his mother’s home. According to police records, the incident occurred when he was unable to locate his clothing and identification card. Another violent incident occurred in April 1981 when he punched his father in the eye. Richard’s early delusions involved beliefs that he was Jesus Christ, was born with wings, and could foretell the future. He also averred that his mother was “Queen Mary.” From 1993 to 1997, Richard was arrested 84 times. He has approximately 140 lifetime arrests. His first arrest was for trespassing at an upscale hotel in downtown Chicago. In that incident, police reported that he was trying to set the hotel lobby on fire. Richard was accused of setting fires at another hotel many years ago, although he claims that the fire started “accidentally” after he dropped a cigarette on the floor. Richard acknowledged that he has been arrested numerous times. He remembered being arrested for sleeping on the streets, trespassing, and disorderly conduct. His final arrest, before being identified by the TJP, was on December 12, 1997. Richard insisted that alcohol and drug use have “never caused him” problems. However, police and other reports show that Richard has been arrested while publicly intoxicated, but there are no records of his being treated for a substance abuse or dependence disorder. Richard reported that he was homeless continuously for eight years. Records indicated that he slept on air vents, in shelters, and on pedways. Richard often alienated people in the community with his bizarre behaviors and style of dress. He is an inveterate smoker who insists on smoking whenever and wherever he pleases. His caseworker stated that Richard 368 Clinical Case Studies picks up cigarette butts from the ground and smokes them. Richard has panhandled and eaten frequently from garbage cans even when food was available. For most of his adult life, Richard has dressed inappropriately and worn brightly colored and unusual attire, such as belts over shirts, a shirt tied at the midriff, and shorts worn over pants. Sometimes, he wandered the streets wearing no shoes, untied shoes, or shoes several sizes too small. He collected much of his clothing by rummaging through garbage dumps. He seems to wear unusual clothing most often during periods of decompensation. Psychiatric records noted a history of cross-dressing and effeminate behaviors. In addition, hospital reports indicated that Richard paced constantly and talked to himself even while medicated. According to one hospital entry, Richard “lost his concentration quickly” and “displayed a silly smile,” when interacting with hospital staff. At times, he responded violently to auditory hallucinations by punching or chopping the air. 5 Assessment Richard was fully oriented and indicated that he understood the purposes of the interview. Although he reported that he had previously heard voices that “attacked him and called him dirty names,” he stated that the voices were “no longer a problem.” Richard’s fund of knowledge of current events was poor, and he displayed considerable short- and long-term memory deficits. His speech content was moderately organized but highly deficient. He was able to answer simple questions about his current living arrangements and daily activities but he was unable to respond to more complicated questions. His thinking was highly concrete. At various points in the interview, he spoke remorsefully about his separation from his family, especially his mother, and his lost employment and relationship opportunities. He stated that he frequently “felt ashamed of himself ”; however, he provided few specific details regarding the nature of his failures or regrets. Richard claimed to be a “famous singer and entertainer” who was once “well known throughout the country.” When he was pressed for concrete information concerning his entertainment career, Richard became confused and evasive, stating only that he had “sung in the church choir.” Psychiatric records indicated that both of Richard’s parents died more than 20 years ago. Nonetheless, Richard clung tenaciously to the belief that they were still living and residing in his childhood home. He spoke longingly about being reunited with his mother who would “wash away” the “contaminations” that he had been exposed to in the hospital and jail. Despite his longstanding dependence on nicotine and periodic misuse of alcohol, Richard reported no problems with alcohol or drug use, or other medical conditions. His responses to questions concerning his present life were replete with religious ideation and references. He spoke with obvious contentment about his relationship with God. Richard stated that he “knows God and sees God everywhere he goes.” He described God as a “gentle, beautiful figure with white hair and a peaceful voice.” The only time in the interview that Richard appeared animated and energized was when he talked about his religious experiences and activities, such as Bible reading. Despite repeated questions regarding the nature of his contacts with God, it was unclear whether Richard’s reported experiences with Lurigio, Fallon / Serious Mental Illness 369 God were hallucinatory or metaphorical. Based on this information, Richard was assigned the following DSM-IV diagnosis at the time of his interview: Axis I 295.10 Schizophrenia, disorganized type, continuous 305.10 Nicotine Dependence 300 Alcohol Abuse (provisional) Axis II 799.9 Diagnosis Deferred on Axis II Axis III None Axis IV Criminal Justice Involvement History of Housing and Employment Problems No Family Support Axis V Global Assessment of Functioning35 (current) 6 Case Conceptualization Overview The case study of Richard P. profiles an individual with SMI who has been chronically involved in the criminal justice and mental health systems. His experiences personify the term “criminalization”; he was frequently arrested and jailed because his manifestations of symptoms created a public nuisance. Richard’s threats and expressions of violence were aimed primarily at his family, and his criminal activities were typically haphazard and impulsive. Although Richard’s records of psychiatric and criminal recidivism are remarkable, his history exemplifies how the absence of community-based care leads to perpetuating cycles of psychiatric disability, disruptive behaviors, and police contacts. Whether his display of symptoms resulted in an arrest or a hospitalization depended on a wide variety of factors that were mostly unrelated to his illness (e.g., who called the police, the willingness of a complainant to press charges, the responding police officers’ inclination to arrest, and hospital staff persons’ willingness and ability to admit Richard). Richard received effective treatment in the state hospital and the medical facility of the jail, but he was simply unable to care for himself or manage his life without the continued assistance and partnership of professionals in the mental health and criminal justice systems. The collective interventions of those professionals helped Richard achieve the consistent support that he needed to live successfully in the community. The TJP was the “boundary spanner” between the mental health and criminal justice systems (Steadman, 1992). Richard achieved stability only after he received the concerted attention of persons working in the court, jail, community-based treatment network, and state hospital. All members of Richard’s case management team recognized that they were unable to break the hospitalization–incarceration cycle alone. Richard’s case clearly illustrates the remarkable complexity of helping a transinstitutionalized client who requires the services of several treatment systems (i.e., hospitals, jails, prisons, courts, shelters, and substance abuse facilities). Continuity of care is critical in maintaining such clients’ progress. Inadequate or interrupted care is tremendously costly and drains the resources of each system in which they appear. Richard’s experiences also demonstrate the effectiveness of a case management approach to supportive services that protects public safety, reduces treatment costs, and improves the quality of clients’ lives. Richard’s case shows that community care is greatly fostered when staff persons of the jail and state hospital regularly communicate. Without effective medication titration, both in the hospital and community-based treatment settings, clients with SMI can never be completely ready to pursue independent and productive lives. Community providers can help jail and hospital staffs learn which medications are necessary to achieve client stability after discharge. For example, although medications effectively controlled Richard’s behavior in structured settings (i.e., jails and hospitals) he was overwhelmed by stimuli when released from inpatient care and immediately became symptomatic and at risk for reinstitutionalization. Armed with this basic information from the TJP, inpatient staff adjusted Richard’s medication in order to prepare him for successful discharge. Cooperation among agencies was the key to Richard’s success. Specifically, police officers in the district where Richard lived learned about him from the TJP, and they began to regard him as a disabled person who needs to be assisted rather than a dangerous person who needs to be arrested and incarcerated. When they encountered Richard in troubled circumstances, they called the TJP instead of processing him through the station house and the lockup. Given the knowledge of his lengthy psychiatric history, judges (with Richard’s consent) considered more therapeutic dispositions that increased Richard’s compliance with treatment regimens and held him accountable for behaving appropriately and responsibly. TJP’s assertive community treatment model was greatly enhanced with the cooperation of the trained and knowledgeable officers of the specialized mental health probation unit (MHU) of the Cook County Adult Probation Department (Lurigio, Bacula, & Williams, 2005). MHU staff strictly enforced treatment mandates, assisted the team to achieve initial treatment goals, and encouraged team members to develop long-term relationships with hospital and community-based treatment providers. These relationships allowed Richard to experience continued reintegration and progress beyond the term of his probation sentence. Thresholds Jail Program The TJP began as a two-year, privately funded demonstration project and later became a state-funded specialized ACT program for individuals with SMI leaving the Cook County Department of Corrections (CCDOC) with long histories of arrests and state psychiatric hospitalizations and a failure to engage in traditional outpatient programs. Participation in the TJP can be ordered as a special condition of probation. The program’s basic goals are to reduce significantly the numbers of rearrests, reincarcerations, and rehospitalizations among participants. To attain these goals, the program assists participants in obtaining psychiatric treatment, medical care, housing, welfare, and other social services. The program also assists participants in managing their money and adhering to their medication regimens. Participants can remain in the program beyond their sentencing requirements if they need or wish to do so. During its initial phase, the TJP managed approximately 20 individuals with chronic psychiatric disorders and lengthy histories of inpatient care. Participants, such as Richard, must be eligible to receive Social Security Income or Social Security Disability Insurance, convicted 370 Clinical Case Studies of nonviolent offenses, and at low risk for violence in the community when compliant with their medications. They must also meet several other criteria, including a willingness to take psychiatric medications and allow Thresholds to become their representative payee. Probation Programs Participants can be admitted to the program at the pretrial or postadjudication stages. At the pretrial stage, eligible participants include two types of defendants: those who have been diagnosed and treated for major psychiatric disorders in the CCDOC and released pending trial and those who are being supervised in Cook County Adult Probation Department’s (CCAPD) Pretrial Services Unit, which monitors defendants in the community under court-ordered conditions while they await trial. At the postadjudication stage, participants are sentenced to probation and supervised in CCAPD’s MHU. The MHU supervises approximately 300 clients throughout Cook County; most have Axis I disorders and lengthy histories of psychiatric hospitalizations (Lurigio, Bacula, & Williams, 2005). This unit has been instrumental in developing cooperative relationships between the criminal justice and community mental health systems. 7 Course of Treatment and Assessment of Progress Richard currently resides at the Lorali Hotel, a board-and-care facility. He has grown accustomed to living on the streets and occasionally absconded from the hotel for several days. Caseworkers use Richard’s photographs to help the police find him when he is lost. (Richard signed releases that allowed the staff to show his picture to the police.) Caseworkers encouraged police officers to consider calling them instead of arresting Richard. This arrangement has averted several arrests. For example, TJP staff brought Richard home from the Chicago Transit Authority, Northwestern, and the Metra Train Stations in response to calls from the stations’ security officials. After Richard acclimated to his apartment in the Lorali Hotel, his disruptive public behaviors gradually stopped. Richard started seeing a Threshold’s psychiatrist in June 1998 for medication and symptom management. Richard meets his psychiatrist weekly for prescriptions. He is allergic to Thorazine and currently takes Prolixin IM, 1 cc, weekly; Depakote, 500 mg, twice daily; Zyprexa, 10 mg, daily; and Cogentin, 12 mg, daily. When he was initially on his medication regime, he complained of chronic vomiting and other gastrointestinal problems without a known pathogenesis. The problems subsided when his Depakote dosage was lowered to its present level. Richard appears to be content living at the Lorali Hotel. When asked about having his own apartment, Richard responded, “It helps me to get away to my own world, every day, having a room, clothes, food, and money—every day.” TJP staff members visit him daily to help him manage his medication and money. Although Richard still displays signs of mental illness—grimacing, inappropriate smiling, silliness, and talking to himself—he has shown marked improvement. He continues to maintain that his mother is living, but he has stopped returning to his old home and annoying the current residents there. He has not been hospitalized since June 1998. Lurigio, Fallon / Serious Mental Illness 371 Richard was rearrested in downtown Chicago at the beginning of 1999. The police report of the incident indicated that he was brandishing a weapon in a train station and scaring the commuters. He stated that he found a piece of scrap metal and pretended it was a gun. He was released from jail in one week. At that time, Richard decided that he would avoid the downtown area. To date, he has not returned to the jail. In February 2000, TJP staff and other program participants held a dinner party to celebrate Richard’s one-year anniversary of being jail-free. Without the TJP’s structure and support, Richard would likely stop adhering to his medications and start wandering the streets again. Richard plans to stay at the Lorali Hotel as long as he is unable to care for himself in a less structured living arrangement. Richard reported that he would like to be employed. His symptoms, however, are presently too severe for job placement. If Richard’s symptoms improve in the future, Threshold’s staff will help him find a suitable job. The severity and chronicity of his illness demand that Richard receives continual support from Thresholds in order to monitor his symptoms, finances, medications, and hygiene. Thresholds helps him remain safely housed, control his psychiatric symptoms, and avoid incarceration and hospitalization. 8 Complicating Factors Richard was referred to the TJP by staff from CCDOC’s medical facility. The CCDOC is located in Chicago and is the largest single-site jail in the United States, housing more than 11,000 detainees and treating more than 1,000 detainees daily for mental disorders. Richard had been detained in the jail on numerous occasions and repeatedly refused to cooperate with any member of the jail staff ’s efforts to refer him for continued psychiatric treatment after his release. At the time of his referral to the TJP, Richard was homeless and had a long history of psychiatric hospitalizations, incarcerations, and irregular adherence to a wide range of psychiatric medications. He also had three pending misdemeanor court cases in one courtroom and a fourth felony case in another. A TJP team leader met with Richard for the first time while Richard was detained in the CCDOC’s isolation unit because he had been exposed to tuberculosis. Psychiatric reports from Richard’s CCDOC admission, which preceded his first contact with the TJP, showed that he was unmedicated and highly delusional and disorganized at intake. While in medical isolation, he stated to the TJP team leader that he needed no assistance with Social Security Income or housing because he lived with his mother (known to be long deceased) on Chicago’s West Side. He refused to participate in the TJP at that time and demonstrated no insight into his psychiatric problems. Nonetheless, he agreed that program staff could visit him again while he was in custody. Richard was contacted by a TJP caseworker for a second visit in Cermak’s Psychiatric Unit where Richard was being treated and stabilized. Although still symptomatic, he appeared much more coherent than he was during the initial contact, and he agreed that the TJP would be “good for him.” He signed releases that allowed TJP staff to meet with court and jail personnel on his behalf in order to assist him with housing, treatment, and financial needs following his release from the CCDOC. A TJP caseworker accompanied Richard to court on 372 Clinical Case Studies Lurigio, Fallon / Serious Mental Illness 373 his first pending misdemeanor case, which was dismissed because the complaining witness failed to appear. The judge in this case was unwilling to cooperate with the TJP caseworker. As a result, Richard was reincarcerated and released with no follow-up care. All three of the misdemeanor cases before the judge would eventually be dismissed after Richard was detained for 30–45 days in the CCDOC. The last of Richard’s four cases, a felony charge, was with a judge who was sensitive to Richard’s psychiatric problems. TJP staff met the judge to discuss the program and presented a letter from MHU staff that informed the judge of the unit’s interest in working with the TJP to help break Richard’s long-standing cycle of arrests, detentions, and hospitalizations. The judge responded by referring several other detainees to be evaluated by the TJP and raising Richard’s bond to ensure that he would be detained long enough for the TJP to develop an adequate discharge plan before his release. MHU and CCDOC staff prepared for Richard’s upcoming felony court case. Cermak staff notified the TJP that Richard was queued unexpectedly to be released from the CCDOC. Sheriff ’s deputies granted Richard an individual-recognizance bond (I-Bond) because of jail overcrowding. This decision was rendered despite Richard having two more pending misdemeanor cases with cash bonds totaling $8,000 and only a week to prepare for his court case that day. The TJP attempted to notify the Cook County Sheriff ’s Office that Richard had a court appearance scheduled on the day of his release, which he was likely to miss if he was discharged from the CCDOC. The program’s caseworker was unable to change the sheriff ’s decision. Hence, Richard was released and his second pending misdemeanor case was dismissed. The pending felony case and the formulation of a coordinated discharge plan were both postponed. With an hour’s notice, TJP’s director met Richard outside the jail and offered to drive him to his mother’s home. Richard displayed psychotic symptoms immediately upon release (e.g., laughing inappropriately and talking to voices) even though he was stable while in custody. As we noted earlier, this was important information in establishing Richard’s need for a higher dose of medication before being discharged from the hospital. Richard ran away four times from TJP caseworkers who attempted to engage him in the program. For example, Richard and the TJP director stopped to eat at a restaurant. Richard started smoking, stole a pouch of tobacco, and dashed out of the restaurant. TJP staff members later caught up with Richard and invited him to help them find his mother’s old house so they could verify that Richard had no relatives living there. Confronted with no evidence of his parents’ presence, he simply insisted, “They would return and still lived on the second floor;” but the floor was unoccupied. Richard ran through several buildings and later jumped from a TJP caseworker’s car; this time, he was not followed. The team was unable to locate him and learned later that Richard was hospitalized nearly 90 blocks away on the same day, even though he had no money or transportation. TJP staff had taken Richard’s photograph after his most recent release from CCDOC. After he had run away, staff members distributed his picture to the Thresholds mobile assessment and the linkage teams that worked in Chicago’s three state hospitals. Richard was eventually rearrested. Following the arrest, he attended court on the third of his three pending misdemeanor cases, which also was dismissed. He was released again from the CCDOC before he could be adequately stabilized or medicated. TJP’s director met with the judge for Richard’s pending felony case to discuss sentencing options. Richard was absent from his scheduled appearance. The judge issued a felony warrant to guarantee that Richard would be held in custody if he were arrested again. Richard’s whereabouts were unknown at this time. 374 Clinical Case Studies A Thresholds caseworker was notified that Richard was in Chicago Read Hospital, one of the state’s three psychiatric hospitals in the city. The Mobile Linkage Team recognized his picture and name and called a TJP caseworker as soon as he arrived in the hospital unit. Before the hospitalization, police had been called after Richard was found wandering in the parking lot of another local hospital, dressed in only a hospital gown. Richard was hospitalized for more than two months at Chicago Read Hospital. A TJP caseworker arranged to have Richard’s cases assigned to the felony judge who was sympathetic to his psychiatric problems. Richard’s outstanding warrant and felony case were addressed at the same hearing. Hospital security brought Richard to court, and his warrant was quashed. He was sentenced to mental health probation for 15 months and ordered to return to Chicago Read Hospital so he could finish his treatment and begin discharge planning with a TJP caseworker. After he was stabilized, TJP staff transported him to the Stratford Lodge, a structured living environment for persons with chronic mental illness. Program staff helped him immediately to prepare applications for food stamps and Social Security Income. Staff also ensured that he would receive clothing, toiletries, and money to tide him over while his benefits were pending. 9 Managed Care Considerations Richard’s case involved no managed case considerations because all his treatment services were covered with public dollars. 10 Follow-Up As shown in Figure 1, we graphed Richard’s progress in the program by recording the number of arrests and days in the hospital and jail from the time he entered the program (midyear 1998) until the end of calendar year 2003. These data were obtained from the official records of the Chicago Police Department, the Illinois Office of Mental Health, and the CCDOC. Richard had been arrested on numerous occasions and spent considerable time in the hospital and jail before his participation in the TJP. From 1994 through the first 6 months of 1998, Richard was arrested 89 times, an average of 20 arrests each year, which included 1995, a year in which he spent most of his time in the hospital. During the 4.5- year period that immediately preceded his entry into the TJP, he spent a total of 608 days in the hospital and 220 days in jail. He was confined in jail or the hospital for nearly half his life in those years. In sharp contrast, during his 5.5-year participation in the program, he was arrested only 5 times, an average of less than 1 arrest each year. Furthermore, he spent a total of only 14 days in jail and no days in the hospital in that period. He successfully completed probation and now enjoys living in the community. 11 Treatment Implications of the Case Treatment programs for individuals with SMI who are involved in the criminal justice system should adopt continuous care models with single-point access to services, which are Lurigio, Fallon / Serious Mental Illness 375 especially important for people with lengthy hospitalization and arrest records. The mentally ill on community supervision at the pretrial, postadjudication, or postrelease levels can be managed effectively with ACT models that have demonstrated their success with the chronically mentally ill (Veysey, 1996). Originating in Madison, Wisconsin, in the late 1960s, ACT employs a multidisciplinary team approach to provide intense, comprehensive, coordinated, and integrated services (psychiatric, rehabilitative, and social support) to persons with serious and persistent mental illness. ACT has been widely implemented and researched in the United States, Canada, and Australia, and has proven clinical and cost effectiveness (Bond, 2002). ACT is a particularly suitable modality for many individuals in the criminal justice system: persons with chronic mental illness, limited insight, severe functional impairments, substance abuse and dependence disorders, limited financial resources, and housing instability. In addition, many mentally ill individuals in the criminal justice system have frequently avoided, or have responded poorly to, traditional outpatient mental health care (Lurigio & Lewis, 1987). Therefore, ACT is a highly appropriate model for individuals with SMI participating in pretrial release or probation programs. The ACT team’s services include mental health and substance abuse treatment, health education, mobile crisis intervention, medical care, ongoing psychiatric assessments, employment and housing assistance, family support and education, and legal advocacy. Services are available 24 hours a day, 7 days a week, and 365 days a year. These services Figure 1 Richard’s Arrests and Days in the Jail and Hospital 376 Clinical Case Studies are delivered in patients’ communities rather than in hospital or clinic settings (Assertive Community Treatment Association, 2006). 12 Recommendations to Clinicians and Students Offenders with SMI present clinicians with special challenges that complicate patient treatment and recovery. These challenges revolve around three related, major issues: comorbidity, criminal status, and clinical responsibilities. First, as we noted earlier, mentally ill offenders are likely to have co-occurring psychiatric and substance use disorders. Hence, integrated treatment that simultaneously addresses both problems is essential to patient recovery. Such patients also are likely to have serious needs for housing, employment, education, and habilitation services. Few of these patients are insured and even fewer have a broad social network. Their behaviors are not only disturbed, but also disturbing, leaving them bereft of the support of family and friends who can help them confront problems relating to housing, finances, and symptom management. In working with mentally ill offenders, clinicians must become accustomed to serving on a team (preferably ACT) with other providers. Team treatment strategies involve psychologists, psychiatrists, and other mental health service providers as pivotal spokes in an extensive wheel of services, with a dedicated case manager at the hub. Second, unlike other patients, those with criminal justice involvement are often mandated to receive psychotherapy and medications. Hence, clinicians must be prepared to develop different approaches to building and sustaining a therapeutic alliance with such patients. Probation is an excellent vehicle for delivering services to mentally ill offenders, and can exercise the authority of the court to monitor adherence to medication and other court-ordered conditions of release. Numerous studies indicate that coerced drug treatment, using the leverage of the court and criminal justice systems, increases enrollment and participation in recovery programs (Lurigio, 2002). These findings also apply to coerced mental health treatment. Involuntary treatment for mentally ill offenders can dramatically increase their compliance with medication, and significantly reduce the likelihood of psychiatric and criminal recidivism (Bernstein & Seltzer, 2004; Heilbrun & Griffin, 1998; Lamb et al., 1999). Probation supervision “creates and maintains the boundaries and structures that [will allow mentally ill offenders] to focus on their recovery” (Massaro, 2003, p. 41). Finally, the rules governing client confidentiality apply differently to patients under the authority of the criminal justice system. For example, clinicians who are treating probationers with mandated care are obligated to report to the court on their patients’ attendance at sessions, compliance with medications, and progress in therapy. But they are also obligated to protect their patients’ limited confidentiality rights. Thus, clinicians must balance their legal responsibilities with the diligent protection of patients’ rights and the conscientious fulfillment of their treatment needs. The tension that arises between these roles reflects a fundamental philosophical difference between the mental health and criminal justice systems: the former is designed to treat, the latter to punish. 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John Fallon received his bachelor’s degree in psychology from the University of Illinois at Urbana Champaign. Mr. Fallon is a long-time advocate of residential and community-based care for persons with mental illness and was the director of the Thresholds Jail Project. He is now coordinating a Threshol