
Rehabilitation of Mentally Ill Offenders: Before and After the Arrest
By Ellen Schimmels
When a patient elopes from a locked psychiatric ward, the first question asked is what the potential is for violence, to himself or others. Is the patient dangerous? Should society be afraid? The mental health profession is expected to evaluate these concerns and answer these questions.
It appears that a concern about the psychiatric patient is not as much about the treatment of the illness or the potential for rehabilitation, but whether the patient is going to hurt someone. There is a tremendous stigma about mental illness and dangerousness. Mentally ill patients are perceived to be a threat. The general consensus among society is that these patients are a risk to either themselves or others.1
How can the forensic nursing profession help with a stigma that starts before it begins? How can we convince society that rehabilitation of perpetrators with mental illness is possible, when we currently convict those who have committed no crime but who are mentally ill? This paper will explain the forensic psychiatric nurse (FPN) role in assisting with the disconnection between mental health and law enforcement and the process of rehabilitation, which includes addressing the stigma of mental illness and dangerousness.
The stigma of mental illness and dangerousness exists in the therapeutic setting. Psychiatric wards are locked. Psychiatric patients are locked up even though no crime has been committed. Is this treating the patient or enforcing the stigma? Is our concern the safety of the patient, or society’s concern about feeling safe?
It may be because of or along with this stigma, but there is a high incidence of mental illness in the corrections system. It was found that women with at least one psychiatric admission were 3.08 to 11.27 times more likely to be convicted of a crime and men were 2.29 to 7.5 times more likely.2 In a Chicago study, it was found that 80 percent of the 1,272 women in jail studied, met DSM III-R criteria for at least one psychiatric disorder and in North Carolina, 67 percent of the 805 women met criteria for a psychiatric diagnosis. 3 Prisoners tend to have three times the prevalence of mental illness than the general population and of a survey of 22,790 prisoners in western countries, 3.7 percent of men (4 percent of women) were psychotic, 10 percent of men (12 percent of women) had major depressive disorder, and 65 percent of men (42 percent of women) had personality disorders.4
Despite the fact that there is such a large population of mentally ill in the corrections system, there are different views of mental illness and criminal behavior. There are also different views about the treatment modalities for perpetrators with mentall illness. Some believe that people with mental illness commit criminal acts and it is their mental illness that causes their actions. Others believe that there are people engaging in criminal behavior and they happen to be mentally ill.5
The law enforcement and mental heath systems each have the capacity to manage specific behaviors, but they tend not to be coordinated. It would make more sense economically and clinically to combine these services to assist patients with rehabilitation.6 More cooperation is needed among the mental health and law enforcement systems to help patients throughout the process of rehabilitation. Rehabilitation of the mentally ill offender begins with their introduction into the law enforcement system.
People with mental illness can end up in the law enforcement system because their behavior is considered socially or criminally deviant, or sometimes out of fear of the public, or negligence of the law enforcement system. The mentally ill are more vulnerable to arrest and are more vulnerable to injustice.7 This may explain why there is a higher prevalence of mental illness within the corrections system. Arrest is not the only way these patients are brought into the system. Non-criminal reasons, such as “inappropriate” behavior, may not be an appropriate reason for detention, but that is how some people with mental illness are introduced into the penal system.
Police do not have encounters with those with mental illness through criminal or socially unacceptable behavior alone. Law enforcement is also called to transport those with mental illness to the hospital, mediate conflicts, and respond to reports of trespassing, loitering, or panhandling involving person with mental illness.6
The law enforcement system is inadequately trained to handle mental illness, but that is not the only reason why mental health and law enforcement should work together. Mental health workers may not be aware that a patient has a criminal record and they could take better precautions if that is known.6
Another reason these two systems should coordinate services is because the needs of people with mental illness cannot be handled by mental health or law enforcement alone. People with mental illness are a lot like people in the general population. They may commit criminal behavior to meet their basic needs, or may have lost hope for any other way to cope with their situation. They may also be looking for a way to get the psychiatric help that they desire.6
Both police and mental health frequently complain of a lack of information exchange between the two systems. They both complain that the other system dumps patients into their system. The hospital complains that the police dump patients that should be in jail, and the police complain that the mental health system dumps patients that they are not able to help.6
A partnership between the mental health and law enforcement systems would be beneficial to both the patients and the staff involved. Mental health and law enforcement can learn from one another and work together to break the cycle of re-incarceration.8 An FPN could be a cost-effective liaison between the two systems. To better explain the many different roles of the FPN within the law enforcement system, it is important to explain the process of rehabilitation.
Psychiatric rehabilitation is complex. It is a mixture of goals, roles, settings, and strategies. 9 The process of rehabilitation begins when the patient with mental illness first comes into the penal system. This process will continue depending on if the patient is placed in a correctional facility, psychiatric facility, or forensic/psychiatric facility. It also depends on whether the treatment is inpatient or outpatient. If admitted or detained, the process will continue after discharge or release. If not admitted or detained, the process still should continue through adequate follow up to help prevent further introduction into the law enforcement system.
First of all, there are programs that have shown the combination of mental health and law enforcement working together at the time of arrest. In a California study, police and mental healthcare providers teamed up to answer calls. It was found that 98 percent of these resulted in release or diversion of the person into community treatment. Mental health went along on calls where mental illness was suspected.5
A similar program was implemented in Milwaukee. It was found that the number of people referred to the criminal justice system decreased, and the number detained for mental health observation increased. Working together also improved relations between officers and mental health professionals.5
Another option would be to have mental health screening of all incoming detainees.5 Currently there are no psychiatric screening systems in place in most law enforcement systems. There could be a diagnostic screening tool used with criteria for admission to prison.4 Mental health screening would lead to determining those who may not be suitable for the correctional environment. Some persons with mental illness are brought into the law enforcement system out of fear of the public, or because of socially inappropriate behavior.7 However, the law enforcement system is not necessarily the best place for the mentally ill. Using corrections facilities as an alternative or more cost effective means to psychiatric treatment is counter-therapeutic.5
Often it is only a short-term crisis that needs to be handled for a mentally ill patient. When the law enforcement system gets involved, they may not manage the crisis situation therapeutically. Consequently, the patient may end up incarcerated. The corrections system is not the only way to respond to short-term crisis for these patients. Diverting patients into the mental health system when non-violent, petty crimes, or victim-less crimes are committed could involve possible dismissal of charges, but may be more appropriate treatment.5 In prison, there is potential for high rates of deterioration. The majority of psychiatric prisoners are doubtfully getting appropriate care.4 This does not mean that mentally ill patients never need to be put in the corrections system. That is the purpose of the mental health screening for all patients.
Of course, if the screening of mentally ill patients is going to be successful, it requires some sort of diversion program. Diversion programs create a community-based treatment plan to meet medical, psychological, and public safety needs. Programs such as this in Baltimore and Milwaukee offer rehabilitation for mental health once released or diverted into the system.8
If the patient is incarcerated, there are also community programs to assist with rehabilitation after release. In the Baltimore program, mental-health professionals work with parole officers starting before the person is released from prison. They work on monetary and housing needs, medications, and follow-up care while the person is still in prison. After release, the patient is involved with both his parole officer and the community rehabilitation program. 8 This is discharge planning.
In a study of 6,813 surveys from community treatment, residential programs, only 6 percent of their clients were very likely to be perceived as threatening in the community. Only 12 percent had committed acts of violence, compared to 18 percent of the general population. Three percent were unable to adjust to community life.10
Another program available after release from incarceration is a nursingrun forensic program in Ontario. An interdisciplinary team focus is used. The program involves social work, forensic nursing, psychiatry, careworkers, and occupational therapy. The patient and the forensic nurse agree to terms of the disposition order (from incarceration); and, if rules are not followed, it can lead to more frequent visits and monitoring, or revocation of the patient’s outpatient status. There is also a risk-management plan that is activated when the patient displays signs of mental decompensation. Signs may include noncompliance with treatment or aggressive behavior. This program considers housing, financial, vocational, family and community support needs of the patient. There is an ongoing evaluation of mental status and potential for violence by the forensic psychiatric nurse.11
The Nursing Care Partnership Program (NCPP) is a nurse-developed programin Denver that assists women with mental illness after release from jail. The goals are to help women stay out of jail and become healthier. In this program, women requiring mental health services or a psychiatric evaluation are seen by a psychiatric clinical nurse specialist within one week of release from jail. These women are seen by a psychiatrist within two weeks of release. This program was developed between nursing and criminal justice professionals who believe that rehabilitation involves health, mental health, and social health issues. The NCPP evaluates the arrest records as well as developmental events, economic events, personal growth, life changes and relapse events.12
Persons with mental illness are locked up in prisons to protect them from others, and they are locked into psychiatric wards to protect others and themselves. They are treated as dangerous and helpless and then expected to be able to live happily and be independent after either release or discharge Dysfunction becomes more ingrained.13 Rehabilitation is complex. It is not a mental health or law enforcement process, but a social one.
FPNs could be the link throughout the rehabilitation process. The FPN could work with police departments from the beginning. An FPN on staff within the law enforcement system could easily work along with police officers as a liaison between mental health and law enforcement. The FPN could ride with police when mental illness is suspected or they could be involved with mental health screening of detainees.5 or screen convicts prior to admission to prison.4 An FPN could also assist the police staff with debriefings and other staff conflicts, and could determine placement of detainees with mental illness in the mental health system, the prison system, or into one of several diversion programs. Within those diversion programs, the FPN could coordinate either inpatient psychiatry or outpatient community services. The FPN could also work within these types of programs as counselor, educator, or practitioner.
Another area that forensic psychiatric nurses could work is after release. Programs that involve the FPN working with prisons and jails as a liaison for the person to adjust to civilian life. It would be appropriate for the FPN to manage this type of program in the outpatient setting. They would be the liaison between the law enforcement system and the community by educating both groups about mental illness and mental health needs of these patients.
Nursing is focused on patient advocacy and is therefore in the unique position to assist with collaboration between mental health and the criminal justice system for the benefit of the patients, the staff and society. It is not the nature of nursing to let people remain victims of their own fears and self-imposed limitations. But, it is ultimately the patient’s responsibility to change that view. It is the patient who ultimately makes his/her own decisions. It is the patient who is responsible for his/her behaviors. It is the patient who has been viewed for far too long by society as a dangerous offender. Nursing can only work on the stigma of mental illness and dangerousness within our patients who become socially healthy members of society. We need to believe in rehabilitation and be instrumental in determining the appropriate plan of care before the patient’s introduction into the law enforcement system. The FPN is in the ideal position to initiate this change.
Ellen Schimmels is an Army nurse currently stationed in Germany at Landstuhl Regional Medical Center. She has served in military nursing for almost six years, with three years in psychiatric nursing, and is currently working on her master’s in forensic nursing through Duquesne University.
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