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| Recidivism Among Mentally Ill Offenders |
| By Lynda Frost and Dick Sheppard |
| Published: 09/12/2002 |
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This article was reprinted with permission from the Jail Suicide/Mental Health Update, Volume 11, Number 1, Spring 2002. Copies of the publication are available free by request. Client A, a 57-year-old male diagnosed with Schizophrenia, began interfacing with the criminal justice system at age 14 and has been arrested more than 50 times on charges ranging from misdemeanor theft, trespassing and public intoxication to felony weapon and drug offenses. For 30 years he drifted from place to place, at times being hospitalized at the local and state level in residential care. Ms. E is a 27-year-old African-American female with a dual diagnosis of Bipolar Disorder and rug Dependence (crack cocaine). She began a cycle of homelessness, prostitution, arrests and incarceration at age 22. At the time of program admission, she was estranged from her family and had not been in contact with her nine-year-old daughter for four years. DS is a 44-year-old male with diagnoses of Schizophrenia-Paranoid Type, Alcohol-Induced Psychotic Disorder with Delusions, and Learning Disorder-NOS. He was born to alcohol-addicted parents, raised in institutions and released from the in-patient mental health system at age 30. He has been a vagrant for the past 14 years and has been arrested numerous times for public intoxication and vagrancy. The State of California has made a significant investment in determining the most effective strategies for helping these individuals - and thousands of other mentally ill persons - avoid further involvement in the criminal justice system by improving their ability to function within the community. The catalyst for this investment was the growing recognition that jails have become the treatment facilities of last (or perhaps first) resort for an increasing number of persons with mental illness. In 1984, for example, persons diagnosed with a mental illness comprised less than three percent of California's jail population. Today, it is estimated that between 7 and 15 percent of California's 74,000-plus jail inmates are mentally ill. Some of these offenders must be incarcerated because of the serious nature of their crimes; however, far more get caught in a cycle of re-offending due in large part to the lack of adequate community-based mental health treatment and services. Against this backdrop, the California State Sheriffs' Association and Mental Health Association co-sponsored legislation in 1998 (Senate Bill 1485) that established the Mentally Ill Offender Crime Reduction Grant (MIOCRG) Program - an initiative that supports the implementation and evaluation of locally developed demonstration projects designed to curb recidivism among persons with mental illness. SB 1485 directed the California Board of Corrections (Board) to administer the MIOCRG Program and to assess its overall effectiveness in reducing crime, jail time and criminal justice costs associated with the mentally ill offender population. Since 1998, the Legislature has provided a total of $104 million to the MIOCRG program, which involves 30 projects in 26 counties. The grants for half of these projects resulted from legislative appropriations in 1998/99 and began in July 1999. For administrative purposes, the Board refers to this first group of grantees as MIOCRG I. Grants for the other 15 projects, referred to as MIOCRG II, resulted from an appropriation in 2000/01 and began in July 2001. Collaborative Planning Process In developing the framework for the MIOCRG Program, lawmakers recognized that cooperation and communication between law enforcement, corrections, mental health and other agencies, even when goals and expectations appear to conflict, was key to meeting the challenges posed by offenders with a mental illness. Lawmakers also recognized that one size doesn't fit all in crime prevention efforts. As a result, the MIOCRG Program requires that projects be collaborative and that they address locally identified gaps in jail and community-based services for persons with a serious mental illness. Specifically, to be eligible for a demonstration grant, SB 1485 required that counties form a Strategy Committee comprised, at a minimum, of the sheriff or department of corrections director; chief probation officer; county mental health director; a superior court judge; representatives of local law enforcement agencies and mental health provider organizations; and a client from a mental health treatment facility. By statute, the Strategy Committee was responsible for developing a Local Plan that describes the county's existing responses to mentally ill offenders, its identified service gaps, and its proposed strategies for addressing the mental health treatment and other needs of mentally ill offenders released from custody. To support this undertaking, the Legislature earmarked a portion of the program's initial $27 million appropriation for local planning grants. In December 1998, in consultation with the Department of Mental Health and Department of Drug and Alcohol Programs, the Board awarded noncompetitive planning grants totaling over $1.2 million to all applicants (45 of California's 58 counties). Regardless of whether counties ultimately received a demonstration grant, they indicated that they benefited immensely from this local planning process - not only in terms of identifying strategies for helping mentally ill offenders successfully reintegrate into the community but also in terms of establishing ongoing collaboration among the myriad of agencies that interface with these individuals. Competitive Demonstration Grants The Board's primary objective in awarding MIOCRG demonstration grants was to ensure that the Request for Proposal (RFP) process was both equitable and valid. Toward this end, the Board established an Executive Steering Committee (ESC) comprised of state and local corrections and mental health officials to provide recommendations on the content, format and requirements of the RFP; the proposal evaluation criteria and the weight associated with each rating category; and the proposal screening procedures (e.g., submission and review of written proposals, oral presentations, and final selection process). In awarding demonstration grants, SB 1485 required the Board to consider, at a minimum, the following criteria: *percentage of the jail population with severe mental illness; *demonstrated ability to administer the program, and to provide treatment and stability for persons with severe mental illness; *demonstrated history of maximizing federal, state, local and private funding sources; and *likelihood that the program will continue after state funding ends. The ESC determined that the following criteria should also be used in evaluating the proposals: need for the program; probability of success; evaluation design; proposal quality; and oral presentation. The ESC also determined the scoring priority that would be given, pursuant to SB 1485, to proposals that included a local match exceeding the statutorily required 25 percent of the grant amount. The Board approved the ESC's recommendations and, in March 1999, received 40 project proposals requesting a total of nearly $114 million. In May 1999, following an extensive review and priority ranking of these proposals by the ESC, the Board awarded available funds (approximately $22.9 million) to the following seven counties: Humboldt, Kern, Orange, Sacramento, San Bernardino, Santa Barbara, and Santa Cruz. The 1999/00 State Budget allocated an additional $27 million to the MIOCRG and specified that most of this appropriation would support demonstration projects based upon the prioritized list already established by the Board. The Budget also capped grants at $5 million and specified that Los Angeles and San Francisco Counties would each receive $5 million for projects that target mentally ill offenders likely to be committed to state prison ('High Risk Models'). In addition to Los Angeles and San Francisco, the 1999/00 allocation and previously unexpended funds supported demonstration grants totaling over $27.7 million in the following six counties: Placer, Riverside, San Diego, San Mateo, Sonoma and Stanislaus. The Board repeated this entire process following passage of the 2000/01 State Budget, which contained an additional $50 million for the MIOCRG Program, and in May 2001, the following 15 counties received demonstration grants: Alameda, Butte, Kern, Los Angeles, Marin, Mendocino, Monterey, San Bernardino, San Francisco, San Joaquin, Santa Clara, Solano, Tuolumne, Ventura and Yolo. Interventions and Challenges The counties participating in the MIOCRG Program are providing a broad array of enhanced services to seriously mentally ill offenders - services that address the specific needs of these individuals as identified during the local planning process. The jail-based interventions that have been implemented include early identification and screening procedures; enhanced mental health assessments; case management and brokerage services; dedicated housing; pet therapy; and pre-release planning. Enhanced services in the community include intensive case management and probation supervision; assistance in securing short and/or long-term housing, vocational training, employment, and financial entitlements; individual and group counseling; life skills training; substance abuse testing; medication education and management; transportation services; crisis intervention; residential treatment; and day treatment or drop-in centers. Several counties also created a mental health court or dedicated court calendar as a part of their demonstration project. On the whole, one of the biggest challenges MIOCRG I counties have had to grapple with is the slower than anticipated rate of client enrollment into projects (whether this also proves true for MIOCRG II counties remains to be seen). Counties are identifying potential program participants and conducting comprehensive assessments to determine if they meet the eligibility criteria established by the county. This screening process has involved hundreds - in a few counties, thousands - of offenders. In the end, the vast majority is found ineligible. One reason is that many offenders, once they are no longer under the influence of drugs and/or alcohol, do not have a serious mental illness as their primary diagnosis, thus excluding them from the program. In addition, many offenders are found ineligible because they committed offenses the county opted to exclude for pubic safety reasons or because they do not have the criminal justice history required for participation (e.g., a specific number of previous arrests). Of the nearly 2,800 inmates screened in one county, for example, less than six percent met the criminal justice criteria. The voluntary nature of these projects - i.e., any offender can refuse to participate - has also contributed to the fact that counties are serving fewer clients than expected at this point. Not surprisingly, counties are also facing challenges in day-to-day program operations. Among these is the lack of temporary, transitional and/or long-term housing for clients. In response, counties are working to establish or expand ties with homeless shelters, motels, board and care facilities, and rental units. Identifying effective treatment strategies for persons with a dual diagnosis (serious mental illness coupled with substance abuse), who comprise a large percentage of clients in many counties, has also been challenging. Within a week of Client A's enrollment in the project, he was back in custody for public intoxication. Upon his release, medication compliance became a primary focus for the treatment team and staff began visiting him twice daily. Upon release from jail, Ms. E was met by her case manager and admitted to the project's short term residential housing program as well as a 60-day highly structured drug and alcohol day treatment program. The treatment plan for DS includes placement at a board and care facility, participation in an alcohol/drug outpatient program five days a week, random drug testing, and psychiatric treatment. Program Evaluation The primary objective of the MIOCRG Program is to determine 'what works' in reducing crime, jail crowding and criminal justice system costs associated with the mentally ill offender population. Toward this end, SB 1485 requires the Board to evaluate the overall effectiveness of demonstration projects in relation to these outcome measures. In addition to the statewide evaluation, counties must assess the efficacy of their respective projects in meeting specified outcomes. For the statewide evaluation, Board staff developed a research design, with considerable input and cooperation from funded counties, that requires grantees to collect and report common data elements concerning the target population (intake data), the services counties are providing to these individuals (intervention data), and the effects of the treatment interventions on curbing recidivism among offenders diagnosed with a serious mental illness (outcome data). Counties submit these common data elements every six months. Board staff then combines the data to create a considerably larger sample size, which increases the statistical power of the research and the extent to which positive results can be generalized. Based on intake data reported on the first 1,900 clients participating in MIOCRG I projects, Board staff constructed the following general profile of the offenders at the time they entered the MIOCRG Program: * the average age of participants is 38 years; * males comprise approximately 62 percent of the participants; * most of the participants (about 55 percent) have never been married; * one-third of participants were unemployed at the time they entered the project; * approximately 20 percent of participants were homeless and half lived in a home or apartment without support of any kind at the time of the qualifying arrest; * the most frequently occurring diagnoses are depressive and bipolar disorders, followed by schizophrenia and other psychoses; and. * approximately three-fourths of participants have a substance abuse problem in conjunction with a primary diagnosis of a serious mental illness. Since the primary goal of this program is to determine effective strategies for reducing recidivism among this population, criminal history is an important aspect of this profile. Data reported by counties indicate that during the three years preceding program entry: * the mean number of bookings for participants is 4.3, the median is 3, and in five cases, the number of bookings was between 32 and 67; * the mean number of convictions is approximately 2, and about one-fifth of participants had four or more convictions during the three years prior to entry into the program; * the three most prevalent types of convictions were for drug offenses (25 percent); misdemeanors other than property or drug offenses, many of which are characterized by law enforcement as nuisance crimes (24 percent); and property offenses (20 percent); and * the median number of days participants were in jail during the 36 months prior to program entry was 54, and five individuals spent more than 720 days in jail during this three-year period. Although it will be a few years before an evaluation of all the data collected and reported by counties during the grant period can be undertaken, early trends are promising. In terms of new bookings into jail, for example, preliminary outcome data indicate that 52 percent of the clients receiving 'treatment as usual' had new bookings following program entry compared to 39 percent of the clients receiving the enhanced treatment and services offered by these demonstration projects. Clients receiving enhanced services have also spent an average of nine fewer days in jail than their 'treatment as usual' counterparts. In addition to collecting and reporting common data elements for the Board's statewide evaluation of this program, counties are using locally developed research designs to test specific hypotheses related to their projects. These evaluations, which provide counties an opportunity to focus on unique aspects of their project, must include sufficient information about the participants, research design, nature and extent of treatment interventions, and data analysis procedures to permit replication of the program by others. The counties must also conduct a process evaluation focusing on how the program operated (vs. the quantitative results it produced), and most counties will be conducting some type of cost/benefit analysis as part of their local evaluation. The professionals collaborating on these demonstration projects - in many cases, to an unprecedented extent - include deputy sheriffs and correctional officers, deputy probation officers, judges, prosecutors, public defenders, psychiatrists, nurses, licensed clinical social workers, and substance abuse specialists. All of these individuals recognize that the vast majority of mentally ill offenders come in contact with the criminal justice system as a result of insufficient treatment, the nature of their illnesses, and the lack of social supports and other resources - and, regardless of their different roles and perspectives, the professionals associated with these demonstration projects are committed to making a positive difference in the lives of the clients they are serving. Client A's progress during his first four months of intensive case management includes being fully compliant with his medications, regularly attending substance abuse counseling sessions, and avoiding contact with law enforcement. He has not used drugs or alcohol and is considering taking on a part-time job or returning to school. Ms. E graduated from the day treatment program and, with the exception of a one-day relapse on her birthday, she has been clean and sober since her program involvement. She no longer prostitutes, sees her psychiatrist regularly, has learned money management skills and does volunteer work as a clerical assistant. She hopes to reunify with her daughter. DS continues to reside at the board and care facility, actively participating in chores and activities offered there. He has maintained sobriety, is compliant with his medications, and has not been taken back into custody or required hospitalization. He has developed a strong support system and even has a 'best friend' for the first time in his life. About the Authors Lynda Frost, a Field Representative with the California Board of Corrections, helps manage the MIOCRG Program. Dick Sheppard, Ph.D., is a member of the Board's Research Team and lead evaluator for the MIOCRG Program. Correspondence may be addressed at the authors at the California Board of Corrections, 600 Bercut Drive, Sacramento, CA 95814, (916) 445-5073. For more information regarding the efforts being undertaken by counties participating in the MIOCRG Program, including project descriptions and directories with contact information for project managers and evaluators, readers are encouraged to visit the Board's web site: http://www.bdcorr.ca.gov. |
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