When it comes to managing people with mental illnesses, a perfect world would treat this population in community centers or other settings that specialize in mental health disorders. But corrections agencies know all too well that this perfect world does not exist.

Instead, people with mental illnesses receive inadequate treatment and assistance in our society, and, without that treatment, they can become addicted to illegal substances and commit crimes. Prisons and jails, then, become the de facto treatment centers for these individuals.

"Corrections agencies will have to deal with this population sooner or later. Prisoners have a constitutional right to mental health care while incarcerated and many systems have already been sued for what the plaintiffs consider to be a lack of mental health service delivery," said Reginald Wilkinson, Director of the Ohio Department of Rehabilitation and Corrections.

Wilkinson speaks from experience. The Ohio DRC was sued in the early 1990s following a major riot at the Lucasville facility. That lawsuit that came from that disturbance was filed by a group of prisoners who claimed that mental health care was inadequate. As a result, the Ohio DRC chose to evaluate and ultimately improve its system.

"We contended that we were constitutional, but we wanted to do was fix a system that needed fixing," said Wilkinson.

The outcome of that fixing is what many consider to be a national model for approaching offenders with mental illness and other mental health problems.

And, in a day and age when offender mental health is the issue on many corrections administrators lips, that model could be come useful to many in the field.

"Slowly over the past 20 years as the number [of mentally ill offenders] has dramatically increased, different systems have recognized this is a large population that needs to be managed," said Tom Fagan, Chair of the Board of Directors for the National Commission on Correctional Healthcare.

But, Fagan said, all agencies are not at the same point in managing this population.

"They are in different places depending on the numbers of mentally ill they have and the staffing patterns they have and how informed they are about good techniques for managing the mentally ill in prison," he said.

These issues, combined with a lack of general education for staff about mental illness and the ever-increasing number of offenders with mental illness coming through the door, all illustrate the need for improvement.

A Mindful Collaboration

Although many people with mental illness and mental health problems find their way into the criminal justice system and behind bars for their actions, the solution to the problem of managing them begins well before they enter a jail or prison.

Many experts in the field believe that it takes a total community response to the population to adequately serve these individuals.

According to Fagan, both law enforcement officials and the judiciary need to be better educated about mental illness and the best way to manage offenders with these problems once they become involved in the criminal justice system.

"That's the place where I think we could get people involved in community based treatment and avoid them having to be incarcerated at all. There also needs to be community-based programs that can manage these cases," said Fagan.

Scott Chavez, Vice President of NCCHC, also believes that community supports need to be in place to help divert mentally ill offenders to the right kinds of programming.

"It's a good idea to have people in mental health courts and put them where they should be - absolutely they shouldn't languish in jails. They should be in places where they can be taken care of," said Chavez. "It's a group effort."

But with or without a strong community support system for mentally ill offenders, prisons and jails need to be prepared to manage those who do come through intake.

According to Jeffrey Metzner, a forensic psychiatrist with the University of Colorado Health Sciences Center, an author on correctional psychiatry and a contributor to several NCCHC health guidelines and publications, good screening at intake is the first step for corrections agencies.

"One of the things you need to do is have a process in place that adequately screens and identifies people who need mental health services. Then you need to have different levels of care and continuity of care," Metzner said.

What that entails, according to Fagan, is an understanding that some offenders with mental illness may be able to function in the general population while others may never be able to.

"Given the state of our science, there are some we can't reach. Period. And for those, we need some kind of chronic care facility or unit," he said.

For those who do live among the general population, staff need to be aware of the behaviors that might lead these offenders toward disciplinary reports. Because these offenders tend to pick up more disciplinary tickets for their actions, some, like Fagan, believe the process for issuing those reports and the associated punishment should be modified.

Beyond this, corrections agencies need to also work together with the community to ensure that when these offenders are released from incarceration they have access to adequate services so that they remain out of trouble and, ultimately, out of the criminal justice system.

"At a minimum, we have to do a better job of communicating with the courts at the front end and at back end with community providers. I think the mind set just needs to change in the community," said Fagan. "If you think about this, it is a public mental health issue. Every person in [prison] comes out If we did a better job of treating it more globally we might be able to short circuit the cycling in."

Ohio's correctional system has taken many of these approaches to treat and manage the mentally ill and has built what many consider to be the model for corrections nationally.

Ohio Model

A major lawsuit against the Ohio DRC in 1993, which alleged inadequate mental health care in the system, actually helped create the basis for the interagency collaboration that exists in the delivery of correctional mental health services today.

As a result of the lawsuit and following investigation and evaluation of the system, recommendations were suggested for improvement. The central theme was to develop an organized approach for the continuity of a holistic quality treatment for offenders.

"I think the big part about this is it has to be a seamless process from what happens to them while they are locked up and then the service delivery continues after release. It's easier said than done, but the best model is to have some semblance of a continuous mode of service delivery," said Wilkinson.

Wilkinson said some of the best examples in the DRC of continuity of mental health care are in two pilot programs that the agency has begun with community service providers in Cincinnati and Cleveland.

According to Wilkinson, the DRC has contracted with these local service providers to provide complete wrap-around services for persons with mental illness who are released from prison. These providers conduct interviews with the offenders while they are incarcerated and help set up a no-gap service delivery for after release. The partnership in the community is between adult parole and the community service providers.

"The service provider is connecting with the [offender] candidates alongside our parole staff. The minute that person gets out of prison, the parole officer knows he is a participant in that particular program," he said.

Wilkinson said the parole officer is key to ensuring that the community service delivery keeps flowing. To support this, the DRC has trained parole officers to deal specifically with a mental health caseload and to specialize in managing these offenders.

"We anticipate this is a model that can be replicated around the state. We're hoping that funds can be saved by reducing recidivism," said Wilkinson.

But these reentry pilot programs are not all that is in place for mentally ill offenders in Ohio.

The DRC also has created nine different residential treatment units clustered throughout the state where a person who has a mental illness and needs more than medication would receive intensive treatment.

Then, if an offender needs even more intensive treatment, he can be placed in the DRC's Oakwood correctional facility, which is certified by the state as a psychiatric hospital.

Wilkinson said that the DRC has a special arrangement whereby it can make an internal decision about transferring an offender to this facility without having to go through the typical probate process.

"We get them in the right setting as quickly and as cheaply as possible," he said. "With the continuation of services and the services that are graduated, [they] are designed to make a person as self-sufficient as they can to help them to re-enter society."

While some in corrections are moving towards a graduated service delivery program for mentally ill offenders, those who haven't may receive some assistance from new guidelines published by the NCCHC.

Guidelines Have Eye Toward Future

The NCCHC's guidelines for the Treatment of Schizophrenia in Correctional Institutions were recently released to help agencies understand the recommended goals for treatment and how to accomplish them. In the end, the guidelines not only discuss those recommended treatment goals, but they also outline some of the real barriers for the treatment of mental illnesses, like schizophrenia, in correctional institutions.

"The commission was trying to establish a clear community standard that could work in a correctional environment. There was a thought that we had done a nice job with several medical problems but had not addressed any of the significant mental health problems," said Fagan, who was involved in the development of the guidelines.

The guidelines talk about assessment of a person with mental illness and suggest that correctional staff consider the differences in assessment protocols for this disorder. They suggest, for example, that cell front assessment, while it may work with other disorders, may not work well with offenders with schizophrenia and other serious mental illnesses.

In addition to a discussion about assessment of mental illness upon entry to the system and regular follow-up with a person diagnosed with the disorder, the guidelines also discuss and define the levels of function for this type of patient.

While bringing a patient to a good level of function through treatment is desired, the guidelines also recognize that not every mentally ill offender will be able to meet the highest level of function in a corrections setting.

"We're trying to get to the best level of function that a person can achieve. That is related to the stratified system of services. The goal is to raise the level of function to the highest possible point. This is much more behavioral and [related to] how a person interacts with the environment," said Fagan.

In addition, the guidelines also suggest simple quality improvement monitors for corrections agencies to consider as they evaluate their own practices in treating the mentally ill.

According to Metzner, the quality improvement measures can help corrections administrators evaluate their treatment strategies for other mental illnesses.

"I think the principles are relevant to continuity of care and quality improvement and they apply equally well to other serious mental illnesses," he said.

Fagan agrees and hopes that correctional administrators use the guidelines to serve as a benchmark.

"I think they will be very educational for corrections administrators. It's a good document for educating people," he added.

These guidelines and additional ones that the NCCHC hopes to issue on mental health disorders will certainly help guide the field as more and more offenders come into the system with these problems.

And, administrators like Wilkinson believe it is only a matter of time before more agencies begin to put comprehensive mental health treatment programs in place.

"One of the biggest reason to [treat this population] is a public safety component," said Wilkinson. "We don't want people with mental illness to continue to victimize more people. [And,] if it's because of a mental illness, then it is something we can control. The philosophy is that public safety is public health and public health is public safety."

Resources:

National Commission on Correctional Healthcare - www.ncchc.org

Ohio Department of Rehabilitation and Correction - www.drc.state.oh.us

Testimony on the Criminal Justice System and Mentally Ill Offenders - www.drc.state.oh.us/web/Articles/article71.htm