Mentally Ill Offenders Need Criminogenic Treatment Too

Many programs for offenders with mental illness (OMIs) seem to assume that serious mental illness directly causes criminal justice involvement. To help evaluate this assumption, we assessed a matched sample of 221 parolees with and without mental illness and then followed them for over 1 year to track recidivism. First, compared with their relatively healthy counterparts, OMIs were equally likely to be rearrested, but were more likely to return to prison custody. Second, beyond risk factors unique to mental illness (e.g., acute symptoms; operationalized with part of the Historical-Clinical-Risk Management-20; Webster, Douglas, Eaves, & Hart, 1997), OMIs also had significantly more general risk factors for recidivism (e.g., antisocial pattern; operationalized with the Level of Service/Case Management Inventory; Andrews, Bonta, & Wormith, 2004) than offenders without mental illness. Third, these general risk factors significantly predicted recidivism, with no incremental utility added by risk factors unique to mental illness. Implications for broadening the policy model to explicitly target general risk factors for recidivism such as antisocial traits are discussed.

crime, violence, mental disorder, psychosis, risk factors

“Individuals with serious mental illness such as schizophrenia, bipolar disorder, and major depression are substantially overrepresented in the criminal justice system…Some investigators have argued that these individuals are also disproportionately reincarcerated after release—that they get caught in a ‘revolving prison door’… Most policy recommendations for this population reflect an implicit assumption that mental illness is the direct cause of criminal justice involvement, and psychiatric treatment is the principal solution…The ‘direct cause’ model that underpins this reentry approach rests on little empirical support…Although individuals with serious mental illness clearly need psychiatric services, managing offenders’ mental health problems may do little to reduce their risk of recidivism. Untreated mental illness is, at best, a weak predictor of recidivism among criminal offenders” (p. 212). “If general risk factors directly lead to criminal behavior far more often than mental illness, then the policy model for offenders with mental illness should be revised” (p. 213).

“In this study…leading measures (the LS/CMI and HCR-20) [were used] to directly compare purported risk factors that are general versus unique to mental illness based on a matched sample of 221 parolees with and without mental illness” (p. 213).

“To address these aims, [the authors] conducted a prospective longitudinal study of parolees with and without serious mental illness…[using] a baseline interview to assess risk factors via the LS/CMI and HCR-20 shortly after participants had been released from prison, and…a review of records at least 12 months after the baseline to assess arrests and return to prison custody” (p. 214).

“The aims of this study were to (a) compare OMIs [offenders with mental illness] and non-OMIs in their frequency of unique and general purported risk factors, (b) assess whether mental illness moderates the predictive utility of general risk factors as a group, (c) explore which general risk factors predict OMIs’ recidivism, and (d) test whether unique factors add incremental utility to those general risk factors for OMIs” (p. 217).

“This study yielded three main findings. First, in addition to variables that are unique to mental illness, OMIs [offenders with mental illness] also have more general risk factors for recidivism than their counterparts without mental illness, including an antisocial personality pattern. Second, general risk factors predict recidivism more than unique variables, regardless of mental health status. Even for OMIs, risk factors such as poorly structured leisure and recreation time significantly predict rearrest and RTC [return to custody], whereas variables unique to mental illness such as medication compliance do not. Third, OMIs are more likely to return to prison custody than their peers without mental illness, even though they are no more likely to be rearrested. This suggests that supervision disparities may contribute to OMIs’ parole failure. Together, all three findings are consistent with the notion that the relation between mental illness and recidivism is not direct” (p. 220).

The authors unpack these three main findings and their implications:

• OMIs Share Substantial General Risk Factors With Non-OMIs

“Relative to their non-OMIs, OMIs in the present study obtained higher scores on the following general risk factors assessed by the LS/CMI: antisocial pattern, procriminal attitudes, education/employment problems, and family/marital problems. However, scores on the antisocial pattern domain alone maximally distinguished between OMIs and non-OMIs. Thus, OMIs were more likely to manifest early and diverse criminal behavior, a generalized pattern of trouble (e.g., financial instability, few prosocial friends), and procriminal attitudes. Broadly, an antisocial personality pattern describes a person who is adventurous, pleasure seeking, aggressive, and has weak self-control.

The term antisocial may evoke adverse and avoidant reactions, particularly from mental health professionals. Nevertheless, it is not tenable to neatly classify OMIs as either “mad” and therefore treatable (because they have serious mental illness) or “bad” and therefore difficult to treat (because they have problematic personality traits). Instead, many of these individuals have both a serious mental illness and troubling personality traits. As such, they require both psychiatric and correctional treatment” (p. 221).

• General Risk Factors Predict Recidivism Regardless of Mental Illness

“Leading risk assessment measures [were used] to isolate potential risk factors that are unique to OMIs (e.g., acute symptoms, poor insight, treatment noncompliance, decompensation) and compare their predictive utility with general risk factors that may apply to any offender (e.g., antisocial pattern, associates, attitudes)… General risk factors predicted both rearrest and RTC [return to custody] for OMIs, and unique factors were unable to improve on their predictive utility…[in addition]…an offender’s mental health status did not moderate the predictive utility of these risk factors.

These findings are consistent with past research indicating that the LS/CMI is equally predictive of recidivism for OMIs and non-OMIs and that the strongest predictors of recidivism are shared by offenders with and without mental illness.

[The authors ] also explored which general risk factors (among the set assessed by the LS/CMI) combined to maximally predict recidivism for OMIs and non-OMIs…across mental health status and recidivism type, two risk factors consistently emerged in predictive equations: antisocial history and poor use of leisure/ recreation time” (p. 221).

• OMIs Have Disproportionate Risk of Parole Failure

The authors found “that psychiatric symptoms predicted parole failure (i.e., RTCs), but not new offenses (i.e., rearrests). Similarly, [they] found that OMIs under intensive supervision were uncommonly likely to return to prison for a technical violation.

This pattern of findings is consistent with past suggestions that supervision disparities contribute to OMIs’ parole failure. Compared with non-OMIs, OMIs are about equally likely to be rearrested for a new offense, but significantly more likely to commit technical violations and have their community terms suspended or revoked. The results of both experimental and ethnographic research suggest that correctional officers keep OMIs on a “tighter leash” than those without mental illness, based partially on stigma-based fear and paternalism.

Although systemic issues were not a focus of the present study, these results shed additional light on the relationship between mental illness and recidivism. Real ‘risk reduction’ for OMIs may require both better targeting of criminogenic needs and less stigma-based correctional decision making” (p. 221).

Conclusions

The authors “believe that the focus of the policy model for OMIs should be definitively shifted to target general risk factors, [but also that] it would be a mistake to jettison psychiatric treatment from the model.

Whether and how psychiatric treatment adds value to risk reduction efforts for OMIs is an empirical question to address in future research. The clearest message from the present study is that risk reduction efforts must be shifted to focus more on general risk factors to break the cycle of recidivism that embeds many parolees in the criminal justice system” (p. 222).

Researchers will enjoy the sophisticated study design and data analytical plan.

As always, please join the discussion below if you have thoughts or comments to add!