What psychotherapeutic interventions should target when treating people with mental illness and criminal justice involvement

What psychotherapeutic interventions should target when treating people with mental illness and criminal justice involvement

To be most successful, when treating criminal justice-involved people with mental illness, practitioners should assess and treat not only symptoms associated with their mental illness, but their criminal risk as well. This is the bottom line of a recently published article in Law and Human Behavior. Below is a summary of the research and findings as well as a translation of this research into practice.

Featured Article | Law and Human Behavior | 2018, Vol. 44, No. 4, 336-346

A comparison of criminogenic risk factors and psychiatric symptomatology between psychiatric inpatients with and without criminal justice involvement.

Authors

Angelea D. Bolaños, Texas Tech University
Sean M. Mitchell, Texas Tech University
Robert D. Morgan, Texas Tech University
Karen E. Grabowski, Texas Tech University

Abstract

Objectives. Research suggests distinct criminal risk factors, not mental illness, are more strongly associated with most criminal behaviors. This notion has been supported among inpatient persons with mental illness (PMI) when examining antisocial cognitions; however, other key criminogenic risk factors (the Big Four and Central Eight risk factors) have not been examined among psychiatric inpatient PMI. Hypotheses. We hypothesized that criminal justice (CJ)- involved PMI would endorse significantly greater criminogenic risk compared to non-CJ- involved PMI, and that these risk factors would significantly and accurately identify whether PMI had CJ involvement. Additionally, we hypothesized that PMI with and without a history of CJ involvement would not significantly differ on their reported psychiatric symptomatology. Method. We examined all Central Eight criminal risk factors and psychiatric symptomatology among psychiatric inpatient PMI (N = 142) with (n = 74) and without (n = 68) CJ involvement histories. Results. Multivariate analysis of variance and discriminant function analysis indicated significant differences between the Big Four and Central Eight criminal risk factors when classifying CJ and non-CJ groups. The Big Four risk factors correctly classified 85.9% of participants, and the Central Eight correctly classified 99.3% of participants into CJ and non-CJ groups; however, psychiatric symptoms only correctly classified 57.7% of participants into CJ and non-CJ groups. Conclusions. Criminal risk factors appear to be more strongly associated with CJ involvement among PMI than psychiatric symptomatology; therefore, psychotherapeutic intervention on criminal risk factors, not only mental illness, may decrease criminal recidivism among CJ-involved PMI.

Keywords

criminogenic risk, mental illness, criminal justice involvement, psychiatric inpatients

Summary of the Research

“Persons with mental illness (PMI) are overrepresented in the criminal justice (CJ) system. Specifically, adult PMI are 3.8 times more likely to be incarcerated than individuals in the general population. Furthermore, 40% of PMI have been incarcerated at some point during their lifetime. However, it is also a truism that justice-involved people are overrepresented in community mental health systems…Therefore, it is imperative that we not only examine variables of interest, such as criminogenic risk factors, among PMI in the justice system, but that we also examine criminogenic risk in community psychiatric populations to ultimately inform interventions that address both psychiatric and criminogenic treatment needs” (p. 336-337).

“Historically, people believed that mental illness significantly contributed to criminal behavior and that treating mental illness would reduce criminal involvement; however, research has demonstrated that a very small percentage (4% to 13%) of the total number of crimes are partially or completely motivated by psychiatric symptoms. Instead, we now know that other criminogenic risk factors are the primary contributors to PMI’s involvement in the CJ system… In fact, the contemporary view is that criminogenic risk factors, such as the Central Eight risk factors for criminal behavior, do not include mental illness as a risk factor. Our study aims to further address the gap in understanding why PMI engage in criminal behavior” (p. 337).

“Specifically, there are eight central risk factors (i.e., the Central Eight) that increase one’s risk for criminal behavior. These risk factors include: (1) history of antisocial behavior, (2) antisocial personality, (3) antisocial attitudes, (4) antisocial peers, (5) family/marital problems, (6) school/employment difficulties, (7) absence of positive leisure/recreational activities, and (8) substance abuse. Additionally, the first four of these risk factors (i.e., the Big Four) are the most impactful risk factors for criminal involvement. There is a significant amount of research to support this framework among offender populations; however, recent research also suggests these risk factors apply to justice-involved PMI…These data suggest that PMI, who are and are not CJ-involved, do not significantly differ in their psychiatric symptomatology despite sharing similar criminal thinking styles. That is, criminogenic risk factors appear to be similar for both CJ-involved PMI and their non- mentally ill peers” (p. 337).

“The purpose of our study was to compare all of the Central Eight risk factors as well as severity of psychiatric symptomatology among a sample of psychiatric inpatient PMI with and without a history of CJ involvement. We hypothesized that CJ-involved psychiatric inpatient PMI would endorse significantly greater criminogenic risk compared to non-CJ-involved psychiatric inpatient PMI, and that these risk factors would significantly and accurately identify whether PMI had CJ involvement. Additionally, we hypothesized that psychiatric inpatient PMI with and without a history of CJ involvement would not significantly differ on their reported psychiatric symptomatology, given empirical support that CJ-involved PMI and non-CJ-involved PMI demonstrate similar levels of psychiatric functioning” (p. 337).

“Results indicated significant differences between the Big Four and Central Eight risk factors when comparing psychiatric inpatient PMI with and without CJ involvement. For the Big Four, antisocial personality traits and attitudes toward criminal associates were primarily driving the differences between PMI with and without CJ involvement. Additionally, the Big Four risk factors correctly classified 85.9% of participants into CJ-involvement and non-CJ-involvement history groups. Regarding the Central Eight, job seeking and antisocial personality traits were primarily driving the differences between CJ-involvement and non-CJ-involvement history groups. Furthermore, the Central Eight correctly classified 99.3% of participants into CJ- involvement and non-CJ-involvement groups. We also found that psychiatric symptomatology only correctly classified 57.7% of participants into CJ-involvement and non-CJ-involvement groups. This is close to chance-level classification and a much lower accuracy rate in comparison to the Big Four and Central Eight variable sets. Notably, psychiatric symptomatology did not improve the accuracy of classification beyond what was accounted for by the criminogenic risk variables” (p. 343).

Although our results indicated that CJ-involved and non-CJ-involved PMI differed in their psychiatric symptomatology, the effect size was small, the classification was poor, and criminogenic risk factors outperformed psychiatric symptomatology in predicting group differences. This small but statistically significant difference in psychiatric symptomatology between CJ-involvement and non-CJ-involvement history groups could be a product of the criminalization of PMI. That is, some PMI might have a CJ history not because they have criminogenic risk, but rather because they are more likely to be overrepresented in the CJ system. These results suggest criminogenic risk factors should be considered when conceptualizing CJ involvement among PMI; therefore, psychotherapeutic interventions on criminogenic risk factors, not only mental illness, may decrease criminal recidivism among CJ-involved PM.

Translating Research into Practice

“Our findings have important practice and policy implications. First and foremost, our results are not only relevant for mental health practitioners working in corrections (i.e., jails, prisons, probation, parole) but also for general mental health practitioners. That is, practitioners working in traditional mental health settings (e.g., community mental health centers, psychiatric hospitals) need to become better acquainted with traditional criminogenic risk factors as they are applicable to the community mental health population. Specifically, our findings suggest that risk assessments and treatments designed to reduce criminal behavior should augment traditional mental health services in community mental health populations when professionals identify CJ involvement or risk of involvement. Just as PMI are overrepresented in the CJ system, so too are CJ-involved individuals overrepresented in mental health systems; our data indicate that 52.1% of psychiatric inpatient PMI have a history of CJ involvement. Thus, community mental health professionals must become cognizant of efforts to treat CJ-involved PMI, including important theoretical advancements such as Risk-Need-Responsivity, assessments that assess both criminal risk and mental health concerns, and treatments for this unique population with co-occurring mental illness and criminal risk” (p. 344).

“Although professionals in CJ settings commonly use assessment tools and treatments for CJ-involved persons, including CJ-involved PMI, these are much less likely to be known or used by peers working in community mental health settings. Therefore, training and continuing education for mental health practitioners in the community that emphasize treating and assessing both mental health and criminal risk would best equip these practitioners to manage the challenges of these co-occurring treatment targets. As a specific example, with the proliferation of mental health courts, it is essential that these programs also include assessments and treatments of criminal risk to have an appreciable effect on crime reduction while also meeting the mental health needs of those involved. Honegger (2015) indicated that mental health courts have not met the standards of evidence-based care, and lack a standard model or criteria for implementation and evaluation. Honegger (2015) suggested mental health courts should consider the interplay of mental health and criminal risk factors when evaluating methods of recidivism reduction. Our findings provide strong support for policy and guidance for these court systems (and other interventions) as programs continue to be developed and refined. Having co-occurring mental illness and criminal risk complicates the management and treatment of CJ-involved PMI, but our results and the existing literature are clear: it is necessary to place equal emphasis on mental health and criminogenic interventions, both at the system and policy level” (p. 344).

Other Interesting Tidbits for Researchers and Clinicians

“Previous research has demonstrated that CJ-involved PMI have elevated criminal thinking and attitudes compared to non-CJ-involved PMI; however, this research did not examine the full range of the Central Eight criminal risk factors. Our study has expanded upon previous literature by testing all of the Central Eight criminal risk factors and how they differentiate CJ-involved PMI from non-CJ involved PMI. Consistent with the findings related to criminal thinking and attitudes, our study indicated that the Central Eight criminal risk factors strongly discriminated between these groups. Our findings are also consistent with Andrews and Bonta’s (2016) position that the distinction between the Big Four and the remaining Central Eight criminal risk factors may not be necessary. Whereas our Big Four risk factor variables correctly classified 85.9% of participants, the full set of Central Eight risk factor variables correctly classified 99.3% of participants, which indicates the full set of Central Eight Risk factors provides the most comprehensive classification information. Therefore, our results provide further evidence that inpatient PMI who have a history of CJ involvement have different treatment needs from those without a history of CJ involvement” (p. 343-344).

“Our results further support findings from previous research with the notion that psychiatric symptomatology is not strongly linked to inpatient PMI’s risk for engagement in crime. This finding is congruent with previous findings, which indicated no significant differences in psychiatric symptomatology between PMI with and without CJ involvement. That is, when considered in totality, the collective data is becoming overwhelmingly clear that PMI become CJ-involved because they share criminogenic risk factors with non-PMI offenders rather than due to a lack of access to mental health care or the result of untreated mental illness. What is less clear and still needs to be examined is the nature of the mental illness and criminogenic risk relation. For example, we still do not know the impact of the criminogenic-mental illness relationship on treatment needs or individual and societal outcomes” (p. 344).

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Authored by Amanda Beltrani

Amanda Beltrani is a doctoral student at Fairleigh Dickinson University. Her professional interests include forensic assessments, professional decision making, and cognitive biases.

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