Read "Individuals with Serious Mental Illness in the Criminal Justice System: The Case of Richard P." located in this week's Electronic Reserve Readings.
Review UOP's Sample PowerPoint Presentation to guide you in creating an effective presentation.
As a Team, create a visually engaging 10- to 12-slide Microsoft® PowerPoint® presentation to describe the role of communication skills in handling the case.
Include speaker notes with each slide of your presentation that provides information on the topics below. Each topic should have at least two corresponding slides.
· Describe how you could use different communication models to assist in communicating with this offender.
· Describe how interpersonal communication skills and motivational interviewing could be used with this offender.
· Describe how you would take this offender's culture and mental capacity into consideration when communicating with him.
· Describe how the use of jargon may affect communicating with this offender.
Include a minimum of three reputable sources.
Format any citations in your presentation consistent with APA guidelines.
Click the Assignment Files tab to submit your assignment.
Individuals With Serious Mental Illness in the Criminal Justice System The Case of Richard P. Arthur J. Lurigio Loyola University Chicago, Illinois John Fallon Thresholds This paper presents a case study that illuminates the clinical and practical challenges that accompany the treatment of people with serious mental illness (SMI) and criminal involvement. We discuss the historical conditions that led to the influx of a large number of people with SMI into the criminal justice system. We discuss the case history of Richard P., which illustrates the use of Assertive Community Treatment (ACT) to care for criminally involved people with SMI. We focus on the ACT model that was employed by Thresholds to treat Richard P. It was known as the Thresholds Jail Program. We track his progress in the program and explicate the case management considerations that are most salient in treating offenders with SMI. Keywords: criminalization, mental illness, crime, deinstitutionalization, mental health services, probation, ACT 1 Theoretical and Research Basis Fundamental changes in mental health policies and laws have brought criminal justice professionals into contact with the seriously mentally ill at every stage of the justice process: police arrest people with serious mental illness (SMI) because few other options are readily available to handle their disruptive public behaviors; jail and prison administrators strain to attend to the care and safety of the mentally ill; judges grapple with limited sentencing alternatives for individuals with SMI who fall outside of specific forensic categories (e.g., guilty but mentally ill); and probation and parole officers scramble to obtain scarce community services and treatments for people with SMI and attempt to fit them into standard correctional programs or monito.
Read Individuals with Serious Mental Illness in the Criminal Just.docx
1. Read "Individuals with Serious Mental Illness in the Criminal
Justice System: The Case of Richard P." located in this week's
Electronic Reserve Readings.
Review UOP's Sample PowerPoint Presentation to guide you in
creating an effective presentation.
As a Team, create a visually engaging 10- to 12-slide
Microsoft® PowerPoint® presentation to describe the role of
communication skills in handling the case.
Include speaker notes with each slide of your presentation that
provides information on the topics below. Each topic should
have at least two corresponding slides.
· Describe how you could use different communication models
to assist in communicating with this offender.
· Describe how interpersonal communication skills and
motivational interviewing could be used with this offender.
· Describe how you would take this offender's culture and
mental capacity into consideration when communicating with
him.
· Describe how the use of jargon may affect communicating
with this offender.
Include a minimum of three reputable sources.
Format any citations in your presentation consistent with APA
guidelines.
Click the Assignment Files tab to submit your assignment.
Individuals With Serious Mental Illness in the Criminal Justice
System The Case of Richard P. Arthur J. Lurigio Loyola
University Chicago, Illinois John Fallon Thresholds This paper
presents a case study that illuminates the clinical and practical
challenges that accompany the treatment of people with serious
mental illness (SMI) and criminal involvement. We discuss the
historical conditions that led to the influx of a large number of
people with SMI into the criminal justice system. We discuss
3. the community, and mentally ill offenders on probation and
parole are already living there. Jails and prisons are legally
required to provide mental health care that meets accepted
standards of practice, and probationers and parolees can be
mandated to receive mental health care as a condition of their
release. Hence, clinicians are more likely, now than ever, to
treat individuals with SMI and criminal justice involvement
(Lurigio & Swartz, 2000). This paper addresses the case
management and care of offenders with SMI. First, we discuss
the factors that contributed to the large numbers of people with
SMI in the criminal justice system. Second, we present the case
study of Richard P., which illustrates the use of Assertive
Community Treatment (ACT) to care for criminally involved
people with SMI. Richard’s symptoms were managed with an
ACT model employed by Thresholds, which was known as the
Thresholds Jail Program (TJP). Thresholds delivers a wide array
of treatment and rehabilitative services for people with chronic
psychiatric disabilities. Third, we track Richard’s progress in
the program in terms of arrests and days in the hospital and jail.
Fourth, we explicate the general clinical and case management
considerations that are most salient in treating offenders with
SMI. Pathways into the Criminal Justice System Nearly 35 years
ago, Abramson (1972) noted that more and more people with
SMI were being routed through the criminal justice system
instead of the mental health system. Since then, data have
suggested that the mentally ill are arrested and incarcerated in
numbers that surpass their representation in the general
population and their tendencies to commit serious crimes or be
arrested (Council of State Governments, 2002). In light of these
data, mental health advocates and researchers have asserted that
people who have been treated in mental health agencies and
psychiatric hospitals are more frequently being shunted into
jails and prisons (Teplin, 1983). People with SMI enter the
criminal justice system, and people involved in the criminal
justice system enter the mental health system, through a variety
of pathways, including “crisis services, departments of social
4. services, human services agencies, educational programs,
families, and self-referrals” (Massaro, 2003, p. 2). For most
mentally ill offenders, SMI complicates rather than causes their
involvement in the criminal justice system (Draine, 2003). The
disproportionately high number of people with SMI in
correctional facilities is associated with the rising number of
discharges from state hospitals, the passage of restrictive
commitment laws, the splintering of treatment systems, the war
on drugs, and the deployment of order-maintenance policing
tactics (Lurigio & Swartz, 2000). Deinstitutionalization A
fundamental change in mental health policy, known as
deinstitutionalization, shifted the locus of care for patients with
SMI from psychiatric hospitals to community mental health
centers. Deinstitutionalization is the first major contributor to
the processing of the 364 Clinical Case Studies mentally ill
through the criminal justice system (Grob, 1991). After World
War II, state mental hospitals nationwide began to release
thousands of psychiatric patients to communitybased facilities
for follow-up treatment and services. As a result, the number of
patients in state mental hospitals nationwide was substantially
reduced from 559,000 in 1955 to 72,000 in 1994 to fewer than
60,000 in 2000 (Center for Mental Health Services, 2004). The
length of the average stay in psychiatric hospitals and the
number of beds available also declined sharply (Kiesler, 1982).
The deinstitutionalization movement was fueled by media
accounts of patient abuse and neglect, the development of
effective medications to treat SMI, federal entitlement programs
that paid for community-based mental health services, insurance
coverage for inpatient psychiatric care in general hospitals, and
antipsychiatry polemics written by researchers and academic
scholars (Sharfstein, 2000). Deinstitutionalization, however,
was never properly implemented. Although the policy provided
for appropriate outpatient treatment for a large percentage of
the mentally ill, it failed to care adequately for individuals who
had limited financial resources or social support, especially
those with the most severe and chronic mental disorders
5. (Shadish, 1989). The failed transition to community mental
health care had the most tragic effect on patients who were least
able to handle the basic tasks of daily life. Public psychiatric
hospitals became treatment settings for the indigent. Patients
became younger because new medications obviated the need for
extended periods of hospitalization. Before these medications
were discovered, psychiatric patients could remain in the state
hospital for decades and be released when they were elderly.
New cost-saving measures and hospital policies shifted the
costs of care from state budgets, which paid for hospitalization,
to federal budgets, which paid for community-based mental
health services. Unlike earlier generations of state mental
patients, those who were hospitalized during and after the 1970s
were more likely to have criminal histories, to be addicted to
drugs and alcohol, and to tax the patience and resources of
families and friends (Draine, 2003; Lurigio & Swartz, 2000).
Lack of affordable housing compounds the problems of people
with SMI and interferes with the provision of mental health
treatment. An estimated 20 to 25% of the adult homeless
population is afflicted with SMI (Council of State Governments,
2002). The characteristics of the mentally ill, therefore,
resemble those of many criminally involved persons: poor,
young, and estranged from the community (Draine, 2003;
Silver, Mulvey, & Swanson, 2002; Steadman, Cocozza, &
Melick, 1978). As the Council of State Governments (2002)
noted, “Without housing that is integrated with mental health,
substance abuse, employment, and other services, many people
with mental illness end up homeless, disconnected from
community supports, and thus more likely to decompensate and
become involved with the criminal justice system” (p. 8). In
short, many persons with SMI fall into the lap of the criminal
justice system because of the dearth of mental health treatment
and other community services (Grob, 1991). Links between the
criminal justice and mental health systems have always been
tenuous, and the mentally ill who move from one system to the
other frequently fail to receive enough treatment or services
6. from either. As a result, their mental health deteriorates and
they become both chronic arrestees and psychiatric patients
(Lurigio & Lewis, 1987). Lurigio, Fallon / Serious Mental
Illness 365 Legal Restrictions Reforms in mental health laws
have made it difficult to admit the mentally ill involuntarily
into psychiatric hospitals and are the second major contributor
to the influx of mentally ill persons into the criminal justice
system (Torrey, 1997). Serious restrictions on the procedures
and criteria for involuntary commitment sorely limit the use of
psychiatric hospitalizations. Most state mental health codes
require psychiatric hospital staff to adduce clear and convincing
evidence that patients who are being involuntarily committed
are either a danger to themselves or others, or are so severely
debilitated by their illness that they are unable to care for
themselves. In addition, mental health codes strengthened
patients’rights to due process, according patients many of the
constitutional protections granted to defendants in criminal
court proceedings. Thus, only the most dangerous or profoundly
mentally ill are ever hospitalized resulting “in greatly increased
numbers of mentally ill persons in the community who may
commit criminal acts and enter the criminal justice system”
(Lamb & Weinberger, 1998, p. 487). Fragmented Services The
third major factor that explains the increased presence of
mentally ill persons in the criminal justice system is the
compartmentalized nature of the mental health and other
treatment systems (Laberge & Morin, 1995). The mental health
system consists of fragmented services for predetermined
subsets of patients. Most psychiatric programs, for example, are
designed to treat “pure types” of clients who can be placed into
clear-cut categories for clinical services. By the same token,
vast majorities of drug treatment staff are unwilling or unable to
serve persons with mental disorders, and frequently refuse to
accept such clients. Furthermore, offenders with co-occurring
disorders are difficult to engage in treatment and are often
resistant to efforts to confront their addiction to alcohol and
illicit drugs (Drake, Rosenberg, & Mueser, 1996). Abstinence
7. from substance abuse can be a prerequisite for acceptance into
mental health treatment programs. Therefore, persons with co-
occurring disorders, who constitute a large percentage of the
mentally ill in the criminal justice system, might be deprived of
services because they fail to meet stringent admission criteria
(Abram & Teplin, 1991). When persons with co-occurring
disorders—most of them with SMI and substance abuse and
dependence disorders—come to the attention of the police,
officers might have no other choice but to arrest them given the
lack of available referrals within narrowly defined treatment
systems (Brown, Ridgely, Pepper, Levine, & Ryglewicz, 1989).
Drug Enforcement The fourth major factor associated with the
pervasiveness of mentally ill offenders is the arrest and
conviction of millions of persons for drug-law violations. The
highly significant growth in the volume of drug arrests and
convictions stems largely from the war on drugs. Offenders
convicted of the use, sale, and possession of drugs constitute
one of the fastestgrowing subpopulations in correctional
facilities (Beck, 2000). A fairly large proportion of these
offenders have co-occurring mental illnesses, adding to the
number of mentally ill individuals in the criminal justice system
(Swartz & Lurigio, 1999). 366 Clinical Case Studies Police
Tactics The fifth major factor that contributed to the processing
of people with SMI through the criminal justice system is the
recent adoption of law enforcement strategies that emphasize
quality-of-life issues and zero tolerance policies in response to
public-order offenses: loitering, aggressive panhandling,
trespassing, disturbing the peace, and urinating in public (Fagan
& Davies, 2000). These crime-control strategies have netted
large numbers of the mentally ill for publicly displaying the
symptoms of an untreated SMI. The implementation of public-
order policing tactics has outpaced the development of
diversionary programs for persons with SMI, which has
exacerbated the problem of criminalization (Ditton, 1999). 2
Case Introduction Richard P. is a 49-year-old African American
man who has never married. He is slender and slightly built,
8. with specks of gray in his hair. He has several missing teeth,
and those in his mouth are visibly discolored or decaying
making him look somewhat older than his recorded age. Richard
was appropriately dressed in a clean jogging suit and running
shoes. He moved somewhat slowly and spoke in deliberate,
often inaudible, whispers. He was compliant with requests and
often looked to his TJP caseworker for direction (e.g., where to
sit for the interview). He seemed comfortable from the outset of
the interview, displaying no signs of anxiety and appearing
unconcerned when his caseworker left the room before the start
of the assessment. Throughout the interview, Richard was
friendly, made eye contact, and appeared relaxed. His affect
was somewhat flat and his emotionality was immature. At the
time of the interview, he was adhering to medications and living
in a board-and-care facility. Richard reported that his life in the
facility was very “safe and nice,” compared with his many stays
in the hospital and jail, which left him filled with “bad
memories.” 3 Presenting Complaints An independent assessment
was conducted to determine the course of Richard P.’s
continued involvement with the TJP. 4 History Richard P. grew
up on Chicago’s West Side—a highly impoverished and crime-
ridden area of the city—with his parents and 12 siblings: 8
sisters and 4 brothers. He is the youngest in the family and no
longer has contact with any of his siblings. Richard’s mother
died in September 1985, and his father died a year later.
However, Richard has refused to believe that his parents are
dead and talked longingly about contacting his mother “to see if
she’s all right.” In addition, he has maintained that his parents
still live at the residence where he spent his childhood and
adolescence. He has occasionally harassed the current residents
of Lurigio, Fallon / Serious Mental Illness 367 his former home,
especially during times when he was homeless. The fragmented
nature of Richard’s psychiatric records and the speed at which
he moved between systems and institutions caused discharge
planners to believe mistakenly that his mother’s home was a
place where Richard could stay when he had no other housing
9. options. No reported history of mental illness was found in
Richard’s family. Psychiatric records state that one of his
brothers was engaged in illegal drug use and other criminal
activities. Richard had little to say about his childhood except
that his parents were married and he “got along well” with his
siblings. He reported that he attended high school but was often
truant and “got into trouble” with his friends. He dropped out in
the 11th grade. Richard has a long history of substance use,
starting in high school with LSD and alcohol. Richard reported
that his first hospitalization occurred shortly after he dropped
out of high school. He indicated that he earned his GED at one
of the state’s psychiatric hospitals. Richard reported that he has
held “at least” four jobs—as a dye cutter, a filer in a clothing
warehouse, a factory worker, and a mail clerk. Richard’s
earliest psychiatric hospitalization occurred in 1976. From 1978
to 1998, he was hospitalized 27 times in state facilities,
including numerous transfers between facilities. Richard’s
longest period of hospitalization was 5.5 years. His early
hospitalizations resulted from incidents of threatened violence
and uncontrollable behaviors in the presence of his family
members. He was admitted to one state facility following a
verdict of not guilty by reason of insanity that stemmed from a
charge of criminal trespass to property. Between 1978 and 1998,
he was hospitalized a total of 11.5 years. Since 1985, the
majority of his hospitalizations have followed the commission
of petty crimes or public displays of disruptive, psychotic
behaviors. In 1980, Richard stabbed his mother six times with a
pair of scissors and threatened to kill the young children who
resided at his mother’s home. According to police records, the
incident occurred when he was unable to locate his clothing and
identification card. Another violent incident occurred in April
1981 when he punched his father in the eye. Richard’s early
delusions involved beliefs that he was Jesus Christ, was born
with wings, and could foretell the future. He also averred that
his mother was “Queen Mary.” From 1993 to 1997, Richard was
arrested 84 times. He has approximately 140 lifetime arrests.
10. His first arrest was for trespassing at an upscale hotel in
downtown Chicago. In that incident, police reported that he was
trying to set the hotel lobby on fire. Richard was accused of
setting fires at another hotel many years ago, although he claims
that the fire started “accidentally” after he dropped a cigarette
on the floor. Richard acknowledged that he has been arrested
numerous times. He remembered being arrested for sleeping on
the streets, trespassing, and disorderly conduct. His final arrest,
before being identified by the TJP, was on December 12, 1997.
Richard insisted that alcohol and drug use have “never caused
him” problems. However, police and other reports show that
Richard has been arrested while publicly intoxicated, but there
are no records of his being treated for a substance abuse or
dependence disorder. Richard reported that he was homeless
continuously for eight years. Records indicated that he slept on
air vents, in shelters, and on pedways. Richard often alienated
people in the community with his bizarre behaviors and style of
dress. He is an inveterate smoker who insists on smoking
whenever and wherever he pleases. His caseworker stated that
Richard 368 Clinical Case Studies picks up cigarette butts from
the ground and smokes them. Richard has panhandled and eaten
frequently from garbage cans even when food was available. For
most of his adult life, Richard has dressed inappropriately and
worn brightly colored and unusual attire, such as belts over
shirts, a shirt tied at the midriff, and shorts worn over pants.
Sometimes, he wandered the streets wearing no shoes, untied
shoes, or shoes several sizes too small. He collected much of his
clothing by rummaging through garbage dumps. He seems to
wear unusual clothing most often during periods of
decompensation. Psychiatric records noted a history of cross-
dressing and effeminate behaviors. In addition, hospital reports
indicated that Richard paced constantly and talked to himself
even while medicated. According to one hospital entry, Richard
“lost his concentration quickly” and “displayed a silly smile,”
when interacting with hospital staff. At times, he responded
violently to auditory hallucinations by punching or chopping the
11. air. 5 Assessment Richard was fully oriented and indicated that
he understood the purposes of the interview. Although he
reported that he had previously heard voices that “attacked him
and called him dirty names,” he stated that the voices were “no
longer a problem.” Richard’s fund of knowledge of current
events was poor, and he displayed considerable short- and long-
term memory deficits. His speech content was moderately
organized but highly deficient. He was able to answer simple
questions about his current living arrangements and daily
activities but he was unable to respond to more complicated
questions. His thinking was highly concrete. At various points
in the interview, he spoke remorsefully about his separation
from his family, especially his mother, and his lost employment
and relationship opportunities. He stated that he frequently “felt
ashamed of himself ”; however, he provided few specific details
regarding the nature of his failures or regrets. Richard claimed
to be a “famous singer and entertainer” who was once “well
known throughout the country.” When he was pressed for
concrete information concerning his entertainment career,
Richard became confused and evasive, stating only that he had
“sung in the church choir.” Psychiatric records indicated that
both of Richard’s parents died more than 20 years ago.
Nonetheless, Richard clung tenaciously to the belief that they
were still living and residing in his childhood home. He spoke
longingly about being reunited with his mother who would
“wash away” the “contaminations” that he had been exposed to
in the hospital and jail. Despite his longstanding dependence on
nicotine and periodic misuse of alcohol, Richard reported no
problems with alcohol or drug use, or other medical conditions.
His responses to questions concerning his present life were
replete with religious ideation and references. He spoke with
obvious contentment about his relationship with God. Richard
stated that he “knows God and sees God everywhere he goes.”
He described God as a “gentle, beautiful figure with white hair
and a peaceful voice.” The only time in the interview that
Richard appeared animated and energized was when he talked
12. about his religious experiences and activities, such as Bible
reading. Despite repeated questions regarding the nature of his
contacts with God, it was unclear whether Richard’s reported
experiences with Lurigio, Fallon / Serious Mental Illness 369
God were hallucinatory or metaphorical. Based on this
information, Richard was assigned the following DSM-IV
diagnosis at the time of his interview: Axis I 295.10
Schizophrenia, disorganized type, continuous 305.10 Nicotine
Dependence 300 Alcohol Abuse (provisional) Axis II 799.9
Diagnosis Deferred on Axis II Axis III None Axis IV Criminal
Justice Involvement History of Housing and Employment
Problems No Family Support Axis V Global Assessment of
Functioning35 (current) 6 Case Conceptualization Overview
The case study of Richard P. profiles an individual with SMI
who has been chronically involved in the criminal justice and
mental health systems. His experiences personify the term
“criminalization”; he was frequently arrested and jailed because
his manifestations of symptoms created a public nuisance.
Richard’s threats and expressions of violence were aimed
primarily at his family, and his criminal activities were
typically haphazard and impulsive. Although Richard’s records
of psychiatric and criminal recidivism are remarkable, his
history exemplifies how the absence of community-based care
leads to perpetuating cycles of psychiatric disability, disruptive
behaviors, and police contacts. Whether his display of
symptoms resulted in an arrest or a hospitalization depended on
a wide variety of factors that were mostly unrelated to his
illness (e.g., who called the police, the willingness of a
complainant to press charges, the responding police officers’
inclination to arrest, and hospital staff persons’ willingness and
ability to admit Richard). Richard received effective treatment
in the state hospital and the medical facility of the jail, but he
was simply unable to care for himself or manage his life without
the continued assistance and partnership of professionals in the
mental health and criminal justice systems. The collective
interventions of those professionals helped Richard achieve the
13. consistent support that he needed to live successfully in the
community. The TJP was the “boundary spanner” between the
mental health and criminal justice systems (Steadman, 1992).
Richard achieved stability only after he received the concerted
attention of persons working in the court, jail, community-based
treatment network, and state hospital. All members of Richard’s
case management team recognized that they were unable to
break the hospitalization–incarceration cycle alone. Richard’s
case clearly illustrates the remarkable complexity of helping a
transinstitutionalized client who requires the services of several
treatment systems (i.e., hospitals, jails, prisons, courts, shelters,
and substance abuse facilities). Continuity of care is critical in
maintaining such clients’ progress. Inadequate or interrupted
care is tremendously costly and drains the resources of each
system in which they appear. Richard’s experiences also
demonstrate the effectiveness of a case management approach to
supportive services that protects public safety, reduces
treatment costs, and improves the quality of clients’ lives.
Richard’s case shows that community care is greatly fostered
when staff persons of the jail and state hospital regularly
communicate. Without effective medication titration, both in the
hospital and community-based treatment settings, clients with
SMI can never be completely ready to pursue independent and
productive lives. Community providers can help jail and
hospital staffs learn which medications are necessary to achieve
client stability after discharge. For example, although
medications effectively controlled Richard’s behavior in
structured settings (i.e., jails and hospitals) he was
overwhelmed by stimuli when released from inpatient care and
immediately became symptomatic and at risk for
reinstitutionalization. Armed with this basic information from
the TJP, inpatient staff adjusted Richard’s medication in order
to prepare him for successful discharge. Cooperation among
agencies was the key to Richard’s success. Specifically, police
officers in the district where Richard lived learned about him
from the TJP, and they began to regard him as a disabled person
14. who needs to be assisted rather than a dangerous person who
needs to be arrested and incarcerated. When they encountered
Richard in troubled circumstances, they called the TJP instead
of processing him through the station house and the lockup.
Given the knowledge of his lengthy psychiatric history, judges
(with Richard’s consent) considered more therapeutic
dispositions that increased Richard’s compliance with treatment
regimens and held him accountable for behaving appropriately
and responsibly. TJP’s assertive community treatment model
was greatly enhanced with the cooperation of the trained and
knowledgeable officers of the specialized mental health
probation unit (MHU) of the Cook County Adult Probation
Department (Lurigio, Bacula, & Williams, 2005). MHU staff
strictly enforced treatment mandates, assisted the team to
achieve initial treatment goals, and encouraged team members
to develop long-term relationships with hospital and
community-based treatment providers. These relationships
allowed Richard to experience continued reintegration and
progress beyond the term of his probation sentence. Thresholds
Jail Program The TJP began as a two-year, privately funded
demonstration project and later became a state-funded
specialized ACT program for individuals with SMI leaving the
Cook County Department of Corrections (CCDOC) with long
histories of arrests and state psychiatric hospitalizations and a
failure to engage in traditional outpatient programs.
Participation in the TJP can be ordered as a special condition of
probation. The program’s basic goals are to reduce significantly
the numbers of rearrests, reincarcerations, and
rehospitalizations among participants. To attain these goals, the
program assists participants in obtaining psychiatric treatment,
medical care, housing, welfare, and other social services. The
program also assists participants in managing their money and
adhering to their medication regimens. Participants can remain
in the program beyond their sentencing requirements if they
need or wish to do so. During its initial phase, the TJP managed
approximately 20 individuals with chronic psychiatric disorders
15. and lengthy histories of inpatient care. Participants, such as
Richard, must be eligible to receive Social Security Income or
Social Security Disability Insurance, convicted 370 Clinical
Case Studies of nonviolent offenses, and at low risk for
violence in the community when compliant with their
medications. They must also meet several other criteria,
including a willingness to take psychiatric medications and
allow Thresholds to become their representative payee.
Probation Programs Participants can be admitted to the program
at the pretrial or postadjudication stages. At the pretrial stage,
eligible participants include two types of defendants: those who
have been diagnosed and treated for major psychiatric disorders
in the CCDOC and released pending trial and those who are
being supervised in Cook County Adult Probation Department’s
(CCAPD) Pretrial Services Unit, which monitors defendants in
the community under court-ordered conditions while they await
trial. At the postadjudication stage, participants are sentenced to
probation and supervised in CCAPD’s MHU. The MHU
supervises approximately 300 clients throughout Cook County;
most have Axis I disorders and lengthy histories of psychiatric
hospitalizations (Lurigio, Bacula, & Williams, 2005). This unit
has been instrumental in developing cooperative relationships
between the criminal justice and community mental health
systems. 7 Course of Treatment and Assessment of Progress
Richard currently resides at the Lorali Hotel, a board-and-care
facility. He has grown accustomed to living on the streets and
occasionally absconded from the hotel for several days.
Caseworkers use Richard’s photographs to help the police find
him when he is lost. (Richard signed releases that allowed the
staff to show his picture to the police.) Caseworkers encouraged
police officers to consider calling them instead of arresting
Richard. This arrangement has averted several arrests. For
example, TJP staff brought Richard home from the Chicago
Transit Authority, Northwestern, and the Metra Train Stations
in response to calls from the stations’ security officials. After
Richard acclimated to his apartment in the Lorali Hotel, his
16. disruptive public behaviors gradually stopped. Richard started
seeing a Threshold’s psychiatrist in June 1998 for medication
and symptom management. Richard meets his psychiatrist
weekly for prescriptions. He is allergic to Thorazine and
currently takes Prolixin IM, 1 cc, weekly; Depakote, 500 mg,
twice daily; Zyprexa, 10 mg, daily; and Cogentin, 12 mg, daily.
When he was initially on his medication regime, he complained
of chronic vomiting and other gastrointestinal problems without
a known pathogenesis. The problems subsided when his
Depakote dosage was lowered to its present level. Richard
appears to be content living at the Lorali Hotel. When asked
about having his own apartment, Richard responded, “It helps
me to get away to my own world, every day, having a room,
clothes, food, and money—every day.” TJP staff members visit
him daily to help him manage his medication and money.
Although Richard still displays signs of mental illness—
grimacing, inappropriate smiling, silliness, and talking to
himself—he has shown marked improvement. He continues to
maintain that his mother is living, but he has stopped returning
to his old home and annoying the current residents there. He has
not been hospitalized since June 1998. Lurigio, Fallon / Serious
Mental Illness 371 Richard was rearrested in downtown Chicago
at the beginning of 1999. The police report of the incident
indicated that he was brandishing a weapon in a train station
and scaring the commuters. He stated that he found a piece of
scrap metal and pretended it was a gun. He was released from
jail in one week. At that time, Richard decided that he would
avoid the downtown area. To date, he has not returned to the
jail. In February 2000, TJP staff and other program participants
held a dinner party to celebrate Richard’s one-year anniversary
of being jail-free. Without the TJP’s structure and support,
Richard would likely stop adhering to his medications and start
wandering the streets again. Richard plans to stay at the Lorali
Hotel as long as he is unable to care for himself in a less
structured living arrangement. Richard reported that he would
like to be employed. His symptoms, however, are presently too
17. severe for job placement. If Richard’s symptoms improve in the
future, Threshold’s staff will help him find a suitable job. The
severity and chronicity of his illness demand that Richard
receives continual support from Thresholds in order to monitor
his symptoms, finances, medications, and hygiene. Thresholds
helps him remain safely housed, control his psychiatric
symptoms, and avoid incarceration and hospitalization. 8
Complicating Factors Richard was referred to the TJP by staff
from CCDOC’s medical facility. The CCDOC is located in
Chicago and is the largest single-site jail in the United States,
housing more than 11,000 detainees and treating more than
1,000 detainees daily for mental disorders. Richard had been
detained in the jail on numerous occasions and repeatedly
refused to cooperate with any member of the jail staff ’s efforts
to refer him for continued psychiatric treatment after his
release. At the time of his referral to the TJP, Richard was
homeless and had a long history of psychiatric hospitalizations,
incarcerations, and irregular adherence to a wide range of
psychiatric medications. He also had three pending
misdemeanor court cases in one courtroom and a fourth felony
case in another. A TJP team leader met with Richard for the
first time while Richard was detained in the CCDOC’s isolation
unit because he had been exposed to tuberculosis. Psychiatric
reports from Richard’s CCDOC admission, which preceded his
first contact with the TJP, showed that he was unmedicated and
highly delusional and disorganized at intake. While in medical
isolation, he stated to the TJP team leader that he needed no
assistance with Social Security Income or housing because he
lived with his mother (known to be long deceased) on Chicago’s
West Side. He refused to participate in the TJP at that time and
demonstrated no insight into his psychiatric problems.
Nonetheless, he agreed that program staff could visit him again
while he was in custody. Richard was contacted by a TJP
caseworker for a second visit in Cermak’s Psychiatric Unit
where Richard was being treated and stabilized. Although still
symptomatic, he appeared much more coherent than he was
18. during the initial contact, and he agreed that the TJP would be
“good for him.” He signed releases that allowed TJP staff to
meet with court and jail personnel on his behalf in order to
assist him with housing, treatment, and financial needs
following his release from the CCDOC. A TJP caseworker
accompanied Richard to court on 372 Clinical Case Studies
Lurigio, Fallon / Serious Mental Illness 373 his first pending
misdemeanor case, which was dismissed because the
complaining witness failed to appear. The judge in this case was
unwilling to cooperate with the TJP caseworker. As a result,
Richard was reincarcerated and released with no follow-up care.
All three of the misdemeanor cases before the judge would
eventually be dismissed after Richard was detained for 30–45
days in the CCDOC. The last of Richard’s four cases, a felony
charge, was with a judge who was sensitive to Richard’s
psychiatric problems. TJP staff met the judge to discuss the
program and presented a letter from MHU staff that informed
the judge of the unit’s interest in working with the TJP to help
break Richard’s long-standing cycle of arrests, detentions, and
hospitalizations. The judge responded by referring several other
detainees to be evaluated by the TJP and raising Richard’s bond
to ensure that he would be detained long enough for the TJP to
develop an adequate discharge plan before his release. MHU
and CCDOC staff prepared for Richard’s upcoming felony court
case. Cermak staff notified the TJP that Richard was queued
unexpectedly to be released from the CCDOC. Sheriff ’s
deputies granted Richard an individual-recognizance bond (I-
Bond) because of jail overcrowding. This decision was rendered
despite Richard having two more pending misdemeanor cases
with cash bonds totaling $8,000 and only a week to prepare for
his court case that day. The TJP attempted to notify the Cook
County Sheriff ’s Office that Richard had a court appearance
scheduled on the day of his release, which he was likely to miss
if he was discharged from the CCDOC. The program’s
caseworker was unable to change the sheriff ’s decision. Hence,
Richard was released and his second pending misdemeanor case
19. was dismissed. The pending felony case and the formulation of
a coordinated discharge plan were both postponed. With an
hour’s notice, TJP’s director met Richard outside the jail and
offered to drive him to his mother’s home. Richard displayed
psychotic symptoms immediately upon release (e.g., laughing
inappropriately and talking to voices) even though he was stable
while in custody. As we noted earlier, this was important
information in establishing Richard’s need for a higher dose of
medication before being discharged from the hospital. Richard
ran away four times from TJP caseworkers who attempted to
engage him in the program. For example, Richard and the TJP
director stopped to eat at a restaurant. Richard started smoking,
stole a pouch of tobacco, and dashed out of the restaurant. TJP
staff members later caught up with Richard and invited him to
help them find his mother’s old house so they could verify that
Richard had no relatives living there. Confronted with no
evidence of his parents’ presence, he simply insisted, “They
would return and still lived on the second floor;” but the floor
was unoccupied. Richard ran through several buildings and later
jumped from a TJP caseworker’s car; this time, he was not
followed. The team was unable to locate him and learned later
that Richard was hospitalized nearly 90 blocks away on the
same day, even though he had no money or transportation. TJP
staff had taken Richard’s photograph after his most recent
release from CCDOC. After he had run away, staff members
distributed his picture to the Thresholds mobile assessment and
the linkage teams that worked in Chicago’s three state hospitals.
Richard was eventually rearrested. Following the arrest, he
attended court on the third of his three pending misdemeanor
cases, which also was dismissed. He was released again from
the CCDOC before he could be adequately stabilized or
medicated. TJP’s director met with the judge for Richard’s
pending felony case to discuss sentencing options. Richard was
absent from his scheduled appearance. The judge issued a
felony warrant to guarantee that Richard would be held in
custody if he were arrested again. Richard’s whereabouts were
20. unknown at this time. 374 Clinical Case Studies A Thresholds
caseworker was notified that Richard was in Chicago Read
Hospital, one of the state’s three psychiatric hospitals in the
city. The Mobile Linkage Team recognized his picture and name
and called a TJP caseworker as soon as he arrived in the
hospital unit. Before the hospitalization, police had been called
after Richard was found wandering in the parking lot of another
local hospital, dressed in only a hospital gown. Richard was
hospitalized for more than two months at Chicago Read
Hospital. A TJP caseworker arranged to have Richard’s cases
assigned to the felony judge who was sympathetic to his
psychiatric problems. Richard’s outstanding warrant and felony
case were addressed at the same hearing. Hospital security
brought Richard to court, and his warrant was quashed. He was
sentenced to mental health probation for 15 months and ordered
to return to Chicago Read Hospital so he could finish his
treatment and begin discharge planning with a TJP caseworker.
After he was stabilized, TJP staff transported him to the
Stratford Lodge, a structured living environment for persons
with chronic mental illness. Program staff helped him
immediately to prepare applications for food stamps and Social
Security Income. Staff also ensured that he would receive
clothing, toiletries, and money to tide him over while his
benefits were pending. 9 Managed Care Considerations
Richard’s case involved no managed case considerations
because all his treatment services were covered with public
dollars. 10 Follow-Up As shown in Figure 1, we graphed
Richard’s progress in the program by recording the number of
arrests and days in the hospital and jail from the time he entered
the program (midyear 1998) until the end of calendar year 2003.
These data were obtained from the official records of the
Chicago Police Department, the Illinois Office of Mental
Health, and the CCDOC. Richard had been arrested on
numerous occasions and spent considerable time in the hospital
and jail before his participation in the TJP. From 1994 through
the first 6 months of 1998, Richard was arrested 89 times, an
21. average of 20 arrests each year, which included 1995, a year in
which he spent most of his time in the hospital. During the 4.5-
year period that immediately preceded his entry into the TJP, he
spent a total of 608 days in the hospital and 220 days in jail. He
was confined in jail or the hospital for nearly half his life in
those years. In sharp contrast, during his 5.5-year participation
in the program, he was arrested only 5 times, an average of less
than 1 arrest each year. Furthermore, he spent a total of only 14
days in jail and no days in the hospital in that period. He
successfully completed probation and now enjoys living in the
community. 11 Treatment Implications of the Case Treatment
programs for individuals with SMI who are involved in the
criminal justice system should adopt continuous care models
with single-point access to services, which are Lurigio, Fallon /
Serious Mental Illness 375 especially important for people with
lengthy hospitalization and arrest records. The mentally ill on
community supervision at the pretrial, postadjudication, or
postrelease levels can be managed effectively with ACT models
that have demonstrated their success with the chronically
mentally ill (Veysey, 1996). Originating in Madison, Wisconsin,
in the late 1960s, ACT employs a multidisciplinary team
approach to provide intense, comprehensive, coordinated, and
integrated services (psychiatric, rehabilitative, and social
support) to persons with serious and persistent mental illness.
ACT has been widely implemented and researched in the United
States, Canada, and Australia, and has proven clinical and cost
effectiveness (Bond, 2002). ACT is a particularly suitable
modality for many individuals in the criminal justice system:
persons with chronic mental illness, limited insight, severe
functional impairments, substance abuse and dependence
disorders, limited financial resources, and housing instability.
In addition, many mentally ill individuals in the criminal justice
system have frequently avoided, or have responded poorly to,
traditional outpatient mental health care (Lurigio & Lewis,
1987). Therefore, ACT is a highly appropriate model for
individuals with SMI participating in pretrial release or
22. probation programs. The ACT team’s services include mental
health and substance abuse treatment, health education, mobile
crisis intervention, medical care, ongoing psychiatric
assessments, employment and housing assistance, family
support and education, and legal advocacy. Services are
available 24 hours a day, 7 days a week, and 365 days a year.
These services Figure 1 Richard’s Arrests and Days in the Jail
and Hospital 376 Clinical Case Studies are delivered in
patients’ communities rather than in hospital or clinic settings
(Assertive Community Treatment Association, 2006). 12
Recommendations to Clinicians and Students Offenders with
SMI present clinicians with special challenges that complicate
patient treatment and recovery. These challenges revolve around
three related, major issues: comorbidity, criminal status, and
clinical responsibilities. First, as we noted earlier, mentally ill
offenders are likely to have co-occurring psychiatric and
substance use disorders. Hence, integrated treatment that
simultaneously addresses both problems is essential to patient
recovery. Such patients also are likely to have serious needs for
housing, employment, education, and habilitation services. Few
of these patients are insured and even fewer have a broad social
network. Their behaviors are not only disturbed, but also
disturbing, leaving them bereft of the support of family and
friends who can help them confront problems relating to
housing, finances, and symptom management. In working with
mentally ill offenders, clinicians must become accustomed to
serving on a team (preferably ACT) with other providers. Team
treatment strategies involve psychologists, psychiatrists, and
other mental health service providers as pivotal spokes in an
extensive wheel of services, with a dedicated case manager at
the hub. Second, unlike other patients, those with criminal
justice involvement are often mandated to receive
psychotherapy and medications. Hence, clinicians must be
prepared to develop different approaches to building and
sustaining a therapeutic alliance with such patients. Probation is
an excellent vehicle for delivering services to mentally ill
23. offenders, and can exercise the authority of the court to monitor
adherence to medication and other court-ordered conditions of
release. Numerous studies indicate that coerced drug treatment,
using the leverage of the court and criminal justice systems,
increases enrollment and participation in recovery programs
(Lurigio, 2002). These findings also apply to coerced mental
health treatment. Involuntary treatment for mentally ill
offenders can dramatically increase their compliance with
medication, and significantly reduce the likelihood of
psychiatric and criminal recidivism (Bernstein & Seltzer, 2004;
Heilbrun & Griffin, 1998; Lamb et al., 1999). Probation
supervision “creates and maintains the boundaries and
structures that [will allow mentally ill offenders] to focus on
their recovery” (Massaro, 2003, p. 41). Finally, the rules
governing client confidentiality apply differently to patients
under the authority of the criminal justice system. For example,
clinicians who are treating probationers with mandated care are
obligated to report to the court on their patients’ attendance at
sessions, compliance with medications, and progress in therapy.
But they are also obligated to protect their patients’ limited
confidentiality rights. Thus, clinicians must balance their legal
responsibilities with the diligent protection of patients’ rights
and the conscientious fulfillment of their treatment needs. The
tension that arises between these roles reflects a fundamental
philosophical difference between the mental health and criminal
justice systems: the former is designed to treat, the latter to
punish. The case of Richard P., however, demonstrates that the
mental health and criminal justice systems can Lurigio, Fallon /
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Lurigio, PhD, a psychologist, is associate dean for faculty in the
College of Arts and Sciences and a professor of criminal justice
and psychology at Loyola University Chicago, where he
received tenure in 1993. He is also a member of the graduate
faculty and director of the Center for the Advancement of
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Thresholds Jail Project. He is now coordinating a Threshol
