Introduction

Nearly three times as many people detained in a jail have a serious mental illness (SMI) when compared to community samples.¹ Once an individual with SMI gets involved in the criminal justice system, they are more likely than the general population to stay in the system, face repeated incarcerations, and return to prison more quickly when compared to their nonmentally ill counterparts.² Confronted with this harsh reality, the inevitable question must be posed:

By the 1970s, the concept of “diversion” emerged in response to the increasing number of individuals with a mental illness who became incarcerated. Diversion models attempt to identify those detained individuals with an SMI who may be better served outside the justice system through linkage to community-based treatment.³ Although definitions of SMI may vary, the National Institute of Mental Health’s definition of SMI typifies many organizations’ definition and reads as follows:

Some states add specific diagnoses to the broader definition provided above. For example, the New York City jail system notes that jail inmates diagnosed with schizophrenia spectrum and other psychotic disorders, bipolar spectrum disorders, depressive disorders, and post-traumatic stress disorder all qualify for SMI.⁵

Ideally, a diversion program would identify all individuals with an SMI who may be eligible for their program. There are a range of different screening mechanisms utilized to identify individuals with mental illness who may be appropriate for diversion. Some jails have a screening questionnaire that includes only one question about the person’s mental health history, whereas other jails incorporate more extensive questionnaires that include observations by transporting officers, booking staff, and mental health staff. Many jails utilize empirically validated screening questionnaires, such as the Brief Jail Mental Health Screen (BJMHS).⁶ The BJMHS is completed by booking officers and includes eight “yes/no” questions about the person’s mental health history and symptoms.⁷ Because there are concerns that the BJMHS does not sufficiently identify SMI in women, Kessler et al. recommend the use of the mental health screening instrument known as the Kessler Psychological Distress Scale (K6). The K6 includes six broad screening questions that ask the individual to rate the severity of their symptoms over the past month. The questions ask if the person has been: (1) nervous; (2) hopeless; (3) restless or fidgety; (4) so depressed that nothing can cheer you up; (5) everything was an effort; and (6) feeling worthless.^8,9 In their study examining the use of the K6 in a jail setting, Bronson and Berzofksy determined that 26% of jail inmates met current criteria for a mental health problem.¹⁰

In a subsequent study examining screening procedures in New York Jail, Kubiak et al. found that 20% of inmates scored positive for mental health problems on the K6 with an additional 16% identified through staff identification. These findings indicate that best practices for screening likely include both a structured questionnaire combined with identification of those with a likely SMI by jail staff.⁶ Once an individual with an SMI is identified, their appropriateness in a community diversion treatment program can be considered.

Diversion programs have a goal of decreasing criminal recidivism. Therefore, understanding why individuals with SMI become involved with criminal justice is critical to the success of diversion interventions. Two key theories have evolved to help explain the relationship of individuals with SMI to criminal offending. The first theory is known as the “criminalization of the mentally ill” hypothesis. According to this hypothesis, several factors increase the risk that individuals with SMI will be involved in the criminal justice system. These factors include stricter involuntary commitment laws with fewer psychiatric patients receiving inpatient care, poorly funded community mental health treatment services with undertreatment of mental illness, and the discharge of large numbers of psychiatric patients from psychiatric hospitals into the community with limited treatment resources.¹¹ Based on this “criminalization of the mentally ill” theory, untreated mental illness is the primary explanation as to why those with SMI are involved in the criminal justice system.

Under this hypothesis, enhanced mental health programs were developed and included diversion programs, mental health courts, forensic assertive community treatment (FACT) teams, and re-entry programs. These approaches have been called “first-generation” criminal justice interventions.¹² If a causal relationship between the lack of mental health treatment and criminal involvement by those with SMI exists, then programs primarily focused on treating mental illness would be expected to have fewer criminal arrests from persons enrolled in their program. Despite these first-generation diversion programs assisting in the treatment of individuals with SMI, the evidence does not indicate that these programs have had a lasting impact on decreasing criminal recidivism. Likewise, research evidence does not indicate that dual-diagnosis treatment programs for this population have resulted in a decrease in involvement in the criminal justice system.¹¹

One noted concern is that the “criminalization of the mentally ill hypothesis” does not adequately explain or address nonclinical factors that result in individuals with mental illness becoming involved in the criminal justice system.¹¹ In fact, only 10–20% of criminal behavior committed by individuals with mental illness symptoms has been attributed to mental illness symptoms.^13,14

Clearly mental health and substance use treatment is an important component of any diversion program for individuals with a SMI. However, to further reduce criminal recidivism, is there another perspective that should be considered? The answer to this question is a strong “yes.” More recently, research has emerged emphasizing the importance of risk factors for criminal justice involvement that play a primary role for individuals both with and without a SMI. This approach is known as the “criminogenic risk perspective.”¹¹ Andrews and Bonta proposed a model known as the Risk–Need–Responsivity (RNR) model and this model has served as an important foundation for the criminogenic risk perspective. Under the RNR rehabilitation model, treatment interventions address each person’s identified risks, their dynamic treatment needs, and their responsivity to treatment.¹⁵ Eight criminogenic risk factors have been identified under the RNR model and are listed in Table 16.1.

The first four criminogenic risk factors listed in Table 16.1 are known as the “Big Four” as they have demonstrated the strongest relationship to future criminal offending.¹⁵ These criminogenic risk factors are relevant to individuals with and without a SMI. The remaining four risk factors have a moderate, though less robust, association with criminal justice involvement. To further improve outcomes for individuals enrolled in diversion programs, addressing criminogenic needs in addition to utilization of evidence-based treatments for both mental illness and substance use are more likely to be effective than standard community mental health treatment alone. This combined intervention approach represents a “second generation” of services and is relevant for delivery of care at all stages of a person’s involvement with the criminal justice system.¹¹

An important component to assist in diverting individuals with SMI away from the criminal justice system is identifying various stages where alternative programs can be introduced to either prevent involvement in the criminal justice system or provide programming to keep persons with SMI from returning to jail or prison. One recognized model in identifying such intercepts is known as the Sequential Intercept Model (SIM).¹⁶

The SIM covers six different intercepts, numbered 0–5, each of which identifies an alternative solution or strategy that can be offered to divert someone with mental illness out of the criminal justice system.

Figure 16.1

The Sequential Intercept Model.

The basic assumption of the SIM is that criminalization of the mentally ill can be curtailed by recognizing points of interception “at which intervention can be made to prevent individuals from entering or penetrating deeper into the criminal justice system.”¹⁶ Early identification of psychiatric disorders allows individuals to be diverted into appropriate community care where symptoms can be treated and behaviors that invite criminal justice involvement can be reduced.

This continuum includes programs such as Crisis Intervention Training (CIT) to help police officers communicate and interact with individuals with mental illness (Intercept 1) to improved parole/probation contacts for individuals with mental illness (Intercept 5). Empirical studies of the interventions across the six intercepts demonstrate varying levels of effectiveness, with some community-based alternative services showing strong support, such as FACT teams, while others require further evaluation.

The SIM can also help guide policy development by providing a framework for stakeholders to understand what gaps exist in their provision of services and programs for individuals with mental illness and criminal justice involvement. Communities are encouraged to review local SIMs with pertinent stakeholders, including but not limited to county behavioral health departments, district attorneys, public defenders, judicial representatives, probation, and local law enforcement. These stakeholders could utilize the SIM to assess and identify where improvements can be made in service provision to increase the likelihood of positive change with criminal justice-involved persons with mental illness.

This article summarizes 10 key aspects of suggested treatment goals and interventions for diversion programs that can be incorporated throughout the SIM stages to maximize treatment of diverted individuals and minimize their risk for future involvement in the criminal justice system. These treatment goals and the methods to achieve them are summarized in Table 16.2.