Reports reveal an increase in the number of individuals with serious mental illness in jails, prisons and forensic hospitals. Despite the wide-ranging and devastating consequences of this 'criminalization' of mental illness, there remains a lack of information on the subject as well as on the provision of care for these patients. This important new book fills a gap in the literature by examining topics such as: the history and policy factors related to criminalization; original research on forensic populations; pharmacological and psychological treatment strategies; and principles and guidelines for diversion out of the criminal justice system.
Criminogenic Risk and Mental Health: A Complicated Relationship
Robert D. Morgan, Faith Scanlon, and Stephanie A. Van Horn
The relationship between criminogenic risk and mental illness in justice-involved persons with mental illness (PMI) is complex and poorly understood. As previously noted,1 the general public is misinformed on the nature of this relationship, erroneously believing that mental illness causes violence and crime. This perception is compounded by news reports immediately speculating about mental illness in response to sensationalized criminal acts such as mass shootings, as well as in popular and social media. Of greater concern, however, is when clinicians, administrators, and policymakers are also misinformed. Criminal risk includes static (e.g. age, gender) and dynamic (e.g. antisocial attitudes, substance misuse) factors that place an individual at greater risk of involvement in crime. Criminogenic risk, on the other hand, refers to dynamic risk factors that directly contribute to criminal behavior and therefore need to be a focus of intervention (e.g. need to reduce antisocial attitudes, need to reduce substance misuse). Known criminogenic risk factors provide treatment targets for professional service providers and decision- and policymakers aiming to reduce crime.
Criminogenic risk is well understood in correctional settings and often guides the nature of rehabilitative services.2 Criminogenic risk is less understood in mental health circles, however, and even when working with justice-involved PMI, mental health professionals often remain uninformed on the necessity of including criminogenic risk factors in mental health treatments. In fact, mental health professionals working with incarcerated PMI have historically emphasized mental health recovery (e.g. reduce symptomatology, medication management) over, and at times to the exclusion of, criminogenic risk.3,4 This is particularly problematic given evidence that targeting criminogenic risk reduces criminal involvement, including for PMI (see5 for a thorough review). Notably, it is the first author’s experience that when consulting with mental health professionals in correctional and forensic settings, there remains a belief that PMI are involved in the criminal justice system due to lack of adequate mental health care, and that mental illness is the primary culprit when it comes to these individuals’ criminal behavior. However, research data clearly refute this position such that this naivety and lack of understanding of criminogenic risk is inexcusable.
Researchers have clearly demonstrated the link of criminal risk with criminal outcomes for PMI. In fact, a body of literature now supports the conclusion that mental illness is not the driving force behind PMI’s criminal justice involvement, but that criminogenic risk (dynamic risk factors commonly associated with criminal activity) is likely the primary cause of crime, similar to criminal justice populations that do not have mental illness (see for example6–8). In other words, it is now well understood that the relationship of mental illness to crime is weak and that other factors, including criminogenic factors, better account for crime.9 Most compelling in this line of investigation were the results of a meta-analysis showing that traditional criminogenic risk factors (e.g. antisocial attitudes, antisocial associates, substance misuse) were better predictors of criminal justice involvement (i.e. recidivism) than were traditional clinical (i.e. mental health) factors for justice-involved PMI.10 In fact, results demonstrated that the variables that best predicted recidivism for PMI were essentially the same as the variables that predicted recidivism for offenders without mental illness. Specifically, this body of research demonstrates that justice-involved PMI exhibit criminal risk factors similarly to nonmentally ill criminal justice populations across a variety of criminal justice settings and populations, including prison inmates,11–13 young jail inmates,14 forensic psychiatric patients15 and justice-involved PMI hospitalized in acute inpatient psychiatric units.15,16 Nevertheless, the traditional approach of targeting psychiatric stabilization remains the predominant service model used for justice-involved PMI17 without concomitant services targeting their criminal risk or criminalness. Thus, it is not surprising that traditional psychiatric services have had limited impact on criminal justice outcomes.18 To be effective, services for justice-involved PMI must address the co-occurring issues of mental illness and criminal risk.7,11,18
Although it is clear that criminogenic risk places PMI at risk for criminal justice involvement, we still do not know the nature of this criminogenic–mental illness relationship. Importantly, then, we also do not know how this relationship impacts treatment needs, and of ultimate concern, what this relationship means in terms of individual and societal outcomes. Bartholomew and Morgan1 proposed that “mental illness and criminalness feed each other in a continuous loop” (p. 5) as depicted in Figure 23.1. If Figure 23.1 accurately reflects the relationship between mental illness and criminalness, there would be a complex directionality such that mental illness and criminalness are independent (untreated mental illness results in increased psychiatric recidivism and untreated criminalness results in increased criminal recidivism), but also multidirectional such that untreated mental illness results in increased criminal risk, and vice versa. In this latter relationship, for example, a PMI experiencing decompensation in terms of mental health functioning (e.g. increased symptomatology) will experience reciprocal decompensation in their cognitive and behavioral controls that allow them to manage their criminal risk.
From the Risk-Need-Responsivity (RNR) model, the criminalness-mental illness relationship, as depicted in Figure 23.1, suggests that mental illness may be a responsivity factor for crime, but of equal importance is that criminalness may be a responsivity issue for mental health functioning. The nature of this relationship and the conceptualization of mental illness and criminalness as risk or responsivity factors will, in our opinion, guide the next wave of research. Such research will have practical implications beyond our understanding of this relation with the potential to significantly alter how we approach the issue of mental illness across the criminal justice landscape, and similarly, how we address criminal justice involvement across the mental health landscape. Even as we write this narrative discussing both criminal justice and mental health systems – structured as separate entities in the United States – we recognize that such research may help break the artificial silos that now exist, which put justice-involved PMI in a criminal justice or mental health system vacuum.