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.
Building a Therapeutic Relationship Between Probation Officers and Probationers with Serious Mental Illnesses
Matthew W. Epperson, Leon Sawh, and Sophia P. Sarantakos
For the first time in nearly four decades, the incarcerated population in the United States has begun to level off and decline, suggesting that mass incarceration has reached a tipping point.1 Additionally, there is growing empirical evidence that incarceration does not meet its stated goals of increasing public safety and rehabilitating individuals; in most cases, incarceration does just the opposite.2 Incarceration is also not applied evenly, as people of color and people with behavioral health disorders are grossly over-represented in jails and prisons.3–5 In recent years, criminal justice systems across the country have begun to develop new decarceration policies and practices in attempts to reduce the overuse of incarceration.6 However, decarceration efforts will be most successful if they intentionally target and reverse disparities, an approach termed “smart decarceration.”7
This article presents a smart decarceration approach to addressing mental health disparities in the criminal justice system, with a particular focus on probation. First, we discuss the role of probation within the criminal justice system and the complex needs of probationers with serious mental illnesses (SMI). We then describe the multistage collaborative development of an intervention that focuses on building a therapeutic relationship between probation officers and probationers with SMI in order to better address their unique and complex needs. We present findings on intervention content as a result of a stakeholder-engaged process, as well as acceptability and feasibility findings through qualitative interviews and observations with probation officers and probationers with SMI.
There are nearly seven million people under the control of the U.S. criminal justice system and more than half of these individuals are on probation, making probation the largest segment of the criminal justice system.8 Probation entails a “community supervision” sentence, often in lieu of incarceration, with specific court-ordered conditions such as abstinence from substances, avoiding additional criminal activity, and engaging in rehabilitative supports. People on probation are at a critical juncture, either successfully completing the terms of probation and exiting the criminal justice system or violating the terms of their supervision and falling deeper into the system via incarceration.
For decades, a persistent over-representation of people with mental illnesses has been documented in the criminal justice system.4,5 As a result, probation departments across the United States supervise approximately half a million probationers with SMI, which includes schizophrenia spectrum, bipolar spectrum, and major depressive disorders.9 As highlighted in the Sequential Intercept Model,10 a framework that details opportunities for intervening with justice-involved persons with SMI, service provision is needed across continuous points of contact in the criminal justice system. Key tasks of those who work throughout the system include identifying justice-involved persons with SMI and providing them with linkages to mental health treatment, counseling, and psychiatric care, as well as other needed wraparound services such as family, housing, and employment supports. Despite probation being an optimal site for intervention, there is limited research that has fully developed the capacity of probation to meet the multifaceted legal and treatment needs of justice-involved persons with SMI.11,12
Addressing the complex needs of persons with SMI presents unique challenges to probation departments. When persons with SMI are sentenced to probation, the symptoms of their disorders often hinder the individual’s ability to successfully comply with the terms of their probation, further exacerbating the difficulties associated with successful community tenure.13 Compared with those without mental illnesses, probationers with SMI have a greater likelihood of violating their probation and are at higher risk of reincarceration.14 Probationers with SMI are also more likely to have a co-occurring substance use disorder than those without SMI,15 resulting in a greater need for integrated treatment services for both types of disorders.16 Meeting the treatment needs of probationers with SMI while simultaneously assessing and intervening on criminogenic risk factors have become tandem goals for probation departments.17,18
Due to the influx of individuals with SMI in probation departments, specialized mental health probation caseloads have grown considerably over the last 25 years. Consisting of probation officers who have been trained in supervising probationers with SMI, specialized mental health probation is one of the most prevalent criminal justice/mental health collaborative models, next to mental health courts, and has been designed to more effectively meet the needs of probationers with SMI. In specialized mental health probation units, probation officers are tasked with serving dual law enforcement and case management types of functions. For example, specialized probation officers receive mental health training, work to establish relationships with local mental health treatment and wraparound service providers, and utilize problem-solving approaches (e.g. case management, counseling techniques) to better link probationers with SMI to needed services.18
Research on the positive effects of specialized probation on reducing criminal justice involvement for probationers with SMI has grown in recent years. In a longitudinal study designed to test whether use of specialized mental health caseloads resulted in better public safety outcomes than standard probation programming, those probationers assigned to specialized probation were less likely to be rearrested for any crime than probationers in the standard group, with this effect lasting for up to five years after program enrollment.19 Another study found a greater decrease in jail days for people on specialized probation compared with probationers with SMI on standard probation, although there was also an increase in probation violations.20 In a study comparing specialized and standard probation approaches, specialized mental health probation officers were able to establish higher quality relationships with probationers, participate more directly in probationer treatment, utilize positive compliance strategies, and report fewer violations than the standard probation group.21 Most recently, Skeem et al. found that use of specialized mental health caseloads was more cost-effective than standard probation in supervising probationers with SMI due to savings associated with reduced recidivism and behavioral health care costs.22
A positive working relationship between professional and client is a key ingredient in effective delivery of human services.23 This working relationship is achieved through a shared understanding of goals, clear assignment of therapeutic tasks, and development of a bond between worker and client.24 Studies across a range of therapeutic services have identified essential therapist characteristics that positively influence the working relationship, including attributes such as warmth, empathy, and trustworthiness and techniques such as exploration, reflection, and conveying support.25 Thus, the therapeutic relationship (also referred to as working relationship or working alliance) is a strong predictor of clinical outcomes, particularly for people with mental health and substance use disorders.26
Growing evidence demonstrates that the importance of building a therapeutic relationship is also critical within criminal justice settings such as probation, and this is particularly true of programs that work with clients with SMI.27 Studies examining the effectiveness of specialized programming for justice-involved persons with SMI consistently agree that sole reliance on surveillance and punishment is ineffective at improving mental health and preventing further criminal justice involvement.28 Working with probationers with SMI complicates the work of the probation officer to include roles such as advocate, helper, and confidant, and conflict between these support-oriented and law enforcement roles can hamper the effective work of probation officers.29,30 In order to successfully navigate these roles, officers must build a positive therapeutic relationship with their clients in order to address sensitive issues such as mental health symptoms and specific treatment needs.31,32
Although limited in scope, several empirical studies have shown that a positive probation officer/client therapeutic relationship is related to several desired outcomes, including reduced substance use,33 response to treatment for spousal abuse,34 and reduced criminal recidivism, including lessened time spent in jail.35–37 Although most research on the therapeutic relationship in community supervision settings has been conducted with the general probation and/or parole population, some work has explored this relationship specifically among justice-involved persons with SMI, identifying key characteristics of a positive therapeutic relationship such as caring, fairness, trust, and support.23,28,29 Moreover, successful engagement of justice-involved persons with SMI is related to an increased sense of procedural justice (or fairness) and lower perceptions of coercion, both of which are indicators of higher participation in mental health treatment and criminal justice programming.40,41
In a study conducted by members of the study team,43 qualitative interviews with 21 probation officers were conducted to better understand how officers in a specialized mental health probation unit, mental health court, and standard probation program utilize different supervision approaches and balance the perceived dual roles of law enforcement and rehabilitation when working with SMI probationers. As part of the same study, researchers analyzed data from a sample of 98 probationers with SMI who completed the Dual-Role Relationship Inventory – Revised (DRI-R),35 as well as qualitative interviews in which probationers discussed their experiences with probation officers while on specialized and standard probation. The DRI-R was developed to assess the quality of relationships between justice-involved individuals and the professionals who supervise them, and the developers state that the instrument is best validated for probation and parole settings.35 After controlling for significant covariates, probationers in mental health court rated the quality of their relationships with their probation officers higher than probationers in specialized mental health probation or standard probation groups.23 However, officers who were assigned to supervise mental health caseloads were perceived by the probationers under their supervision as more caring, trustworthy, supportive, and less authoritarian than those probationers assigned to standard probation. The authors conclude that being treated with genuine care, fairness, and support is therapeutic and can be transformative for probationers with SMI. The challenge, however, is the operationalization of these ideas into regular day-to-day practices within probation programs.23 Some existing probation officer training programs address core correctional practices including limited content on relationship quality, but these approaches have not been adapted for probationers with SMI.44,45
Although these studies demonstrate that the quality of the relationship between officer and client is a critical ingredient in achieving better mental health and criminal justice outcomes, no evidence-based interventions have been developed to target this relationship among probationers with SMI. The purpose of this study was to engage in a collaborative process to develop a probation officer-led intervention that aims to enhance the therapeutic relationship between officers and probationers with SMI. We discuss a systematic process of engagement with a range of stakeholders to identify core intervention components, and assess their acceptability and feasibility in a real-world probation setting. Within this approach, the building of a therapeutic relationship is conceptualized as a foundational element on which additional intervention components can be delivered to facilitate service engagement and reduce criminal justice involvement for people with SMI on probation.