Mandated community treatment: beyond outpatient commitment.

Outpatient commitment, although often viewed as merely an extension of inpatient commitment, is only one of a growing array of legal tools used to mandate treatment adherence. The authors describe various forms of mandated community treatment. People with severe and chronic mental disorders often depend on goods and services provided by the social welfare system. Benefits disbursed by representative payees and the provision of subsidized housing have both been used as leverage to ensure treatment adherence. Many discharged patients are arrested for criminal offenses. Favorable disposition of their cases by a mental health court may be tied to participation in treatment. Under outpatient commitment statutes, judges can order committed patients to comply with prescribed treatment. Patients may attempt to maximize their control over treatment in the event of later deterioration by executing an advance directive. The ideological posturing that currently characterizes the field must be replaced by an evidence-based approach.

Assessing the New York City involuntary outpatient commitment pilot program.

OBJECTIVE: The study evaluated the effectiveness of a three-year outpatient commitment pilot program established in 1994 at Bellevue Hospital in New York City. METHODS: A total of 142 participants were randomly assigned; 78 received court-ordered treatment, which included enhanced services, and 64 received the enhanced-service package only. Between 57 and 68 percent of the subjects completed interviews at one, five, and 11 months after hospital discharge. Outcome measures included rehospitalization, arrest, quality of life, symptomatology, treatment noncompliance, and perceived level of coercion. RESULTS: On all major outcome measures, no statistically significant differences were found between the two groups. No subject was arrested for a violent crime. Eighteen percent of the court-ordered group and 16 percent of the control group were arrested at least once. The percentage rehospitalized during follow-up was about the same for both groups-51 percent and 42 percent, respectively. The groups did not differ significantly in the total number of days hospitalized during the follow-up period. Participants' perceptions of their quality of life and level of coercion were about the same. From the community service providers' perspective, patients in the two groups were similarly adherent to their required treatments. CONCLUSIONS: All results must be qualified by the fact that no pick-up order procedures for noncompliant subjects in the court-ordered group were implemented during the study, which compromised the differences between the conditions for the two groups, and that persons with a history of violence were excluded from the program.

A specialized crisis response site as a core element of police-based diversion programs.

Transporting an individual in psychiatric crisis to an emergency department is often frustrating for both law enforcement and mental health professionals. To facilitate collaboration between police and mental heath professionals in crisis cases, some communities have developed prebooking diversion programs that rely on specialized crisis response sites where police can drop off individuals in psychiatric crisis and return to their regular patrol duties. These programs identify detainees with mental disorders and work with diversion staff, community-based providers, and the courts to produce a mental health disposition in lieu of jail. This paper describes three of the diversion programs participating in the Substance Abuse and Mental Health Services Administration jail diversion knowledge development application initiative that demonstrate the importance of specialized crisis response sites. The three programs are in Memphis, Tennessee; Montgomery County, Pennsylvania; and Multnomah County, Oregon. The authors describe important principles in the operation of these programs: being a highly visible, single point of entry; having a no-refusal policy and streamlined intake for police cases; establishing legal foundations to detain certain individuals; ensuring innovative, intensive cross-training; and linking clients to community services.

Successful systems integration strategies: the access program for persons who are homeless and mentally ill.

In 1993, the Access to Community Care and Effective Services and Supports (ACCESS) federal demonstration program was initiated. Using a quasi-experimental design, the 5-year demonstration program sought to assess the impact of integrated systems of care on outcomes for homeless persons with mental illness. The authors report on which integration strategies were chosen and how their implementation is quantified. Data collected primarily through annual site visits revealed that only two strategies were used by all nine systems. The systems integration strategies employed remained relatively stable over the 5 years. Successful implementation appears to be related to the strategies selected.

From dangerousness to risk assessment of community violence: taking stock at the turn of the century.

This article focuses on a history of ideas-the history of the last quarter century, in which great advances have occurred in the reshaping of the concept of dangerousness while, at the same time, disappointingly little has happened to improve the abilities of frontline clinical decision-makers to make violence risk assessments. We are now operating in a fundamentally changed environment in the three core areas of research, clinical practice, and law as a result of evolving thinking and new data, shown in the following ways. (1) Risk assessment concepts and associated research models have altered the focus to probabilistic thinking and ideas of graduated interventions as opposed to the Yes-No, In-Out dichotomies formerly associated with the concept of dangerousness. (2) Likewise, it has become clear that dangerousness is a legal and not a medical concept, in which the actual clinical corollary is risk of future violent behavior. (3) The accuracy of psychiatric assessments of future violent behavior is limited, but it may increase for specific subgroups within specified time frames and locations.

Developing a clinically useful actuarial tool for assessing violence risk.

BACKGROUND: A new actuarial method for violence risk assessment--the Iterative Classification Tree (ICT)--has become available. It has a high degree of accuracy but can be time and resource intensive to administer. AIMS: To increase the clinical utility of the ICT method by restricting the risk factors used to generate the actuarial tool to those commonly available in hospital records or capable of being routinely assessed in clinical practice. METHOD: A total of 939 male and female civil psychiatric patients between 18 and 40 years old were assessed on 106 risk factors in the hospital and monitored for violence to others during the first 20 weeks after discharge. RESULTS: The ICT classified 72.6% of the sample as either low risk (less than half of the sample's base rate of violence) or high risk (more than twice the sample's base rate of violence). CONCLUSIONS: A clinically useful actuarial method exists to assist in violence risk assessment.

Comparing outcomes of major models of police responses to mental health emergencies.

OBJECTIVE: The study compared three models of police responses to incidents involving people thought to have mental illnesses to determine how often specialized professionals responded and how often they were able to resolve cases without arrest. METHODS: Three study sites representing distinct approaches to police handling of incidents involving persons with mental illness were examined-Birmingham, Alabama; and Knoxville and Memphis, Tennessee. At each site, records were examined for approximately 100 police dispatch calls for "emotionally disturbed persons" to examine the extent to which the specially trained professionals responded. To determine differences in case dispositions, records were also examined for 100 incidents at each site that involved a specialized response. RESULTS: Large differences were found across sites in the proportion of calls that resulted in a specialized response-28 percent for Birmingham, 40 percent for Knoxville, and 95 percent for Memphis. One reason for the differences was the availability in Memphis of a crisis drop-off center for persons with mental illness that had a no-refusal policy for police cases. All three programs had relatively low arrest rates when a specialized response was made, 13 percent for Birmingham, 5 percent for Knoxville, and 2 percent for Memphis. Birmingham's program was most likely to resolve an incident on the scene, whereas Knoxville's program predominantly referred individuals to mental health specialists. CONCLUSIONS: Our data strongly suggest that collaborations between the criminal justice system, the mental health system, and the advocacy community plus essential services reduce the inappropriate use of U.S. jails to house persons with acute symptoms of mental illness.

A classification tree approach to the development of actuarial violence risk assessment tools.

Since the 1970s, a wide body of research has suggested that the accuracy of clinical risk assessments of violence might be increased if clinicians used actuarial tools. Despite considerable progress in recent years in the development of such tools for violence risk assessment, they remain primarily research instruments, largely ignored in daily clinical practice. We argue that because most existing actuarial tools are based on a main effects regression approach, they do not adequately reflect the contingent nature of the clinical assessment processes. To enhance the use of actuarial violence risk assessment tools, we propose a classification tree rather than a main effects regression approach. In addition, we suggest that by employing two decision thresholds for identifying high- and low-risk cases--instead of the standard single threshold--the use of actuarial tools to make dichotomous risk classification decisions may be further enhanced. These claims are supported with empirical data from the MacArthur Violence Risk Assessment Study.

The impact of federal systems integration initiatives on services for mentally ill homeless persons.

Nearly everyone writing on homelessness over the past 15 years has called for comprehensive integrated systems of care to address the multiple and complex needs of people who become homeless, especially those with mental illness. What is often overlooked is that calls for systems integration are far from new. Although the names have changed over the years, the underlying concepts have not. The purposes of this paper are fourfold: (1) to clarify the distinction between services integration and systems integration; (2) to map the evolution of federal programs to demonstrate that most of these really have been focused on services integration rather than systems integration; (3) to assess the extent that data from these programs supports the idea of systems integration; and (4) to show how the current ACCESS demonstration for persons who are homeless and mentally ill is likely to provide answers that prior programs have not. Without these new data, systems integration, as one solution to the problems of homelessness, remains a theory without empirical evidence; albeit a theory with persuasive conceptual underpinnings.

A SAMHSA research initiative assessing the effectiveness of jail diversion programs for mentally ill persons.

For nearly 30 years jail diversion programs have had wide support as a way to prevent people with mental illnesses and substance use disorders from unnecessarily entering the criminal justice system by providing more appropriate community-based treatment. Although these programs have had wide support, very few systematic outcomes studies have examined their effectiveness. This paper discusses findings on rates of incarceration of persons with serious mental illness and co-occurring substance use disorders in U.S. jails, summarizes recently completed research on jail diversion programs, and describes a three-year research initiative begun in 1997 by the Substance Abuse and Mental Health Services Administration that uses a standardized protocol to examine the characteristics and outcomes of various types of jail diversion programs in nine sites throughout the U.S.

Emerging partnerships between mental health and law enforcement.

Police departments in the 194 U.S. cities with a population of 100,000 or more were surveyed in 1996 to identify strategies they used to obtain input from the mental health system about dealing with mentally ill persons. A total of 174 departments responded (90 percent). Ninety-six departments had no specialized response for dealing with mentally ill persons. Among the 78 departments with special programs, three basic strategies were found: a police-based specialized police response, a police-based specialized mental health response, and a mental-health-based specialized mental health response. At least two-thirds of all departments, even those with no specialized response program, rated themselves as moderately or very effective in dealing with mentally ill persons in crisis.

Comparing outcomes for diverted and nondiverted jail detainees with mental illnesses.

Jail diversion programs have been proposed for use with persons with mental illnesses. While much support exists for these programs in theory, little is known about their characteristics, the individuals they divert, or their effectiveness. The current study focuses on identifying the characteristics of persons diverted through a court-based program in one midwestern city and their outcomes during the first 2 months after diversion. Information on participants (n = 80) was gathered through detainee interviews, staff interviews, and record abstracts. Two factors appear to be important in diversion: (1) community risk and (2) availability of specialized programs for diverted offenders. Demographic, clinical, and social context variables appear to influence diversion decisions. Overall, the diverted and nondiverted groups did approximately the same upon release, but one third of the nondiverted group never got released during the follow-up.

Using the Referral Decision Scale to screen mentally ill jail detainees: validity and implementation issues.

The prevalence of serious mental illnesses in jail populations is significantly greater than in the general population. Identifying individuals who warrant psychiatric evaluations is important and benefits correctional staff as well as detainees. One widely used screening instrument intended for this task is the Referral Decision Scale (RDS). This paper reviews the development and validation of the RDS. Using data from a multisite study which assessed postrelease outcomes for detainees with mental illness, various types of validity are addressed. The results confirm that the RDS has some inherent characteristics that seriously limit its practical application as a screening instrument for use by correctional staff.

Violence by people discharged from acute psychiatric inpatient facilities and by others in the same neighborhoods.

BACKGROUND: The public perception that mental disorder is strongly associated with violence drives both legal policy (eg, civil commitment) and social practice (eg, stigma) toward people with mental disorders. This study describes and characterizes the prevalence of community violence in a sample of people discharged from acute psychiatric facilities at 3 sites. At one site, a comparison group of other residents in the same neighborhoods was also assessed. METHODS: We enrolled 1136 male and female patients with mental disorders between the ages of 18 and 40 years in a study that monitored violence to others every 10 weeks during their first year after discharge from the hospital. Patient self-reports were augmented by reports from collateral informants and by police and hospital records. The comparison group consisted of 519 people living in the neighborhoods in which the patients resided after hospital discharge. They were interviewed once about violence in the past 10 weeks. RESULTS: There was no significant difference between the prevalence of violence by patients without symptoms of substance abuse and the prevalence of violence by others living in the same neighborhoods who were also without symptoms of substance abuse. Substance abuse symptoms significantly raised the rate of violence in both the patient and the comparison groups, and a higher portion of patients than of others in their neighborhoods reported symptoms of substance abuse. Violence in both patient and comparison groups was most frequently targeted at family members and friends, and most often took place at home. CONCLUSIONS: "Discharged mental patients" do not form a homogeneous group in relation to violence in the community. The prevalence of community violence by people discharged from acute psychiatric facilities varies considerably according to diagnosis and, particularly, co-occurring substance abuse diagnosis or symptoms.

Police perspectives on responding to mentally ill people in crisis: perceptions of program effectiveness.

In this study, we sampled sworn police officers from three law enforcement agencies (n = 452), each of which had different system responses to mentally ill people in crisis. One department relies on field assistance from a mobile mental health crisis team, a second has a team of officers specially trained in crisis intervention and management of mentally ill people in crisis, and a third has a team of in-house social workers to assist in responding to calls. Calls involving mentally ill people in crisis appear to be frequent and are perceived by most of the officers to pose a significant problem for the department; however, most officers reported feeling well prepared to handle these calls. Generally, officers from the jurisdiction with a specialized team of officers rated their program as being highly effective in meeting the needs of mentally ill people in crisis, keeping mentally ill people out of jail, minimizing the amount of time officers spend on these calls, and maintaining community safety. Officers from departments relying on a mobile crisis unit (MCU) and on police-based social workers both rated their programs as being moderately effective on each of these dimensions except for minimizing officer time on these calls where the MCU had significantly lower ratings.

In search of the missing linkages: continuity of care in U.S. jails.

Persons with symptoms of acute mental illnesses present problems for jail management. Jails have a constitutional duty to provide psychiatric services to all persons in need of such care. However, mental health resources are frequently insufficient to meet the many needs of persons with mental illnesses in jails, and are often inaccessible to those released to the community. This study focuses on the experiences of a cohort of detainees (n = 379) with mental illnesses who have been incarcerated in seven U.S. jails. Data gathered include criminal and demographic characteristics, mental health services received by the detainees in jail, discharge planning activities by jail staff, and community-based outcomes after release. This is primarily a descriptive study depicting typical experiences and processes related to detainees with mental illnesses. The goal is to provide information to support more detailed studies on the effectiveness of mental health-criminal justice linkages.

Mental health clinicians' attitudes about reporting threats against the president.

OBJECTIVE: A recent review by the United States Secret Service of cases involving threats against the President indicated that about 50 percent of subjects had received mental health care. However, only 12 percent of referrals for investigation came from mental health professionals. This study explored reasons for this discrepancy by examining mental health clinicians' attitudes about reporting threats against the President to the Secret Service. METHODS: A questionnaire developed using findings from a series of focus groups was mailed to a stratified sample of 1,200 psychiatrists, psychologists, and social workers in four states. The instrument included questions about their experience with threats against the President, factors that influence reporting of threats, and knowledge about the Secret Service and its functions. RESULTS: A total of 592 questionnaires were returned, for a response rate of 49.3 percent. Therapists know very little about the Secret Service and are unclear about how to appropriately respond to threats against the President by their clients. The majority of respondents (89.9 percent) indicated they would report a threat against the President only if they thought the threat was "real," contingent on situational and patient variables and elements of the threat itself. Most of the respondents (62.4 percent) indicated that regardless of what information they considered clinically relevant to the investigation. CONCLUSIONS: Given the importance of clinical information for assessing risk to the President, the Secret Service should consider increased educational efforts to inform the mental health community about the functions and mission of the Secret Service and to clarify professional obligations to report threats against the President.

A national survey of hospital -and community-based approaches to pretrial mental health evaluations.

To document the scope of recent trends in performing pretrial mental health evaluations, telephone interviews were conducted with 157 authorities in 50 states and the District of Columbia. These authorities included forensic mental health program directors and forensic clinical professionals. In all states, evaluations were made on an outpatient basis to some extent, and 45 states used inpatient evaluations. However, only ten states relied primarily on inpatient pretrial evaluations, generally in facilities with statewide catchment areas. A total of 32 states relied primarily on outpatient evaluations, generally conducted by providers with regional or local catchment areas.

The diversion of mentally ill persons from jails to community-based services: a profile of programs.

OBJECTIVES: A major proposal for appropriately treating persons with mental illnesses who have been arrested is to divert them from jail to community-based mental health programs. However, there are few available definitions, guidelines, and principles for developing effective diversion programs. The goal of this research was to determine the number and kinds of jail diversion programs that exist, how they are set up, and which types of programs are effective. METHODS: On the basis of information gathered during a national mail survey (n = 1263) and follow-up telephone survey of 115 responding jails, 18 sites were selected for on-site interviews based on perceived effectiveness and presence of a formal diversion program. RESULTS: Data are presented from a national sample of jail diversion programs (n = 18). Key factors for developing diversion programs and descriptors of effective programs are presented. CONCLUSIONS: It is clear that controlled, longitudinal studies of these programs' effectiveness, using client-based and organizational outcome measures, are badly needed.