The plight of mental health and comorbid substance abuse treatment in the criminal justice system: A grounded theory study
vii Table of Contents Acknowledgments v List of Tables x List of Figures xi CHAPTER 1. INTRODUCTION 1 Background of the Problem 1 Statement of the Problem 8 Purpose of the Study 12 Significance of the Study 14 Research Design 21 Research Question 23 Assumptions and Limitations 24 Definition of Terms 25 Expected Findings 26 CHAPTER 2. LITERATURE REVIEW 28 Brief History of Deinstitutionalization 29 Role of Psychiatric Hospitals Today 30 Forensic Patients and the Criminal Justice System 32 Substance Dependence Defined 36 Comorbid Psychiatric Disorders 37 Mental Institutions of Last Resort 38 Alternatives to Incarceration 39 Diversions, Mental Health and Drug Court Programs 40
viii Reentry Risk Factors for Offenders With Mental Illness and/or Substance Disorders 42 Substance Treatment Models 45 Ethical Issues 54 CHAPTER 3. METHODOLOGY 57 Purpose of the Study 57 Research Design 57 Target Population and Participant Selection 59 Procedures 62 Instruments 62 Research Question 64 Data Analysis 65 Expected Findings 69 CHAPTER 4. DATA COLLECTION AND ANALYSIS 71 Introduction 71 Description of Participants 72 Research Methodology 72 Data Analysis 76 Story Line: Total Transformation of an Offender 100 Validation of the Scheme 112 Summary 113 CHAPTER 5. DISCUSSION, RECOMMENDATIONS, CONCLUSIONS 115 Introduction 115
ix Significance of the Study 116 Review of Methodology 118 Discussion of the Results 120 Significance of Findings and Relationship to Current Literature 124 Limitations of the Study 127 Recommendations for Future Research 129 Conclusion 132 REFERENCES 133 APPENDIX A. DATA ANALYSIS 145 APPENDIX B. MOCK QUALITATIVE RESEARCH INTERVIEW QUESTIONS 146 APPENDIX C. LINE-BY-LINE ANALYSIS 148
x List of Tables Table 1. Open Codes 81 Table 2. Categories Consequential of Axial Coding 88
xi List of Figures Figure 1. Four spheres that have an effect (Central category: Total transformation of an offender) 111
CHAPTER 1. INTRODUCTION
Background of the Problem A report released by the U S Department of Justice (2006) showed that the number of Americans with mental illnesses incarcerated in the nation’s prisons and jails is disproportionately high. The report asserts that mental health disorders affect over half of all inmates in local jails, state, and federal prisons. There are many reasons for the escalation; however, for most, incarceration results from a community’s lack of mental health treatment options or other appropriate resources (Cobb, 2006). Mental health treatment is defined as professional care (psychiatry, psychological, counseling, case management, and crisis intervention) provided to people with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV–TR, American Psychiatric Association, 2000) Axis I primary diagnosis. The U.S. Department of Justice (2006) pointed out that many of the offenders with mental illnesses have treatable disorders such as major depression, bipolar disorder, and substance use disorders. Nevertheless, the mission and policies of prison institutions alone are obstacles in providing quality health care to prisoners. Prisons are institutions where people who have been convicted of crimes are securely housed apart from the rest of society. The mission of prisons does not include the provision of quality health care (Cole, 2002). However, the United States has the highest adult incarceration rate among
2 developed countries with 2.2 million people currently in jails and prisons. Prisoners with mental disorders have been incarcerated at an increasing rate during the past 3 decades because of the deinstitutionalization of the state mental health system (Daniel, 2007). Consequently, many of the mentally ill who are poor and/or homeless are unable to obtain the treatment they need. The National Technical Assistance Center (2002) report detailed two reasons that substantially increase the probability of persons with mental illness coming into contact with the criminal justice system. One, without access to community-based mental health services, people with serious mental illnesses often have no other place to go. A subset of this population becomes homeless, medicates themselves with street drugs, and experiences crises in public settings, attracting the attention of law enforcement; two, the overall number of people in jails and prisons has increased with the advent of tough-on-crime policies. Stricter laws have resulted in the incarceration of a wider range of offenders. Moreover, a lack of appropriate services designed to reintegrate a person with serious mental illness into the community following release from jail or prison enhances the likelihood of coming into contact with the criminal justice system. Drapkin (2003) declared that large numbers of mentally ill people commit crimes and find themselves swept up into the burgeoning criminal justice system because they were ignored, neglected, and often unable to take care of their basic needs. Substance use and misuse also create more problems for prison officials. In the United States, use of illegal drugs and misuse of legal drugs is nothing new. However, the consequences of some forms of drug use have become more dangerous. Kim (2007) mentioned that the 10 most dangerous substances are heroin, cocaine, barbiturates, street methadone, alcohol, Ketamine, benzodiazepines, amphetamines,
3 tobacco, and buprenorphine. National concerns over spreading drug use brought about harsher punishment for drug offenses beginning in the mid-1970s. The presumption was that either the severity of punishment or the effect of incarceration would reduce both drug abuse and crime. A report by Sabol, Couture, and Harrison (as cited in Common Sense for Drug Policy, 2007) affirmed that 53% of drug offenders in federal prisons are serving time for possession, and Mumola and Karberg (as cited in Common Sense for Drug Policy, 2007) reported that 27.9% of drug offenders in state prisons are serving time for possession. This rapid increase in incarceration has introduced into the criminal justice system a large number of offenders who are addicted to drugs (Lo & Stephens, 2000). In essence, prisons have become the primary psychiatric hospital in the United States even though they are not equipped for this mission. The Substance Abuse and Mental Health Services Administration (SAMHSA, 2002) Drug and Alcohol Services Information System report elaborated on the numerous variations that may exist between federal, state and local correctional treatment and treatment settings. Approximately 94% of federal prisons provided substance abuse treatment, with close to 13,000 individuals receiving treatment in federal prisons on the date of this survey. About 56% of state prisons provided substance abuse treatment, with nearly 100,000 individuals receiving treatment in state prisons on the survey date. Some 33% of jails provided substance abuse treatment, with more than 34,000 individuals receiving treatment in jails on the survey date. The Drug and Alcohol Services Information System survey characterized treatment in three distinct settings. Almost all (94%) federal prisons that provided
4 substance abuse treatment provided treatment within the general population of the facility; 41% provided treatment in specialized units, and 6% offered treatment in hospital or psychiatric units. The majority (82%) of state prisons that provided substance abuse treatment provided it within the general population of the facility; 33% offered treatment in specialized treatment units, and 6% offered treatment in a hospital or psychiatric unit. About 79% of jails that provided substance abuse treatment offered treatment within the general population of the facility; 31% offered treatment in specialized treatment units, and 8% offered treatment in hospital or psychiatric units (SAMHSA, 2002). The American Psychiatric Association (2008) reported it is a national tragedy that jails and prisons have become, in effect, mental health care facilities in the United States. In 1970, there were fewer than 200,000 people in state and federal prisons in America. This number had remained remarkably stable during the preceding 7 decades of the 20th century. From the beginning of World War II through 1972, the combined state and federal incarceration rates for sentenced prisoners remained close to or below 100 per 100,000 people. However, in 1973, the nation’s inmate population began to increase and this trend continues to this day. By June 2005, the number of state and federal prisoners had increased more than sixfold to an estimated 1,512,823. An additional 747,230 inmates in local jails brought the number of people behind bars to 2,186,230 for a national incarceration rate of 738 per 100,000 people, the highest recorded rate in developed countries (M. C. Young, 2006).
5 Overview of Substance Problems in Correctional Facilities The U.S. Department of Health and Human Services (USDHHS, 2001) reported that a substantial majority of the nearly 2.2 million people who are now in prison or jail have used illegal drugs. Many of the prisoners have problems with alcohol as well as multiple other drugs. The report noted that 83% of state and 73% of federal prison inmates and 66% of jail inmates reported they had used drugs in the past. The answer to why offenders continue abusing drugs spans basic neurobiological, psychological, and environmental factors. The repeated use of addictive drugs eventually changes how the brain functions. Resulting brain changes, which accompany the transition from voluntary to compulsive drug use, affect the brain’s natural inhibition and reward centers, causing the addict to use drugs in spite of the adverse health, social, and legal consequences. Craving for drugs may be triggered by contact with people, places, and things associated with prior drug use as well as by stress. The USDHHS (2001) went on to affirm that forced abstinence without treatment does not cure addiction. Abstinent individuals including individuals who have been incarcerated and may have been abstinent for a long period of time must still learn how to avoid relapse. Potential risk factors for released offenders include pressures from peers and even family members to use drug and a return to criminal lifestyle. Tensions of daily life, violent associates, few opportunities for legitimate employment, lack of safe housing, even the need to comply with correctional supervision conditions can also create stressful situations that can precipitate a relapse to drug use (USDHHS, 2001). Research on how the brain is affected by drug abuse promises to help medical and mental health professionals learn much more about the mechanics of drug-induced brain
6 changes and their relationship to addiction. Research also reveals that with effective drug abuse treatment, individuals can overcome persistent drug effects and lead healthy, productive lives (Fletcher & Chandler, 2007). In addition to the significant number of substance use problems in correctional facilities, there is a tremendous number of mentally ill offenders in correctional facilities, too. Overview of Mental Health Problems in Correctional Facilities In a systematic review of 62 surveys of the incarcerated population from 12 Western countries, data showed that among the men, 13.7% had an Axis I mental disorder, and 65% had an Axis II personality disorder, including 47% with antisocial personality disorders (Daniel, 2007). In responses to this data, Daniel asserted that correctional institutions have become state hospitals. While the goal was not to make jails and prisons alternatives to state hospitals, there are more seriously and persistently mentally ill offenders in prisons than in all state hospitals in the United States. A recent study by the U.S. Department of Justice (2006) found that more than half of all prisons and jail inmates have a mental health disorder compared with 11% of the general population; yet only one in three prison inmates and one in six jail inmates receive any form of mental health treatment. When mental health hospitals across the country shut down during the last couple of decades as part of the process of deinstitutionalization, the community-based health services that were supposed to replace them were never adequately developed. Deinstitutionalization is defined as a long-term trend wherein fewer people reside as patients in mental hospitals, and fewer mental health treatments are delivered in public hospitals (National Institute of Mental Health, 2007). This trend is directly due to the process of closing public hospitals and the ensuing transfers of patients
7 to community-based mental health services in the latter 20th century. It represents the dissipation of patients over a wider variety of health care settings and geographic areas. Deinstitutionalization also illustrates evolution in the structure, practice, experiences, and purposes of mental health care in the United States (National Institute of Mental Health, 2007). Yet the ensuing developments adversely affected many of the mentally ill. The mentally ill most affected are poor and homeless who were unable to obtain the services needed to remain stable and ended up in the criminal justice system. Even though prisons and jails are not equipped for mental health services, they have become the country’s front-line mental health providers (Drapkin, 2003). Subsequently, there is a huge population of mentally ill offenders with co-occurring substance disorders within the criminal justice system in need of treatment services. Overview of the Dually Diagnosed Problems in Correctional Facilities Many of the people with mental illnesses and comorbid substance abusers are good candidates for alternatives to incarceration. Comorbidity is defined as a person who has been diagnosed with one or more substance-related disorders as well as one or more co-occurring mental disorders (USDHHS, 2008). Nevertheless, community mental health services are especially likely to fail to meet the needs of mentally ill persons with co- occurring disorders. SAMHSA (2004) has estimated that 72% of mentally ill individuals entering the jail system have a drug abuse or alcohol problem. Mental health programs are often reluctant to treat persons with substance abuse problems for many reasons; however, the most noticeable reasons are the fear that addicts will prove particularly disruptive and that addicts may try to bring drugs into the program. Moreover, many
8 mental health staff are not trained to diagnose or to treat a person with co-occurring disorders. Changes in sentencing legislation including mandatory sentencing and three-strike laws inadvertently contributed to the imprisonment of greater numbers of mentally ill and dually diagnosed substance disordered citizens. Therefore, public policy decisions have brought this dually diagnosed population, already bearing the double stigma of mental illness and substance abuse, into closer contact with the criminal justice system (Hartwell, 2004).
Statement of the Problem The National Center on Addiction and Substance Abuse at Columbia University (2010) indicated that access to substance abuse treatment is limited throughout the criminal justice system, and only 11% of inmates who need treatment receive it. Yet without an effective treatment protocol, drug and alcohol abusers and addicts as well as persons with co-occurring mental illnesses are likely to continue committing crimes after their release from prison. Treatment for the substance abuse alone is not enough, however. Most offenders who are drug and alcohol addicts and abusers also need medical care, psychiatric help, and literacy and job training. An effective treatment program should not only reduce offenders’ substance abuse but also enable them to meet family and financial responsibilities. Effective treatment should include offenders finding and keeping gainful employment and to become productive members of society (Falkin, Wexler, & Lipton, 1992).
9 Public health officials, practicing physicians, and society have long ignored prisoners’ physical, mental, and behavioral health. This oversight is a problem. The causes for a greater number of incarcerated mentally ill and co-occurring substance disordered offenders are many; however, corrections and mental health professionals point primarily to community mental health services that are supposed to provide services and the country’s punitive criminal justice policies as reasons for the condition of health care in prisons and jails (Human Rights Watch, 2003). In the state of Florida, a mental health professional is a person who is licensed under Sections 491.005(1)(c), (4)(c), and 491.0046(3) of the Florida Statutes. Psychotherapists are licensed under Chapter 491. Psychologists are licensed under Chapter 490. Psychiatrists are licensed under Chapter 458 or 459 who are certified by the American Board of Psychiatry and Neurology. Advanced registered nurse practitioners are certified under Section 464.012, Florida Statutes, and are certified by a board approved national certification organization pursuant to Rule 64B9-4.002 F.A.C. (Florida Department of Health, 2000). A report by the U.S. Department of Justice (2006) observed that more than half of the population incarcerated in U.S. prisons and jails has a mental illness, including 56% of state prisoners, 45% of federal prisoners, and 64% of local jail inmates. Many of these inmates suffer from treatable disorders such as major depression, bipolar disorder, and substance use disorder. Robinowitz, president of the American Psychiatric Association, reported that people with mental illness who are left untreated are at risk to develop symptoms and behaviors that lead to their arrest and incarceration (as cited in the American Psychiatric Association, 2008).
10 Mentally ill people with substance disorders (comorbidity, co-occurring disorders or dual-diagnosed) are among the fastest growing population within the criminal justice system in this country. The connection between drug abuse and crime is well-known. Drug abuse is implicated in at least three types of drug-related offenses: (a) offenses defined by drug possession or sales, (b) offenses directly related to drug abuse (e.g., stealing to get money for drugs), and (c) offenses related to a lifestyle that predisposes the drug abuser to engage in illegal activity (e.g., through association with other offenders or with illicit markets). Furthermore, untreated substance abuse adds significant cost to communities. The cost includes violent and property crimes, prison expenses, court and criminal costs, emergency room visits, child abuse and neglect, lost child support, foster care and welfare cost, reduced productivity, unemployment, and victimization. The cost to society because of drug abuse in 2002 was estimated at $181 billion, $107 billion of which was associated with drug-related crime (National Institute on Drug Abuse [NIDA], 2009a). Roskes and Feldman (1999) asserted that the needs of this population are grossly under addressed while they are incarcerated. Yet the plight of treatment goes beyond these agencies. However, in many states, department of correction systems have taken the lead in treatment programs for the mentally ill and substance dependent offender populations. One state program is Delaware Department of Correction’s Therapeutic Community Treatment Program. Drug abuse treatment can be incorporated into the criminal justice setting in a variety of ways. These incorporations include treatment as a condition of probation, drug courts that blend judicial monitoring and sanctions with treatment, treatment in prison followed by community-based treatment after discharge, and
11 treatment under parole or probation supervision (NIDA, 2009b). Outcomes for substance abusing individuals can be improved by cross-agency coordination and collaboration of criminal justice professionals, substance abuse treatment providers, and other social service agencies. By working together, the criminal justice and treatment system can optimize resources to benefit the health, safety, and well-being of individuals and the communities they serve (NIDA, 2009b). Massachusetts created a forensic transition program for mentally ill offenders that show promising outcomes. A study by Hartwell and Orr (1999) found that 74 clients had been discharged from the Massachusetts Forensic Transition Program after completing the 3-month monitoring period. At the time of discharge, 42 of the 74 clients were living in the community and engaged in mental health services, seven were hospitalized immediately after release, two were hospitalized after a brief stay in the community, and eight were lost to follow-up. Minnesota Department of Corrections (DOC) meets the needs of people with mental illness by creating programs such as using nonformulary medications on a trial basis and giving inmates access to general mental health services and chemical dependency treatment. Furthermore, access to prompt psychiatric care, integrated mental healthcare and primary care, and discharge planning that link mentally ill offenders to community mental health agencies are prominent features, too (Minnesota Psychiatric Society’s Correctional Psychiatry Caucus, 2006). A fact sheet completed by the Bureau of Research and Data Analysis on the Department’s Institutional and Community Substance Abuse Programs (as cited in Correctional Compass, 2003) reported that there was a reduction in recommitment rates to prison and community supervision for new offenses for offenders who complete
12 substance abuse treatment programs in Florida prisons. In the fiscal year 2001–2002, 15,363 offenders in Florida prisons participated in substance abuse treatment services, and within 2 years of initial program entry, nearly 65% of substance abuse treatment participants successfully completed the program. At 24 months after release from supervision, substance abuse program completers are recommitted to prison or supervision for a new offense at a rate 33.2% less than that of drug offenders who did not receive treatment (Correctional Compass, 2003). These examples show that DOC in some states has taken steps to enhance quality of life issues for this population of offenders. This study explored the conditions of mental health and substance treatment practices for a population of mentally ill offenders in the state of Florida with substance disorders using primary qualitative methods to ascertain the experience of these offenders.
Purpose of the Study This study explored the conditions of mental health and substance treatment practices for a population of mentally ill offenders in the state of Florida with substance disorders using primary qualitative methods to ascertain the experience of these offenders. This exploratory study is important to the field of psychology because it might give additional insight concerning mental health and substance dependent offenders’ treatment practices to the mental health professional communities as well as the communities in the state of Florida. The focus of this study addressed the dimensions of an effective program within Florida’s criminal justice system for offenders with mental health and substance disorders. Moreover, this study explored therapeutic community
13 (TC) mental health treatment providers/staff and administrator’s perceptions of dimensions of an effective program within the Florida criminal justice system for offenders with mental disorders and substance disorders. Correctional Compass (2003) reported that in the fiscal year 2001–2002, 31,980 offenders in Florida prisons participated in community-based substance abuse treatment services. Nearly 20% participated in residential programs, and more than 80% participated in outpatient programs. Within 2 years of initial program entry, 59% of the residential treatment program participants successfully completed treatment, and the outpatient program success rate was 61%. Prisons and jails are not equipped to provide the necessary mental health services this population needs; however, the correctional system has, in effect, become the provider of mental health services for this population of offenders. Robinowitz, president of the American Psychiatric Association, pointed out that it is a national tragedy that jails and prisons have become the primary mental health care facilities in the United States today (as cited in the American Psychiatric Association, 2008). Treatment protocols for substance use disorders and co-occurring mental disorders are limited for inmates throughout the criminal justice system, and without effective remedies, this population will likely continue to commit crimes once they are released from confinement (Center for Health Improvement, 2009). This study employed qualitative grounded theory design to ascertain what the TC treatment providers/staff and administrators perceive as the dimensions of an effective program in Florida’s criminal justice system for offenders with substance and mental health disorders.
14 Significance of the Study This exploratory study is important to the field of psychology because it may advance the knowledge base in the mental health professional community as well as the communities in Florida concerning mental health and substance dependent treatment practices for offenders. Furthermore, this study is significant to the mental health professional community and communities in Florida because it examined the perception TC treatment providers/staff and administrators had about dimensions of an effective program for offenders with mental health and substance disorders. It is well-documented that prisons and jails are not equipped to provide the necessary services this population of offenders needs; however, this institution is the de facto provider of mental health services for this population. A study by Lovell, Gagliardi, and Peterson (2002) found that despite the large numbers of mentally ill offenders in prisons, few studies of mentally ill offenders released from prison have been conducted. However, Feder’s (1991) study reported that 64% of mentally ill offenders were re-arrested within 18 months of release, compared with 60% of offenders without mental illness. The explosive growth of the incarceration of severely and persistently mentally ill and comorbid substance abusers mandate attention and innovative approaches to health care. A recent study by the U.S. Department of Justice (2006) found that more than half of all inmates have a mental health disorder, compared with 11% of the general population. Yet only one in three prison inmates and one in six jail inmates receive any form of mental health treatment (Daniel, 2007). The U.S. Department of Justice reported that at midyear 2005, more than half of all prison and jail inmates (1,264,300, or 56%) had a mental health disorder. The