Clinical Implications of Working With Patients on Parole or Probation

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“Hi, Doc! My parole officer says I need to see you.”

This is a sentence many of us may be hearing. Patients on parole or probation present us with many challenges and many opportunities to make a real difference in their lives.

For a host of reasons we all know well, individuals with mental illness may become involved in the justice system. Sometimes, following a call to the police, they may be diverted to a local emergency department or to mobile psychiatric services. All too often, though, they are arrested, arraigned, and incarcerated (see the Table for definitions of terms used in community supervision). The incarceration might stem from an underlying lack of community resources, a lack of adherence to treatment, or substance abuse issues. The overwhelming majority of individuals are then released back to the community, whether early through an Alternative to Incarceration program, Mental Health Court, or similar initiative, or later on to community supervision through parole or through probation.

A look at the numbers

By the end of 2011, more than 2 million American adults were in jail or prison, and close to 5 million American adults were on probation or parole.^1,2 National data indicate that 29% to 33% of this population had a diagnosable mental illness and 7% to 8% (at least 337,000 people) had a serious mental illness and were in need of treatment; roughly a quarter received no mental health treatment.³ To add to the challenge, substance abuse among this population is nearly pandemic-findings suggest that 69% of mentally ill offenders released into the community have comorbid substance abuse disorders.⁴ And, only 61% of offenders accessed substance abuse treatment within 24 months of release.

While women make up only about 10% of the incarcerated population, they make up 25% of those on community supervision.² Similar to men in this population, 75% women with serious mental illness (primarily bipolar disorder) released to parole or probation have a co-occurring substance abuse disorder.⁵ The good news is that parole or probation can make a difference: the majority of those who accessed care were under parole or probation supervision that mandated such treatment.

What new information does this article provide?

Many patients who have a serious mental illness become entangled with the justice system. They often have complex comorbid psychiatric and substance abuse disorders. Recidivism is high-more than 3 of every 4 persons with serious mental illness released from prison are reincarcerated.

What are the implications for psychiatric practice?

Extending our notions of interdisciplinary teams to include parole and probation officers provides options in support of our patients that are not typically available to sole providers. By engaging patients involved in the criminal justice system in an effective, coordinated, therapeutic alliance, and supporting the process of meaningful recovery, we can make a real difference in the future of these individuals.

The story, of course, is more complex: when parole supervision ends, the risk of recidivism increases. Once released from state prison, 78% of people with mental illness are reincarcerated during their lifetime.⁶ Cloyes and colleagues⁷ looked at people released from prison from 1998 to 2002 (N = 9245); a quarter met criteria for serious mental illness (n = 2112). Controlling for variables, the median time for persons with serious mental illness to be reincarcerated was just over 1 year (385 days) versus about 2 years (743 days) for those without serious mental illness (P < .001).

Most reincarcerations of persons on parole or probation are for technical violations. These are frequently behaviors that are not illegal for those not under judicial supervision. Depending on the stipulations, these violations may include drinking alcohol or being too close to a school or playground.

Inadequate or inappropriate care

The most obvious consequence of inadequate or inappropriate care can be community reintegration failure and recidivism. Patient motivation is inevitably a critical key to success, as is the perception by the patient of the value to them of the interventions (ie, patient-centered care). In one study, those who perceived medications to be less helpful and those who were less motivated for treatment were more likely to be reincarcerated.⁸

This is also true for more intensive interventions, such as Assertive Community Treatment (ACT): one early study randomized individuals with serious mental illness released from jail to individual case management or to ACT teams.⁹ A year post-release, ACT team patients were more likely to be reincarcerated than those given individual treatment.

This is not surprising because the goal of ACT is to reduce hospitalization rather than reincarceration. ACT patients with forensic histories were found to be at higher risk for adverse outcomes than persons without such a history.¹⁰ To address these challenges, and with modest evidence of benefit, forensically modified ACT (FACT) teams have been developed. While the structure and design of these teams vary, in general they include only patients with serious mental illness involved in the criminal justice system, accept referrals from criminal justice agencies, and include supervised residential placement.

Although persons with serious mental illness respond favorably to specialized interventions emphasizing treatment and recovery, there are caveats. Treatment is expensive: small case size and individual attention are essential. One study tracked inpatient, outpatient, and jail costs for groups randomized to FACT teams or to individual case management. Over a 12-month period, the cost was $20,859 for each patient in the FACT team group compared with $17,475 for patients who received individual case management. These increased costs were associated with fewer jail bookings, increased outpatient contact, and reduced inpatient days.¹¹

Patient perception and motivation are also important; treatment engagement and a patient-centered approach produce better outcomes. Finally, those with comorbid disorders of mental illness and substance abuse require extra effort to engage and integrated care.

The challenges facedby patients

The basic challenges include what one might expect in working with a population coping with serious mental illness: lack of employment, limited or absent social and/or family network, poor access to care, and a struggle to define personal goals that are socially adaptive and recovery-oriented. The single biggest concern is housing: homelessness has been linked to elevated risk of reincarceration for the mentally ill.¹²

The stigma that people with serious mental illness face is substantial. Add to that the stigma of being on community supervision and (all too likely) substance-addicted. These can be significant, if not overwhelming, burdens with which our patients must cope. The stipulations for persons on parole or probation include scheduled and unscheduled visits to their parole or probation officer.

Some of our patients are lucky enough to be on the caseload of specialized mental health parole/probation teams that are experienced with the need for engagement and outreach. The majority, however, must negotiate the demands of a complex bureaucracy, schedules, and travel; as we know, these are frequently challenges not easily met by those with serious mental illness. Lack of compliance with these demands often leads to a violation of parole or probation, with the result being reincarceration.

What we can do

Clinically, there are 2 issues and 1 process that deserve our attention: impulsivity, co-occurring substance abuse, and therapeutic engagement. In their study of 220 parolees, half of whom had a serious mental illness, Peterson and colleagues¹³ found that while a small percentage of crimes were directly associated with untreated psychosis, the majority (90%) were associated with reactive behaviors (eg, disinhibition, impulsivity, emotional instability). This suggests that while treating psychosis is important, treating affective lability and impulsivity is “where the money is.”

While it might be useful to provide simple pharmacotherapy for impulsivity, currently there is no FDA-approved medication for this.The medications now in use rarely address the concerns fully and adequately. Consistent with a growing body of literature about treating impulsivity, integrating skills-based cognitive-behavioral therapy (CBT) with pharmacotherapy may yield far better results than pharmacotherapy alone.^14,15

CASE VIGNETTE

Ms Watson, a 21-year-old with PTSD, MDD, and heroin addiction, is on a year of probation for possessing and selling illicit drugs. She is currently taking an antidepressant, an anxiolytic, and an opioid partial agonist. She has one child, whose custody has been transferred to the child’s grandmother. Her goal is to have custody of her child returned to her.

Her CBT focuses on skills acquisition and practice for effective emotion regulation and impulse management. In further support, a psychiatrist is working with her to wean her off of the anxiolytic and, given her frequent previous relapses, with her probation officer to get her into a residential drug treatment program.

Comorbid addictive behaviors are highly associated with criminal behavior in persons with serious mental illness. Getting patients into addiction therapy, and keeping them in treatment, is a key element for success. Treatment failure and relapse, as we have come to learn, is common and part of the recovery process: so, don’t give up.

Perhaps the most important element is treatment engagement. While still in training, we were taught that finding ways to engage our patients is key to successful therapy, and it is one of the few things that has not changed. In addition to the traditional approaches to building a therapeutic relationship, motivational interviewing is particularly valuable.¹⁶ Going beyond substance abuse, integrating primary care for those with serious mental illness may also contribute to successful community reintegration.¹⁷

A unique challenge with this population as well as a substantial resource (if used correctly) is the fact that these patients are under community supervision and there are stipulations they must adhere to. This coercive element can be either detrimental or advantageous to the successful community reintegration of patients. Many of us have been faced with the following question: Are my patient’s symptoms due purely to a psychiatric condition or are they due solely or in part to substance abuse? Most people on community supervision have mandatory random drug testing. This information can help sort out mania from a cocaine high, depression from alcohol addiction, and acute psychosis from bath salts intoxication.

Collaboration with the parole or probation team can also be leveraged to gain access to information and services that would generally not be easily available to a sole practitioner. The imprimatur of court-ordered care or of forensic involvement, sadly, may open doors that might otherwise remain closed to our patients. Assistance with entitlements, appropriate permanent housing, meaningful work, family reunification efforts, and expedited access to optimal addiction treatment are significant benefits of this clinical/forensic collaboration, providing recoveryoriented options that reduce the risk of recurring survival-oriented illicit behaviors.

Summary

Many patients with serious mental illness become entangled with the justice system. Extending our notions of interdisciplinary teams to include parole and probation officers provides us with options and opportunities not typically available otherwise in support of our patients. By engaging our patients in an effective, coordinated therapeutic alliance and supporting the process of meaningful recovery, we can make a real difference in the future of these persons.

Disclosures:

Dr Trestman is Professor of Medicine, Psychiatry, and Nursing; Executive Director of Correctional Managed Health Care; and Interim Division Chief of Occupational and Environmental Medicine at the University of Connecticut Health Center in Farmington. He reports no conflicts of interest concerning the subject matter of this article.

References:

1. Glaze LE, Parks E. Correctional populations in the United States, 2011. November 2012. http://www.bjs.gov/content/pub/pdf/cpus11.pdf. Accessed July 9, 2013.

2. Maruschak LM, Parks E. Probation and parole in the United States, 2011. November 2012. http://www.bjs.gov/index.cfm?ty=pbdetail&iid=4538. Accessed July 9, 2013.

3. Feucht TE, Gfroerer J. Mental and substance use disorders among adult men on probation or parole: some success against a persistent challenge. 2011. http://www.samhsa.gov/data/2k11/MentalDisorders/MentalDisorders.htm. Accessed July 9, 2013.

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15. Shelton D, Sampl S, Kesten KL, et al. Treatment of impulsive aggression in correctional settings. Behav Sci Law. 2009;27:787-800.

16. Barrowclough C, Haddock G, Tarrier N, et al. Randomized controlled trial of motivational interviewing, cognitive behavior therapy, and family intervention for patients with comorbid schizophrenia and substance use disorders. Am J Psychiatry. 2001;158:1706-1713.

17. Held ML, Brown CA, Frost LE, et al. Integrated primary and behavioral health care in patient-centered medical homes for jail releases with mental illness. Crim Just Behav. 2012;39: 533-551.