When persons with mental illness are released from prison, they encounter all the difficulties inherent in being an ex-offender, but these difficulties are exacerbated by mental illness. For instance, mentally ill people often experience extreme social isolation when residing in the community, and the majority are at risk for a co-occurring substance use disorder (1,2). Their potential to be a danger to themselves or others increases when noncompliance with treatment is coupled with social isolation and substance abuse (3).
An assertive community treatment model of continuing care with attention to the specific vulnerabilities of mentally ill persons seems essential for public safety and future correctional diversion (4,5). Without monitoring and support after release from incarceration, mentally ill offenders will continue to cycle through social service agencies, courts, jails, and prisons (6).
Massachusetts' county houses of correction and state prisons manage approximately 22,850 inmates annually. It is estimated that 5 percent to 20 percent suffer from schizophrenia, bipolar disorder, or another mental illness (7). These inmates are expected to reside in the community after release (8). However, securing a place to stay and employment, managing medications, entitlements, and money, and coping with the adjustment from prison to the open community is daunting for those with a major mental illness and a criminal history (9).
This paper describes a Massachusetts program to ease the transition to community living for individuals with mental illness released from correctional facilities. Data from the first year of program operation are examined.
In an attempt to ease community reintegration for mentally ill offenders completing prison sentences, the division of forensic services of the Massachusetts Department of Mental Health established the forensic transition program in 1998. The program is a statewide initiative that involves the collaboration of several state agencies to provide continuous services to inmates making the transition to community life.
The objectives of the forensic transition program are to coordinate services for clients of the Massachusetts Department of Mental Health during the transition from prison to the community; to maximize treatment outcomes for mentally ill offenders through early engagement, consistent support, and a well-monitored transition; to enhance community safety by collaborating with state and public safety agencies and community service providers; and to develop a demographic profile to identify the most needed and most appropriate services for mentally ill offenders.
Eight program staff across six regions of the state work with inmates identified as mentally ill. At least three months before release, staff members begin to coordinate relevant psychosocial and criminal information for the treatment planning process. To help alleviate immediate obstacles to community adjustment, staff members provide ongoing case coordination and consultation to community providers for up to three months after the client is released.
Although the services provided by the forensic transition program are interim and time limited, they are informed by the most recent innovations in social service collaboration, including jail diversion and assertive community treatment programs. Staff from the Massachusetts Department of Corrections identify appropriate inmates for the program and provide their approximate release dates to program staff, who are employees of the Massachusetts Department of Mental Health. Program staff are based in the community and do not have offices in the correctional facilities.
Once clients are identified, program staff conduct a review of their needs and seek appropriate community mental health resources. Essentially, client engagement begins while clients are still incarcerated and continues in the community. Clients are linked to intensive outpatient treatment programs that provide medication, rehabilitation, and proper supports, including entitlements, housing, family counseling, and employment opportunities (10).
The program collects data about the mentally ill offenders served and their functioning in the community after release from correctional facilities. Client data are captured at three time points. At baseline, or three months before release, the client is interviewed by a program staff member. About two weeks after release, the staff member interviews the client in the community. The time-limited services of the program end at three months after release, when the staff member and client complete a form with disposition and outcome information, if the client has not been lost to follow-up.
Program staff have access to clients' clinical and criminal records. The forms they complete are reviewed and coded, and the client information is entered into the program database. Client data are organized under four headings: demographic information, clinical information and current criminal charge, service information, and outcome information. This method of organization allows staff to generate client and service profiles and comparisons.
Although the three-month period during which clients receive program services is brief, it is a critical time during which clients' adjustment can serve as a basis for examining the success or failure of their community integration. Data for the program's first year of operation were analyzed to help program staff better understand how the interplay of demographic, clinical, and service variables contributes to successful community integration. Differences in client outcomes were examined to determine how they were related to clients' characteristics and service needs.
During the first year of the program 233 mentally ill offenders received services. The majority of clients were men (78 percent). Most clients were between the ages of 27 and 45 (65 percent). Approximately 60 percent of the offenders were white, 23 percent were black, 15 percent were Latino, and the remaining 2 percent were Native American. Nearly 30 percent of the clients reported that they would be homeless on release.
Clients' primary diagnoses included thought disorders (schizophrenia, schizoaffective disorder, or delusional disorder) for 124 clients, or 53 percent; mood disorders (major depression or bipolar disorder) for 84 clients, or 36 percent; and anxiety disorders (posttraumatic stress disorder or panic disorder) for 16 clients, or 7 percent. Nine clients had a primary diagnosis other than mental illness, including mental retardation and substance abuse. After the initial assessment, clients with mental retardation or substance abuse do not continue to receive services from the program.
Of the 233 mentally ill offenders who received services, more than half (124 offenders, or 53 percent) were serving time in county houses of correction for misdemeanors, with sentences of less than two and a half years. A smaller percentage (103 offenders, or 44 percent) were completing sentences at state correctional institutions for major felonies, including violent offenses such as assault, robbery, sexual assault, and murder. The remainder of the clients served by the program were in jail awaiting trial. Clients emerging from state correctional facilities received more extensive risk assessments. Their lengthier sentences allowed staff more time to plan and prepare for safe community re-entry.
As of April 1, 1999, a total of 74 clients had been discharged from the forensic transition program after completing the three-month monitoring period. At the time of discharge, 42 of the 74 clients (57 percent) were living in the community and engaged in mental health services. Fifteen clients (20 percent) were hospitalized immediately after release, seven (10 percent) were reincarcerated, two (3 percent) were hospitalized after a brief stay in the community, and eight (11 percent) were lost to follow-up.
As the forensic transition program develops, several barriers need to be addressed to improve services and enhance clients' functioning in the community. More coordination between correctional staff and program staff is needed so that program staff are informed of the specific dates and times that clients are to be released from correctional facilities. Treatment engagement strategies need to be improved for clients who have little interest in the services offered by the program. Some refuse treatment or are lost to follow-up. Procedures must be refined so that client confidentiality is safeguarded when information is shared across service systems.
It is anticipated that these operational obstacles will be overcome with further experience, continued communication, and the development of clear policy statements and procedural guidelines. Despite these obstacles, data from the first year of operation indicate that clients of the forensic transition program are receiving the services they need to re-enter the community.
The authors thank Deborah Scott, L.I.C.S.W., for comments and suggestions.
Dr. Hartwell is affiliated with the department of sociology and the criminal justice program of the University of Massachusetts Boston, 100 Morrissey Boulevard, Boston, Massachusetts 02125-3393 (e-mail, firstname.lastname@example.org). Ms. Orr is with the division of forensic services of the Massachusetts Department of Mental Health in Boston.