Employment and Psychosocial Outcomes for
Offenders with Mental Illness.
Southern Illinois University
Koch, D. S.
Southern Illinois University
Southern Illinois University
University of North Texas
Sneed, Z., Koch, D. S., Estes, H., &
and Psychosocial Outcomes for
Offenders with Mental Illness.
Rehabilitation. 10 (2), 103-112 .
Mental illness, unemployment and continual involvement with the
criminal justice system, results in a lower quality of life for
offenders with mental illness. Prevalence rates of mental illness among
individuals involved with the criminal justice system are 2-5 times
higher than rates among the general population. Roughly 16% of
offenders in the United States’ prisons and jails have been diagnosed
with mental illness or reported a prior admission to a psychiatric
facility (Ditton, P., 1999). Mental health courts, similar to drug
courts, are specifically designed to divert or decriminalize offenders
with mental illness, by connecting them with appropriate community
services. Recently these courts have expanded in number and scope,
attempting to address diverse needs of offenders; however relatively
little data exists regarding the employment outcomes of mental health
court participants. The purpose of this paper is to provide employment
related data from the evaluation of a mental health court in the
Southwest United States.
Mental illness, Mental health court, Employment
Rates of mental illness among offenders are markedly higher than those
found among the general United States population (Lamb &
Weinberger, 1998). Approximately 16% or 283,000 offenders in the
nation’s institutional correctional systems have a mental illness or
reported a prior admission to a psychiatric facility (Ditton, 1999).
Furthermore, jails have been referred to as hospitals of last resort
for people with mental illness (Perez, Leifman, & Estrada, 2003).
Similarly, Ditton (1999) found that more than 40% of jail inmates
reported receiving some type of treatment for a mental illness.
Employment rates of people with mental illnesses are lower than for
other disability groups, and are disproportionate compared to the
current United States population (Corbière, Mercier, &
Lesage, 2004; Henry & Lucca, 2004; World Health Organization,
2000). Additionally, offenders with a mental illness face double
jeopardy. That is, not only do offenders with mental illness have the
stigma of a mental illness, there is the additional stigma associated
with an offender status. Furthermore, poor treatment while
incarcerated, and even less access to treatment and services
post-release contribute to high recidivism rates for offenders with
Employment and Mental Illness
Mental disorder or mental illness is defined in the DSM-IV, as “…a
clinically significant behavioral or psychological syndrome or pattern
…that is associated with present distress or disability or with a
significantly increased risk of suffering death, pain, disability or an
important loss of freedom,” (American Psychiatric Association, 1994, p.
xxi). In general, mental illnesses typically cause impairments in
activities of daily living, with regards to familial, educational,
social, and vocational responsibilities. Rates of mental illness in the
United States are hard to pinpoint, for a variety of reasons. The
definition of mental illness within the psychological, psychiatric, and
research communities has changed over the years with various
definitions used (Hong, 2002). Additionally, diagnostic criteria have
been modified, updated, and revised to reflect current research and
theories. One study, the Epidemiological Catchment Area Program in
1995, indicated that upwards of 28% of the current population in the
United States has a diagnosable mental illness (Reiger & Burke,
Stigma and stereotypes about mental illness present barriers to gaining
or maintaining employment for people with mental illness. Compared to
people with physical disabilities, people with mental illness
experience greater levels of discrimination, less access to services
and treatment, and higher rates of unemployment (Brodwin, Tellez, &
Brodwin, 2002; Henry & Lucca, 2004; Hong, 2002). People with mental
illness are often characterized as irrational, illogical, prone to
violent acts, and unreliable. All of these barriers combine to
contribute to poor employment and psychosocial outcomes for individuals
with mental illnesses.
There are a variety of other barriers to employment for people with
mental illnesses. Specifically, Henry and Lucca (2004) identified a
number of barriers to employment, through use of focus groups composed
of consumers with mental illnesses and service providers across a
variety of disciplines and human services. Disorder-specific symptoms
for which there were few or no options for accommodations interfere
with work. Also consumers’ fear of a work-induced relapse creates a
significant barrier. This barrier is so significant that individuals
may be reluctant to even attempt to work. Consumers also identified
limited skills, education, and work history as profound barriers. This
barrier can only be overcome through some type of education or
experiential training, which in turn may elevate a consumer’s fear of
returning to work. Also lowered work expectations, both on the part of
the employee and employer contribute to lower employment rates. All of
these barriers cause a Pygmalion effect, which serves to reinforce the
stereotype that individuals with mental illness cannot maintain
employment. Finally, financial disincentives and reliance upon
entitlement programs was identified as a significant barrier. That is,
a loss of healthcare benefits in return for engaging in employment.
Consumers reported that disincentives are so prevalent, coupled with
the complexity of entitlement systems, that even trying to gain or
maintain employment almost did not seem worthwhile (Henry & Lucca,
Regarding mental health and rehabilitation service delivery systems a
number of barriers to employment are also present for individuals with
mental illness. Specifically, poor communication among service
providers and conflicting expectations contribute to frustrating
consumers. Moreover, lowered expectations among mental health and
rehabilitation service providers were identified as factors related to
fewer options for employment (Henry & Lucca, 2004).
Consumers and service providers also reported that mental health and
rehabilitation service systems seemed to value therapy and medications
over work. This is an example of systems adhering more to the medical
model of disability, than the psychosocial model, which emphasizes
interactions with other people are considered important as are how the
consumer perceives interactions with others (Henderson & Bryan,
2004). Also stigma, negative attitudes and stereotypes and their impact
on the psychosocial status of the individual are considered as well.
All of these factors contribute to the psychosocial model being more
applicable to working with consumers who are diagnosed with a mental
Employment rates of individuals with mental illness are lower than for
other groups of people with disabilities. For people with mental
illness, employment rates vary from 10-20% (Corbière, Mercier,
& Lesage, 2004; Henry & Lucca, 2004; World Health Organization,
2000). Furthermore, high percentages of people with mental illness
report a desire to work and stress the importance of work in
establishing a good quality of life (Henry & Lucca, 2004; Jones,
2005; Scheid & Anderson, 1995). For offenders with mental illness,
employment outcomes are even worse, often due to the added stigma of
incarceration, lack of community resources to connect the individual
with work, and increased likelihood of reentry into the criminal
Offenders with Mental Illness
Among offenders, several mental illnesses occur more frequently than
others. Frequently present disorders among offenders include Axis I
disorders such as substance-related disorders, mood disorders, anxiety
disorders, and schizophrenia. Axis II diagnoses of mental retardation
and personality disorders are also more prevalent in this population
(Alexander, 2000). The high numbers of offenders with mental illness
have been ascribed to a combination of factors: the
deinstitutionalization movement, the homelessness epidemic of the
1980s, and the current War on Drugs (Lamberti, Weisman, Schwarzkopf,
Price, Ashton, & Trompeter, 2001; Lamb, Weinberger, & Gross,
1999; Munetz, Grande, & Chambers, 2001; Perez et al., 2003). These
factors have directly impacted people with mental illness and have
substantially increased the likelihood of interaction with the criminal
Screening, assessment, diagnosis, and treatment for mental illness in
the United States’ correctional facilities have been documented as less
than adequate (McLearen & Ryba, 2003; Applebaum, Hickey, &
Packer, 2001). Also it is important to note that confinement can
actually exacerbate psychiatric symptoms (Borum, 1999). Furthermore,
the lack of adequate community services post-release has been
identified as a predictor of exacerbation of the offender’s illness and
return to the criminal justice system (Harris & Koepsell, 1998;
Lovell, Gagliardi, & Peterson, 2002; Osher, Steadman, & Barr,
2003). Lamberti and Weisman (2004) identified that access to mental
health care was a primary concern for probation and parole officers who
worked with offenders with mental illness.
The bulk of offenders with mental illness currently incarcerated have
committed minor offenses (Ditton, 1999). This incarceration of minor
offenders with mental illness has been characterized as the
criminalization of the mentally ill (Lamb & Weinberger, 1998; Perez
et al., 2003). Relatively few offenders with mental illness require
confinement in a secure facility due to the severity of their disorder
or offense, nor do they pose a clear danger to themselves or society.
Complicating the issue of offenders with mental illness are the
disproportionately high rates of co-occurring substance use disorders.
Among offenders with mental illness, nearly 75% were also diagnosed
with a substance use disorder (Substance Abuse and Mental Health
Services Administration, 2002). In examining jail populations,
offenders with mental illness were more likely to be under the
influence of drugs or alcohol at the time of the current offense than
offenders without mental illness (Ditton, 1999).
Due to a lack of community-based programs and services, the majority of
offenders with mental illness have frequent contact with the criminal
justice system. This group of offenders poses the greatest challenge to
corrections and the criminal justice system. Offenders with mental
illness have higher rates of recidivism compared to offenders without
mental illness (Ditton, 1999; Lovell et al., 2002; Swartz, Swanson,
Hiday, Borum, Wagner, & Burns, 1998). Without specialized
supervision programs to link offenders with necessary services,
offenders with mental illness are at a greater risk for recurring
contact with the criminal justice system (Roskes & Feldman, 1999;
Lurigio, 2001). In addition, most jurisdictions do not have specialized
programs to supervise offenders with mental illness in the community
(Lurigio, Cho, Swartz, Johnson, Graf, & Pickup, 2003).
Mental Health Courts
A variety of circumstances have contributed to large numbers of persons
with mental illness in the criminal justice system. The impact of
handling increased numbers of arrests of people with mental illness has
fallen upon the court and jail systems. The impact on local jails and
prisons is overwhelming. Specific problems that have been identified in
providing services for offenders with mental illness include: few
resources, high turnover rates of inmates and staff, and inadequate
training of staff (Steadman & Veysey, 1997). Often if the offender
does receive treatment while incarcerated, those services are likely to
cease upon release from the institution (Lurigio, 2001). Mental health
courts were created to address the previously discussed issues by
establishing working relationships between the court and mental health
agencies (Goldkamp & Irons-Guynn, 2000).
Mental health courts were based on the drug court models with the first
mental health court established in Broward County Florida in 1997
(Goldkamp & Irons-Guynn). The early courts emphasized the
rehabilitation of offenders with mental illness by securing appropriate
services in the community (Goldkamp & Irons-Guynn). There are over
100 mental health courts currently in operation in the United States
(Steadman, Redlich, Griffin, Petrila, & Monahan, 2005).
The philosophy behind the mental health court is that the judge can
take an active role in the case, have open communication with the
offender and implement resources for therapeutic change (Goldkamp &
Irons-Guynn, 2000). Interaction with the judge and court personnel as
well as the judge taking on the new role by becoming a mechanism for
change can be viewed as tenets of the psychosocial model (Henderson
& Bryan, 2004). Furthermore, because of the interactive process,
the offender becomes a stakeholder, having an active part in the
process rather than being a passive recipient (Marinelli & Dell
Orto, 1999; Smart, 2001). Poythress, Petrila, McGaha, & Boothroyd
(2002) found that clients reported lower levels of coercion, perceived
the system as more fair, and were more satisfied with the mental health
court than a comparison group in a traditional court.
The court under evaluation has been in operation since October 2003,
and was created to expedite the identification and treatment of
individuals with mental illness within the local jurisdiction. Similar
to other mental health courts, this court emphasizes early
identification and screening of mental illness as well as the
importance of connecting the offender to local community mental health
and social service agencies.
Once referred to the court, offenders are explained the purpose
and the process of the court, and voluntarily enroll in the pre-trial
diversion program. Once enrolled, the offender aids in developing a
treatment plan, which may include services such as counseling, therapy,
medication access, referral to a variety of agencies and assistance in
obtaining housing. Offenders in the mental health court program meet
once a month with their assigned judge to review progress and
performance. If the offender achieves his/her program goals at the end
of an agreed upon period, the client graduates from the court and the
charges may be dismissed. The goals of the court include reducing
recidivism while maintaining community safety. Another goal is to
establish community linkages with mental health and social service
agencies to provide services for offenders with mental illness.
Extant data. To date, 94 offenders have entered the court with close to
40 completions as of Feb. 26, 2006. The data for this analysis was
gained by analyzing existing records of court participants, created and
collected by the probation officer and case manager of the mental
health court. Thus far these individuals have been collecting data on
demographic and mental health variables such as age, race, gender,
employment, criminal history, diagnosis, mental health services
provided, referrals to services, prior hospitalizations, medication
compliance, program violations and sanctions.
Demographics. In total 94 offenders with mental illness have entered
the court during this evaluation period. Over a third of offenders were
between the ages of 17-25 and nearly equal percentages, between the
ages of 26-35 (21.3%) and 36-45 (23.4%). Seventeen offenders were over
the age of 46 (18.1%). More than half of the offenders served by the
court were Caucasian (64.9%), 23.4% were African-American and just less
than 10% were Hispanic (9.6%). The court enrolled an equal percentage
of male and female offenders (50%).
Approximately half of the offenders lived with their parents (44.7%),
13.8% with other family members and 3.2% with a roommate. Less than
one-fifth (18.1%) lived with a spouse, 11.7% reported living with a
significant other and less than 5% lived alone (4.3%). Two offenders
lived in a supported living home and only 1 offender was homeless at
the time of intake. Nearly 63% of the offenders were single at the time
of intake, equal percentages were married or divorced (17% each), with
the remaining 3% reporting a status of widowed or separated.
Education. Surprisingly, 70% of the offenders in the mental health
court reported having attained a high school education, high school
equivalency or post-secondary degree. Of this group a third of the
offenders received a high school diploma and nearly 15% received their
GED. Ten offenders completed a post-secondary degree and 7.4% reported
some college or ‘other’ degree or certification. Nearly 30% had less
than a high school education.
Mental health characteristics. Thirty percent of the offenders had no
history of hospitalizations for mental health problems. Nearly 47%
reported being hospitalized 1-3 times and 13.8% reported 4-7 prior
hospitalizations. A smaller percentage of offenders, 7.4% had more than
seven mental health-related hospitalizations.
All of the offenders had a current psychiatric diagnosis. Less than
half of the offenders (41.5%) were diagnosed with only one
diagnosis, 36.2% reported two diagnoses and 11.7% had three psychiatric
diagnoses. Eight offenders or 8.5% had four mental health diagnoses and
two offenders had five diagnoses. Nearly a quarter of the offenders had
a diagnosis of Schizophrenia (23.4%). Mood disorders, such as Bipolar
Disorder and depressive disorders were the most prevalent among the
mental health court clients (80.9%). Fifteen offenders (16%) reported
an anxiety disorder, such as Generalized Anxiety Disorder and
Post-Traumatic Stress Disorder. Just over a quarter of the offenders
(25.5%) were diagnosed with learning or developmental disorders.
Examples of disorders present included Mental Retardation, Pervasive
Developmental Disorder and disorders typically diagnosed in childhood
such as Oppositional Defiant Disorder and Attention Deficit Disorder.
Nearly 20% (19.1%) of the offenders were diagnosed with a substance use
disorder, and 9.6% reported diagnoses of personality disorders.
While 19.1% had a reported substance use diagnosis, only 12.8% reported
current daily use of alcohol and 8.5% daily drug use. Nearly a quarter
of the offenders in the mental health court reported receiving
treatment for substance abuse or dependency in the past (22.3%). The
percentages do not total to 100%, because a majority of offenders were
diagnosed with multiple disorders.
Nearly 12% of the offenders in the mental health court reported no
current medication prescription. Roughly two-thirds of the group
(62.8%) had between 1 and 3 prescriptions. Just over 20% of the
offenders had between four and eight prescriptions, while four
offenders reported having more than 8 current prescriptions.
Participants in the mental health court had prescriptions for both
physical and mental health conditions. Of particular interest to the
court is the number of prescriptions for psychotropic medications.
Nearly 12% of the offenders in the court program had no prescription
for psychotropic medications, with 70.2% reporting between 1 and 3
psychotropic medications, and nearly 11% (10.6%) taking between four
and six psychotropic medications. One offender reported taking more
than 6 psychotropic medications.
At the twelve-month completion point, 27.5% of the court participants
reported no current prescriptions. Another 40% reported taking between
1 and 2 prescriptions. The participants were rated as compliant or
non-compliant with regards to their medication regimen, with 74.4%
being rated as compliant. The majority (86.8%) of court participants
reported no hospitalizations prior to the close of the program.
Mental health services. More than half of the participants (56.4%)
reported receiving no current mental health services when interviewed
for the intake. Conversely, the court appears to have made the biggest
impact in this area, as 61.5% of the offenders with mental illness
reported receiving services from the court at the twelve-month
assessment. Common types of services were mental health counseling,
psychiatric monitoring, individual counseling, and group counseling. Of
these services, 28% of participants received one service, and 25.6%
reported receiving two types of services, and 28% of participants
received more than 2 types of services.
Over four-fifths (81%) of the court participants receiving services
received individual counseling during the program. Approximately a
quarter received 11 or more hours of individual counseling and 19%
received 1-5 hours. Only 9.8% of the offenders attended
group-counseling sessions. More than half (54%) of the court
participants had one or two psychiatric appointments (11.9% and 42.9%
Employment. At the time of intake, nearly 75% of the offenders were
unemployed (74.5%). Twelve offenders (12.8%) reported they were
employed full-time. Another 8.5% reported working part-time. One
offender reported working less than 10 hours per week and 3 offenders
described their employment status as retired.
At the end of the twelve-month program, the majority of mental health
court participants reported no change in employment status (89.7%). One
individual reported gaining full-time employment and one individual
reported becoming unemployed. Regarding referrals to agencies for
employment related needs, the court provided a variety of information
packets and brochures to participants. Additionally the court used a
psychoeducational approach working with court participants to emphasize
the importance of accessing vocational rehabilitation, supported
employment or other agencies that focuses on employment related needs.
While 12 months is a relatively short period of time to expect vast
changes in employment among the court participants, the absence of
referrals for services that could potentially increase the probability
of finding and maintaining employment is problematic. The failure to
refer for vocational services may be due to the inability of the court
to offer formal case management services. Furthermore, court personnel
have noted the creation of informal collaborative practices among
agencies; however, the need to refine and formalize these connections
cannot be overemphasized.
Employment can be viewed as a key factor in improving the quality of
life of people with mental illness. Another factor that is important to
consider in improving the quality of life for people with mental
illness, is that a large number of individuals have a desire to work
(Drake, Becker, & Bond, 2003; Jones, 2005; Scheid & Anderson,
1995; Strong, 1998). Additionally, employment provides individuals with
a sense of purpose and accomplishment, helps delineate one’s identity,
and provides a variety of social situations and opportunities for
interaction with others (Henderson & Bryan, 2004).
Furthermore, some individuals believe that if an individual is able to
work, then they are obligated to do so, as part of being a good citizen
(Marrone & Golowka, 1999).
A variety of research has demonstrated that employment services for
people with mental illnesses must be specifically designed and
delivered for the individual, to maximize employment outcomes. Of
particular importance is the emergence of supported employment for
people with mental illnesses. Supported employment, which grew out of
vocational rehabilitation, is a program that has been modified over
time to work well with people with mental illness (Clark &
Samnaliev, 2005). This program is designed to increase a person’s
chances of successfully acquiring and maintaining a job in competitive
employment, rather than working in a sheltered workshop or remaining
unemployed (Henderson & Bryan, 2004). The program entails on-site
provision of services for the consumer. Thus far, a variety of
studies have concluded that supportive employment is effective at
improving competitive employment rates, hours worked per month, and
average earnings per month (Clark & Samnaliev, 2005; Shankar &
Collyer, 2002; Twamley, Jeste, & Lehman, 2003). Furthermore, the
supported employment approach involves a case-manager, also known as a
job coach. The job coach is the central person involved in this method,
which identifies appropriate jobs and assists in providing training
(Henderson & Bryan, 2004). In some instances the job coach or case
manager may work with individuals on a daily basis.
As evidenced by the results previously discussed from the mental health
court, 89.7% of the mental health court participants experienced no
change in employment status. This means that the 74.5% unemployment
rate of court participants stayed the same, as only 1 individual
reported gaining a job and another individual reporting becoming
unemployed. The court took efforts to provide the participants with
informational and educational materials designed to refer and prompt
court participants to seek out vocational services; however it appears
these measures were ineffective with this population. The unique
aspects of vocational rehabilitation services and more specifically
supported employment programs, designed for consumers with mental
illness, underscore the need for mental health courts to adopt a
case-management style approach. Offenders with mental illness often
encounter a variety of barriers to employment connected not only to
their mental illness, but also to their status as an offender. In
situations like this a case-manager can work with individuals to ensure
they are accessing services, following up on scheduled appointments,
and/or providing direct employment placements and training (Jones,
2005; Shankar & Collyer, 2002).
For offenders with mental illness, employment can be viewed as a
therapeutic agent. Often unemployment, homelessness, and poverty lead
to exacerbation of symptoms and an increased likelihood of reentry into
the criminal justice system (Harris & Koepsell, 1998; Lovell,
Osher, Steadman, & Barr, 2003). The mental health court was
successful at linking court participants with a variety of types of
services (counseling, individual and group therapy, psychiatric
monitoring); however it appears employment related community services
for offenders with mental illness requires a different approach. A more
formalized case-management approach may be necessary to improve
employment outcomes for offenders with mental illness.
Substantial research shows that people with mental illnesses are
unemployed at a disproportionate rate compared to the general
population. Additionally, the research shows that people diagnosed with
a mental illness have a strong desire to work, but are faced with a
variety of barriers. Offenders experience significant barriers to
employment as well. For offenders diagnosed with a mental illness, the
barriers to work are more problematic and rates of unemployment more
staggering. Mental health courts have developed over the last decade,
as a response to the disproportionate number of offenders with a mental
illness in the criminal justice system. The objectives of these courts
are to assist offenders by establishing linkages with community mental
health agencies, increase motivation to seek and attend treatment and
to provide an interactive process with the judge that can reduce
recidivism and facilitate change. The mental health court examined in
this study was able to increase participant access to a number of
community-based services; however, the employment rates of the
participating offenders did not change.
Employment is a key factor for improving psychosocial outcomes for
offenders with mental illness, as it improves socioeconomic status,
provides social interaction, helps provide a meaning or purpose for the
individual, and may be viewed as a therapeutic agent. More formalized
case-management techniques exist that may improve access to and
performance in employment services for offenders with mental illness.
Recent research indicates that supported employment may be the
best-suited type of employment services for this population. Future
research needs to address the unique challenges of evaluating mental
health courts as well as the role of employment in improving
psychosocial outcomes and reducing recidivism among offenders with
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