The International Journal of Psychosocial Rehabilitation

Employment and Psychosocial Outcomes for
Offenders with Mental Illness.

Sneed, Z.
Southern Illinois University

Koch, D. S.
Southern Illinois University

Estes, H.
Southern Illinois University

Quinn, J.
University of North Texas



<> Citation:
Sneed, Z., Koch, D. S., Estes, H., Quinn, J. (2006).Employment and Psychosocial Outcomes for
Offenders with Mental Illness.
   International Journal of Psychosocial Rehabilitation. 
10 (2), 103-112 .




Abstract
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.
Key Words:Offenders, Mental illness, Mental health court, Employment



Introduction
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 mental illness.

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, 1995).

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, 2004).

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 illness. 

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 justice system.

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 justice system.

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).

The Courts
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.

Method
Court Process
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.

Data collection
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.

Descriptive results
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% respectively).
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.

Discussion
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.

Conclusion
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 mental illness.
 

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