Planning for a new generation of interventions

In response to doubts about the effectiveness of current interventions and evidence of their limitations, researchers across several fields have proposed alternative models that take a more nuanced approach to thinking about the relationship between mental illness and crime.15 These new models are sensitive to social context and to the myriad factors that may overlap with mental illness, but are also closely linked to the characteristics of socially disadvantaged communities. They thus share the perspective of a social determinants model—a focus on the circumstances in which people are born, grow up, live, work, and age, that is more focused on inequality than illness in affecting health.16

Indeed, scholars proposing next-generation interventions consistently turn attention to the fact that effective interventions cannot be limited to mental health services if the strongest predictors of recidivism (such as homelessness and criminal history) appear in people with and without mental illness. For example, one proposal calls for designing interventions guided by a person-place framework that accounts for individual factors including mental illness, addictions, trauma, and established risks for criminal behavior, including such traits as antisocial personality, as well as environmental factors such as social and environmental disadvantage.17 This framework suggests that person (individual) and place (environment) risk factors interact to create stress that becomes a catalyst for criminal justice entanglement.18 A second alternative describes the link between mental illness and criminal justice as one of “moderated mediation,” in which the effect of mental illness on criminal behavior is indirect and mediated by more general criminal behavior risk factors such as antisocial history and “poorly structured leisure and recreation time.”19 People diagnosed with mental illness may have more of these risk factors than people without diagnoses, but general risk factors predict recidivism regardless of mental illness. 

Both of these proposed interventions suggest that the focus of evidencebased practices must be expanded beyond linkage with mental health treatment to target other risk factors including antisocial thinking, addiction, and stress. In “Envisioning the Next Generation of Behavioral Health and Criminal Justice Interventions,” the authors identified the Monroe County, New Yorkbased Project Link, and Changing Lives and Changing Outcomes, a holistic, manual-based treatment program for people with mental illness who are involved in the criminal justice system, as two interventions showing promise in targeting multiple issues.20 An evaluation of Project Link—which comprises a mobile treatment team including a psychiatrist and nurse practitioner; a dual diagnosis treatment residence; and a team of case advocates (who engage clients and link them to mental health, primary care, residential and social services in the community)—demonstrated significant reductions in arrests, number of incarcerations and hospitalizations, and days spent in jail or the hospital.21 A preliminary evaluation of Changing Lives and Changing Outcomes, which includes nine therapeutic modules, showed significant reductions in mental health symptoms and distress as well as modest reductions in reactive criminal thinking among a group of incarcerated men.22

The focus of evidence-based practices must be expanded beyond linkage with mental health treatment to target other risk factors including antisocial thinking, addiction, and stress.