The Sequential Intercept Model and Criminal Justice: Promoting Community Alternatives For Individuals With Serious Mental Illness

The Sequential Intercept Model and Criminal Justice: Promoting Community Alternatives For Individuals With Serious Mental Illness

Editors: Patricia A. Griffin, Kirk Heilbrun, Edward P. Mulvey, David DeMatteo, and Carol A. Schubert
Publisher: Oxford, UK; New York: Oxford University Press, 2015. 320p.
Reviewer: Colleen Clark | January 2016

The number of people with serious mental illnesses who have been incarcerated has increased dramatically in past decades. At one point, the Los Angeles County jail was deemed the nation’s largest psychiatric ward. The Sequential Intercept Model (SIM) was developed as a framework for understanding how vulnerable populations, especially people with mental illnesses, interact with the criminal justice system. People with serious mental illnesses were also more likely than the general population to be recidivist to the system.  The SIM model presents the interaction of the criminal justice system and those with psychiatric problems as a series of points where interventions can be made to prevent a person from entering the justice system or becoming further entangled. Points of diversion or intercepts include (1) law enforcement/emergency services, (2) booking, initial detention and hearings, (3) jails/courts, (4) reentry from jails and prisons, and (5) community corrections/probation/parole.

This book is a welcome addition to the literature. Despite widespread dissemination by the GAINS Center (Center for Behavioral Health and Justice Transformation) and prevalent use of the model, very little has been published about it in the academic literature. A first view of the chapter headings and multiple authors and editors was daunting due to its complexity. However, it seems that the SIM is not only an effective model and organizing tool to address the myriad issues of people with serious mental illnesses in the criminal justice system, it also works well to organize a book on the associated issues.

The comprehensive review of the literature on people with serious mental illnesses in the criminal justice system is organized by the intercepts, identifying the best evidence for interventions and programs at each juncture. The structure of the five intercepts is also used within most of the chapters to clarify, for example, the byzantine world of privacy and confidentiality laws from HIPAA to state statues. This elaborate system of state and federal laws and policies is made more comprehensible by breaking down the issues into the separate intercepts with specific examples, where the privacy and confidentiality issues may apply.

There is some overlap with this approach, which may have benefited from more summary comments in the final chapter. A theme in more than one chapter was that of the Risk-Responsivity-Need theory of criminogenic need. As is generally known, to prevent criminal recidivism it is important to address the issues of anti-social cognition, anti-social companions, anti-social personality/temperament, and family and/or marital issues. While substance use and socio-economic issues are often implicated in predicting further criminal behavior, psychiatric issues per se are not.

Researchers and reviewers in this area appear to have reached similar conclusions to those in the area of homelessness. In homelessness research, the focus on treating the symptoms of psychiatric illnesses has been replaced with finding affordable supported permanent housing as a solution. Similarly, these reviews of the literature strongly suggest that people with serious mental illnesses need to have their criminogenic needs addressed, as a more effective deterrent to recidivism or deep-end involvement in the criminal justice field than mental health treatment alone. In other words, people with serious mental illnesses are people first, whether homeless or justice-involved. The research reviewed here also suggests a reframing of the problem of over-representation of people with serious mental illnesses in the criminal justice system as a political/structural issue, rather than a psycho-social one. For example, one of the authors points out that between 1973 and 2009, the nation’s prison population grew by some 700 percent. Just as homelessness policy and research have determined that the solution to the problem lies more in increased affordable housing with appropriate supports, these findings suggest that rather than criminalizing behavior to fill prisons, the focus (and the dollars) should be on developing community based rehabilitation and recovery solutions. Some of the authors repeat the fallacy that increased numbers of people with serious mental illnesses in the criminal justice system is the result of deinstitutionalization. Demographic researchers have shown that the number of people in psychiatric hospitals was never high enough to account for the subsequent increases in either homelessness or criminal justice involvement.

The introduction includes cogent points concerning the need for community based alternatives for people with serious mental illnesses, and highlights important issues. For example, while diversion can be depicted as a cost savings for the criminal justice system, in fact it is most often a cost shift to the overburdened and underfunded community behavioral healthcare system and/or resources for homelessness.

The chapters on intercepts 1, 2 and 5 cover a great deal of the research on these points. In general, the authors describe the research as preliminary and point out the difficulties of conducting rigorous studies such as random controlled trials. However, several findings are consistently seen in the body of work at all three intercepts. One is that, as mentioned above, programs that focus on mental health symptoms or treatment of mental illnesses do not appear to be successful in reducing recidivism or deeper-end involvement. In fact, especially for intercept five, programs specifically designed to give people with serious mental illnesses special attention with smaller caseloads for example, appear to result in more parole violations uncovered by increased scrutiny. The authors also include studies that demonstrate an overestimation of the number of people with serious mental illnesses in the criminal justice system because of the symptoms of their mental illnesses, or because of untreated psychoses.

Unfortunately, another cross-cutting theme is a lack of findings supportive of the most common interventions. At intercept 1, the earliest encounters with law enforcement, the outcome of interest is lower arrest rates for people with mental illnesses, and more diversion to other options. Critical intervention teams have been embraced as a logical approach, i.e., a group of highly trained law enforcement and other professionals responding to incidents with people that may have mental health issues. The results do not support an effect on arrest rates; however there does appear to be a decrease in officer injuries. There are similarly mixed findings on specially trained SWAT teams.

The chapter on intercept 2 also includes an excellent review of the literature on programs designed to divert people at initial detention, booking, or hearings. While in general there appears to be some benefit of diversion for more serious charges, there is no strong evidence for diversion on important outcomes such as re-arrest and recidivism.

The authors do point out that a primary problem in evaluating programs at intercept 2 is the diversity of program models or even consistent criteria in defining and measuring program elements. This chapter and the one on specifically using the SIM process to generate and use data do carefully outline the critical elements to be measured and set out the building blocks for program evaluation. This eminently practical discussion addresses research strategies that also use the resolution of cross-system data issues as an opportunity for collaboration. The authors offer practical suggestions to address barriers in data gathering and sharing at each point in the SIM process.

Intercept 3 which is post-booking diversion in jails and courts, particularly specialty courts, has a larger body of research and wider empirical support than the other intercepts. Scattered throughout the book, interesting concerns are raised suggestive of follow-up investigation. For example, in this chapter the authors also raise the question of whether problem-solving courts are being used in lieu of insanity defenses and as backdoors to override questions of competence. These authors also touch on the matter of mandated versus non-mandated diversion programs. Both of these concerns raise issues about the intersection of individual rights and the needs of the person and public safety.

A broader discussion of the history of this intersection is discussed in the fascinating chapter on rethinking mental health legal policy and practice. The authors describe how mental health policy has come full circle, and now our jails are once again psychiatric warehouses. They conclude the chapter with building a case for strengthening civil commitment laws, even arguing that involuntary treatment is necessary to prevent the neurological harm untreated psychotic episodes may cause. This is dangerous territory as the authors acknowledge. By this logic, people that are obese, are alcoholics, or have any types of behaviors or addictions that could theoretically lead to harm could be forced into the treatment chosen by the courts before they have harmed anyone or themselves. This is especially problematic, considering, as mentioned earlier, most studies suggest only a small percentage of people with serious mental illness are involved with the criminal justice system due to behaviors directly related to their symptoms.

Despite the commitment of the GAINS center to involve consumers in all aspects of planning, development, and execution of their programs, there is an obvious absence of the voice of the person who has lived the experiences outlined in this book. There are other issues that could have been covered in the book: the prevalence of trauma among people with serious mental illnesses that are incarcerated, and the high possibility of retraumatization; gender differences; racial and ethnic differences, especially differences in rates of criminal justice involvement; and, the role of substance use disorders especially as a criminogenic risk factor. The book is, however, really focused on people with serious mental illnesses, the group for whom the Sequential Intercept Model was developed. As important as the aforementioned issues are, in some ways the book sets the stage for exploration of each of them at another time. The perspective of the people who are in the intersections of these systems, however, would enrich and enlighten the work.

The description of the cross systems mapping process, the heart of the SIM, is very clear-cut. It illustrates how the process illuminates the current system in a given locale, offers opportunities for improving the process, and actually creates collaborations.

The strongest part of the book is the summary of research on each aspect of the SIM model, including related HIPAA and mental health law issues. Illustrations of local applications are thought-provoking and show the diverse nature of the programs implemented and the challenges confronted. The book also stands as a foundation for further research, program and policy development, and it will be interesting to see what grows from this foundation.

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