Treatment Recommendations

In spite of recent advances in understanding the relationship of neurobiological mechanisms and criminal behavior, psychosocial interventions remain the current treatment of choice [63]. To be maximally beneficial, however, we submit that treatments should align with the etiological mechanisms of crime [18,64]. That is, the evidence is overwhelmingly clear that PMI with a history of violence and/or CJ involvement present with a complex set of co-occurring etiological factors that include biological, psychological, psychiatric, and social variables. Effective treatments must target this network of contributing factors.

The plethora of research on criminal risk with CJ-involved PMI summarized in this article clearly suggests that clinicians must conceptualize these individuals as having both mental illness and criminal proclivities. Although we do not yet know the intricacies and nature of this co-occurring relationship (an area ripe for future research), it seems reasonable to suggest that mental illness and criminalness feed each other in a continuous loop (see Figure 29.1). Negative outcomes in one domain (e.g., increased criminalness) negatively feed into and exacerbate outcomes in the other (e.g., increased psychiatric symptomatology) and vice versa. Thus, there is a complex interplay that includes bidirectionality within the criminal and mental health domains independently (untreated criminal risk results in increased criminal recidivism; untreated mental illness results in increased psychiatric recidivism) and multidirectionality across the two domains, in that decompensation in one results in complications and decompensation in the other domain. For example, PMI who display a greater number of criminal risk factors may have limited CJ contact until such time that situations associated with their mental illness bring them to the attention of law enforcement (e.g., criminal trespassing); however, upon law enforcement involvement, the individuals become defiant, resistant, and combative with officers resulting in a criminal offense. Thus, interventions need to break this cycle to reduce negative outcomes in both CJ and mental health domains. In other words, we submit that, from a therapeutic perspective, mental illness and criminalness should be conceptualized as a self-propelling system, and that to treat one at the exclusion of the other is to facilitate change in only one domain. To enhance and improve criminal outcomes (e.g., reduced criminal recidivism, increased prosocial behavior) and psychiatric outcomes (e.g., reduced psychiatric recidivism, increased quality of life), interventions must be dually targeted to both domains.

Historically, tailoring treatments to the dual needs of CJ-involved PMI as outlined in Figure 29.1 has not been the treatment of choice. For example, Bewley and Morgan [65] surveyed correctional mental health professions that treat incarcerated PMI. Given the correctional setting of the mental health professional’s work, it would seem likely that treatment efforts would be focused on reducing criminalness; however, results indicated that treatment providers considered mental illness recovery, personal growth, and improved institutional functioning to be more important treatment considerations than treating criminalness and preparing inmates for emotions management, criminogenic treatment needs, and community re-entry. Further, they reported spending significantly more therapeutic time on noncriminal mental health issues. In a meta-analytic review of current treatment efforts for CJ-involved PMI, it was discovered that only 8% of reviewed treatment studies targeted dual issues of mental illness and criminalness [63]. Thus, the model depicted in Figure 29.1 is not, from these authors’ perspectives, particularly innovative or novel, but it emphasizes that it is imperative that treatment efforts be tailored to these co-occurring needs of CJ-involved PMI, which recent research suggests is not being done. In fact, we submit that the evidence of co-occurrence is so strong that it may be appropriate to consider any treatment program for CJ-involved PMI that is not concurrently targeting issues of mental illness and criminalness as professionally irresponsible.

Historically we have treated the mental health needs of CJ-involved PMI, resulting in positive psychiatric outcomes with no appreciable reductions in CJ outcomes (e.g., recidivism) [36,37]; however, less is known about treating criminalness in this unique psychiatric population. The treatment foci and corresponding interventions are one component of effective treatment, but the model that guides the delivery of the treatment may be just as important for addressing the criminalness of CJ-involved PMI. In other words, what models or strategies may be used to successfully intervene with this population?

Risk-Need-Responsivity (RNR) [66] is one model of service delivery, and is guided by three principles.

Empirical evidence overwhelmingly supports the adherence to principles of RNR when intervening with offenders (see Andrews and Bonta [13] for a thorough review of this literature). In fact, interventions that adhere to the principles of RNR typically produce 10%–30% reductions in criminal recidivism [67]. The empirical support for RNR is such that it is widely accepted that the most effective rehabilitative programs adhere to the principles of RNR [68]. Given the empirical support of RNR, and the findings summarized above examining criminal risk in CJ-involved PMI, it stands to reason that interventions for this population must incorporate principles of RNR; however, as noted above, this has not typically been the case in practice [63,65]. For example, it was historically believed that simply enhancing mental health services to PMI in the community would result in reduced criminal activity (see for example Lamb and Bachrach [69], Lamb and Weinberger [70], and Teplin [71]), but we now know that treatment of mental health concerns fails to elicit change in criminal behavior [36,37]. Furthermore, when treating incarcerated PMI, treatment providers tend to place greater emphasis on basic mental health services (e.g., symptom management and stabilization) and personal growth, than on rehabilitative efforts, including principles of RNR, such as reducing criminal risk and preparing inmates for release [65]. This emphasis on mental health at the exclusion (or reduced emphasis) on criminalness is likely also true in mental health settings, such as forensic psychiatric units and general mental health practice. Given the current findings of the role of neuroanatomical abnormalities and criminal risk in PMI that become CJ-involved, such approaches are no longer recommended. It is time to provide services to CJ-involved PMI that target the co-occurring needs of this population, that is, both mental illness and criminalness [18,71].

Results of two separate meta-analytic reviews support the benefit of targeting both mental illness and criminalness by demonstrating important improvements in both domains post-treatment. Specifically, mental health interventions for incarcerated offenders found significant treatment improvements for general mental health outcomes, to include reduced symptom distress, improved coping skills, and improved behavioral functioning [63,72]. Notably, however, interventions also appear to have an appreciable effect on criminal and psychiatric recidivism, complementary goals of interventions aimed at targeting offending, and mental illness needs. These meta-analyses also provide important insights into effective therapeutic strategies, including the use of homework and behavioral practice of new behaviors [63]. Also, continuity of services between institutions and community, some level of voluntariness in treatment participation, and not utilizing time-limited approaches [72] all produced more favorable outcomes.

Notably absent from these reviews were studies that targeted co-occurring issues of mental illness and crime. In fact, Morgan et al. [63] found only one study that examined the effectiveness of an enhanced assertive community treatment (ACT) treatment delivery model for reducing both criminal and psychiatric recidivism, and produced positive treatment effects for both (d = 1.17 for psychiatric recidivism and d = 0.54 for criminal recidivism; see Lamberti et al. [73]). These are significant findings, given that CJ-involved PMI present unique challenges, requiring service providers to treat both psychiatric symptoms and criminalness [74]. To enhance treatment options, Morgan et al. developed Changing Lives and Changing Outcomes: A Treatment Program for Justice Involved Persons with Mental Illness, a comprehensive intervention designed to target the dual issues of mental illness and criminal propensity [75]. Changing Lives and Changing Outcomes includes nine treatment modules that are uniquely tied to both mental illness and criminal risk. Results of preliminary program evaluations are promising, with evidence that participants generally learn the content and concepts presented [76], as well as clinically significant improvements over time (pre–post) on measures of psychiatric symptoms and psychopathology, and important aspects of criminal thinking [75]. Current efforts are examining effects on criminal recidivism and community re-entry.

The treatment summary discussed above reviews treatment gains with regard to PMI and general criminal behavior, but what about therapeutic interventions for PMI and violence? Special consideration for reducing one’s risk for violence is especially important, as substance abuse in conjunction with poor medication compliance has been shown to lead to an increase in the risk for violent acting out among PMI [77,78].

Current approaches to treating violent offenders are based on social learning and social information processing theories [79–82], with little to no discourse on the role of neurobiology in the treatment process. The basic premise of these psychosocial approaches is that past violent behaviors have been learned (modeled) and reinforced. Not unexpectedly then, treatment efforts have aimed to reduce violence by teaching nonviolent alternatives or methods of responding. Specifically, treatment efforts typically seek to help participants increase awareness of triggers and develop skills of behavioral control, while also challenging antisocial attitudes (consistent with the Needs principle of RNR). Typical programs for reducing violence generally appear to be intensive in nature (recommended minimum of about 6 months), structured, and skills-based with an emphasis on modeling alternatives to violence. Such programs have proven to be quite successful. For example, an examination of a multimodal systemic intervention rooted in psychosocial and behavioral interventions, supplemented with psychopharmacology when warranted, resulted in significant behavioral improvements such as reduced disciplinary infractions, and reduced inmate–inmate and inmate–staff assaults [83]. Although this intervention is systemically based (and therefore quite costly), pure psychosocial interventions have also proven to be effective. A recently developed program, The Violence Reduction Program: A Treatment Program for Violence Prone Forensic Clients (VRP) [84], offers particular promise. The VRP includes three therapeutic phases: (1) learning about aggressive behaviors and readiness for change; (2) skill development to manage thoughts, feelings, and behaviors associated with violence; and (3) over-learning skills and relapse prevention. The intervention is not time-limited, so it allows participants to work at their own pace, and preliminary evaluations to date have resulted in reduced community violence, as well as institutional improvements including less restrictive housing placements and fewer institutional behavioral problems [82,85,86].

Recent gains in understanding neurobiological mechanisms that are associated with crime and violence offer promising areas of future research. Specifically, as research moves from correlational studies of this complex relationship to studies examining causal neurobiological mechanisms of crime and violence, the potential exists for a plethora of new treatment options. For example, if future studies advance beyond the findings summarized above to identify etiological markers, early detection of individuals at biological risk (beyond the Central 8 risk factors) becomes possible. As such developments occur, the breadth of treatment options significantly increases. At the very least, this will provide opportunities for early detection and intervention. Notably, intervening as early as 3 years of age can produce improved brain functioning and subsequent reductions in crime [87]. In fact, the earlier an intervention is delivered, the greater likelihood for a successful outcome [88]. As summarized by Miller [88], even simple physiological interventions, such as diet, can result in reduced criminalness and possibly violence. In other words, as Rainy noted, “Biology is not destiny. We can change the biological roots of crime and violence— there’s no question about it” (as cited in Miller [88], p. 39).

Thus, the potential for more integrated interventions that holistically target the complex etiological mechanisms of crime exists.

Discussion

Mental illness, crime, and violence involve a complex interaction of neurobiological, social, and psychological/ sociological factors that are poorly understood by lay persons [1,2], and, in our opinion, professionals alike (see for example research by Bewley and Morgan [65]). Although historically, clinical practice emphasized the enhancement of mental health treatment to PMI to reduce CJ involvement, it is now clear that mental health treatment is insufficient for reducing crime and violence. Specifically, it is now clear that CJ-involved PMI present with criminal risk factors similar to offenders who are not mentally ill [15,17,19,28,29,43]. Given these findings, it is imperative that treatment efforts target co-occurring issues of mental illness and criminalness. Notably, psychosocial interventions offer significant potential for reducing criminal and psychiatric recidivism [43,68], and new programs are being developed that target these goals [56].

Of particular interest with regard to new research developments in CJ, forensic psychiatry, and forensic psychology are the findings by neuroscientists such as Pardini et al. [8] The use of MRIs to identify individuals at risk for future criminal activity, generally, and violence, specifically, presents numerous treatment possibilities. Specifically, findings that crime is associated with neurological dysfunction and atrophy opens new possibilities for interventions; however, more research, particularly research that allows for causal inferences, is needed to further advance our understanding and possible treatment options associated with neurobiological dysfunction. Until this is accomplished, increased efforts at improving the management of incarcerated PMI and housing situations for CJ-involved PMI in correctional institutions, psychiatric facilities, or the community are essential. Furthermore, current treatment efforts must not limit focus to treatment of mental illness, and must include efforts at reducing criminalness by implementing treatment strategies and models of intervention such as RNR.

In spite of the many significant gains that have produced enhanced understanding of the etiological and treatment needs of CJ-involved PMI, much work remains to be done. Future studies should continue with neuroimaging studies with PMI with and without criminal histories or comorbid antisocial traits. Specifically, future studies should aim to examine the etiology of neurobiological abnormalities and the role of environment in causing or exacerbating such abnormalities. Furthermore, although research has begun to demonstrate that psychosocial interventions can be effective for reducing both criminal and psychiatric recidivism, further research is warranted to identify effective treatment programs and the identification of best practices for reducing violence, crime, and psychiatric disturbance, while simultaneously improving quality of life when intervening with CJ involved PMI.

Disclosures

The authors do not have anything to disclose.