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Aug 10, 2010 - severe mental illness in the criminal justice system is dis- proportionate .... master's degree (non-social work; MA or MS), 71 (31%) obtained the ...
Law Hum Behav (2011) 35:351–363 DOI 10.1007/s10979-010-9242-4

ORIGINAL ARTICLE

A National Survey of Mental Health Services Available to Offenders with Mental Illness: Who Is Doing What? Marshall T. Bewley • Robert D. Morgan

Published online: 10 August 2010  American Psychology-Law Society/Division 41 of the American Psychological Association 2010

Abstract The purpose of this study was to examine the national practices of psychotherapy services for male offenders with mental illness (OMI) in state correctional facilities. Participants consisted of 230 correctional mental health service providers from 165 state correctional facilities. Results indicated that mental health professionals provided a variety of services to OMI that can be conceptualized by six goals considered important in their work: mental illness recovery, emotions management, institutional functioning, re-entry, risk-need, and personal growth. Mental health professionals in this study generally viewed mental illness recovery, institutional functioning, and personal growth as significantly more important and spent more time focused on these goals than emotions management, re-entry, and risk-need. Mental health professionals tended to believe the services they provided were effective across four key treatment foci including mental illness, skill development, behavioral functioning, and criminogenic needs with more progress perceived in areas related to mental illness and skill development than their ability to effectively change behavioral functioning. Implications of these findings and directions for future research are discussed. Keywords Offenders  Mental illness  Mental health services

The population of offenders with mental illnesses (OMI) in U.S. correctional facilities has been of increasing concern over the last two decades (Condelli, Bradigan, & M. T. Bewley  R. D. Morgan (&) Department of Psychology, Texas Tech University, Lubbock, TX, USA e-mail: [email protected]

Holanchock, 1997; Hodgins, 1995; James & Glaze, 2006; Steadman, Morris, & Dennis, 1995; Torrey, 1995). Researchers have examined the prevalence of mental illness in U.S. jails, which indicated that of the 10 million arrestees admitted to jail each year, approximately 13% have a severe mental illness (Bureau of Justice Statistics, 2006; Ruddell, 2006; Teplin, 1984, 1990; Watson, Hanrahan, Luchins, & Lurigio, 2001). Others have found the rates of mental illness in prisons to be even higher, with as many as 24% of offenders having a mental illness (James & Glaze, 2006). Notably, the prevalence of persons with severe mental illness in the criminal justice system is disproportionate with the general population (i.e., nonoffender populations), where major mental disorders are found up to four times as often among the offender population than the general population (Hodgins, 1995). Much research has focused on services that are available to OMI in jail settings. Particular focal points in the treatment of OMI in jails have been psychotropic medications (Lamb & Weinberger, 1998; Lamb, Weinberger, Marsh, & Gross, 2007; Veysey, Steadman, Morrissey, & Johnsen, 1997), crisis intervention services (Abram & Teplin, 1991; Veysey et al., 1997), case management services (Lamb et al., 2007; Veysey et al., 1997), and mental health referrals (Teplin, 1990); however, jail services are not necessarily representative of services for OMI in prisons. In fact, discrepancies between the two settings hinder the extent to which research findings from jails can be applied to prisons (Diamond, Wang, Holzer III, & Cruser, 2001). The greater incidence of mental illness in prison could be due to the number of OMI serving lengthy sentences. Given the length of stay is much longer in prisons than in jails (Diamond et al., 2001), the need for long-term treatment options is warranted. Accordingly, the need to obtain information on what mental health services are available to OMI in prisons

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is essential to shed light on what specific treatments are perceived to be the most effective with this population. Scholars have realized the importance of obtaining research on mental health services available to OMI. Specifically, research needs to determine what therapy ‘‘is most appropriate to treat mental illness among prisoners’’ (Leuchter, 1981, p. 140). Identifying effective treatments for OMI are increasingly necessary as a lack of mental health services compounds the severity of the prison environment for these inmates (Abramsky & Fellner, 2003; Leuchter, 1981). Simply stated, prison environments are not conducive to optimal mental health functioning. For example, OMI are more likely to incur disciplinary infractions (James & Glaze, 2006; O’Keefe & Schnell, 2007) and victimization (i.e., physically and sexually assaulted) while in prison (Abramsky & Fellner, 2003; Blitz, Wolff, & Shi, 2008). Additionally, the longer female OMI were incarcerated the more psychiatric symptoms, including severe symptoms, reported (Morgan, et al., 2010, unpublished manuscript). Although further examination of the effects of incarceration on OMI is needed, these results highlight the necessity of tailoring services to the needs of OMI as well as identifying those services that are most effective. With respect to treating offenders, probably the most widely recognized and comprehensive treatment theory is risk/need/responsivity, or ‘‘R-N-R’’ (Andrews & Bonta, 2003; Andrews, Bonta, & Hoge, 1990; Andrews, Bonta, & Wormith, 2006; Andrews & Dowden, 2006; Andrews, Zinger, et al., 1990; Gendreau & Andrews, 1990). This theory emphasizes the need to assess offenders on risk factors that are associated with recidivism. The ‘risk’ principle of R-N-R focuses on treating the offenders at highest risk of returning to prison, as they have consistently been found to benefit the most from treatment (Andrews & Bonta, 2006). Treating offenders at low risk for recidivism will not work as well, because they will likely not be affected by treatment as greatly as high-risk offenders. The ‘need’ factor of R-N-R focuses on treating a specific set of risks of an offender, also known as criminogenic needs. Criminogenic needs include targeting antisocial thoughts, antisocial actions, peer associations, and substance abuse problems that the offender may have internalized (Andrews, Zinger, et al., 1990). The ‘responsivity’ factor of R-N-R focuses on having treatment tailored to the learning styles of the individual offender to ensure effectiveness. Adhering to principles of R-N-R significantly reduces the risk for recidivism (Andrews & Bonta, 2006; Andrews, Bonta, et al., 1990; Ward, Mesler, & Yates, 2007); however, it is unknown whether principles of R-N-R are incorporated into services for OMI. It is also unknown whether interventions proven effective with persons with mental illness (PMI) are implemented with incarcerated OMI. For example, Illness

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Management and Recovery (IMR; Gingerich & Mueser, 2005; available from the United States Department of Health and Human Services) is an emerging evidencebased practice for individuals suffering from severe and persistent mental illnesses. IMR is a psychoeducational program developed to enhance PMIs’ knowledge and awareness of their illness, psychotropic medication adherence, relapse prevention strategies, social skills, and coping skills (Mueser et al., 2002) to promote recovery (return to pre-illness levels of independence and prosocial functioning). The aim of IMR is to facilitate collaboration between the PMI and treatment providers to reduce the risk for relapse (psychiatric recidivism), and increase the individual’s ability to cope with their illness (Mueser et al., 2002). Although R-N-R has proven effective with offenders and IMR is effective for PMI, it is unknown whether treatments are adhering to principles of R-N-R or implementing strategies of IMR strategies in work with incarcerated OMI. In fact, it is unknown what services of any kind are provided to incarcerated OMI. Given that recidivism rates continue to hover around 70% (Andrews & Bonta, 2006), focus on offender rehabilitative (crime prevention) needs is warranted, including for OMI who present with criminal risk factors such as cognitive styles and attitudes comparable to offenders without mental illness (Morgan, Fisher, et al., 2010). Thus, services for OMI must target co-occurring issues of criminalness1 and mental illness (e.g., Hodgins et al., 2007; Morgan, Steffan, Shaw, & Wilson 2007); however, it is unknown to what extent this is occurring in clinical practice. Thus, the purpose of this study was to examine the type and structure of mental health services available to OMI in state prisons, as well as service provider’s goals and perceived effectiveness when working with this population. This study aimed to describe a wide range of practice issues including the demographics of mental health service providers, the nature and purpose of services offered, the structure and procedures of the mental health services being provided, mental health service providers’ goals, discussion topics, and areas of progress, and perceived outcomes of the services provided to incarcerated OMI. It was hypothesized that service providers would be diverse with regard to training and background and consequently provide a myriad of different services that they perceived to be as effective; however, based on previous research by the second author (see Morgan, Flora, et al., 2010) it was further hypothesized that there would be a disconnect

1

We define criminalness here to refer to behavior that breaks laws and social conventions and/or violates the rights and well-being of others and may or may not lead to arrestable offenses such as abuse of sick leave, drug possession, person, property, and violent crime (Morgan, Fisher, et al., 2010).

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between services focusing on issues of mental illness and criminalness.

Method Participants Mental health professionals from 165 state correctional facilities participated in this study. A total of 474 surveys were sent to these 165 facilities, with 230 surveys completed and returned (return rate of 48.5%). Of the 50 states in the United States, 47 are represented by at least one participating correctional facility. There were 35 state correctional facilities recruited to participate in this study that did not participate for a variety of reasons: 22 facilities were not able to obtain approval from either their institution or the department of corrections, 7 facilities stated they did not have OMI, 4 facilities were unable to participate due to time constraints, and 2 facilities did not have mental health service providers. The sample of mental health professionals included 115 men and 114 women, with a mean age of 49 years (SD = 11.1). The participants were predominantly Caucasian (n = 198, 86.1%); however, other racial groups were represented in this sample including African American (n = 14, 6.1%), Hispanic/Latino(a) (n = 5, 2.2%), Asian American (n = 4, 1.7%), Native American (n = 3, 1.3%), and 6 (2.6%) participants identified their ethnicity as ‘‘other.’’ Of the 230 participants, 77 (33.6%) obtained a master’s degree (non-social work; MA or MS), 71 (31%) obtained the doctorate of philosophy (Ph.D.), 36 (15.7%) obtained a master’s of social work degree (i.e., MSW), 4 (1.7%) obtained a medical degree (MD), 26 (11%) participants endorsed ‘‘other’’ type of degree, 10 (4%) obtained a bachelor’s degree (BA or BS), and 5 (2%) obtained a doctorate of education degree (Ed.D.). Thus, the sample consisted of a variety of mental health professionals including psychologists (n = 133, 57.9%), professional counselors (n = 38, 16.5%), social workers (n = 30, 13.0%), psychiatrists (n = 6, 2.6%), a criminologist (n = 1, .4%), and ‘other’ mental health professionals (n = 22, 9.6%). The majority of the participants were mental health providers (n = 134, 58.3%), whereas 94 (40.9%) participants were directors of psychological or mental health departments. The average number of years of experience working in a correctional setting was 9.2 years (SD = 7.4). Cognitive-behavioral (n = 101, 45.5%) and eclecticism (n = 56, 25.2%) were identified as the most common theoretical orientations, whereas other orientations (e.g., client-centered, psychodynamic, reality, existential) accounted for a combined 14.9% (n = 33). Approximately half of the participants (57%) received no

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specific training in correctional or forensic psychology during their post-baccalaureate training. Similarly, only one-fourth of participants (n = 52, 22.9%) completed coursework in correctional psychology, and of those receiving such training, an average of 4.5 (SD = 4.1) classes were taken. Some participants were involved in a correctional practicum (n = 49, 21.6%); those in correctional or forensic practica received an average of 12.7 (SD = 6.3) months of training and experience. Additionally, close to one-fourth of participants spent time at a correctional internship (n = 61, 27%) with an average of 10 (SD = 3.5) months at the internship site. A small number of participants (approximately 10–15%) completed coursework in correctional or forensic psychology and spent time at a correctional internship. Finally, respondents were employed in state correctional facilities ranging in inmate population from 20 to 7000 with a mean of 1,462 (SD = 1107.4), median of 1,243, and a mode of 1,500 inmates (it should be noted that facilities with unusually high inmate populations such as 7,000 were likely a large correctional complex that included multiple facilities). Materials The survey used in this study was adapted from the survey in Morgan, Winterowd, and Ferrell (1999), which examined group therapy services provided to a general population of male incarcerated offenders. After modifying the survey for mental health professionals providing services to OMI, the survey was pilot tested and revisions made based on feedback from psychologists actively providing services to OMI but not employed in a state correctional facility. The survey (survey available upon request) asked participants to respond to fill-in-the-blank, multiple choice, and Likert-type questions. Questions assessed a variety of content areas including demographics of mental health service providers, mental health services that are offered and facilitated in each prison, the structure and procedures of mental health services being provided, and the goals and perceived outcomes of mental health services provided to OMI. The survey packets included the five-page survey entitled ‘‘Survey of Mental Health Services for Mentally Ill Offenders in Prison,’’ a cover letter, and a return envelope. The cover letter provided a general overview of the survey, informed consent and limits of confidentiality, and an opportunity to request results of the study. The addressed, stamped envelopes were provided for easy return of the surveys. Procedures For this study, four state’s prisons were randomly selected from each of the 50 states for a total of 200 potential prisons. All of the state prisons were randomly selected

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from the 2007 American Correctional Association’s directory, which included a listing of state correctional institutions (American Correctional Association, 2007). The mental health director at each site was contacted by phone from either the primary investigator or a trained undergraduate research assistant to explain the nature and purpose of the study and to assess their willingness to volunteer their participation in the study. If the director verbally committed to participate in the study, s/he was asked how many mental health professionals were actively treating OMI in the correctional facility. The number reported by the director determined the number of surveys sent to the prison (i.e., one survey for the mental health director and one survey for each mental health service provider). Mental health service providers were defined in this study as any licensed or qualified specialist providing mental health services to OMI identified by the program director of their mental health department (i.e., psychologist, psychiatrist, social worker, addiction counselor, professional therapist/counselor, doctoral student in training, master’s student in training). Each participating mental health director was mailed an envelope that included the specified number of research packets containing a survey, informed consent form, and an addressed, stamped return envelopes for each participating mental health provider. By completing and returning the survey, mental health professionals provided informed consent to participate in the study. All consenting mental health professionals were then instructed to complete the five-page survey and return the completed packets to the primary investigator within 2 weeks. Two weeks after the primary investigator mailed the packets to each prison, the director was sent a postcard reminding the particular mental health director of their participation in the study, as well as requesting they remind potential research participants within their facility to participate if they so chose. In addition, 2 weeks following the postcard, a phone call was made to the mental health director reminding them of their participation. This phone call was also used to ensure that the mental health director received all necessary materials to complete their participation in the study.

Results Service Facilitation Participants’ responses indicated that 99% of facilities employed at least one mental health professional to provide service to OMI with the majority of facilities employing at least one psychologist (83%) and one psychiatrist (81%). Prisons in this study also hired other mental health

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professionals including at least one therapist/counselor (61% of prisons), social worker (59%), addiction counselor (33%), master’s student in training (28%), doctoral student in training (25%), and paraprofessional (11%). Participants in this study estimated that approximately one-fourth (23%) of their offender population suffers from mental illness; however, participants further estimated that 27% of all offenders receive mental health services. Participants were asked how mental illness is classified in their prison and a majority of participants (56%) defined mental illness as including both Axis I and Axis II disorders (American Psychiatric Association [DSM-IV-TR], 2000), whereas others limited mental illness to any Axis I Disorder (22%), or as selected Axis I Disorders (18%). When asked to identify specific disorders that constitute a mental illness, an overwhelming majority (98%) defined the major diagnoses of Schizophrenia, Bipolar Disorder, and Major Depressive Disorders as mental illnesses and (92%) included Anxiety disorders. Other diagnoses were frequently endorsed as mental illnesses, such as adjustment disorders (76%), personality disorders (71%), and dissociative disorder (66%). Diagnoses that were endorsed close to half the time (52%) included somatoform and substancerelated disorders. Only a few disorders were endorsed less frequently as a mental illness, such as factitious (39%), sexual and gender identity (36%), eating (32%), and sleep disorders (22%). Mental health professionals were asked how OMI accessed mental health services at their respective facilities. Participants estimated that 52% of OMI received services on a volunteer basis, 24% from staff referral, 11% were court mandated to attend mental health services, and 8% attended because it was an assigned program requirements. Occupational Functions Participants were asked how they spent their professional work time in their respective facilities. On average, the respondents in this study spent about the same amount of their total work time providing individual psychotherapy and counseling (38.5%, Mode = 50, SD = 27.5) services to OMI as they did performing administrative duties (35.6%, Mode = 0, SD = 31.7), such as program development and program supervision. Respondents estimated less time (12.8%, Mode = 0, SD = 17.1) providing group psychotherapy or group counseling services to OMI. The majority of participants (80%) reported ‘no’ when asked if there was an interest in mental health research activities at their correctional facilities (i.e., any research related to mental health services); however, 43 participants (18.7%) reported involvement in mental health research activities. Of those participants that reported ongoing

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research activities, 28 (65%) reported their department conducted research specifically related to issues of mental illness over the past year (i.e., research explicit to issues of mental illness). Institutional Relationships and Security Issues Participants were asked about institutional relationships and security issues at their facilities. They rated their level of agreement on these items using a 7-point Likert scale (1 = strongly disagree, 7 = strongly agree). The mental health professionals reported some autonomy for the development of treatment services provided to OMI (M = 5.28, SD = 1.70), and for developing new or innovative therapies for OMI (M = 4.82, SD = 1.75). With regards to flexibility, 61% of participants endorsed agreement (i.e., mildly agree, agree, strongly agree) that they had flexibility when determining services offered to inmates, compared to 21% that disagreed (i.e., strongly disagree, disagree, mildly disagree). Mental health professionals generally reported feeling safe when working with OMI (M = 5.74, SD = 1.11) and very few participants (n = 11) felt unsafe when working with OMI. Participants were asked about their involvement in continuity of care for OMI. ‘Continuity of care’ can best be described as a system that directs and tracks clients over time through a comprehensive array of health, mental health, and social services spanning all levels of intensity of care (Mainous III & Salisbury, 2009). A majority of participants (71%) reported some involvement in continuity of care for OMI in their prisons. Additionally, 68% of mental health professionals agreed that they consult with other departments about the mental health services they provide to OMI. Although 64% of mental health professionals agreed that they were supported by prison administration and 54% agreed that rehabilitation (of both mental health functioning and crime reduction) was an important goal of their institution, 65% of participants were dissatisfied with the funding they received for treatment programming for OMI. Type of Mental Health Services Offered to OMI As summarized in Table 1, mental health professionals providing services to OMI individually facilitated a variety of psychotherapy services which they believed to be somewhat effective (4.43–5.43 mean range) in achieving positive outcomes with OMI. The 16 potential content areas of psychotherapy presented in Table 1 were rationally combined into the following 4 treatment foci: mental illness (including content areas of mental illness awareness, symptoms management, medical adherence, and negative affect), skill development (including content areas of anger

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management, stress management, problem solving, social skills training, and decision skills training), behavioral functioning (including content areas of recidivism and institutional adjustment), and criminogenic needs (including content areas of substance abuse, vocational skills training, cognitive restructuring, relationship enhancement, antisocial peers/associates, and negative affect). Mental health professionals produced the following mean perceived effectiveness ratings on each of these four treatment foci: mental illness (M = 5.21), skill development (M = 5.19), criminogenic needs (M = 4.89), and behavioral functioning (M = 4.79). A one-way analysis of variance was conducted to examine the differences among general treatment areas (i.e., mental illness, skill development, behavioral functioning, and criminogenic needs) in terms of the participant’s perceived effectiveness rating for each. Results indicated statistically significant differences among the four general treatments (i.e., mental illness, skill development, behavioral functioning, and criminogenic needs) and perceived effectiveness of treatment, F(3, 428) = 9.96, p \ .000. A Tukey post hoc procedure indicated that participants perceived themselves as significantly more effective with mental illness (p \ .001) and the skill development (p \ .001) treatment content areas than they were with the behavioral functioning treatment area. There were no other significant differences (p [ .05) between the remaining comparisons of treatments including between mental illness and skill development, or criminogenic needs and the three treatments areas of mental illness, skill development, or behavioral functioning with regard to perceived effectiveness of treatment. Potential Mental Health Service Goals, Discussion Topics, and Areas of Progress Participants were provided a list of 38 items that represented potential treatment goals, discussion topics, and areas of therapeutic progress. A principal components analysis with an oblimin rotation was completed on the 38 items. Table 2 lists all potential 38 items and areas of treatment. Based on the Kaiser rule where one retains factors with eigenvalues greater than 1 (Stevens, 1996) and an examination of a scree plot, six components were extracted from the pattern matrix. These six components accounted for 63% of the common variance and each represented a theoretically meaningful structure. Component 1 (Mental Illness Recovery) consisted of 11 items with an eigenvalue of 14.035 and accounted for 37% of common variance. The 11 items retained for this component focused on the development of relapse prevention, including mental illness awareness and medication adherence (Tables 3 and 4).

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Table 1 Content areas of psychotherapy facilitated in state correctional settings with male OMI Type of mental health service

Service facilitated

Type of facilitation

Yes

Individual

Co-therapy

Both

%

n

%

n

%

n

%

M

No n

Perceived effectiveness

n

%

SD

Mental illness awareness

177

77

45

20

127

70

35

19

19

11

5.28

Anger management

196

85

28

12

96

50

70

36

28

14

5.22

1.07

Stress management Problem solving

196 188

85 82

27 34

12 15

116 119

58 64

56 46

28 24

27 22

14 12

5.21 5.03

1.05 1.00

Recidivism

130

57

91

40

100

71

25

18

16

11

4.45

1.26

Institutional adjustment

164

71

58

25

132

75

28

16

16

9

5.07

.989

Symptoms management

202

88

20

9

140

70

40

20

20

10

5.34

.850

Medical adherence

174

76

48

21

127

73

30

17

16

9

5.16

1.04

Substance abuse

125

54

97

42

80

63

36

28

12

9

4.67

1.51

Vocational skills

37

16

186

81

30

64

12

25

5

11

4.62

1.48

Social skills

152

66

69

30

76

50

54

35

22

15

4.99

1.06

Decision skills

142

62

80

35

76

54

47

34

17

12

4.96

1.01

Negative affect

147

64

75

33

107

71

27

18

17

11

4.78

1.14

Cognitive restructuring

186

81

37

16

119

64

44

24

23

12

5.18

1.03

Relationship enhancement

124

54

98

43

76

59

34

27

18

14

4.82

1.18

Antisocial peers

128

56

94

41

91

67

29

22

15

11

4.43

1.33

.996

Note: Likert-type scale ranges for perceived effectiveness of services range from (1 = strongly ineffective, 2 = mildly ineffective, 3 = ineffective, 4 = neutral, 5 = effective, 6 = mildly effective, 7 = strongly effective)

Component 2 (Emotions Management) consisted of seven items. The eigenvalue for Component 2 was 2.760 and accounted for 7.3% of common variance. The seven items inquired about behavioral skills and managing emotions, including impulse, anger, negative affect, and catharsis. Component 3 (Institutional Functioning) had an eigenvalue of 2.295 and accounted for 6% of common variance. Six items loaded on this component and focused on dealing with prison life, which included institutional adjustment, relationships with inmates, and relationships with staff. Component 4 (Re-entry) had an eigenvalue of 2.189 and accounted for 5.8% of common variance. Eight items loaded on this component and consisted of planning for life outside of prison, such as career planning, vocational training, and leisure activities. Component 5 (Risk-Need) had an eigenvalue of 1.374 and accounted for 3.6% of common variance. This component consisted of seven items addressing recidivism issues, addictive behaviors, and antisocial peers. Component 6 (Personal Growth) had an eigenvalue of 1.307 and accounted for 3.4% of common variance. The five items that loaded on this component inquired about ways the offender can gain insight, realistic thoughts, and mood adjustment. Component intercorrelations (see Table 5) among the six components suggest mental health professionals

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generally perceive mental illness recovery, institutional functioning, and personal growth as significantly more essential, spend more time on, and perceive there to be more progress over the areas of emotions management, reentry, and risk-need. Also, mental health professionals’ thought they made more progress in emotions management over the areas of re-entry and risk-need. Last, participants estimated they spent less time on re-entry and considered this area less important than the area of risk-need; they also estimated they spent less time on re-entry than issues of emotions management. A one-way multivariate analysis of variance procedure was conducted to examine the six components obtained from the principle component analyses (i.e., mental illness recovery, emotions management, institutional functioning, re-entry, risk-need, and personal growth) mental health professionals’ rated on perceived essentialness, time spent, and progress. Results indicated a statistically significant difference between the six components and the outcomes of interest, K(15, 3478) = 24.716, p \ .001. A univariate post hoc analysis using Scheffe procedures indicated several statistically significant differences between the six components and mental health professionals’ ratings in each outcome of interest. A 7-point Likert scale (1 = no progress or no improvement, 7 = much progress or improvement) was used to measure mental health professionals’ perceived progress in each outcome of interest. Significantly more

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Table 2 Descriptive statistics for mental health professionals’ ratings of the perceived progress, amount of time spent discussing/processing, importance as a service, and how essential each service is when treating male OMI Therapeutic factor

Progress M

Time SD .931

M

Importance SD

M

Essentialness SD

M

SD

Institutional adjustment

5.16

4.94

1.29

1.04

.198

5.53

1.28

Life outside of prison

4.17

1.29

4.62

1.41

1.08

.273

5.43

1.48

Teaching social skills Existential issues

4.44 4.15

1.14 1.31

4.66 4.07

1.33 1.53

1.10 1.29

.299 .455

5.19 4.36

1.43 1.60

Career planning

3.19

1.50

2.93

1.53

1.58

.494

3.89

1.72

Improving relationships with inmates

4.44

1.21

4.67

1.38

1.16

.370

4.92

1.43

Improving relationships with prison staff

4.57

1.24

4.89

1.35

1.11

.312

5.14

1.45

Imitating new behaviors

4.39

1.28

4.55

1.46

1.16

.366

5.06

1.49

Stress management

4.95

1.09

5.40

1.14

1.01

.095

5.73

1.15

Insight/personal growth

4.22

1.35

4.66

1.56

1.16

.369

4.98

1.72

Diet/nutrition & exercise

3.39

1.46

3.42

1.55

1.37

.484

4.17

1.67

Symptom management

5.11

1.06

5.55

1.14

1.01

.095

5.85

1.14

Mood adjustment

4.99

5.45

1.13

1.02

.134

5.84

1.10

Realistic thoughts/beliefs

4.88

1.19

5.60

1.19

1.02

.133

5.80

1.32

Antisocial personality

3.93

1.63

4.87

1.55

1.15

.357

5.05

1.75

Conflict resolution

4.44

1.14

5.18

1.27

1.04

.188

5.60

1.30

.995

Substance abuse/dependency problems

4.11

1.58

4.10

1.78

1.18

.386

5.09

1.74

Risk for recidivism Reducing addictive behaviors/relapse

4.12 3.97

1.43 1.52

4.74 4.33

1.57 1.67

1.09 1.15

.281 .357

5.60 5.23

1.44 1.70

Assertiveness training

3.90

1.17

4.01

1.49

1.22

.418

4.37

1.58

Self-esteem enhance

4.07

1.28

4.33

1.59

1.18

.389

4.66

1.68

Impulse/anger control

4.64

1.23

5.57

1.25

1.00

.000

5.91

1.12

Negative affect

4.11

1.31

4.73

1.49

1.12

.331

5.08

1.44

Improving relationships with partners/family

3.78

1.27

4.08

1.56

1.20

.402

4.68

1.61

Catharsis

4.61

1.53

4.52

1.72

1.26

.439

4.53

1.79

Avoid re-offense cycle

4.25

1.35

4.87

1.47

1.07

.262

5.41

1.43

Normalizing problems

4.45

1.32

4.68

1.42

1.15

.361

4.74

1.56

Institutional rules

4.96

1.27

5.40

1.33

1.02

.150

5.63

1.31

Crisis intervention

5.01

1.25

5.32

1.38

1.03

.177

5.71

1.26

Importance of relationships with others

4.58

1.30

4.87

1.43

1.10

.296

5.20

1.45

Leisure activities

3.65

1.38

3.72

1.58

1.35

.480

4.24

1.70

Hope/faith in treatment

4.34

1.25

4.60

1.44

1.14

.347

4.92

1.60

Criminal thinking/attitudes

4.26

1.39

4.98

1.49

1.07

.262

5.46

1.35

Mental illness awareness Medication adherence

5.09 5.16

1.23 1.22

5.40 5.66

1.36 1.32

1.06 1.04

.231 .189

5.56 5.72

1.40 1.39

Problem solving skills

4.69

1.18

5.45

1.27

1.02

.151

5.66

1.27

Vocational training

3.05

1.53

2.98

1.62

1.49

.501

3.87

1.81

Antisocial peers/associates

3.62

1.51

4.39

1.61

1.16

.369

4.72

1.68

Note: These therapeutic factors were rated on a 7-point Likert-type scale: Progress (1 = no progress or no improvement, 7 = much progress or improvement), time spent (1 = no time spent on topic, 7 = much time spent on topic), importance of service (1 = Yes, 2 = No), whether service is essential (1 = not at all essential, 2 = very essential)

progress was estimated in mental illness recovery (M = 4.59, SD = .95, CI = 4.45–4.72) than emotions management (M = 4.18, SD = .92, CI = 4.06–4.30), re-entry (M = 3.81, SD = .91, CI = 3.69–3.94), or riskneed (M = 3.88, SD = 1.17, CI = 3.72–4.04). Institutional

functioning (M = 4.66, SD = .85, CI = 4.54–4.77) was estimated to be significantly improved over emotions management, re-entry, and risk-need. Participants estimated significantly more progress on personal growth (M = 4.63, SD = .93, CI = 4.51–4.76) than emotions management,

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Law Hum Behav (2011) 35:351–363

Table 3 Pattern matrix of the component loadings for the six components of content and process goals in treatment of male OMI in state correctional settings Therapeutic factor

Components 1

2

3

4

5

6

Institutional adjustment

.047

-.131

.421

.418

-.195

Life outside of prison

.214

-.118

.105

.368

.359

.141

Teaching social skills Existential issues

.117 .135

.010 .387

.413 .048

.209 .320

.098 -.274

.173 .174

-.027

.074

.096

.493

.433

.038

Improving relationships with inmates

.106

.027

.776

.083

-.038

-.031

Improving relationships with prison staff

.101

.002

.832

-.147

.165

-.033

Imitating new behaviors

.113

.205

.546

-.128

.137

.194

Stress management

-.098

.091

.620

.112

-.083

.357

Insight/personal growth

-.033

.276

.016

.427

-.041

.418

.022

-.108

.015

.726

.122

.105

Symptom management

.191

-.008

.126

.011

-.017

.689

Mood adjustment

.102

.001

.268

.036

.171

.564

Realistic thoughts/beliefs

.137

.072

.209

-.067

.212

.597

Teaching career planning

Diet/nutrition & exercise

Antisocial personality pattern

.052

.002

.224

-.002

-.073

.592

.417

Conflict resolution

-.008

-.043

.368

.112

.278

.363

Substance abuse/dependency problems

-.070

-.007

-.096

.122

.107

.802

Risk for recidivism

.009

-.044

.003

.218

.718

.211

Reducing addictive behaviors/relapse

.010

.054

.103

.115

.792

-.017

Assertiveness training Self-esteem enhancement

.032

.759

.103

-.033

.165

-.092

-.022

.732

.204

.039

.030

.011

Impulse/anger control

.207

.400

-.011

.169

.027

.266

Negative affect

.006

.465

.103

.058

.181

.106 -.107

-.051

.448

.037

.497

.010

Catharsis

Improving relationships with partners/family

.177

.714

-.150

.012

-.140

.141

Strategies to avoid re-offense cycle

.463

.139

.040

.007

.476

-.066

Normalizing problems

.507

.247

.008

-.082

.123

.045

Institutional rules

.606

-.247

-.062

.004

.170

.291

Crisis intervention

.589

.158

-.004

.000

-.210

.283 -.282

Importance of relationships with others

.406

.267

.279

.061

.066

Leisure activities

.155

.251

.144

.483

.032

-.334

Hope/faith in treatment

.502

.275

.191

.138

.034

-.142

Criminal thinking/attitudes

.536

.175

-.036

.032

.337

.035

Mental illness awareness Medication adherence

.732 .744

.039 -.076

.080 .181

.011 .023

.021 .016

.056 -.071

Problem solving skills

.679

.030

.075

.122

-.143

.126

Vocational training

.092

.085

-.060

.652

.284

-.125

Antisocial peers/associates

.505

.237

-.161

.011

.485

.033

Note: Significant loadings of .364 or higher are in bold face Component 1 mental illness recovery, Component 2 emotions management, Component 3 institutional functioning, Factor 4 re-entry, Factor 5 risk-need, Factor 6 personal growth

re-entry, and risk-need. Moreover, significantly more progress was estimated with risk-need than re-entry issues. Significantly more progress was estimated with emotions management over re-entry and risk-need. See Fig. 1 for a display of the means among the six components.

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For mental health professionals’ estimates of time spent discussing each outcome of interest, a 7-point Likert scale was used (1 = no time spent on topic, 7 = much time spent on topic). Significantly more estimated time was spent on mental illness recovery (M = 5.06, SD = .99,

Law Hum Behav (2011) 35:351–363

359

Table 4 Mean differences between therapeutic factors in essentialness, time spent on factor, and progress in each factor

Table 5 Component intercorrelations among the six therapeutic factors

Factor

Factor

1

2

3

4

5

6

Essentialness of area 1. Mental illness recovery

2

3

4

5

6

Essentialness of area .57**

2. Emotions management

.03 -.53**

3. Institutional functioning

.76** .19 .73**

4. Re-entry

.36** -.20 .33* -.39**

5. Risk-need

-.14 -.70** -.17 -.90** -.50**

6. Personal growth Time spent on area 1. Mental illness recovery

1

.41** -.06

2. Emotions management

-.48**

3. Institutional functioning

.78**

.71**

-.04

.37**

.30*

-.45**

.84**

.78**

.02

4. Re-entry

-.06

5. Risk-need 6. Personal growth

1. Mental illness recovery

.67** .60** .59** .71** .63**

2. Emotions management

.51** .65** .49** .54**

3. Institutional functioning 4. Re-entry 5. Risk-need

.61** .56** .67** .67** .58** .68**

6. Personal growth Therapeutic factors that have a positive number with a ** have a significant intercorrelations with the corresponding factor at the .01 level ** p \ .01

-.82** -.75**

Progress in area 1. Mental illness recovery 2. Emotions management 3. Institutional functioning 4. Re-entry 5. Risk-need

.58**

.13

1.18**

.74**

-.16

-.45**

.54**

.16

-.73**

.99**

.61**

-.29*

-.38** -1.28** .90**

6. Personal growth Therapeutic factors on the Y-axis that have a positive number with an * have a significantly higher mean than the corresponding factor on the X-axis at the .05 level. Therapeutic factors that have a positive number with a ** have a significantly higher mean than the corresponding factor at the .01 level. A negative number indicates a significantly lower mean than the other factor * p \ .05, ** p \ .01

CI = 4.93–5.20) than emotions management (M = 4.49, SD = 1.08, CI = 4.34–4.63), risk-need (M = 4.33, SD = 1.19, CI = 4.17–4.49), or re-entry (M = 3.95, SD = .98, CI = 3.81–4.08). In addition, significantly more estimated time was spent discussing institutional functioning (M = 4.94, SD = 1.00, CI = 4.80–5.07) than emotions management, re-entry, and risk-need. Significantly more estimated time was spent discussing personal growth (M = 5.22, SD = .97, CI = 5.09–5.35) than emotions management, re-entry, and risk-need. Moreover, significantly more estimated time was spent on risk-need than on re-entry. See Fig. 1 for a display of the means of time spent discussing each of the six outcomes of interest.

Fig. 1 Means among the six factors in each of the outcomes of interest (i.e., essentialness, time spent, and progress)

Mental health professionals’ perception of the essentialness of each outcome of interest was measured using a 7-point Likert scale (1 = not at all essential, 7 = very essential). Mental illness recovery (M = 5.36, SD = 1.07, CI = 5.21–5.51) was perceived as significantly more essential than emotions management (M = 4.80, SD = 1.08, CI = 4.65–4.94), re-entry (M = 4.60, SD = 1.13, CI = 4.45–4.76), and risk-need (M = 5.00, SD = 1.26, CI = 4.83–5.17). Institutional functioning (M = 5.33, SD = 1.01, CI = 5.20–5.47) was perceived as significantly more essential than emotions management, re-entry, and risk-need, whereas personal growth (M = 5.50, SD = 1.08, CI = 5.35–5.64) was perceived as significantly more essential than emotions management, re-entry, and riskneed. Also, risk-need was perceived as significantly more essential than re-entry. See Fig. 1 for a display of the means of perceived essentialness for each of the six outcomes of interest.

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360

Law Hum Behav (2011) 35:351–363

Discussion The purpose of this study was to examine the national practices of mental health services for male OMI in state correctional facilities. It was found that mental health professionals providing services to OMI facilitated a variety of services that they believed were somewhat effective in achieving positive outcomes with OMI. Although some authors have noted there is no minimum recognized response rate in the literature (Heppner, Wampold, & Kivligham, 2008), it is suggested that survey data collection typically produces response rates between 30 and 40% from an initial mailing and an additional 20% return from a follow-up postcard. Therefore, with a 48% response rate, this study is slightly lower than the average response rates of other published research. Additionally, there is the potential for sampling bias and limited generalizability of the results due to only certain participants responding. There might be something unique to this population that does not apply to mental health providers that did not respond. For example, respondents might have had greater encouragement from their chief administrators in their mental health departments than participants who chose not to participate. Consistent with the principles of effective treatment for non-mentally ill offenders, where the use of styles and modes of treatment (e.g., Cognitive Behavioral Therapy) are linked with the offender’s learning style and need (Andrews et al., 1990; Gendreau & Goggin, 1997), the most frequently endorsed theoretical orientation by participants was cognitive-behavioral (43.9%). However, given the benefits of cognitive-behavioral treatments to offenders (Clements, 1987; Gendreau, 1996; Milan, Montgomery, & Rogers, 1994), it is surprising that more participants did not endorse cognitive-behavioral theory as their primary theoretical orientation. This possibly suggests that mental health professionals may not be attending to the offender literature when treating OMI (possibly in favor of attending to the general mental health literature) or those correctional administrators are not attending to therapist– offender match during the hiring process. However, it should be noted that participants were asked a general question about their theoretical orientation, and not specifically about CBT approaches with regard to criminogenic risk. Thus, participants may be implementing cognitive-behavioral techniques in their mental health services but not endorsing it as their primary theoretical orientation. In any event, in an effort to improve services for OMI, practitioners should be educated about the benefits of treatment matching (i.e., responsivity principle from R-N-R). Cognitive-behavioral orientations are particularly appealing because it allows for social learning principles of interpersonal influence, cognitive restructuring, and skill development (Andrews, Zinger, et al., 1990).

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Although OMI present with criminogenic risk (e.g., antisocial attitudes) consistent with offenders without mental illness (Morgan, Fisher, et al., 2010), it is surprising that more mental health professionals were not incorporating principles of R-N-R into their treatment. Notably, only 36 (15.7%) participants incorporated each of the R-N-R principles into their treatment work with OMI, even though participants viewed principles of R-N-R as important areas of treatment and perceived this treatment area as somewhat effective. It is possible that this result reflects the legal requirements (see for example Conn v. City of Reno, 591 F.3d 1081 which extends the findings of Estelle v. Gamble, 429 U.S. 97 to include mental health services) for prison systems to provide basic mental health services with no complementary requirement to provide rehabilitative services. However, it is also possible that mental health professionals feel more effective working with symptom reduction and mental illness awareness. It is not unreasonable to suggest that this is likely due to emphasis in graduate programs on treating mental illness. In fact, few mental health training programs emphasize factors relevant for treating offender populations which highlights the necessity of practicum and internship training programs. Given that corrections is a leading employer of psychologists (Federal Bureau of Prisons, 2007), practica and internships provide an opportunity for clinicians to round out their general clinical skills, as well as develop specialized skill and knowledge for working with an offender population. Although internship programs currently exist (e.g., Bureau of Prisons consistently have approximately ten predoctoral internships for clinical and counseling psychology students), only approximately one-fourth of participants in this study completed a formal internship training program. A disconcerting finding of this study was the lack of treatment efforts focusing on vocational issues, as occupational functioning is a significant predictor for criminal recidivism (Andrews & Bonta, 2006) and essential to patients recovery from mental illness (Steele & Berman, 2001). The problem is magnified, given criminal history and mental illness pose significant challenges in obtaining employment (Sneed, Koch, Estes, & Quinn, 2006). Vocational counseling or vocational skills training are going largely ignored with only 16% of participants offering such services to OMI. Lack of emphasis on vocational rehabilitation in prisons may be one reason why most offenders are unemployed within 1 year of release from prison (Petersilia, 2001). It is unclear if mental health professionals devalue vocational issues in treatment, simply value other treatment issues more so, or simply have not been trained in this type of work. Regardless, the relative shortage of vocational counseling, as reported by participants in this study, highlights an important deficit and gap in continuity of care geared toward offenders’ re-entry.

Law Hum Behav (2011) 35:351–363

It is important to note that one limitation of factor analysis is that factors only comprise the items available. Thus, certain factors may arise due to the mere presence items in the survey. In spite of this limitation, one purpose of this study was to identify key factors associated with the important process and content goals of mental health services for OMI. Six factors emerged: Mental Illness Recovery, Emotions Management, Institutional Functioning, Re-entry, Risk-Need, and Personal-Growth. Given these six important treatment factors for OMI, mental health professionals can use these overarching goals as a guide in developing programs for OMI. Specifically, it is hoped that these service areas will guide the future practice of mental health work with OMI, where professionals are targeting both criminal justice issues and mental health issues (Morgan, Kroner, & Mills, 2010). The finding that mental health professionals are dissatisfied with the funding they received for treatment programming for OMI raises important implications for policy makers. Specifically, policy makers might consider allocating money specifically for specialized services for mental health professionals working with OMI. Notably, there does appear to be significant movement toward improved funding for OMI. Congress recently passed the omnibus appropriations bill, which included $12 million for the Mentally Ill Offender and Treatment Crime Reduction Act (MIOTCRA). The act supports the enhancement of mental health treatment for offenders, educating law enforcement staff to react to incidents concerning individuals with mental illness, and assisting mental health courts to better meet the needs of this offender population (Richmond, M., personal communication, December 14, 2009). In addition, the Bureau of Justice has released several recent calls for proposals specific to services and/or research with OMI (particularly OMI with co-morbid substance abuse issues). Given previous findings that correctional mental health professionals are overwhelmed with offenders’ mental health needs (Boothby & Clements, 2000) with mental health services less accessible to an increasing number of offenders who require services (Boothby & Clements, 2000; Manderscheid, Gravesande, & Goldstrom, 2004) it is hopeful that additional resources will be allocated to rehabilitation programming rather than sanctioned approaches. Although the results of this study are informative regarding the availability, importance, and effectiveness of mental health services for OMI, some limitations of the study should be noted. First, although the survey utilized in this study has face validity and was pilot tested with experts providing treatment to OMI, the reliability and validity of reported information is unknown. This is particularly relevant with regard to perceptions of effectiveness which is likely to be the data from this survey

361

most susceptible to response bias. Just as client estimates of treatment effectiveness may be biased (e.g., Brock, Green, Reich, & Evans, 1996; Kotkin, Daviet, & Gurin, 1996), so too may treatment providers’ estimates of treatment effectiveness. Additionally, with over half of the participants acknowledging no specific training in correctional or forensic psychology during their post-baccalaureate training, one must question whether the study missed certain services. For instance, with few participants providing vocational counseling or vocational skills training to OMI, it may suggest that such services are provided to the ‘general offender population’ rather than OMI. Further, the low number of psychiatrists in the sample could suggest that other mental health services were missed in the study. Due to the fact that the study investigated psychotherapy and mental health functioning, the possibility also exists that some mental health providers do not consider riskneed interventions to be psychotherapy. Another limitation was that this study only assessed services provided to male OMI in state correctional facilities. Future research should examine mental health services available to other populations of OMI (e.g., juveniles, female OMI, federal prisoners, community-based services). In spite of these limitations, the findings of this study provide mental health professionals with a framework from which to develop their services for OMI. Specifically, six goals were conceptualized as important when working with OMI: mental illness recovery, emotions management, institutional functioning, re-entry, risk-need, and personal growth; however, inconsistent with the corrections literature mental health professionals de-emphasized principles of risk-need compared to the goals of mental illness recovery, institutional functioning, and personal growth. To produce the most positive outcomes, it appears that greater emphasis needs to be placed on balancing mental health and criminal justice needs when providing services to OMI (Morgan, Fisher, et al., 2010). Acknowledgments We thank Kelli Nilsson and Jessica Ezell for assistance with data collection and data entry for this study.

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