Vera Institute of Justice

There is growing public recognition that the number of people diagnosed with serious mental illness in the U.S. criminal justice system has reached unprecedented levels. In 2007, there were more than 2 million jail bookings of people with serious mental illness.1 Although prevalence estimates of serious mental illness in jails and prisons vary widely depending on methodology and setting (jail or prison), recent research estimates that approximately 15 percent of men and nearly one-third of women in jail settings have a serious mental illness and that rates of serious mental illness in state prison populations are at least two to four times higher than community populations.2 This reality places a significant strain on institutional and community resources, including increased expenditures on incarceration. And it sheds light on why so many formerly incarcerated people face daunting prospects for successfully reintegrating into society. Seeking to mitigate these corrosive outcomes, local and state governments have developed a range of programs over the past two decades to serve people with serious mental illness in contact with the criminal justice system.3

The driving idea of interventions developed during the past 20 years is to keep people with serious mental illness out of jails and prisons when possible through prevention and diversion programs and to provide appropriate mental health services to those who need them during and after incarceration.4 Unfortunately, however well intentioned this first generation of interventions is, it has become increasingly clear that it has done little to reduce the number of incarcerated people with serious mental illness.5 Because of the human toll and the staggering expense of incarcerating people with mental illness, policymakers and practitioners in both mental health and justice fields have begun to reevaluate existing policy and practice and to think creatively about what it will take to make meaningful change in how to respond to people with mental illness.6

This report outlines a new framework for designing and delivering integrated mental health and criminal justice interventions. It is predicated on creating mental health treatment programs that intervene consistently and productively at the outset of people’s criminal justice involvement. After an evaluation of current practice and a discussion of the developing new generation of interventions, the report then draws upon interviews with 11 experts in the field to propose a “first-episode incarceration” framework (modeled on first-episode interventions in the treatment of psychosis) for people who have been diagnosed with mental illness and are in contact with the criminal justice system for the first time. Such a framework is rooted in prevention and early intervention, evidence-informed care, and recovery-oriented practice.7 The goal of the report is to seize the opportunity opened up by the current public debate about how to respond to the dearth of care for people with mental illness who come into the criminal justice system, thereby spurring creative thinking and cross-sector collaborations among mental health and justice system practitioners and policymakers.