SPECIAL POPULATIONS OF CLIENTS
WITH MENTAL ILLNESS
Homeless people with mental illness have been the focus of recent
studies. For this population, shelters, rehabilita-tion programs, and prisons
may serve as makeshift alter-natives to inpatient care or supportive housing.
Frequent shifts between the street, programs, and institutions worsen the
marginal existence of this population. Com-pared with homeless people without
mental illness, men-tally ill homeless people are homeless longer, spend more
time in shelters, have fewer contacts with family, spend more time in jail, and
face greater barriers to employment (National Resource and Training Center on
Homelessness and Mental Illness, 2006). For this population, profession-als
supersede families as the primary source of help.
Providing housing alone does not significantly alter the prognosis
of homelessness for persons with mental illness. Psychosocial rehabilitation
services, peer support, vocational training, and daily living skill training
are all important components for decreasing homelessness and improving quality
of life. In the early 1990s, the federal government authorized a grant program
to address the needs of people who are homeless and have mental illness. The
program Projects for Assistance in Transition from Homelessness (PATH) funds
community-based outreach, mental health, substance abuse, case management, and
other support services. Some limited housing services are available, but PATH
works primarily with existing housing services in the given community
(Substance Abuse and Mental Health Services Administration, 2006).
The Center for Mental Health Services initiated the Access to Community Care and Effective Services and Support (ACCESS)
Demonstration Project in 1994 to assess whether more integrated systems of service delivery enhance the quality of
life of homeless people with serious mental dis-abilities through the use of
services and outreach. ACCESS was a 5-year demonstration program located within
15 U.S. cities in nine states that represented most geographic areas of the
continental United States. Each site provided outreach and intensive case
management to 100 homeless people with severe mental illnesses every year.
Participants in the first 2 years of the ACCESS demon-stration
project were surveyed to determine whether they had formed a relationship with
their assigned case manag-ers and what, if any, differences they experienced in
terms of homelessness, symptom management, and use of sub-stances. A total of
2,798 participants completed the survey process. Only 48% reported having
relationships or per-sonal connections with their case managers, underscoring
the difficulty in establishing therapeutic relationships with homeless mentally
ill clients. Clients reporting such rela-tionships described more social
support, received more public support and education, were less psychotic, were
homeless fewer days, and were intoxicated fewer days than participants who
reported having no relationship with their assigned case managers. Although
engaging this pop-ulation in therapeutic relationships is difficult, results
are positive when those relationships are established.
The most recent report from the ACCESS project found that
participants reported multiple factors that influence their quality of life;
managing psychiatric symptoms and receiving social support were most important.
The data from this report suggest that focusing treatment on the mul-tiple
independent domains of psychiatric illness, social sup-port networks, work and
income, housing, and increased service use is necessary to maximally improve
clients’ self-assessed quality of life and decrease the number of homeless
days. These positive outcomes were maintained after termi-nation of the
intervention (Rothbard, Min, Kuno, & Wong, 2004). Desai and Rosenheck
(2005) studied persons in the ACCESS project in terms of unmet physical health
needs. They found that collaborative case management played an important role
in improving the physical health of partici-pants by linking them to
appropriate medical services.
The rate of mental illness in the jailed population is 13%,
compared with 2% in the general population. Offenders gen-erally have acute and
chronic mental illness and poor func-tioning, and many are homeless. Factors
cited as reasons that mentally ill people are placed in the criminal justice
sys-tem include deinstitutionalization, more rigid criteria for civil
commitment, lack of adequate community support, economizing on treatment for
mental illness, and the atti-tudes of police and society (Gostin, 2008). Criminalization of mental illness refers to the practice of arresting and
pros-ecuting mentally ill offenders, even for misdemeanors, at a rate four
times that of the general population in an effort to contain them in some type
of institution where they might receive needed treatment. However, if offenders
with mental illness had obtained needed treatment, some might not have engaged
in criminal activity.
The public concern about the potential danger of peo-ple with
mental illness is fueled by the media attention that surrounds any violent
criminal act committed by a mentally ill person. Although it is true that
people with major mental illnesses who do not take prescribed medica-tion are
at increased risk for being violent, most people with mental illness do not
represent a significant danger to others. This fact, however, does not keep
citizens from clinging to stereotypes of the mentally ill as people to be
feared, avoided, and institutionalized. If such people can-not be confined in
mental hospitals for any period, there seems to be public support for arresting
and incarcerating them instead. In fact, people with a mental illness are more
likely to be the victims of violence, both in prisons and in the community
(Blitz, Wolf, & Shi, 2008).
People with mental illness who are in the criminal jus-tice system
face several barriers to successful community reintegration:
·
Poverty
·
Homelessness
·
Substance use
·
Violence
·
Victimization, rape, and trauma
·
Self-harm
Some communities have mobile crisis services linked to their police
departments. These professionals are called to the scene (after the situation is
stabilized) when police officers believe mental health issues are involved.
Fre-quently, the mentally ill individual can be diverted to crisis counseling
services or to the hospital, if needed, instead of being arrested and going to
jail. Often, these same profes-sionals provide education to police to help them
recognize mental illness and perhaps change their attitude about mentally ill
offenders.
Steadman and associates (2005) piloted the Brief Jail Mental Health
Screen (BJMHS) at Cook County jail in Chicago. This is an eight-item
questionnaire that can be administered in 2.5 minutes. Each detainee was given
the questionnaire to see if further evaluation or referral for mental health
services was indicated. The BJMHS correctly classified 73.5% of males, but only
61.6% of females. This led the authors to suggest that this brief screening
tool would increase effective identification and referral of male detainees
and, therefore, could be useful as a standard part of jail admission.
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