Special Populations of Clients with Mental Illness

SPECIAL POPULATIONS OF CLIENTS WITH MENTAL ILLNESS

Homeless Population

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.

Prisoners

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.