Natalie Bonfine

Disease Burden Among Individuals with Severe Mental Illness in a Community Setting

This study examines the prevalence of comorbid physical health conditions within a community sample of individuals with severe mental illness (SMI), compares them to a matched national sample without SMI, and identifies which comorbidities create the greatest disease burden for those with SMI. Self-reported health status, co-morbid medical conditions and perceived disease burden were collected from 203 adults with SMI. Prevalence of chronic health conditions was compared to a propensity-matched sample without SMI from the National Comorbidity Survey-Replication (NCS-R). Compared to NCS-R sample without SMI, our sample with SMI had a higher prevalence of seven out of nine categories of chronic health conditions. Chronic pain and headaches, as well as the number of chronic conditions, were associated with increased disease burden for individuals with SMI. Further investigation of possible interventions, including effective pain management, is needed to improve the health status of this population.

Epidemiology of trauma: Childhood adversities, neighborhood problems, discrimination, chronic strains, life events, and daily hassles among people with a severe mental illness

Trauma during childhood and adolescence is a common event among people with a serious psychological disorder. Few studies assess a wide range of stressors for this population. This is surprising given that these stressful events are implicated in poorer outcomes related to course and treatment of mental health problems. This study of 214 people with serious mental illness examines the prevalence of childhood traumas, perceived neighborhood problems, discrimination, chronic strains, negative life events, and daily hassles. We use regression analyses to determine if these stressors are associated with quality of life. Results show that 95% of the sample report at least one childhood adversity. Perceived neighborhood problems, experiences of discrimination, chronic strains, life events, and daily hassles were also common. Examining the relationship between demographic factors and stressors suggests that older respondents, Whites, those who have never been married, and people diagnosed with Schizophrenia reported fewer stressors compared to those who are older, non-White, ever married, or suffering from other types of mental health problems. Finally, three of the six types of stressors were related to lower quality of life and depression. We discuss the implications of these findings for the treatment of severe psychological problems.

The Help-Seeking Experiences of Parents of Children with a First-Episode of Psychosis

The objective was to understand the experiences of parents as they sought psychological and specialized medical services for a loved one having a first episode of psychosis. The research method was qualitative and the data gathering was done through semi-structured interviews. Eleven parents of eight adolescent or young adult children consented to be interviewed. Data from these interviews were coded and sorted. Parents reported that many of their encounters resulted in delays in accessing treatment. These encounters were characterized by misattributions of the child’s behavior, poor advice, misdiagnosis, disbelief in the seriousness of the child’s condition, and an unwillingness to share information. But parents also reported that encounters with other individuals were characterized by helpful advice, emotional support, and suggestions as to how to access early intervention services. Encounters with many professionals were generally not helpful to parents. These encounters served as roadblocks to accessing proper treatment for their child. More publicity, outreach, and education are recommended in the professional community.

From Boundary Spanning to Deep Partnerships

The overrepresentation of people with serious mental illness in the criminal justice system is indisputable. The criminalization hypothesis suggests that deinstitutionalization and the reduced availability of psychiatric inpatient beds has resulted in the criminalization of symptomatic mental illness, with people being “transinstitutionalized” into jails or prisons. However, the interplay betweenmental illness, substance use, and criminal behavior appears far more complicated than that. For instance, symptomatic mental illness directly explains only a small proportion of criminal behavior. A larger proportion results from the same factors that get persons in the general population into trouble with the law. Given the scope and complexity of the overrepresentation problem, a broader conceptualization of its causes must be considered, and we should not restrict ourselves solely to the criminalization hypothesis. Instead, evidence suggests a need to shift to a “multiple risk” hypothesis, recognizing that the criminalization hypothesismay hold true for some individuals, at least some of the time, but thatmental illness, substance use, criminogenic factors, and other social factors all contribute to criminal justice involvement. Successfully addressing these multiple risks requires more than just collaboration across systems. The mental health and criminal justice systems share a target population of justiceinvolved people with mental illness who have diverse and complex needs.Mental illness should be expected amongmany served in the justice system, just as justice involvement shouldbe expected among many community mental health clients. Thus the problem belongs to both the mental health and criminal justice systems, and our two systems should develop what we call “deep partnerships.” Deep partnerships go beyond coordinating efforts between systems and instead require a more complete integration of values, principles, and practices. Developing such partnerships is not easy. Interrelated barriers include different professional orientations and languages and a lack of shared ownership of the problem and of programmatic solutions. Specifically, the criminal justice system values public safety, and the mental health and addictions systems focus on public health. Different professional orientations can create deep divides between the disciplines. Few of us “speak” both mental health and criminal justice, and probably fewer read each other’s literature. Thus this literature can be confusing because key words may have multiple meanings that are often undefined. “Risk” may refer to criminogenic risk, meaning the risk of recidivism, or perhaps to violence risk, suicide risk, or risk of psychiatric relapse and hospitalization. Understanding the type of risk being assessed is crucial for determining appropriate interventions. Intensive correctional supervision is best reserved for those with high or moderate criminogenic risk, but people in jail diversion programs may be selected because of high or moderate psychiatric risk, without consideration of their level of criminogenic risk. “Treatment” can have different targets, with correctional treatment addressing criminogenic risk factors and mental health treatment targeting symptoms and level of functioning. Further, the goals of such treatment may differ: correctional treatment seeks to reduce recidivism, whereas mental health and addiction treatment aims to prevent relapse, reduce symptoms, and improve functioning and quality of life. Once we learn each other’s language, both systems should develop a shared mission that incorporates the values of public safety and public health. Buying into a shared mission is critical for developing shared ownership of programs. By this we mean that program implementation integrates the expertise of mental health, addictions, and criminal justice professionals who have equal investment in the success of the program. We propose that jail diversion programs such as mental health courts or crisis intervention teams will be most effective when all stakeholders identify the program as their own. Doing this requires that all parties do something different from business as usual. Shared ownership requires sharing power and control. The concept of a boundary spanner has long been promoted in the literature as integral for successful jail diversion. In this issue, Skeem, Steadman, and Manchak are spanning disciplinary boundaries with their discussion of the risk-need-responsivity model. Such a model is of great interest to the mental health community and may provide an orienting framework for developing shared ownership. However, we believe that more than boundary spanning is necessary—we need to form deep partnerships. If boundary spanning can be seen as providing a translator for those who speak different languages, a deep partnership implies that all parties are multilingual. When we all speak the same language we can develop the shared vision and mission needed to form deep partnerships. Only then are we likely to successfully address the overrepresentation of people with mental illness in the justice system.

Sequential Intercept Mapping: Developing Systems-Level Solutions for the Opioid Epidemic

Sequential intercept mapping, a community-based application of the sequential intercept model, was recently adapted in Ohio to address the complex challenge of the opioid crisis. Sequential intercept mapping for opioids provides a framework for criminal justice, mental health and addictions treatment providers, family members and opioid-involved individuals, and other stakeholders to develop community-based responses that emphasize prevention, regulation, and treatment for opioid dependency, with a goal of reducing unintended deaths and overdoses. The authors describe a promising approach to using sequential intercept mapping to address the opioid crisis.

Interventions That Target Criminogenic Needs for Justice-Involved Persons With Serious Mental Illnesses: A Targeted Service Delivery Approach:

This research describes the development of a targeted service delivery approach that tailors the delivery of interventions that target criminogenic needs to the specific learning and treatment needs of justice-involved people with serious mental illnesses (SMIs). This targeted service delivery approach includes five service delivery strategies: repetition and summarizing, amplification, active coaching, low-demand practice, and maximizing participation. Examples of how to apply each strategy in session are provided, as well as recommendations on when to use each strategy during the delivery of interventions that target criminogenic needs. This targeted service delivery approach makes an important contribution to the development of interventions for justice-involved people with SMI by increasing the chances that people with SMI can participate fully in and benefit from these interventions that target criminogenic needs. These developments come at a critical time in the field as the next generation of services for justice-involved people with SMI are being developed.

Translating Interventions that Target Criminogenic Risk Factors for use in Community Based Mental Health Settings

This study explored facilitators and barriers associated with engaging criminogenic interventions in community mental health service settings. Focus groups and guided large group discussions were conducted with 46 consumers, providers and administrators. Results suggest that participants were generally supportive of offering criminogenic interventions to justice involved persons with serious mental illness in community based mental health service settings. Key issues to consider when engaging criminogenic interventions in community mental health service settings include identifying sustainable funding sources, providing adequate training for staff, and tailoring the delivery and pace of the content to the particular treatment needs of SMI participants.