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Persons with SMI In the Criminal Justice System: Resources

The below resources provide an overview of the issue, current practices and recommendations, transitioning from incarceration to the community, and recommendations for incarceration alternatives.


Individuals with mental health needs are over-represented in jails and prisons across the United States. While incarcerated, per the ruling set forth in Ruiz vs. Estelle, individuals with serious mental illness (SMI) are entitled by law to mental health treatment that includes standard mental health screening, as well as crisis and suicide intervention. More specialized mental health treatment varies across the prison system depending on type of facility (e.g., jail versus prison), level of security (e.g., minimum versus maximum) (AHRQ), and region and funding. There are also often barriers to basic care including lack of staff retention and training, difficulty maintaining continuity of care, and the environment of most prisons and jails, which often further harm individuals with SMI and continue the cycle of arrest and incarceration (CWRU). Due to these limitations, barriers, and inconsistencies, there is difficulty in both generating and implementing best practices for SMI treatment with the prison system, though there are basic recommended practices. In recent years there has been more emphasis on diversion and re-entry treatment practices which have often been found to be more effective (CWRU).

Recommendations & Standards for Corrections

Key recommendations identified by experts at a 2020 National Institute of Justice national workshop to address the mental health crisis in correctional environments included:

  • Prioritization of mental illness and dedicated sustainable treatment resources, as well as justice system advocacy for better access to community treatment.
  • Prevention of mental illness, early detection, and intervention, particularly for children.
  • Training that fosters improved responses to individuals with SMI for law enforcement agencies.
  • Increased resources for criminal justice institutions to facilitating addressing the mental health needs of incarcerated persons and traits that inform criminal tendencies (i.e., criminogenic needs).
  • Coordinated discharge planning that ensures continuity of care in the community.
  • Connection between the criminal justice system and the mental health system to provide better care to individuals with SMI

Rehabilitation in Prison

Research in the area of inmate rehabilitation continues to provide more clarity around the key issues to addressed in order to provide a comprehensive model of care for persons with mental health needs in prison. These include:

  • Screening for mental illness at reception and other critical times is vitally important.
  • If need is identified, considering if hospital transfer is required or if prison-based care through a treatment pathway such as mental health in-reach teams is an option.
  • Multi-disciplinary teams can address complex mental health and social care needs.  In jurisdictions where indigenous populations or ethnic minorities are over‐represented in the populations, these teams should include relevant cultural expertise.
  • Release planning is an opportunity for “critical time intervention” to ensure continuity of care across providers as the individual transitions to the community. Systematic prison in‐reach models of care are showing positive effects on identifying individuals who require assistance and improving engagement with mental health services after release.

Recommended Minimum Standards for Local & Regional Jails

A 2018 Virginia Department of Behavioral Health & Developmental Standards workgroup developed the following recommended standards for mental health in local regional jails:

1. Access to Care: Inmates have access to care to meet their mental health needs.
2. Policies & Procedures: The facility has a manual or compilation of policies and defined procedures regarding mental health care services which may be part of larger health care manual.
3. Communication of Patient Needs: Communication occurs between the facility administration and treating mental health care professionals regarding inmates’ significant mental health needs.
4. Mental Health Training for Correctional Officers: A training program established or approved by the responsible health authority in cooperation with the facility administration guides the mental health related training of all correctional officers who work with inmates.
5. Mental Health Care Liaison: A designated, trained mental health care liaison coordinates the health services delivery in the facility on those days when no qualified health care professionals available for 24 hours.
6. Medication Services: Medication services are clinically appropriate and provided in a timely, safe and sufficient manner.
7. Mental Health Screening: Mental health screening is performed on all inmates on arrival at the intake facility to ensure that emergent and urgent mental health needs are met.
8. Mental Health Assessment: All inmates receive mental health screening; inmates with positive screens receive a mental health assessment.
9. Emergency Services: The facility provides 24 hour emergency mental health services.
10. Restrictive Housing: When an inmate is held in restrictive housing, staff monitor his or her mental health.
11. Continuity & Coordination of Health Care During Incarceration: All aspects of health care are coordinated and monitored from admission to discharge.
12. Discharge Planning: Discharge planning is provided for inmates with mental health needs whose release is imminent.
13. Basic Mental Health Services: Mental health services are available for all inmates who need services.
14. Suicide Prevention Program: The facility identifies  inmates at risk for suicide and intervenes

Incarceration Alternatives

Several approaches to divert individuals with mental illness from jails and into treatment programs are gaining traction in communities. Overall, the strategies promote treatment over indictment.

Pre-Arrest Intervention
Crisis Intervention Teams, which are formal partnerships between police departments and mental health providers, ensure that personnel responding to a call are trained to identify, assess, and de-escalate mental health crisis situations. According to NAMI these teams lead to reduced arrest rates, increased used of diversion programs, and reduced number of injuries to responding officers.

Mental Health Courts
The first appearance in court presents an opportunity to route defendants with mental health needs away from the traditional criminal justice process. Mental health courts address defendants’ mental health needs by coordinating the expertise of judicial officers, prosecutors, defense counsel, and treatment and supervision personnel. Still holding an individual accountable for their actions, these courts can be used prior to or after a guilty plea, and a successful completion of the program may result in clearing of defendants’ criminal records.

Therapeutic Diversion Units
These multi-disciplinary treatment units are a promising alternative to restrictive housing and are designed to enhance the care and custody of individuals with mental illness. They use evidence based approaches to help participants develop emotional regulation and self management skills, understand their symptoms, and prepare for re-entry into less restrictive environments. With these units, an offenders’ housing, treatment, and advancement through the program are guided by a manual, along with individualized treatment plans and interventions.

Transitioning from Incarceration to the Community

Also known as reentry, this transition involves unique needs and challenges for those with mental health needs.

Reentry needs include:

  • Employment
  • Physical and Mental Health Care
  • Housing
  • Social Support

Examples of interventions provided when transitioning to the community include:

  • Discharge or release planning
  • Critical Time Intervention (CTI)
  • Case Management Interventions
  • Intensive Community Treatment

Reentry Principles
Evidence shows that using the three principles of risk, need, and responsibility increase the likelihood of success.

Risk: The level of service that persons receive should be matched to their risk of recidivism.Need: persons should be assessed for their unique criminogenic needs. Responsivity: persons must be provided appropriate interventions for their learning style and motivation.

Adapted from Bonta, J., & Andrews, D. A. (2007). Risk-need-responsivity model for offender assessment and rehabilitation. Ottawa, Canada: Her Majesty the Queen in Right of Canada. Retrieved from 


Community-Based Services

SAMHSA has developed eight principles for community mental health providers serving people with mental and substance use disorders who are currently involved with or have a history of involvement in the adult criminal justice system:

  • Community providers are knowledgeable about the criminal justice system.
  • Community providers collaborate with criminal justice professionals to improve public health, public safety, and individual behavioral health outcomes.
  • Evidence-based and promising programs and practices in behavioral health treatment services are used to provide high quality clinical care for justice-involved individuals.
  • Community providers understand and address criminogenic risk and need factors as part of a comprehensive treatment plan for justice-involved individuals.
  • Integrated physical and behavioral health care is part of a comprehensive treatment plan for justice-involved individuals.
  • Services and workplaces are trauma-informed to support the health and safety of both justice-involved individuals and community providers.
  • Case management for justice-involved individuals incorporates treatment, social services, and social supports that address prior and current involvement with the criminal justice system and reduce the likelihood of recidivism.
  • Community providers recognize and address issues that may contribute to disparities in both behavioral health care and the criminal justice system.

Mental Health Treatment for Justice Involved Individuals

Evidence-Based Programs
Assertive Community Treatment
Critical Time Intervention
Integrated Mental Health and Substance Use Services
Supported Employment
Permanent Supportive Housing

Promising Programs
Forensic ACT (FACT)
Forensic Intensive Case Management (FICM)
Assisted Outpatient Treatment (AOT)

Evidence-Based Practices
Cognitive Behavioral Therapy
Motivational Interviewing

Promising Practices
Cognitive Behavioral Treatment Targeted to Criminogenic Risks
Case Management
Forensic Peer Specialists

(SAMHSA, 2019)

Treatment of Substance Use Disorders for Justice Involved Individuals

Evidence-Based Programs
Modified Therapeutic Community (MTC)

Promising Programs
12-step or Other Mutual Aid Groups
Peer-based Recovery Support Programs

Evidence-Based Practices
Cognitive Behavioral Therapy (CBT)
Motivational Interviewing
Contingency Management Interventions
Pharmacotherapy (i.e., Medication-assisted treatment)
Relapse Prevention Therapy
Behavioral Couples Therapy (BCT)

Promising Practices
Case Management

(SAMHSA, 2019)

Criminal Justice System

Guidelines for Successful Transition of People with Mental or Substance Use Disorders from Jail and Prison: Implementation Guide

Provides examples of the implementation of successful strategies for transitioning people with mental or substance use disorders from institutional correctional settings into the community.
Criminal Justice System

An Overview of Evidence-Based Practices and Programs in Prison Reentry

An article from the Illinois Criminal Justice Information Authority Research and Analysis Unit covering best practices for parole supervision, evidence-based reentry principles, and evidence-based reentry programs.
Criminal Justice System

What Works in Reentry Clearing House

A collection of research on the effectiveness of a wide variety of reentry programs and practices, featuring programs rated by the National Institute of Justice’s
Criminal Justice System

National Reentry Resource Center

Briefs, funding opportunities, reports, research, and toolkits from this organization funded and administered by the U.S. Department of Justice's Office of Justice Programs, Bureau of Justice Assistance (BJA),
Criminal Justice System

Principles of Community-based Behavioral Health Services for Justice-involved Individuals: A Research-based Guide

SAMHSA information pertaining to supporting community-based behavioral health providers in their clinical and case management work with individuals who have mental and substance use disorders and either have current