Specialized Caseloads: One Obvious Solution


In my last post, I raised the following question: How do we address the growing population of incarcerated individuals with mental illness?

One approach gaining popularity around the country is the idea of “specialized caseloads” for parole officers. Practically, what this means is that parolees with mental illness are assigned to parole officers who have received training on how to best manage this population and carry a reduced caseload.

One of my recent cases is a perfect example of how this can work:

Mr. M was a 47 year old man referred to me by his parole officer. He had been convicted years before of a bank robbery, and his prior terms of release had been unsuccessful, usually related to his use of cocaine and failure to take his prescribed medication. Within months of release, he relapsed and became psychotic, manic and disorganized. Standard parole officer responses of threats and ultimately of movement toward revocation ensued.

During the initial months of my treatment with him, he adhered to his medication regimen, participated in therapy sessions, engaged in 12 step meetings, and lived in a halfway house for people committed to recovery. After two years or so, he came to an appointment speaking rapidly and loudly, and he was somewhat disorganized. Despite these symptoms, he adamantly denied using cocaine or other drugs, insisted that he had been taking all of his medications as prescribed, and agreed to take any tests I asked him to take. However, he steadfastly refused to consider being admitted into the hospital even for a short period of stabilization.

I contacted his PO who spoke with Mr. M via speaker phone. The PO reinforced my recommendation that he agree to go into a hospital, but he continued to refuse. His PO asked him why he would not agree, expressing his concern with Mr. M that if he remained unstable and refused to hospitalize himself, the PO would be left with a decision about pursuing revocation. Mr. M then said: “Today is the 28th of the month. My check comes on the 3rd. If you live where I live and you ain't home when your check comes, it won't be there when you get back.”

After a bit more discussion, Mr. M agreed to enter a “day hospital,” which is a program where people attend intensive treatment during the day but return home every evening. Designed as a short term intervention, together we decided that this would be a reasonable compromise for Mr. M, allowing him to access more intensive evaluation and treatment while not removing him from his home setting. He attended the day hospital for three weeks, his medications were adjusted, and he returned to outpatient care and to his parole without further incident.

This plan worked because the PO and I had devised an agreement that problem behaviors should be seen first as requiring a therapeutic response, and only when therapeutic efforts failed to resolve the situation should enforcement actions be considered. This PO was a “mental health specialist” in his agency, carrying a reduced caseload of parolees, all of whom had mental health problems. His smaller caseload allowed him to do the needed case management that permitted his parolees to access care and minimized their returns to incarceration.

Examples of jurisdictions that provide specialized approaches to probationers or parolees with mental illness include the United States Probation Office, the Cook County Mental Health Unit, the New York State Division of Parole, and the Project Renewal Parole Support and Treatment Program.

Why don't all probation and parole offices have specialized caseloads? Given the prevalence of mental health issues among the parolee and probationer population, this seems to be an obvious solution. Is it really that much more expensive than recurrent incarcerations?

Erik Roskes is a forensic psychiatrist and currently the Director of Forensic Services at the Springfield Hospital Center in Maryland. The opinions expressed are those of the author only, and do not represent those of any of Dr. Roskes' employers or consultees, including the Maryland Department of Health and Mental Hygiene. He can be found a http://mysite.verizon.net/eroskes.

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