Treatment of Offenders with Mental Disorders.

Author:Geraghty, Thomas F.
Position::Review
 
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TREATMENT OF OFFENDERS WITH MENTAL DISORDERS. Robert M. Wettstein, editor. The Guilford Press 1998. 438 pp.

This useful book provides a number of valuable perspectives on the pressing problem of how to address the treatment needs of mentally-ill offenders. The book also addresses the needs of prison, hospital, and community-based administration and staff, whose multi-faceted and sometimes contradictory responsibilities are: to protect the public, to provide humane treatment for patients aimed at the release of most from custody, and to provide a safe, supportive, and productive working environment for those who work with mentally-ill offenders. An added challenge of working with mentally-ill offenders is the reality that even with the best treatment programs, predictions of future conduct can never be certain. However, the public demands protection from offenders who are feared, sometimes with, and sometimes without justification, to be dangerous recidivists.(1) The dilemma of the therapeutic community is to respond to its duty to patients as well as to the political realities which can affect the efficacy and scope of programs designed to reintegrate mentally-ill offenders back into the community.

The problem is pressing because the number of our citizens subject to the jurisdiction of our penal systems has risen sharply in recent years. With that increase, those charged with addressing the problems of mentally-ill offenders see increasing numbers of inmates who are mentally-ill. Estimates of the percentage of the mentally-ill in prison populations vary from 5%-16% with serious mental illness, 35% with personality disorders, and 25% with substance abuse problems.(2) Adding to the gravity of the situation, 2%-10% of the prison population meet the diagnostic criteria for mental retardation, and 88% of the remaining population is mildly impaired.(3) Sexual offenders are a particularly difficult population to treat, especially those whose behavior is chronic.(4) Indeed the Supreme Court of the United States, in response to evidence that this population is difficult to treat, permitted the state of Kansas to civilly detain a prisoner who had completed his sentence on the ground that he was dangerous due to a "mental abnormality" rather than a mental illness.(5) The various approaches to treating this population need further evaluation, the evidence tending to support the development of "comprehensive" treatment programs.(6) The provision of mental health services for delinquents is also a key issue for the therapeutic community. Unfortunately, the provision of services to children in trouble with the law is governed more by what services are "available" than by informed choices based upon knowledge of appropriate treatment choices.(7)

The legal rules governing the rights of offenders who are mentally-ill are evolving in response to the realities of prison and community based correctional systems. In an informative chapter on the development of the law governing the administration of treatment programs for mentally-ill offenders, (including those in prisons, mental hospitals, and out-patient treatment settings), Thomas Hafemeister documents the tension between the needs of administrators for flexibility in running their programs and the treatment needs of mentally-ill prisoners, noting that

[a]lthough only a limited right to treatment for nonsentenced offenders with mental disorders has been recognized, ironically, pressure for an enhanced right to treatment may come from a setting where traditionally few individual rights were recognized, namely prisons.... Judges presiding over prison cases have shown a tendency to discuss whether the treatment provided represents a substantial departure from the professional judgment expected in this setting.(8) Hafemeister's chapter also discusses such important issues as the right to refuse treatment, the law governing treatment techniques such as aversive therapies and experimental drug programs, and informed consent for experimental programs. This comprehensive chapter also includes discussion of the law governing disclosure of information gained in the course of treatment, transfers from one institution to another, the conflict between the need for community placements and community concerns about safety, and the power of legislatures to maintain control over "dangerous," but not "mentally-ill" offenders.(9)

The chapters which address the legal...

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