Mr. A, age 35, presents to your outpatient community mental health practice. He has a history of psychosis that began in his late teens. Since then, his symptoms have included derogatory auditory hallucinations, a recurrent persecutory delusion that governmental agencies are tracking his movements, and intermittent disorganized speech. At age 30, Mr. A assaulted a stranger out of fear that the individual was a government agent. He was arrested and experienced a severe psychotic decompensation while awaiting trial. He was found incompetent to stand trial and sent to a state hospital for restoration.
After 6 months of treatment and observation, Mr. A was deemed competent to proceed and returned to jail. He was subsequently convicted of assault and sentenced to 7 years in prison. While in prison, he received regular mental health care with infrequent recurrence of minor psychotic symptoms. He was released on parole due to his good behavior, but as part of his conditions of parole, he was mandated to follow up with an outpatient mental health clinician.
After telling you the story of how he ended up in your office, Mr. A says he needs you to speak regularly with his parole officer to verify his attendance at appointments and to discuss any mental health concerns you may have. Since you have not worked with a patient on parole before, your mind is full of questions: What are the expectations regarding your communication with his parole officer? Could Mr. A return to prison if you express concerns about his mental health? What can you do to improve his chances of success in the community?
Given the high rates of mental illness among individuals incarcerated in the United States, it shouldn’t be surprising that there are similarly high rates of mental illness among those on supervised release from jails and prisons. Clinicians who work with patients on community release need to understand basic concepts related to probation and parole, and how to promote patients’ stability in the community to reduce recidivism and re-incarceration. The court may require individuals on probation or parole to adhere to certain conditions of release, which could include seeing a psychiatrist or psychotherapist, participating in substance abuse treatment, and/or taking psychotropic medication. The court usually closely monitors the probationer or parolee’s adherence, and noncompliance can be grounds for probation or parole violation and revocation.
This article reviews the concepts of probation and parole (Box1,2), describes the prevalence of mental illness among probationers and parolees, and discusses the unique challenges and opportunities psychiatrists and other mental health professionals face when working with individuals on community supervision.
Box
Probation and parole in the United States
The US Bureau of Justice Statistics (BJS) defines probation as a “court-ordered period of correctional supervision in the community, generally as an alternative to incarceration.” Probation allows individuals to be released from jail to community supervision, with the potential for dismissal or lowering of charges if they adhere to the conditions of probation. Conditions of probation may include participating in substance abuse or mental health treatment programs, abstaining from drugs and alcohol, and avoiding contact with known felons. Failure to comply with conditions of probation can lead to re-incarceration and probation revocation.1 If probation is revoked, a probationer may be sentenced, potentially to prison, depending on the severity of the original offense.2
The BJS defines parole as “a period of conditional supervised release in the community following a term in state or federal prison.”2 Parole allows for the community supervision of individuals who have already been convicted of and sentenced to prison for a crime. Individuals may be released on parole if they demonstrate good behavior while incarcerated. Similar to probationers, parolees must adhere to the conditions of parole, and violation of these may lead to re-incarceration.1
As of December 31, 2016, there were more than 4.5 million adults on community supervision in the United States, representing 1 out of every 55 adults in the US population. Individuals on probation accounted for 81% of adults on community supervision. The number of people on community supervision has dropped continuously over the last decade, a trend driven by 2% annual decreases in the probation population. In contrast, the parolee population has continued to grow over time and was approximately 900,000 individuals at the end of 2016.2
Mental illness among probationers and parolees
Research on mental illness in people involved in the criminal justice system has largely focused on those who are incarcerated. Studies have documented high rates of severe mental illness (SMI), such as schizophrenia and bipolar disorder, among those who are incarcerated; some estimate the rates to be 3 times as high as those of community samples.3,4 In addition to SMI, substance use disorders and personality disorders (in particular, antisocial personality disorder) are common among people who are incarcerated.5,6
Comparatively little is known about mental illness among probationers and parolees, although presumably there would be a similarly high prevalence of SMI, substance use disorders, and other psychiatric disorders among this population. A 1997 Bureau of Justice Statistics (BJS) survey of approximately 3.4 million probationers found that 13.8% self-reported a mental or emotional condition and 8.2% self-reported a history of an “overnight stay in a mental hospital.”7 The BJS estimated that there were approximately 550,000 probationers with mental illness in the United States. The study’s author noted that probationers with mental illness were more likely to have a history of prior offenses and more likely to be violent recidivists. In terms of substance use, compared with other probationers, those with mental illness were more likely to report using drugs in the month before their most recent offense and at the time of the offense.7
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