Relational Leverage in a Reentry Program for Seriously Mentally Ill Ex-Offenders: An Alternative to Coercion?

Purpose: Alarming numbers of people with serious mental illness (SMI) in prisons have led to the development of specialized reentry services for this population, such as forensic assertive community treatment (FACT). While FACT is a promising model, its evidence base is not firmly established and controversy surrounds whether it should involve mental health-criminal justice system collaboration and most particularly, the use of leverage (e.g., threat of sanctions) to encourage adherence to treatment and program rules. Using ethnographic data from a study of forensic assertive community treatment for recently released prisoners with SMI, this presentation examines: 1) the involvement of FACT clinicians in enforcing parole stipulations; and 2) informal strategies used by clinicians to increase program compliance and success, as perceived by both program staff and clients.

Methods: This presentation uses data from a two-year ethnographic study of a FACT program in Chicago, IL. Respondents included 20 program participants, who were followed by a team of researchers for one year following prison release and program entry using participant observation, in-depth unstructured interviews, and structured surveys. Additional data sources included interviews with program staff, observation of staff meetings, and client program records. Analysis was guided by Schatzman's (1991) grounded dimensional analysis method and involved triangulation of perspectives (client, staff, and observer) around key dimensions and categories.

Results: Examination of baseline characteristics reveals that this group of ex-offenders is a high-risk sample in which most have significant histories of involvement in the criminal justice system. Over the first year of the program half of the sample was rearrested at least once, a third were hospitalized, and three returned to prison on new charges, and few were able to access high quality housing or competitive employment. Qualitative analyses showed that staff collaboration with parole and other correctional authorities was limited to client advocacy, and clinicians played no direct role in enforcing parole terms through sanctioning or leverage. Informal methods of promoting adherence took place via the money management/payee role and through the strategic use of interpersonal capital or “relational leverage” derived from clients' feelings of gratitude toward staff for facilitating the transition from prison. While client-staff therapeutic relationships generally remained strong across the first year, money management issues tended to produce friction, particularly for clients who did not fully understand the payeeship system.

Conclusions and Implications: Findings reinforce the intense challenges associated with serving former prisoners with serious mental illness who are under correctional supervision. The period following prison release proved to be an especially critical period for client engagement and building of the therapeutic relationship, which in turn motivated many clients to participate in treatment and avoid criminal activity. For mental health programs serving SMI offenders that choose to avoid contaminating the therapeutic role with social control/leverage functions, this study suggests that alternative strategies are available for encouraging adherence that preserve the quality of the client-provider relationship. Research that assesses the effectiveness of relational leverage in preventing recidivism among SMI offenders is an important next step.