Bond or Conflict: The Role of the Alliance Among Adults with Serious Mental Illnesses and Criminal Justice Involvement

Background and Purpose: Roughly 16% of individuals in jails and prisons have mental illnesses (MI). Individuals with MI spend more time in custody, which often exacerbates symptoms, and are more susceptible to victimization by other inmates.  In response to concerns about the health and safety of individuals with MI in the justice system and the financial strain of incarceration, stakeholders advocated for mental health courts (MHCs).  MHCs are specialized courts based on principles aimed at addressing underlying causes of criminal behaviors in order to produce therapeutic outcomes. Rather than incarceration, MHC consumers receive supervised community treatment.

MHCs are growing rapidly across the nation. Research is beginning to shed light on outcomes like reduced criminal recidivism and increased access to services.  However, little is known about the factors facilitating change. The proposed paper focuses on one possible factor, relationships, by exploring the role relationships with MHC caseworkers play in promoting change. It is hypothesized that consumer perceptions of the alliance with their caseworker will be positively associated with program retention and service use.

Method: Participants were recruited from two mid-western, urban MHCs. All active MHC participants who were involved in the MHC between two and 18 months were invited to participate in the study.  Ninety-two individuals were eligible; eighty individuals consented to participation in the study. Study participants took part in a 60-minute structured interview involving survey questions and a battery of empirically-tested measures. The Working Relationship Scale (WRS), which includes a bond and conflict subscale, was used to measure the alliance.  The WRS is not a widely used measure; however, it is designed to capture the alliance within caseworker relationships from consumer perspectives. Descriptive statistics, bivariate analyses, and multiple regression are used to analyze the data.

Results: Participants were primarily African American (56%) and male (55%). Participants were, on average, 40 years old (SD=12.1). Most participants had a substance use disorder (83.8%).

The alliance with MHC caseworkers is significantly associated with service use when holding symptom severity, attitudes towards medication, months in the MHC, and race constant. Specifically, the conflict subscale, rather than the bond, is significant such that as conflict decreases, service use increases, B = -0.12 ± -0.23, -0.01, p = 0.05, f ² = 0.40.  Similarly, when controlling for MHC, number of months in the MHC, symptom severity, and substance use diagnosis, the conflict with MHC caseworkers was significantly lower among consumers who remained in or graduated from the MHC than individuals who quit or were terminated, OR = 0.91, p = 0.01.

Conclusions:  Among MHC participants, perceptions of conflict within relationships with caseworkers are one factor facilitating service use and engagement. These findings have important implications for social work practice. Although the bond with caseworkers does matter, perceptions of conflict are even more important in promoting treatment engagement. Conflict with caseworkers is likely inevitable as conflict is a natural part of relationships. Caseworkers should be equipped with strategies that are helpful in managing conflict openly with clients in order to address conflict in a therapeutic way.