Facilitators, Challenges and Strategies of Implementing a Specialized Probation Model for Adults with Severe Mental Illness: Variations in Rural and Urban Settings

Background and purpose: Adults with severe mental illnesses make up a substantial portion of the population under community supervision and have high rates of technical violations and recidivism. The features of specialty mental health probation (SMHP) include: (a) reduced caseload sizes; (b) specialized caseloads in which all probationers have a mental illness; (c) ongoing mental health training for officers; (d) a problem-solving approach for community supervision; and (e) enhanced collaboration with community resources and mental health providers. SMHP is widely disseminated; however, two key limitations in the literature inhibit high-fidelity model implementation. First, no studies describe the challenges and facilitators associated with the implementation of SMHP’s core elements. Second, although SMHP relies on probation officers interfacing with local community resources, the context in which the model is implemented (e.g., urban versus rural) has not been examined. To address these limitations, this study examined three research questions: (1) What are the challenges and facilitators of implementing SMHP? (2) What implementation strategies were used to address these challenges? and (3) How do the challenges, facilitators and implementation strategies vary across rural versus urban contexts?

Methods: We implemented a hybrid efficacy-implementation study in one urban and one rural county in a southeastern state and collected data from 26 key stakeholders using a semi-structured interview guide. We used a grounded theory approach to identify challenges, facilitators, and strategies used during the implementation of SMHP. Then, we deductively coded the strategies using a taxonomy from Powell et al. (2015) and then deductively coded the challenges and facilitators using the Consolidated Framework for Implementation Research (CFIR) from Damschroder et al. (2009). We enhanced the rigor of our analysis with consensus coding techniques (i.e., 100% coding agreement).

Results: Results suggest several implementation challenges, including probation agency vacancies, differences in language and communication across disciplines, and availability of community resources. Implementation facilitators included having committed leadership, building officer rapport with local agencies, and having interdisciplinary engagement. Multiple implementation strategies were identified, including developing stakeholder interrelationships, providing interactive assistance, and supporting probation officers. Further, each of the strategies facilitated the implementation of at least one SMHP component. Although implementation strategies were consistent between the rural and urban counties, strategy specification varied by the local context, particularly for developing stakeholder interrelationships.

Conclusions and Implications: This study addresses significant gaps in the literature that impede the scale up and fidelity of SMHP for probationers with severe mental illnesses. Our results illuminate the challenges and rewards of cross-system collaborations to address a significant public health and public safety issue and provide practical recommendations for implementation strategies for state and local entities to enhance the uptake and scalability of SMHP. In particular, agencies should focus on developing relationships across community stakeholders, providing interactive technical assistance to officers, and engaging leaders from across mental health and criminal justice systems to improve mental health and criminal justice outcomes for probationers with severe mental illnesses.