August 2008
In This Issue…
 Facts and figures .......... 1
 Risk factors ................... 2
 Jail diversion.................. 3
 In-reach programs......... 4
Volume 1, Issue 2
 Reentry programs ......... 4
Practical advice from the Co-Occurring
and Homeless Activities Branch
The Intersection of Cooccurring Disorders,
Homelessness, and the
Criminal Justice System
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People who are homeless and have co-occurring
substance use and mental disorders often cycle
through the criminal justice system, moving from
the street or the shelter to jail or prison and back.
This situation is perpetuated by the lack of
appropriate treatment and social services; the
criminalization of homelessness; the dearth of
affordable, appropriate housing; and related risk
factors. Programs tailored to address these
problems must respond to the needs of the
population specific to their setting. Interventions
include those at the front door of the justice
system (e.g., jail diversion, crisis intervention
teams), within jail or prison, and on discharge.

 The success of IDDT ..... 5
 References .................... 7
than individuals who do not have these
disorders.3
An estimated 1,100,000 people—8 percent
of annual jail bookings—have current
symptoms of serious mental illness.4
Twenty percent of State prison inmates, 19
percent of Federal prison inmates, and 30
percent of local jail inmates with mental
illnesses were homeless in the year before
their arrest.5 In addition, these offenders
report a high incidence of substance use, and
more than half are under the influence at the
time of their crime.6
People with co-occurring disorders who are
homeless are arrested more often,
incarcerated for longer periods of time, lack
access to treatment in jail or prison, are
discharged without adequate planning, and
are re-arrested at higher rates.7
Risk Factors for Criminal Justice System
Involvement
Numerous individual and systemic factors
contribute to the overrepresentation of people
with co-occurring disorders and people who are
homeless in the criminal justice system. They
include those noted below.
Scope of the Problem
In February, the PEW Center on the States
released a report with the grim statistic that for
the first time in our Nation’s history, more than 1
in 100 American adults are behind bars.1 Previous
research has revealed that co-occurring disorders,
homelessness, and incarceration are inextricably
linked. For example, we know that:
 The prevalence rate of substance use
disorders among both male and female jail
detainees with serious mental illnesses is 72
percent.2
 Individuals with substance use disorders or
mental illnesses are more likely to be arrested
Criminalization of Homelessness
In 2006, advocacy organizations reported that
“city ordinances frequently serve as a prominent
tool to criminalize homelessness”.8 These
measures prohibit activities such as
sleeping/camping, eating, sitting, and begging in
public spaces, and usually include criminal
penalties for violations. The laws have become
increasingly popular during the past 25 years
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News & Views: A Bimonthly Newsletter
because communities are concerned about
violent, unpredictable, or inappropriate behavior
in their localities. However, proper treatment,
rather than incarceration, enables individuals to
control risk factors, such as substance use,
associated with socially undesirable behavior.9
Frequently, law enforcement officials feel
compelled to arrest people who are homeless for
lack of better options. In one study, 29 percent of
jail administrators stated that they incarcerate
homeless individuals with behavioral problems
who are not facing criminal charges.14
The laws criminalizing homelessness are having
an impact: rates of multiple arrests are four times
higher for homeless men than for domiciled
men.10 However, observers note, the laws do
nothing to address the underlying causes of
homelessness. Instead, they make the problems
more difficult to identify and treat. People who are
made to “move along” frequently move away from
services. When individuals are arrested and
charged under these measures, they develop
criminal records, making it more difficult to obtain
employment or housing. Furthermore,
criminalization measures are not cost efficient. In
a nine-city survey of supportive housing and jail
costs, jail costs were on average two to three
times the cost of supportive housing.11
“I’d go to jail at least twice a week for sleeping
in the park, sleeping on the street, possession of
[drug] paraphernalia, drinking beer in public
… [and] when they released me, they released
me right back into the same thing.”
—Kenny, Housing Rapid Response client, Portland,
Oregon, as told to a caseworker
High Rates of Trauma
Research points to high prevalence rates of
sexual abuse and other trauma in the lives of
people with co-occurring disorders who are
homeless, particularly women.15 Findings also
indicate a 90 percent lifetime prevalence of
trauma among participants in the CMHS
Treatment Capacity Expansion for Jail Diversion
Program, according to Henry J. Steadman, Ph.D.,
Director of the National GAINS Center for
Evidence-Based Programs in the Justice System.
The Lack of Appropriate Housing
Although homelessness and incarceration are
linked, a causal relationship has not been
established. Nonetheless, the high rates of
homelessness among populations in the justice
system and high rates of incarceration among
individuals who are homeless are at least partially
explained by the lack of accessible and
appropriate housing.12 Reasons for the lack of
suitable housing include13:
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Volume I, Issue 2
The high prevalence of trauma and its
implications often go unacknowledged and
unaddressed in the criminal justice system. For
example, behavior triggered by memories of past
traumas often is misdiagnosed and viewed as
resistance to engaging in the treatment program,
notes Joan Gillece, Ph.D., with the National Center
for Trauma-Informed Care. A future issue of News
& Views will focus on the need to develop traumainformed services and systems for people with cooccurring disorders who are homeless.
Regional Department of Housing and Urban
Development (HUD) regulations prohibiting
individuals with substance use problems from
applying for public housing
Community opposition to providing local
housing for people who have criminal records
and/or histories of homelessness, substance
use problems, and mental illnesses
Heightened demand due to increasing
numbers of former prisoners released into the
community
Limited numbers of residential community
programs for individuals with co-occurring
disorders
Successful Interventions
Evidence indicates that clinical interventions can
succeed at various points in the criminal justice
system, such as during pre- and post-booking, jail
or prison confinement, or reentry into the
community. Ideally, most people will be
intercepted at early points, with decreasing
numbers at each subsequent point.
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News & Views: A Bimonthly Newsletter
Volume I, Issue 2
client compliance to avoid jail or prison time.
Previously used for individuals with either
substance use disorders or mental illnesses,
specialty courts are being established to assist
individuals with co-occurring disorders and people
who are homeless. For example:
Diverting People at the Front Door of the
Criminal Justice System
Jail diversion programs target low-level offenders
with behavioral problems that would likely cause
them to cycle in and out of the criminal justice
system. The programs provide participants with
community-based services in lieu of jail or prison
time. The number of jail diversion programs has
increased from just a handful in the late 1990s to
more than 500 today. All diversion programs
engage in some form of community linkage, but
no definitive organizational model exists.16


Although few systematic outcome studies have
been conducted to examine the effectiveness of
diversion programs, a recent study found that
clients received more counseling, medication, and
other treatments, Dr. Steadman notes.
Pre-booking jail diversion programs are initiated at
the client’s point of contact with law enforcement
officers and rely heavily on effective interactions
between police and community treatment
programs. Because potential clients may walk
away from these voluntary programs, treatment
providers often incentivize participation. For
example, clients may receive temporary housing,
fresh clothes, or help signing up for entitlement
programs. These incentives also appear to be
effective tools for client retention, according to Dr.
Steadman.
Lane County, Oregon, has developed a court
for minor offenders with co-occurring
disorders. Results thus far show that this cooccurring drug court model has provided
enhanced supervision and increased
treatment adherence.18
Contra Costa County, California, now has court
sessions in shelters for individuals who are
homeless and accused of minor legal
violations. Participants are given credit for
participating in the program, which includes
activities designed to help them reintegrate
into the community, and for adhering to their
treatment plan.
Jail- and Prison-Based Programs
Individuals not selected for diversion programs
may receive services in jail or prison. Jail stays are
short, usually ranging from 72 hours to 1 year.
Prison stays are usually 1 year or longer. The
prison or jail setting often presents a unique
opportunity for introducing services to
underserved populations. With mandatory health
screening upon booking, jails and prisons
frequently become the first place a person
receives a diagnosis of mental illness. For people
with substance use disorders, incarceration may
offer a window of opportunity to initiate
treatment.6
Most pre-booking programs are characterized by
specialized training for police officers and a 24hour crisis drop-off center with a no-refusal policy
for persons brought in by the police. Studies show
that police-based diversion programs, especially
those modeled after the Crisis Intervention Team
(CIT) approach developed in Memphis, Tennessee,
significantly reduce arrest and re-arrest rates.17
Key Memphis model components are training and
collaboration: officers receive 40 hours of training
and work extensively with local substance abuse
and mental health treatment providers.
Jail programs provide rapid screening and
assessment, court liaison services, and reentry
planning. These programs also often provide
short-term interventions such as
psychoeducation. Specific challenges for jail
programs center on motivating inmates to
maintain their engagement in programs upon
discharge.19
Post-booking jail diversion programs are more
common than pre-booking diversion and usually
are supervised by specialty courts that require
During prison stays, inmates may receive longer
term treatment and more extensive reentry
planning. However, making community linkages
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News & Views: A Bimonthly Newsletter
may create significant challenges for staff based
at the prison because these institutions frequently
are located in rural areas distant from the
inmates’ communities. Transitional and in-reach
services to people still incarcerated help respond
to these challenges as well as build motivation to
change among inmates.
Volume I, Issue 2
Various community models and approaches have
been developed for promoting effective service
delivery and to smooth reentry into the community
for individuals with co-occurring disorders who are
leaving incarceration or participating in jail
diversion programs. Two of these services are
housing and treatment for co-occurring disorders.
Project Path to Recovery, a program of the
Postgraduate Center for Mental Health, a
Treatment for the Homeless grantee in New York
City, provides a 3-month group in-reach program
for women with co-occurring disorders who are
preparing to leave prisons in rural parts of New
York State to return to New York City. Staff
conducts assessments and help the women
identify the issues that led to incarceration and
find practical ways to avoid repeating their
missteps.
Housing
Empirical evidence about the effectiveness of
housing models lags behind their implementation
in the field. Nonetheless, it is generally agreed
that individuals who have co-occurring disorders
require a range of housing options to reenter the
community successfully.12
Options range from “rapid housing” to “housing
ready.” In the former approach, housing usually is
provided to help stabilize the client and then
treatment modalities are added. In contrast,
“housing ready” usually begins with treatment and
moves clients into various housing options as they
progress.13
The program also provides motivation through
activities such as sharing inspirational letters from
former inmates now in the community. However
Postgraduate Center Program Director Krista King
cautioned that participants in in-reach programs
do not necessarily become long-term treatment
clients. “A big percentage of in-reach participants
still relapse rapidly upon release,” King says.
The Housing Rapid Response (HRR) program
based at Central City Concern in Portland, Oregon,
which has a Treatment for the Homeless grant,
combines rapid housing and forensic case
management approaches to serve clients
identified by the police as among those most
frequently arrested for misdemeanors.
Collectively, the 140 HRR clients had been
arrested an average of 24 times per month prior
to being recruited into the program.
Since HRR’s inception at the end of 2005, the
Portland Police Bureau has measured a 70
percent reduction in recidivism among the
targeted group of offenders, according to Sarah
Goforth, Director of Engagement and Recovery
Services.
The Transition Home model in Contra Costa
County, California, another Treatment for the
Homeless grantee, combines “housing ready” and
case management approaches. Although the
program is too new to evaluate, Roberto Reyes,
Director of the Single Adult Interim Housing
Program, shared anecdotes about its impact. One
client, a veteran with physical disabilities and co-
“By not ensuring that there are appropriate
mental health and substance abuse services
available in our communities, we are essentially
putting people in jail.”
—Major Sam Cochran, CIT Coordinator, Memphis,
Tennessee, Police Department
Reentry into the Community
Linking individuals with necessary services and
supports as soon as possible after release is
important to prevent recidivism.20 Evidence shows
that discharge planning, also called transition
planning, is associated with improved client
outcomes.21 Nonetheless, recent statistics
indicate that only one-third of inmates with
substance use and mental disorders in jails and
prisons receive any discharge planning services.
Frequently they are released with bus tokens, a
few pills, and the address of a treatment
program.22
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News & Views: A Bimonthly Newsletter
occurring disorders, was stuck in his wheelchair in
the mud when he literally was picked up by the
outreach team. Since joining Transition Home, he
has become sober and skilled at managing his
medications. He now has housing and is visited
regularly by staff who help him manage his money
and who transport him to appointments.
Volume I, Issue 2
mental health treatment during the same time
period but in different settings and appear to be
satisfactory for helping individuals who do not
have the most severe disorders.
The Integrated Dual Disorder Treatment (IDDT)
model has been developed to help clients receive
substance abuse and mental health treatment at
the same time and in the same setting (see
sidebar in this issue).24 Treatment is clientcentered and begins with the services that he or
she identifies as most pressing; additional
services are provided as needed by the client at
each stage of recovery.
Clinicians use specific listening and counseling
skills to help often demoralized consumers
develop awareness, hopefulness, and motivation
for recovery. Staff must be cross-trained to
address both substance use and mental
disorders. Other training, including motivational
interviewing, medication management, and
trauma services, also is appropriate to help staff
Integrated Treatment for Co-occurring Disorders
Evidence suggests that people with the most
severe co-occurring disorders and who are in
outpatient treatment may be best served by
comprehensive programs that integrate
substance use and mental health services,
providing them simultaneously and in the same
setting.23 More research is needed about the use
of integrated treatment in outpatient, jail, and
prison settings.
To balance care and costs, jails and prisons
increasingly are implementing parallel service
programs. These deliver substance use and
IDDT Moves Clients through Treatment Stages and Helps Prevent Relapse
“Integrated Dual Disorders Treatment (IDDT) has four stages,” explains Melissa Shelek, Clinical Director
of Services for the Severely Mentally Disabled at Southeast, Inc., a Treatment for the Homeless grantee
in Columbus, Ohio. Southeast has provided IDDT for 820 clients, including those with justice system
involvement, for 5 years. “The full program is usually a four-year process moving from engagement, to
persuasion, active treatment, and, finally, relapse prevention,” Shelek says.
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Engage. Program staff focuses on building trusting relationships with potential clients by providing
them with assistance that they request, such as housing or housing referrals.
Persuade. Clients start making more regular contact with the agency. Staff uses these opportunities
to educate clients and gently persuade them to move forward.
Provide Active Treatment. Clients are motivated to take the next steps. They participate in counseling
programs to reduce substance use and increase use of medications that control mental disorders.
Prevent Relapses. After clients have been sober for 6 months, clinicians help them build the skills
needed to succeed in other areas of their lives, such as living independently and working.
Among other benefits, this approach better ensures that clients receive consistent messages about their
treatment, Shelek says. She estimates that about 45 percent of the Southeast clients have reduced or
eliminated alcohol and/or drug use. However, she cautions, client relapse is frequent. In addition, many
clients must be recruited to identify the few who will participate. Success can be fairly dramatic, however.
Cheryl, a former Southeast, Inc., client, once addicted and living on the streets is now a peer counselor at
Southeast. “I’ve gone from someone who was too depressed to do things to someone trusted to get
things done,” Cheryl says. “That means a lot to me.”
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News & Views: A Bimonthly Newsletter
engage clients and encourage their full
participation in treatment.
Volume I, Issue 2
counselors conduct groups inside the prison. In
addition, the program hires peer counselors. For
example, the substance use counselor is a former
inmate who taps into her own experiences to
reach clients. “The room is full for the entire 10week group session,” King reports.
The Need for Cultural Awareness
Regardless of the point in the justice system at
which community and corrections personnel
intervene, there are several key components for
success. One of the most important is the need to
build cultural awareness into programs and
services.
The primary risk in hiring program graduates
appears to be exposing them to opportunities for
relapse. Directors must look for a special type of
person, who has “a spirit of advocacy and a strong
recovery,” King advises.
Racial and ethnic minorities and women are at
special risk. Members of racial and ethnic
minorities are disproportionately represented
among jail and prison inmates. One in 9 black
men, age 18 and older, are serving time, as are 1
in 36 Hispanic men.1 Despite the fact that they
are overrepresented within the criminal justice
system, people of color often do not receive
culturally appropriate treatment for substance use
disorders and mental illnesses.14
Providing services that are sensitive to linguistic
needs may involve hiring staff or making referrals.
Spanish-speaking individuals are on staff at
Transition Home, which primarily serves English
and Spanish speaking clientele, while Project Path
to Recovery makes referrals to other programs for
their multi-ethnic population.
Collaboration Is Critical
Although men are 10 times more likely to be in jail
or prison, the female population is growing at a
faster pace.1 In addition, women in correctional
institutions have a rate of serious mental illnesses
almost twice that of male detainees. 25 They also
are likely to have substance use problems and are
more likely than men to be using cocaine or
opiates.26
Successful collaborations that keep clients from
unnecessary involvement in the criminal justice
system are possible, cost-effective, and beneficial
to clients and communities. However, they take
time to develop. “Representatives from the local
criminal justice, social service, and housing
agencies should be at the table,” Goforth says.
“Each of these agencies is looking to end
homelessness; the key is to start the dialogue.”
Programs must consider the special needs of
racial and ethnic minorities and women to be
successful. Strategies for accomplishing this
include hiring staff with backgrounds similar to
those of the clients. As Sarah Goforth explains,
“Many of the case managers have known … [our
clients] from childhood or from church, or even
from the criminal justice system. The team has
the perspective and street credibility to reach
these folks.”
Krista King adds that “working with people coming
from prison requires knowledge of the forensic
culture. Prisons instill certain behaviors—do your
own time, don’t confront other inmates, don’t
show weakness—that may be misinterpreted as
resistance in the treatment setting.” Project Path
to Recovery has had success building staff
awareness of forensic culture by having program
Each agency also needs to be represented at a
fairly high level, she adds. Getting cooperation
across the agencies may require assistance from
“boundary spanners.” These individuals have the
knowledge, skills, and cross-agency authority and
recognition needed to facilitate communication
and action across the substance use, mental
health, and criminal justice systems.2
Finally, Goforth notes, a successful program is a
“community investment” and it requires both
patience and persistence. The results are worth
the effort, she and other grantees believe.
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References
Volume I, Issue 2
Justice-Involved Individuals: Expert Panel Meeting,
convened by The National GAINS Center, Bethesda,
MD.
14 Osher, F., & Han, Y.L. (2002, March/April). Jails as
housing for persons with serious mental illnesses.
American Jails, 36-39.
15 Goodman, L.A., Dutton, M.A., & Harris, M. (1995).
Episodically homeless women with serious mental
illness: Prevalence of physical and sexual assault.
American Journal of Orthopsychiatry, 65(4), 468-478.
16 National GAINS Center. (2007). Practical advice on
jail diversion: Ten years of learnings on jail diversion
from the National GAINS Center. Delmar, NY: Author.
17 Steadman, H.J., Deane, M.W., Borum, R., &
Morrissey, J.P. (2000). Comparing outcomes of major
models of police responses to mental health
emergencies. Psychiatric Services, 51(5), 645-649.
18 The National GAINS Center. (n.d.). Jail diversion:
Outcome studies. Retrieved from
http://gainscenter.samhsa.gov/html/tapa/jail%20dive
rsion/outcome.asp
19 Center for Substance Abuse Treatment. (2007).
Addressing co-occurring disorders in non-traditional
service settings. Co-Occurring Disorders Center of
Excellence overview paper 4 (DHHS Publication No.
SMA 07-4277). Rockville, MD: Substance Abuse and
Mental Health Services Administration.
20 Judge David L. Bazelon Center for Mental Health
Law. (n.d.). Building bridges: An act to reduce
recidivism by improving access to benefits for
individuals with psychiatric disabilities upon release
from incarceration. Retrieved from
www.bazelon.org/issues/criminalization/publications/
buildingbridges/article1.htm
21 Osher F., Steadman H., & Barr, H. (2002). A best
practices approach to community reentry from jails for
inmates with co-occurring disorders: The APIC model.
Delmar, NY: The National GAINS Center.
22 Judge David L. Bazelon Center for Mental Health
Law. (2001). Finding the key to successful transition
from jail to community. Washington, DC: Author.
23 Drake, R.E., Mercer-McFadden, C., Mueser, K.T.,
McHugo, G.J., & Bond, G.R. (1998). Review of
integrated mental health and substance abuse
treatment for patients with dual disorders.
Schizophrenia Bulletin, 24(4), 589-601.
24 Center for Mental Health Services. (2003). Cooccurring disorders: Integrated dual disorders
treatment. Implementation Resource Kit. Rockville,
MD: Substance Abuse and Mental Health Services
Administration. Retrieved from
http://mentalhealth.samhsa.gov/cmhs/communitysup
port/toolkits/cooccurring
1The
Pew Center on the States. (2008). One in one
hundred: Behind bars in America. Washington, DC:
Author.
2The National GAINS Center. (2004, April). What can
we say about the effectiveness of jail diversion
programs for persons with co-occurring disorders?
Retrieved from
http://gainscenter.samhsa.gov/pdfs/jail_diversion/Wh
atCanWeSay.pdf
3Council of State Governments. (2002). Criminal justice
/ mental health consensus project. New York: Author.
4 The National GAINS Center. (2004). The prevalence
of co-occurring mental illness and substance use
disorders in jails. Delmar, NY: Author.
5Ditton, P. (1999). Mental health and treatment for
inmates and probationers. Washington, DC: Bureau of
Justice Statistics.
6 Center for Substance Abuse Treatment. (2005).
Substance abuse treatment for persons with cooccurring disorders. TIP 42. (DHHS Publication No.
SMA-05-3992). Rockville, MD: Substance Abuse and
Mental Health Services Administration.
7 National Health Care for the Homeless Council.
(2004). Keeping people out of the justice system: The
HCH role. Healing Hands, 8(6), 1-4.
8National Coalition for the Homeless and National Law
Center on Homelessness & Poverty. (2006, January).
Dream denied: The criminalization of homelessness in
U.S. cities. Washington, DC: Authors.
9Corrigan, P.W., & Watson, A.C. (2005). Findings from
the National Comorbidity Survey on the frequency of
violent behavior in individuals with psychiatric
disorders. Psychiatry Research, 136, 153-162.
10 McGuire, J.F., & Rosenheck, R. A. (2004). Criminal
history as a prognostic indicator in the treatment of
homeless people with severe mental illness.
Psychiatric Services, 55, 42-48.
11 National Coalition for the Homeless and National
Law Center on Homelessness & Poverty. (2002). Illegal
to be homeless: The criminalization of homelessness in
the United States. Washington, DC: Authors.
12 Metraux, S., Roman, C.G., & Cho, R.S. (2007).
Incarceration and homelessness. In D. Dennis, G.
Locke, & J. Khadduri (Eds.), Toward understanding
homelessness: The 2007 National Symposium on
Homelessness Research. Washington, DC: U.S.
Department of Health and Human Services and U.S.
Department of Housing and Urban Development.
13 Roman, C., McBride, E., & Osborne, J. (2005).
Principles and practice in housing for persons with
mental illness who have had contact with the justice
system, presented at Evidence-Based Practices for
7
August 2008
News & Views: A Bimonthly Newsletter
Teplin, L. A., Abram, K. M., & McClelland, G. M.
(1996). Prevalence of psychiatric disorders among
incarcerated women. Archives of General Psychiatry,
53, 505–512.
26 Substance Abuse and Mental Health Services
Administration. (2004, January). Blueprint for change:
Ending chronic homelessness for persons with serious
mental illnesses and co-occurring substance use
disorders (DHHS Publication No. SMA-04-3870).
Rockville, MD: Center for Mental Health Services.
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