ABSTRACT

With criminal justice-involved individuals with serious mental illness (SMI) at an all-time high in the criminal justice system, research on community mental health centers (CMHCs) demonstrates a lack of treatment for justice-involved persons. Scholars have argued that providing appropriate treatment to criminal justice-involved individuals with SMI could alleviate symptoms. Therefore improving the effectiveness of mental health treatment to reduce recidivism in this population is paramount. The current study used a qualitative approach to examine how community service providers perceived organizational-level variables and legal constraints to influence treatment decisions for justice-involved individuals with SMI. Findings suggest three critical implications for policy and practice. First, CMHCs remain underfunded. Second, service providers perceived their greatest budget and legal constraints to be driven by Medicaid. Third, and most importantly, collaboration with the criminal justice system can help clients receive the most appropriate treatment to address their criminogenic and mental health needs.

Over two million individuals are incarcerated in American jails and prisons (Sawyer & Wagner, 2022). Estimates suggest that these individuals are disproportionately diagnosed with a serious mental illness (SMI) (Prins et al., 2009). Despite the prevalence of SMI in this population, for almost half a century, collective evidence has revealed that treatment for incarcerated individuals with SMI has been lacking (Abramson, 1972; Barr, 2003) and fragmented (Mallik-Kane & Visher, 2008). Further, although incarcerated settings are labeled as modern-day mental health hospitals, these settings do not prepare individuals to seek treatment upon release (Baillargeon et al., 2010; Barr, 2003). Despite this, criminal justice-involved individuals will most likely be required to participate in community-based mental health treatment by parole or probation as a condition of their reentry

Although this population is more likely to receive treatment in the community, as opposed to while incarcerated, their re-arrest (Daniel, 2007) and re-incarceration rates remain disproportionately higher than their counterparts (Bales et al., 2017). Therefore, it is of the utmost importance to understand the nature of mental health treatment in the community – where individuals are most likely to receive treatment. More specifically, it is essential to understand what organizational and legal factors affect treatment decisions. A better understanding of how service providers perceive their organizations and legal constraints as an influence on treatment decisions can suggest areas of improvement. To address this gap in the literature, the current research provides insight into how service providers in community mental health centers (CMHCs) perceive their organization’s budget, goals, policies, and legal constraints to affect treatment decisions.

Literature Review

Research has attempted to explain employee-level decision-making in organizations. Yet, contemporary decision-making studies have ignored the role of organizational-level and legal variables in mental health treatment. This section provides an overview of decision-making literature from a variety of disciplines. It suggests several important organizational factors in decision-making processes and provides a basic framework to inform the current study. These factors are organized into four domains: organizational budget, goals, policies, and legal constraints. It is important to note that although these domains are different, they are not mutually exclusive in that they can influence one another (Trompenaars, 1994).

Organizational Budget

Since the United States Congress enacted the Community Mental Health Act to provide federal funding for community-based and outpatient treatment centers (Fisher et al., 2009), it is challenging to disentangle CMHC budgets from legal constraints. CMHCs are primarily nonprofit organizations funded by the legislature, but they also rely heavily on low reimbursement rates from Medicaid (Cunningham & O’Malley, 2008). Although budgets are typically considered outside the scope of job-related responsibilities for employees like service providers, from a decision-making perspective, it is well known that budget influences what choices are available (Keogh et al., 2020; Pierse et al., 2021). In part, organizations rely heavily on evidence-based practices to address some aspects of budget (and policy) (Bowen & Zwi, 2005).

While research on healthcare decision-making has continued to increase since the early 2000s (Guindo et al., 2012), research that explores budget remains limited (Keogh et al., 2020). Early research by Siegler (1985) explained how budget and quality of care are in a trade-off relationship; in the age of bureaucracy, budget and cost efficiency are assessed using a bureaucratic risk-benefit analysis. In other words, organizations will prioritize cost over the appropriateness of treatment. More recent research suggests that the budget can restrict what treatment options are available. Keogh and colleagues (2020) examined how resource allocation affected dementia treatment decisions in Irish home and community care settings. Their findings suggested that when providers are free of budgetary constraints, a broader range of services is available for clients. Logic would suggest that the role of the budget might function similarly in mental health treatment decisions in the United States.

Organizational Goals

In the 1970s, the mental health client movement shifted healthcare decision-making from only the provider to a collaborative process between the provider, client, and sometimes family to emphasize the client’s wants (Adams & Grieder, 2014). Consequently, several changes have occurred in how physical and mental health decisions are made in the United States. Two of the most significant changes in these fields are the idea of shared decision-making and client-centered care. Shared decision-making emphasizes the importance of the decision-making process and treatment outcomes, ultimately improving long-term outcomes as clients are more likely to actively participate in their treatment if they were part of the decision (Légaré & Witteman, 2013). Patient- or client-centered care is similar to but distinct from the shared decision-making model. Like shared decision-making, patient-centered care centers on clients’ self-determination or the right to make decisions related to one’s healthcare. This type of decision-making considers the client’s background and family history to understand the needs and goals of an individual to improve outcomes and quality of care (Castro et al., 2016).

Organizational Policy

Policy can be written or unwritten and, therefore, can come from policy and procedure handbooks, influenced by state and federal law, or originate from the organization's inherent nature and those working within it. Early research on policy and decision-making assumed that individuals within an organization shared a purpose and how they achieved it. Put another way, decision-makers within organizations were assumed to function closely or were tightly coupled. Contrary to common scholarly suppositions at the time, Weick (1976) proposed that organizations tend to be complex and comprised of loosely coupled elements. Weick’s assumption posited that individuals who work together, within and between organizations, are often not synergistic in their goals and the means to reach them. From Weick’s perspective, decision-making disparities can be understood by the strength of organizational coupling.

Later research explored the role of discretion when employees work under vague policies without proper resources. Decision-makers must employ discretion to deliver services and resources (Lipsky, 1980). Although Lipsky (1980) asserts that decision-makers should exercise considerable discretion, the rules that shape their agencies can simultaneously impede decision-makers. He described the inadequate resources and difficult working conditions of criminal justice actors, which can be summed up in a few words—the dilemma of supply and demand. A situation that is not novel to the criminal justice or CMHC systems, particularly as it relates to high caseloads (Gayman et al., 2018) that are primarily comprised of complex client needs (Korasz et al., 2018). Empirical evidence also suggests that an organization’s size and employee autonomy influence decision-making. Research shows that organization size and employee autonomy are related in that they affect the extent to which decision-makers work collectively or in silos (Arazan et al., 2019; Ulmer & Bradley, 2006).

Nowadays, evidence-based practices provide some guidance for decision-makers. Organizational policies and procedures continue to be informed by evidence-based practice and are particularly important in healthcare (Aarons et al., 2009). In 2014, Obama’s Affordable Care Act mandated the implementation of evidence-based treatments in healthcare organizations (Beidas et al., 2013). Thus, it is unsurprising that evidence-based practices influence treatment decisions (Janati et al., 2018).

Legal Constraints

One cannot discuss the effects of legal constraints on treatment decisions without acknowledging how healthcare law has affected mental health treatment (Morata, 2018). Deinstitutionalization, probably the most notable of the law’s effects on treatment, is replacing long-stay psychiatric hospitals with federally funded CMHCs (Brown & Lewis, 2015) and private mental health providers (Kennedy-Hendricks et al., 2016). The goal of deinstitutionalization was to transition institutionalized individuals with mental illness into the community where they could receive community-based mental health services (Frank & Glied, 2006). Unfortunately, the effect of deinstitutionalization on subsequent legislation and funding to provide commensurate resources was, and remains, lacking compared to the need in the community. For example, developing countries such as the United States account for 84% of the world’s population and an even higher percentage of worldwide diseases (Schieber & Maeda, 1999; Shen & Snowden, 2014). Yet, “only 11% of the world’s net health spending” comes from developing countries (Shen & Snowden, 2014, p. 5). Individuals with SMI have difficulty managing their biological, psychological, and social needs. Consequently, these individuals often become homeless, self-medicate with illegal substances, and lack effective coping mechanisms, resulting in increased exposure to law enforcement officers (Lamb & Weinberger, 1998), incarceration, and re-incarceration (Daniel, 2007).

More recent laws have also affected treatment decisions for this population. For example, as previously mentioned, Obama’s Affordable Care Act of 2014. Also, consider the Medicaid and Medicare Patient Self Determination Act of 1990, which required healthcare organizations to inform clients of their right to make their own treatment decisions. Medicaid is the largest payer source for mental health treatment in the United States (Cummings et al., 2013). Although the Affordable Care Act was created to address high rates of uninsured Americans by providing universal healthcare insurance to all citizens,  a Supreme Court decision gave states the discretion of whether or not to adopt Medicaid expansion benefits (Courtemanche et al., 2017; Norris, 2016). Therefore, not all states provide equal healthcare to their citizens; these decisions have left healthcare coverage gaps for Americans. Equally as important, Medicaid is often one of the first budgets the government cuts (Berk & Schur, 1998).

Other research has found that clients with private insurance had a higher likelihood of receiving psychological treatment and medication than clients with Medicare, Medicaid, and other payer sources (Goldberg & Lin, 2017). Additionally, while Medicaid is known to improve access to health services, the level of care covered under Medicaid is less than what is covered under private insurance (Berk & Schur, 1998), and approximately one-third of CMHC organizations do not accept Medicaid-insured clients (Cummings et al., 2013; Goldberg & Lin, 2017).

More broadly, Jecker et al. (2011) and Whiteford (2019) explored what barriers exist due to the ambiguity of healthcare law; laws can lack specificity in how organizations should implement or change policies to align with legislation. Vague language can cause conflicting policies across organizations due to individual interpretations (Jecker et al., 2011), leading to uncertainty in healthcare clinicians (Stewart, 2011). Legislative funding is one of the most significant obstacles to mental health treatment (Elpers, 1989). In California, scholars studied the actual expenditures for CMHC financing and found that between 1973 and 2006, the budget for mental health had decreased almost every year and overall had declined by 11.8%. Insufficient legislative funding is not new nor limited to California’s mental health system (Yank et al., 1992). Still, in the 21^st century, despite mass incarceration and the number of individuals who experience reentry, CMHCs suffer from inadequate funding (Bonfine et al., 2019; Lurigio, 2011).

Research Questions

The current study aimed to answer four overarching research questions in light of the existing literature. First, how do CMHC service providers perceive their organization’s budget to affect mental health treatment for criminal justice clients with SMI? Second, how do CMHC service providers perceive their organization’s goals to affect mental health treatment for criminal justice clients with SMI? Third, how do CMHC service providers perceive their organization’s policies to affect mental health treatment for criminal justice clients with SMI? Fourth, how do CMHC service providers perceive legal constraints to affect mental health treatment for criminal justice clients with SMI?

Method

To ascertain how CMHC service providers perceive organizational-level variables to affect treatment decisions for individuals with criminal justice involvement and SMI, this study draws on 61 in-depth, semi-structured interviews conducted between December 2019 and April 2020 with service providers in Indiana. Questions from the interview guide were largely open-ended. These items asked service providers to reflect on how budget, goals, policy, and legal constraints affected their treatment of criminal justice clients with SMI. The researcher posed and probed questions for service providers to elaborate on their answers. Interviews lasted one hour on average.

Funding and Legislation for Mental Health in Indiana

Although all states are subject to federal minimum standards related to Medicaid benefits, each state is required to determine specific types and duration of coverage for residents. Specific to Indiana Medicaid policy and as of 2012, Indiana provided 43 additional benefits for those covered by Medicaid outside of the 16 federally required benefits (Ballotpedia, n.d.). These benefits included public and mental health clinics, psychologists, home and community-based services, and inpatient care for seniors under 21 and over 65. In contrast to neighboring states, Indiana offered more expanded coverage than Illinois and Michigan but less than Ohio (39, 39, and 45, respectively). Despite this, federal and state coverage of Medicaid benefits was approximately 40-54% less than neighboring states.

Notably, Indiana has implemented several additional coverage areas for residents covered by Medicaid. Historically, those seeking mental health coverage for intensive outpatient treatment (IOT) and peer recovery services through Medicaid had to do so under the Medicaid Rehabilitation Option (McNab & Schipp, 2019). On July 1, 2019, Indiana legislators officially expanded Medicaid’s coverage to allow all residents to receive intensive outpatient treatment (IOT) and peer recovery services regardless of Medicaid Rehabilitation Option member status. This expansion in coverage also expanded the options for where individuals could receive services outside of CMHCs. Also, effective as of July 1, 2021, service providers who hold the following licensures can certify a mental health diagnosis without confirmation from a physician, psychiatrist, or health services provider in psychology (HSPP): LCSW, LMHC, Licensed Marriage and Family Therapist (LMFT), and Licensed Clinical Addictions Counselor (LCAC) (Indiana Health Coverage Programs, 2021).

In 1991, the Indiana General Assembly established the Family and Social Services Administration (FSSA) to “consolidate and better integrate the delivery of human services…to compassionately serve Hoosiers of all ages and connect them with social services, health care, and their communities” across all 92 Indiana counties (Family and Social Services Administration, 2021, para. 1). Among many responsibilities of Indiana’s FSSA, the department receives and approves Medicaid applications, administers Medicaid programs, and supports the state’s mental health care providers including overseeing the Division of Mental Health and Addiction (DMHA).

DMHA is a division within FSSA and is tasked with determining the standards for the provision of mental health and addictions care to Hoosiers (Division of Mental Health and Addiction, 2020). Their primary focus is to ensure equitable and quality treatment for those in need of treatment in Indiana. As part of their duties, DMHA 1) certifies all CMHCs and addiction treatment service providers, 2) allocates federal funding for substance abuse prevention projects, 3) licenses inpatient psychiatric hospitals, 4) operates the six state mental health hospitals, and 5) provides financial support for disadvantaged populations in need of mental health and addictions services. DMHA’s latter initiative funds criminal justice populations through the Recovery Works program (Division of Mental Health and Addiction, 2021). Although this program comes with a lifetime maximum allowance per individual, its purpose is to provide services to uninsured members of this population to increase mental health and addiction services and reduce recidivism.

Specific to criminal justice populations, FSSA advocates for county jails to seek presumptive eligibility for inmates (Family and Social Services Administration, 2022). In these cases, the county sheriff can act as an inmate’s authorized representative, so soon-to-be-released inmates can apply for Medicaid coverage to take effect immediately upon release from jail incarceration. It’s worth noting that there are several requirements for inmates to be considered under presumptive eligibility.

Recruitment

In Indiana, the CMHC system comprises 24 independent county-based organizations across 45 different sites throughout the state (several CMHCs service multiple counties). Recruitment began after the principal investigator received IRB approval and once an administrator at each organization was identified. Out of the 45 total organizations, three (7%) CMHCs declined participation. Eighteen organizations did not respond or failed to provide service provider contact information. Sixteen (36%) administrators agreed to participate in the current study of the remaining organizations. Next, a second e-mail requested names and contact information for eligible service providers. Service providers were eligible if they provided services to an active caseload and at least one of their clients was a criminal justice-involved person with an SMI diagnosis. For this study, SMI is defined by the National Institute of Mental Health (NIMH, 2016, para. 4) as “a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.” According to the current standard for mental health diagnostic criteria, the Diagnostic and Statistical Manual of Mental Disorders 5^th Edition (DSM-5), the diagnoses that are most often associated with serious functional impairment, and are therefore categorized as SMI, are Bipolar-related disorders; Major Depressive Disorder without psychotic features; Schizophrenia, and Schizo-affective Disorder (hereafter Schizophrenia spectrum disorders) (American Psychological Association, 2013).

Using a combination of purposive (n =45, 74%) and snowball sampling methods (n=16, 26%), all eligible service providers received a recruitment e-mail. Those who were interested responded to the researcher via e-mail or phone. Interviews were scheduled with approval from the organization’s administrator to be conducted during the workday at the service provider’s convenience. Interviews were conducted by the principal investigator via Zoom and audio-recorded with the service provider's permission and transcribed verbatim.

CMHC and Service Provider Background

The CMHCs that agreed to participate were located in primarily urban areas (74%) with a population of at least 50,000 and represented over 31% of Indiana counties. While each organization was located in a particular county, some service providers delivered direct care in multiple counties. Nine service providers self-reported that they provide direct care in more than one county. This is important because funding and jail policies vary by county, impacting the type of services available for criminal justice clients with SMI.

As shown in Table 1, the sample was predominately non-Hispanic, white females with master’s degrees. Approximately three-quarters (n=47) of service providers held a non-administrator position such as peer recovery coach, case manager, and therapist. It is worth mentioning that several respondents held unique positions that were collapsed into the “Director, Supervisor, or Manager” and “Other” category to maintain confidentiality.

Although respondents were not probed for their area of discipline, several spontaneously offered their licensure information. The most common degrees mentioned were Licensed Clinical Social Worker (LCSW) and Licensed Mental Health Counselor (LMHC), 16% (n=10) and 8% (n=5), respectively.

Analytic Strategy

Using a team-based iterative-inductive approach (Cascio et al., 2019), the researcher and one undergraduate research assistant qualitatively analyzed interviews in four stages using NVivo 12. First, each coder individually listened to three interviews to create a preliminary codebook of themes derived from the data. The coders compared individual codebooks in the second stage and agreed on a combined preliminary codebook. Next, each coder individually coded the same transcript using the preliminary codebook. Coders then met to compare codes and discuss possible changes to the codebook. The coding team individually coded the remaining 58 transcripts in the fourth stage. Memos and analytic notes were written throughout all analytic stages to document results and decision-making processes (Saldana, 2015). Inter-coder reliability in team-based coding is paramount to qualitative analysis. Using NVivo’s comparison query, inter-rater reliability was assessed as high, with kappa values exceeding 0.87. Both coders discussed discrepancies, and a consensus was reached before continuing with stage four of coding.

The coders employed attribute coding of service provider demographic information and magnitude coding to capture the prevalence of individuals with criminal justice involvement and SMI on a service provider’s caseload (Saldana, 2015). More simply, attribute coding can be considered qualitative coding for categorical data. Second, magnitude coding is used when a coded datum is numeric, such as frequency or percentage. All other interview data were coded using the eclectic coding method, which places codes under themes (Saldana, 2015).

Findings

The qualitative analysis yielded six themes related to budget, goals, policy, and legal constraints: CMHCs are underfunded, the generalizability of CMHC goals, appropriateness of treatment, influences on CMHC policies, legal constraints as the greatest barrier, and the role of Medicaid. Differences in respondent perceptions based on administrative or non-administrative positions are discussed. Also, as indicated by the literature review, it is worth noting that many barriers are interconnected and not mutually exclusive.

CMHCs are Underfunded

Most respondents (n= 48, 79%) reported budgetary barriers in treating this population. An administrative supervisor with over 50 years of experience best described the influence of budget:

[b]ack then you know, we really didn’t know a lot, and there was (sic) tons and tons and tons of money to do research and to understand things better…now that we have some really good ideas about what works, we don’t have the money to implement it. Which is very frustrating for us.

Although most respondents identified budget-related barriers to making treatment decisions for this population, administrators shared sentiments about the bigger picture of financial barriers. In contrast, therapists, case managers, and other non-administrative personnel emphasized more micro-level issues related to funding (e.g., handouts, TVs, etc.) than macro-level concerns related to staffing. Respondents identified three primary ways their organization’s budget affected their decision-making: staffing, service provider training, and lack of treatment resources.

Resources Organizational Staffing

CMHCs must maintain staffing to provide appropriate mental health treatment for their clients. However, a sizeable percentage (n=33, 54%) of service providers reported that their organization’s budget made maintaining necessary staff levels difficult as they could not provide attractive and competitive salaries for qualified service providers. Regardless of whether respondents were administrators, all employees knew the salary concerns. Service providers explained that barriers to offering competitive salaries mean organizations are “constantly understaffed because we can’t pay people like other organizations do” (addictions social worker), and staffing directly relates to what and how much treatment can be provided.

Like many other administrative service providers, one described a more macro-level concern of how addressing budget and staffing concerns might exasperate the current problems like the need for treatment being too great. He said, “that would open the flood gates from…the criminal justice system.” He predicted current caseload sizes of 35 would increase to 100 clients, meaning their organization would need more recovery coaches and, therefore, additional financial resources. He wasn’t the only service provider to express this concern, as others explained that there is not enough manpower compared to the treatment needed in the community. One respondent candidly explained, “I could sit in this clinic twenty-four hours a day, seven days a week, and there would still be more people who need me” (health care physician and service provider). It is worth noting that these findings were particularly salient in rural CMHCs. Almost one-fifth (n =12) of the sample proffered how budgetary restrictions related to staffing and commensurate salaries were exacerbated in rural Indiana counties. This sentiment was echoed by many service providers and was most clearly described by a supervisor, who stated, "I will tell you this and tell you this very candidly. We are…in rural Indiana…master’s level therapists, certified therapists, are as rare as hen’s teeth around here.”

Service Provider Training

Regarding staffing and commensurate salaries, Indiana CMHCs experience high turnover rates, particularly in rural southern counties, near Ohio and Kentucky. Given administrators' recruitment and hiring duties, these respondents expressed concern about the preparedness of potential employees. An administrative service provider described how newly graduated or less experienced staff receive their on-the-job training only to leave their rural CMHC or the State of Indiana for a higher paying job:

We sometimes lose, not sometimes, we do lose great clinicians to better paying jobs…we have a lot of interns, who are close to receiving their master’s. It’s not unusual for them to either leave as soon as their internship is completed or stay long enough to get their full licensure…because they can take that same degree now… go get a job somewhere else that pays more.

On the one hand, administrative service providers described the financial responsibility of CMHCs to provide expensive training for new hires. On the other hand, approximately 15% (n = 9) of respondents, who tended to be non-administrators, described their organization’s training budget as limited or completely lacking. For example, one addictions therapist reported that they had received no training since being hired. Moreover, when respondents were asked if they needed additional training or supervision to provide appropriate treatment to this population, over 60% (n=37) of service providers answered in favor of more training. While the most common training needs were related to newer treatment modalities, other service providers expressed how unfamiliarity with the criminal justice system was a barrier to treating this population of individuals. Therefore, criminal justice-specific training would be beneficial.

Lack of Treatment Resources

A sizeable percentage (n = 21, 34%) of service providers who reported budgetary barriers specifically referred to treatment provisions. Unsurprisingly, most non-administrative service providers perceived a lack of financial resources for new and innovative treatment or to expand current treatment (e.g., workbooks and paid videos that are companion pieces to curriculum). Other treatment needs included the implementation of technology, financial resources to pay for client medications, a local mental health court, transitional and residential programs, intensive outpatient treatment, step-down programs, transportation resources, modified intensive outpatient treatment, assertive community treatment (ACT) teams, gender-specific group programming, and a mobile unit to follow up on transitional populations from custody and incarceration into the community.

Generalizability of CMHC Goals

When asked about organizational goals for treating criminal justice-involved clients with SMI, administrative service providers were quick to recite their organization’s written goals. In contrast, non-administrative supervisors described their organization’s goals as client-centered and focused on the whole person. Notably, nine (15%) non-administrative service providers either were unsure or did not feel comfortable speaking on behalf of their organization. Despite these differences in initial responses, respondents (n=34, 55%) broadly described their organization’s goals as generalizable for all clients rather than specific goals for criminal justice-involved clients with SMI. For example, one therapist explained, “whatever is best for the patient, that’s what’s going to drive treatment.” Relatedly, an addictions social worker explained how generalizable goals allow treatment flexibility in working with criminal justice clients, who are most likely mandated to CMHC treatment. An addictions therapist and jail coordinator described the rationale behind not treating a client’s criminogenic behavior specifically, “So, I think [organization] as a whole is all about treating the disease, not the crime because the crime is part of the disease.”

While most service providers felt positive about the general treatment goals, others expressed concern with the lack of specificity and attention to criminal justice involvement. An administrative service provider with decades of experience articulated his concerns as, “I don’t think they really have a well-organized system for dealing with it really. I don’t really think they see the bigger picture of the recidivism.” He described how budgetary concerns might explain the generalizability of goals:

We have a lot of priority for trying to survive, you know as the mental health centers become more and more concerned as they go forward with financial issues, so just making a living.

Although most respondents reported generalizable goals, one-third (n=18, 30%) reported more specific goals for this population. Those service providers similarly described treatment goals as client-centered. However, the primary difference between this dichotomy of service providers was whether client-centered treatment was in light of criminal offending to “avoid recidivism… [or simply] to help people live healthy and productive lives” (behavioral health therapist). Following this distinguishing purpose, commonalities in responses stopped. Further analysis of these data indicated that their organization’s goals were broad, multi-faceted, and varied by organizations. For example, one clinical therapist reported her organization’s goal as promoting community integration, so clients are in “the community and living without so much structure.” Others delineated goals that addressed this population's specific barriers in the community, including expending resources for clients to obtain housing, acquire health insurance, and apply for other state benefits such as food stamps and disability. In these cases, service providers emphasized the benefit of individualized treatment as not all clients face the same barriers.

In some cases, service providers stated that their organization’s goals originated from grant-funded forensic projects or programs to rehabilitate criminal justice clients with SMI. Interestingly, less than half (n=8, 44%) of these service providers discussed goals geared towards addressing recidivism in clients with co-occurring SMI and substance use diagnoses (SUDs). For example, one organization implemented a SUD committee dedicated to providing higher-level care for SUD clients who “the majority of them come from the criminal justice system” (addictions therapist). Moreover, given the complexity of the needs of clients with co-occurring SUD and SMI diagnoses, this subgroup of service providers described their goal in treating this population by stating:

[y]ou know we're willing to give them just everything that we can, and we addressed their criminal thinking along with the addiction” (administrative service provider) and through a focus on client-centered care to “maximize therapeutic functionality across all domain functionality.”

Unfortunately, the latter service provider expanded upon their goal to state that while they aim to address all domains, “in the trenches, it doesn’t always execute.”

Influences on CMHC Policy

Like goal-related findings, most service providers (n = 41, 68%) reported general policies for all clients. Of the 32% (n = 20) of service providers who reported policies specific to criminal justice clients, most referred to unwritten policies and practices such as the commonplace practice of assigning criminal justice-involved clients to moral recognition therapy (MRT) groups designed to address substance abuse and criminogenic behaviors, other group programming, and evaluation for medication. Regardless of the specificity of organizational policies, most service providers (n =42, 72%) identified at least one policy-related barrier to providing treatment to this population. The most common policy-related barriers fell into one of three types: criminal justice policies, insurance-related, and client-related.

First, 20 (n=33%) respondents described how their treatment decisions were restricted by criminal justice policies such as mandatory reporting of positive drug screens, zero-tolerance policies, and the disjointed nature of the community mental health and criminal justice systems. Most concerning were how the criminal justice system’s expectations could impact client-provider rapport. For example, some service providers discussed how the criminal justice system (e.g., probation) expects complete therapeutic reports for all clients. However, they argued that criminal justice partners only need to know that their mutual client participates in treatment rather than a comprehensive account of their life history, trauma, and other privileged discussions with their provider(s). Other service providers discussed how mandated drug screen reporting and the criminal justice system’s zero-tolerance policies counter a therapeutic environment. A licensed social worker described how immediate abstinence from any substance “is unrealistic” when seeking sobriety. Instead, respondents proffered how relapses can provide a teaching opportunity for clients and how zero-tolerance policies are fear-based in that “it’ll get you in the door, but it won’t get you through treatment.” In the end, service providers reported that when criminal justice policies require detailed reporting, clients viewed their provider as an extension of the criminal justice system and only hindered their ability to treat this population.

Second, in many cases, CMHC policies are influenced by the primary insurer of this population of clients, Medicaid. Service providers who reported Medicaid-driven policy barriers described how such requirements influenced their CMHC’s policies related to reporting and documentation and consequently significantly reduced the time available for treatment. Service providers painfully described the process of insurance documentation, including when documentation must occur – during the allotted treatment period. Further complicating the timing were criminal justice documentation requirements. Consider one service provider’s breakdown of a 60-minute appointment and how much time is dedicated to paperwork rather than treatment. He said, “time is of the essence, and so we have 52 minutes basically. Fifty minutes to work with clients, right around there, and then we have ten minutes to do paperwork, and sometimes when people are involved with the criminal justice system, we have more than ten minutes of paperwork…they recommend concurrent documentation…it’s kind of difficult sometimes.”

Respondents also expressed frustration with Medicaid’s automatic cancelation policy when individuals are incarcerated, even for a short period. Initially, uninsured clients must seek Medicaid funding, which can take up to six months to become effective. After being insured, even if clients are active in their treatment, their Medicaid benefits are canceled once incarcerated for any length of time. However, the client must still participate in mandated treatment upon release. To do so, clients must reapply for Medicaid coverage which necessitates a new approval process and perpetuates an interruption in the continuity of care for this population. Surprisingly, seven service providers explained that they circumvented this barrier by providing treatment outside of non-billable hours for the benefit of their clients.

Another commonly reported Medicaid-driven barrier restricts who can provide services. According to service providers, Medicaid only reimburses for services provided by licensed clinical social workers (LCSW) or health service providers in psychology (HSPP). Respondents described how this policy is counter-intuitive given that the most common degree, licensed mental health counselors (LMHCs), are restricted from providing services through Medicaid. Further, an administrative service provider with 25 years of experience also explained that:

The sad part about it is an LMHC is really trained more thoroughly in mental health because that is what the MHC is for, mental health. Where the social worker is far more broad (sic) in what we do.

This policy restriction is particularly problematic given budget-driven staffing challenges.

Relatedly, which services are covered by Medicaid (and any insurance) was also a significant concern. Service providers explained how some therapeutic experiences are impossible to bill for, even with value. For example, one case manager described how this makes treatment difficult, “[t]he spirit of what we’re trying to do for these people, and this is the area where the paperwork does not get like the gestalt of it.” She went on to provide some examples:

Honestly if I can’t document on paper that I’ve taught them 18 different coping mechanisms for depression, but they’re not connected to any prosocial activity that gives them a reason to apply those tools to engage in their life, I have not really improved their live at all…I can’t bill for like, took the client for a walk in the park on a sunny day to get them some vitamin D and make them realize they enjoy being outside. So, they have a reason to get up and wash their face...So there’s a sense in which it’s so compartmentalized that it really becomes prohibitive to like, just intuitively caring for the individual as they are and meeting them where they’re at.

Third, although service providers predominantly reported that their organization’s policies did not restrict treatment, a sizeable percentage (n=8, 13%) of service providers reported barriers. For those respondents, CMHC policies do not allow for discretionary decision-making with criminal justice clients who are resistant, at least initially, to treatment because they are mandated as opposed to voluntarily seeking treatment. An addictions therapist provided an example of how this type of client can impact others in group settings:

[an individual who] makes it very clear that they have no intention, nor do they want to get any help, or even someone that is psychotic…psychiatrically is impacting the group as a whole.

She further explained the challenge of keeping resistant clients engaged and behaving appropriately and how some psychiatric symptoms are not helpful in a group setting. Yet, often, there are no alternatives. Along the same line, service providers also described how difficult it could be to make clients more compliant with treatment (e.g., keeping appointments and medication management).

Legal Constraints as the Greatest Barrier to Treatment

According to service providers, legal constraints were the greatest barrier to treating this population. Of the entire sample, over 90% (n=55) reported barriers related to one of the following areas: Medicaid and the Health Insurance Portability and Accountability Act (HIPAA), conflict with the criminal justice system, and funding. Only six providers in the sample stated that legal constraints did not affect their treatment decisions.

Medicaid and HIPAA

As aforementioned, the effects of organizational variables on treatment decisions are complex. Consistent with findings from the previous sections, Medicaid was the greatest legal constraint for administrative and non-administrative service providers (n=36, 59%). Again, legal concerns associated with Medicaid are frequently related to service providers' licensure restrictions. Eight respondents (13%) described difficulty working with Medicaid as a payer source in that reimbursement for some services is only covered if provided by a doctoral-level health services provider in psychology (HSPP) or an LCSW and not covered if provided by an LMHC. Respondents described the unintended difficulties for clients and providers, including higher caseloads, difficulty with staffing, inability to meet client treatment needs, and their effect on the organizational budget. Service providers also reported barriers related to HIPAA. For example:

HIPAA laws are my biggest headache. And I know that they protect clients and you can if it’s an emergency you know, talk to people and you know parole, probation thinks that HIPAA doesn’t apply to them though sometimes we think it does apply to them and the clients are told they have to sign a release which doesn’t necessarily help the relationship (administrative service provider).

Service providers (n=5, 8%) explained how HIPAA limited them from providing the most appropriate treatment in other examples. In one circumstance, a client refused to check one of the boxes on the release of information for probation and stated, “[n]o I don’t want probation to know about me, and I’m like not good.” The respondent explained that without the client’s consent, due to HIPAA restrictions, she could not discuss with her client’s probation officer how well he was doing related to his Schizophrenia.

Conflict with the Criminal Justice System

Respondents described conflict with the criminal justice system as another of the greatest barriers to treatment. This challenge is often related to conflicting opinions from criminal justice referring agencies about treatment. For example, three service providers described difficulty with law enforcement’s perception of the lack of punitiveness in treatment. One administrative service explained her experiences with local law enforcement personnel:

They, they don’t understand what we do. They think that we should seclude and restrain people, and they get mad at us for not doing a good job because we have people that are agitated and we’re very hands off and told not to touch, and so, that’s our policy. That’s basically DOHA’s [Department of Health and Aging] policy too, I think.”

Although less common, another example of the criminal justice system’s influence on treatment was described by two respondents. One stated her greatest challenge was that “the law won’t stay out of my clinical practice.” Another service provider and health care physician described a different frustration with the local criminal justice system:

Quite frankly, the Vivitrol reps went out to all these judges and all these tiny counties in Indiana and just put the hard sell on them….and I think because they were desperate for treatment so like that’s a case full of people were trying to do the right thing…now I see all these people who refuse to try Vivitrol because they were forced, basically forced, coerced, I mean they signed the plea agreement, but you know, if you said ‘hey you can stay here for ninety more days, or you can take this shot and get out’…like I'd take the shot.

Finally, other respondents in this category described concerns regarding mandatory minimum sentencing and arrests for non-violent charges. Service providers were particularly concerned with how these laws further disproportionately harm this population. Respondents commonly referenced collateral consequences such as gaining employment and housing, state benefits for housing and food and pursuing a college education (from an admissions and financial aid standpoint). They argued that criminal justice practices of punishment instead of treatment place an undue burden on criminal justice and mental health systems.

Funding

According to respondents (n= 6, 9.8%), legislative funding was also a noteworthy barrier to treatment and can be best described as marginalization through a lack of overall funding for mental health treatment. As an addictions therapist explained, “we’re not funding it, we’re not helping it.” Overall, service providers described the circumstances for their clients as lacking resources to divert them from the criminal justice system and the simple lack of treatment slots available due to a lack of funding. Moreover, 17 (29%) service providers described Medicaid as a driving force behind struggling budgets and restrictions on treatment options: Medicaid’s low reimbursement rates, requirements to accept Medicaid, and the limited amount of state-level Medicaid funding. A service provider elaborated on the complex nature of budgets and Medicaid when she said, “[y]ou know? insurance runs the world, right?”

For service providers, Medicaid’s low reimbursement rates and particularly the lack of increase in reimbursement for Medicaid’s Rehabilitation Option have contributed to their organization’s difficulty in providing care and competitive salaries. Further, according to service providers, the requirements to accept Medicaid as a payer source for clients are “very demanding” considering their reimbursement rates, placing an undue burden on service providers. According to one administrative service provider, the reality of the funding situation is that “it gets away then from really the evidence-based practice.” Therefore, minimal resources with less funding are spread across all clients, making it challenging to provide appropriate treatment.

Discussion

A long-standing history of scholarship has examined the disproportionate criminal justice involvement of individuals with SMI. Notwithstanding the process, goals, and effects of deinstitutionalization, and despite the clear illustration that non-fragmented and appropriate treatment can ameliorate symptoms of SMI and reduce recidivism for this population, appropriate treatment to address both criminogenic behavior and mental health is inadequate for criminal justice-involved individuals in communities. This study revealed a burgeoning number of scholarly inquiries exploring decision-making processes. Despite the continued increase in empirical evaluations of organizational effects on decisions, research has yet to examine how these variables affect treatment for criminal justice clients with SMI. This research produced several key findings that provide insight into the intricacies of organizational effects on treatment decisions for criminal justice-involved clients with SMI. Thus, results from this research can be used to inform mental health policy and practice, as well as criminal justice policy and practice.

Analyses from the current study revealed that, consistent with prior research, budget (Keogh et al., 2020; Pierse et al., 2021) was one of the greatest decision-making barriers for service providers. Respondents described the importance of sufficient funding and the consequences on treatment when funding is lacking. The general sentiment from respondents was that there just is not enough funding available. Although there were concerns related to financial resources to purchase newer treatment resources, respondents largely voiced frustration with their organization’s limited ability to hire and pay competitive salaries for qualified employees and fund service provider training. CMHCs are forced to hire service providers with less experience and training. But this comes at a cost. Administrative service providers describe staffing issues as a double-edged sword in that they cannot attract qualified staff given the salaries they can offer. Therefore, recent graduates are the most likely to be hired, and it is the CMHCs responsibility to provide necessary training. Unfortunately, providing training is difficult, expensive, and time-consuming. Many service providers described graduate-level training as insufficient to prepare service providers to treat a population with complex needs. On the other hand, most service providers indicated that they received no or minimal graduate-level education on treating criminal justice populations despite their prevalence in CMHCs. Therefore, new hires are not only undertrained, but as one service provider described, they are new to treating criminal justice-involved clients who are “very complicated” and may require the most intense treatment.

Unfortunately for service providers, the qualitative data suggested that organizations are constrained by the larger system of insurance, more specifically Medicaid, which is out of their immediate control (Cunningham & O’Malley, 2008). This finding is particularly salient as criminal justice clients with SMI are primarily insured by Medicaid, unlike non-criminal justice-involved clients (Cummings et al., 2013). Service providers explained that Medicaid has failed to keep up with the needs of this population. The emphasis for Medicaid is to require extensive provider reporting for a population of clients that can sometimes fail to accomplish daily tasks (e.g., showering, getting in a vehicle, completing paperwork, etc.), which takes away from the available time to provide treatment, and in return, reimburse as little as possible. This finding is consistent with early research on how the budget can impact the quality of care (Siegler, 1985).  

Respondent’s concerns with Medicaid extended beyond budgetary barriers. Although CMHC policies were not of any concern to respondents, many described their treatment decisions as limited by policies driven by Medicaid. Service providers expressed concerns with Medicaid restrictions regarding what treatment and who can provide those treatments. According to respondents, some treatment is difficult, if not impossible, to justify regardless of their necessity and impact. Relatedly, service providers explained the documentation process as a game in that they must find a way to play the system for the client’s benefit. Finally, Medicaid also restricts LMHC providers from providing reimbursable treatment to clients. Instead, despite the specificity of LMHC providers’ mental health training, Medicaid only allows reimbursement for providers with LCSW or HSPP licensure. Given the already complicated issue of staffing and salaries, this restriction seems arbitrary and only further limits the available resources despite the amount of need in communities.

Consistent with prior research (Morata, 2018), legal constraints were also one of the greatest challenges for service providers and arguably, in terms of Medicaid legislation, drove most of this study’s findings. Virtually all service providers reported some legal constraint as a barrier to treatment. Service provider concerns centered around their previously mentioned budgetary challenges related to legislative funding and low Medicaid reimbursements. Despite the July 1, 2021, change to Medicaid’s policy specific to service provider licensure (Indiana Health Coverage Programs, 2021), throughout interviews, service providers described the difficulty in providing direct care under Medicaid, especially as an LMHC instead of an LCSW. This legal barrier is particularly problematic as the most commonly held licensures were LMHCs rather than LCSWs. In light of this finding and the changes to Medicaid’s policy shortly before the data collection for this study began, service providers were concerned mainly with the issue of licensure. A few prior studies explicitly discussed how ambiguity in healthcare law could lead to variations in how organizations implement and change policy to align with legislation (Jecker et al., 2011; Stewart, 2011; Whiteford, 2019). Perhaps it would benefit CMHCs, their service providers, and those they provide services to if there was more clarity from Indiana in the wording of the legislation.

Also, consistent with prior research, respondents primarily described their organization’s goals as general for all clients rather than specific to certain populations (e.g., criminal justice versus non-criminal justice clients) (Adams & Grieder, 2014). General goals were important to respondents as they allow the service provider to focus on an individual’s needs and wants rather than placing certain clients into pre-determined treatment plans driven by the organization’s goals rather than the individual’s goals. Service providers explained that this flexibility allowed them to focus on individualistic treatment and, therefore, is inherently broad enough to encompass client needs specific to criminal justice involvement and SMI. This approach is fundamental as it emphasizes the client’s self-determination and fosters long-term success when the client buys into their treatment plan (Légaré & Witteman, 2013). Comparatively, organizations with specific goals described more measurable outcomes such as helping clients lead healthy and productive lives without the structure of the criminal justice system and assisting clients to develop the skills to locate and access needed resources such as health insurance, housing, and state benefits. Although most service providers who provide treatment under general goals did not express any major concerns, those who did describe how the lack of specificity might be detrimental to the client’s long-term success as the organization does not see the larger picture of recidivism.

In this study, goals can also be examined across systems. For example, service providers delineated their concerns with the conflicting nature of the criminal justice and mental health systems. According to respondents, although decision-makers across the two systems work with the same population, their goals vary widely. Criminal justice decision-makers function under laws and goals within the context of punishment. However, the mental health system operates under an entirely different lens. Yet, both systems work with the same clients – criminal justice involved with SMI. Weick (1976) warns us about what tends to happen when decision-makers have conflicting goals and means by which they achieve them; decision-makers who work towards the same goal make up a tightly coupled organization where disparities in decision-making will be limited. However, decisions will likely vary when decision-makers operate with conflicting goals, the means to reach those goals, and limited resources (Lipsky, 1980). In other words, the criminal justice, mental health, and Medicaid systems all work with the same population, yet their goals and the means to achieve them vary substantially. Hence, the conflict amongst the systems.

This conflict is concerning as criminal justice-involved individuals with SMI historically recidivate at higher rates (Baillargeon et al., 2009; Bales et al., 2017; Daniel, 2007) compared to their non-SMI counterparts. If, as studies show, criminal justice-involved individuals fail to receive appropriate treatment while incarcerated (Abramson, 1972; Barr, 2003) and in the community (Abramson, 1972; Barr, 2003; Mallik-Kane & Visher, 2008), how will this issue be addressed and what is explicitly standing in the way of accomplishing this goal? Many service providers provided an explanation – financial concerns. It is well documented that CMHCs are underfunded (Bonfine et al., 2019; Lurigio, 2011). If these respondents’ sentiments are valid, CMHCs are overwhelmed with keeping their doors open instead of the criminogenic concerns of a disproportionally incarcerated population and failing to receive appropriate treatment to address those concerns; the budget must be addressed. Another viable solution is to address the varying goals across the criminal justice and mental health systems and the legal constraints of healthcare law.

As with any study, it is important to discuss its limitations. The first limitation is the nature in which the sample was obtained. As no complete list of Indiana CMHC service providers exists, the analysis relied on purposive and snowball sampling methods via e-mail. Therefore, the generalizability of these findings is limited. Second, the research team was limited to one criminologist without training in social work, psychiatry, or the delivery of mental health services for individuals with criminal justice involvement with SMI. This study would have benefited from collaboration with a clinician or social worker to further understand service provider responses. Future research should consider an interdisciplinary, collaborative approach and participatory research when applicable. These limitations underscore the importance of future research dedicated to understanding such decisions and their long-term effects on treatment decisions for criminal justice individuals involved with SMI.

Implications

While the qualitative findings from the current study should not be considered generalizable to all Indiana service providers or CMHC organizations in other states, initial results can provide context for future research. Given the salience of Medicaid as a driving factor in many of this study’s findings, policymakers and legislators should consider the role of Medicaid funding on organizational budgets. Additionally, in light of these findings and because prior research suggests that a sizeable percentage of CMHCs in the United States do not accept Medicaid (Cummings et al., 2013), future qualitative research should examine how CMHC service providers' treatment decisions vary across organizations. Future quantitative empirical research will be fundamental in determining how CMHC service provider perceptions compare to service providers in private practices, prisons, and civil and criminal justice organizations and examine the longitudinal effects of these treatment decisions on recidivism in this population. Finally, service providers also tend to report dissatisfaction with the current mandatory minimum sentencing guidelines for non-violent drug offenses. The modal percentage of comorbid substance use for clients on service provider caseloads was 100% (n=61). Given that treatment slots are limited, and budgets are restricted by limited Medicaid and legislative funding, legislators should consider how burdened incarcerated settings are with non-violent drug offenses and the number of resources necessary in jails, prisons, and CMHCs to incarcerate and treat this population. As of 2020, 27 states and the District of Columbia have decriminalized small amounts of recreational marijuana (Hartman, 2022; Marijuana Policy Project, 2022). Indiana legislators should consider following the path set forward by other states.

While it was not within the scope of this study to explore the role of caseload size on community mental health treatment decisions for criminal justice clients with SMI, over 13% of service providers volunteered that their caseload was higher than it should be given their administrative responsibilities. Given this finding, and the corresponding empirical support of caseload size on decision making (Arazan et al., 2019; Ulmer & Bradley, 2006), future research on the role of organizational-level challenges to treatment should extend and refine the current analysis to include the effect of caseload size on service provider perceptions. Related qualitative research would do well to consider why CMHCs do not have criminal justice-specific goals. Finally, considering unsolicited findings from service providers regarding the effects of co-occurring SUDs and trauma histories, future qualitative and quantitative research should explore these relationships.

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Contributor

Brittany Hood, PhD, is an assistant professor of social sciences at Texas A&M International University. Her primary area of interest explores the intersection of mental health and offending, emphasizing the experiences of individuals with mental illness across police, courts, and corrections. Her research uses quantitative and qualitative methods to better understand what works in reducing recidivism for this population, the stigma against mental illness and mental health treatment, and how criminal justice and mental health agency decision-making influences the treatment of this population.

Acknowledgment

The author thanks Drs. Michell Salyers and Matthew Aalsma initially provided qualitative training and helped pursue this career path. Dr. Bradley Ray must also receive acknowledgment in his role as an early mentor. Most importantly, Drs. Bruce Sales, Marla Sandys, and Richard Lippke (Indiana University) should be recognized for their guidance and support throughout the dissertation development and writing process. The acknowledgment must also be given to colleagues and the reviewers who provided further guidance in developing this manuscript.