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Article Commentary

Unmet mental health and criminogenic needs among justice-involved young people: a role for clinicians in the community

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Pages 259-268 | Received 07 Oct 2022, Accepted 25 Apr 2023, Published online: 22 May 2023

ABSTRACT

Justice-involved young people experience greater rates of mental illness than their peers in the general population. They also commonly belong to marginalised and disadvantaged groups and/or have histories of significant developmental adversity, amplifying their needs and increasing the likelihood of multi-agency involvement. While most mental disorders are not criminogenic (i.e., they do not cause offending), there is a disproportionate focus on criminogenic aspects of mental illness, to the neglect of the fundamental but unique mental health care needs of this group. Specialised forensic youth mental health services are an essential component of the care of this population. While they exist in some jurisdictions, they are commonly focused upon custodial care settings and/or young people with the most complex/severe presentations. Yet, most justice-involved young people, or those at risk of entering the justice system, live in the community. They do not, or cannot, access community mental health services. In order to improve access to services, we offer recommendations for clinicians working with, or likely to work with, justice-involved young people. In order to improve psychosocial outcomes for justice-involved young people, mental health and criminal justice services must be mutually responsive to both mental health and criminogenic needs of justice-involved young people.

Key Points

What is already known about this topic:

  1. Justice-involved young people are at greater risk of mental ill-health and frequently come from disadvantaged backgrounds.

  2. Justice-involved young people often do not receive, or are unable to access, the mental healthcare they need.

  3. Specialised forensic youth mental health services, where they exist, are primarily focused on high-risk young people or young people in detention.

What this article adds:

  1. Community-based clinicians can play a role in filling service gaps and complementing specialist forensic youth mental health services, especially for low- and medium-risk justice-involved young people.

  2. Practice recommendations are provided for clinicians working with, or likely to work with, justice-involved young people.

  3. Recommendations include utilising trauma-informed care, tailoring treatment to the young person’s cultural and gender identity, adopting the Risk-Need-Responsivity treatment model, and facilitating comprehensive treatment for substance-use disorders and neuropsychological impairment.

The onset of puberty (around age 10–12 years) marks the commencement of a distinct developmental period that extends to around age 25 years and which supports the acquisition of the skills, self-regulatory capacities, and culturally embodied knowledge that are required to achieve independent adult role functioning and societal integration (Dahl et al., Citation2018; Sawyer et al., Citation2018). This epoch also marks the peak period of onset for mental disorders (Jones, Citation2013; Kessler & Bromet, Citation2013) and the peak incidence in criminal offending (Australian Institute of Health and Welfare [AIHW], Citation2020; Piquero, Citation2008), providing important opportunities for early intervention to support a healthy transition to adulthood.

In this commentary, we describe the relationship between mental ill-health and justice involvement in young people, then highlight research and service provision gaps relevant to the unmet mental health needs of justice-involved young people (i.e., young people known to police, or who have been charged with/convicted of a criminal offence). We contend that, while dedicated, specialised forensic youth mental health services are essential to address the most complex needs among this group, these services should be complemented by community-based mental health service provision that is committed to providing parity of access to this neglected group, with the triple aims of reducing mental ill-health and recidivism among this population, and building greater workforce capacity and capability within community services. Community-based mental health clinicians are particularly well positioned to prevent young people from entering the justice system, support those young people with mild-moderate presentations, and/or many of those experiencing initial encounters with police.

To help orient community-based clinicians and youth mental health services, this commentary offers recommendations for working with this population. These recommendations have been informed by the literature on forensic youth mental health, in addition to the authors’ clinical experience in youth mental health, forensic mental health, clinical psychology, and neuropsychology. While not a comprehensive guide, the aim of this commentary is to orient community-based clinicians and organisations to working with justice-involved young people. We cover six areas of practice: trauma-informed care, the Risk-Need-Responsivity model, culture-sensitive care, gender-sensitive care, addressing substance-use problems, and working with clients who have a neurological impairment.

The mental health of justice-involved young people

Justice-involved young people are at increased risk of mental disorders relative to young people in the general population (Beaudry et al., Citation2021; Kinner et al., Citation2014). There is a complex and reciprocal interface between mental ill-health and offending behaviour in young people (as well as social determinants of both, such as poverty and marginalisation; N. Hughes et al., Citation2020), and the mental health needs of justice-involved young people are often poorly addressed or not addressed at all (Borschmann et al., Citation2020). The relationship between mental illness and offending varies by disorder, with externalising disorders (e.g., conduct disorder) being directly linked to offending, while internalising disorders (e.g., depression) may contribute to offending indirectly by reducing access to protective factors such as social support and simultaneously increasing exposure to risk factors such as antisocial peers (Armytage & Ogloff, Citation2017b).

Factors that might make it particularly challenging to provide mental health support for justice-involved young people in private practice settings are over-represented in this group. Social determinants of health such as unstable housing/accommodation (Kulik et al., Citation2011), poverty, lack of transport (Davy et al., Citation2016; Garney et al., Citation2021), and experiences of racism (Durey et al., Citation2014; D. R. Williams et al., Citation2019) can all reduce the ability of young people to access services (Yonek et al., Citation2019). Taken together, these factors can serve as barriers to accessing services, especially fee-for-service care. Despite high rates of mental ill-health and histories of adverse experiences, justice-involved young people are less likely to engage with mental health services than young people who are not justice-involved (Liebenberg & Ungar, Citation2014). Initial encounters with police or the youth justice system therefore represent an opportunity to connect to mental health or psychosocial services equipped to address their needs (Baker et al., Citation2021, Citation2022), especially in the context of diversion from criminal proceedings (Haysom et al., Citation2023).

Increasing the number of community-based mental health services and clinicians who are willing and able to support justice-involved young people, or those at risk of justice involvement, would contribute to overcoming the above barriers by offering accessible mental healthcare that is tailored to their needs. For example, a justice-involved young person transitioning from custody in a metropolitan youth justice facility to living in a regional, rural, or remote community would benefit from access to a clinician in that community. Given that a positive help-seeking experience is an important predictor of future help-seeking behaviour among young people (Gulliver et al., Citation2010), community-based mental health services might provide a “therapeutic template” and positive orientation to further mental health support for this group. However, treatment success will require close liaison and continuity of care with justice services and specialist mental health services as these young people reintegrate with their communities. Such services could be further improved by rigorous, independent evaluation.

Specialist forensic youth mental health services

The poorer mental health of justice-involved young people is a global phenomenon (Borschmann et al., Citation2020), yet the quality, scale, and funding of mental health services for justice-involved young people varies greatly both within and between countries (Penner et al., Citation2011). The Forensic Child and Adolescent Mental Health Services (F:CAMHS) in England is a recently established nationwide forensic youth mental health service, supporting at-risk or justice-involved young people. F:CAMHS provides direct treatment or consultation for young people with presentations that are beyond the capacity of community-based services; for example, 80% of F:CAMHS clients are referred due to problems with violence and/or aggression (Lane et al., Citation2021).

In contrast, there is no such nationwide service in Australia. Some states have implemented state-wide services, as is the case in the state of Queensland (Royal Commission into Victoria’s Mental Health System, Citation2021), while in the state of Victoria, mental healthcare is delivered through a variety of programmes such as Orygen’s Forensic Youth Mental Health Service (FYMHS). This service supports the mental health needs of justice-involved young people via three core components: (i) a Custodial Programme for sentenced young people detained at Youth Justice centres; (ii) a Children’s Court Mental Health Advice & Response Service for young people presenting with mental health concerns on the day of their Court hearing; and, (iii) a Community Programme for non-custodial young people involved in the youth justice case management programme, the Youth Justice Mental Health Clinician (YJMHC) initiative. This latter component of the programme has embraced the youth age range, extending up to age 25. Orygen’s FYMHS programme is staffed by a multi-disciplinary team of allied health clinicians and psychiatrists experienced in supporting youth presentations. The treatment approach integrates aspects of relational clinical care (e.g., Chanen et al., Citation2022) and seeks to provide mental health services to young people who are exhibiting challenging behaviours associated with mental ill-health, and/or who are at increased risk of offending (or re-offending). Demand for such services is high and increasing. For example, the average monthly caseload of the YJMHC has increased by 60% in the past two years, highlighting the need for the expansion of specialist services alongside community-based services.

Forensic youth mental health research has predominantly focused on young people in specialised (i.e., services targeted at justice-involved young people with complex needs and high-risk presentations; Lane et al., Citation2021) or custodial settings (e.g., Beaudry et al., Citation2021). This focus is largely due to the severe mental health needs of young people in detention or under police supervision, and the inherent difficulties of studying this marginalised population as they move through the justice system (Kumm et al., Citation2019). However, the majority of justice-involved young people reside in the community – in the United States (US), 63% of juvenile justice convictions result in probation orders (Hockenberry & Puzzanchera, Citation2021) and, in Australia, 84% of justice-involved young people live in the community (AIHW, Citation2020). This proportion is growing, given increasing numbers of young people who are referred to probation and diversion programmes (Hockenberry & Puzzanchera, Citation2021), rather than to sentencing and incarceration (Armytage & Ogloff, Citation2017a). Despite this trend, many justice-involved young people living in the community fall through systemic cracks, often magnified by the mismatch between developmental (age 10–25 years) and legal (<18 years) definitions of this population. Following contact with the justice system, young people have an elevated risk of dying by suicide or drug overdose (Kinner et al., Citation2018). Access to specialised forensic youth mental health services is often limited or non-existent, especially for young people who are identified as being at increased risk of offending, but who have not yet been charged or convicted (Fraser et al., Citation2014). Mainstream mental health services are typically ill-equipped or unwilling to fill the gap, and this is even more pronounced in already under-resourced regions such as sub-Saharan Africa (Atilola et al., Citation2020).

With the exception of programmes such as Orygen’s FYMHS, forensic mental health services have yet to adopt the youth mental health paradigm, which spans the age range of 12–25 years (McGorry et al., Citation2022). Services provided to this population need to address interacting clinical, developmental, psychosocial, and environmental challenges. While criminogenic needs – validated risk factors associated with offending and recidivism – do not include mental health diagnoses or symptoms (except for substance misuse), the criminogenic-mental illness relationship remains poorly understood in relation to treatment and individual and societal outcomes (Morgan et al., Citation2020). The eight core criminogenic risk factors most strongly linked with reoffending are: (1) criminal history; (2) antisocial attitudes; (3) antisocial peers; (4) personality traits such as impulsivity, sensation-seeking, and aggression; (5) family and relationship dysfunction; (6) substance misuse; (7) educational/occupational difficulties; and (8) lack of prosocial leisure activities (Andrews & Bonta, Citation2010a; Haqanee et al., Citation2015).

While specialised national or state-based systems are clearly needed to support justice-involved young people (Hindley et al., Citation2017), the substantial investment and systems reform required for such services is rarely addressed in most jurisdictions and, when implemented, they often face capacity and scalability limitations. This presents an opportunity for community-based mental health services to reform their policies and practices to become part of a comprehensive “safety net” that will ensure access to many more justice-involved young people (Fraser et al., Citation2014). Furthermore, community services are needed to provide continuity of care following the often time-limited episodes of care of specialist services. In one study, justice-involved young people attending a community-based youth mental health service (including those who have themselves experienced victimisation) reported reduced psychological distress following non-specialist treatment with a community-based mental health service (Baker et al., Citation2021). This outcome suggests that community-based mental health services can have a meaningful impact on the mental wellbeing of justice-involved youth without adopting an explicit forensic orientation. The capacity of community-based mental health clinicians to support justice-involved young people can be feasibly augmented with consultations with specialist forensic mental health clinicians (e.g., Purcell et al., Citation2012). Recent work also found that diversion to community mental health treatment was associated with reduced recidivism, further suggesting that community-based mental health services can have a positive impact on justice-involved youth as well as public safety (Gaskin et al., Citation2022).

Trauma-informed care

Justice-involved young people experience an average of three adverse childhood experiences (e.g., abuse, neglect, and family dysfunction) prior to their first arrest (Folk, Ramos, et al., Citation2021), necessitating trauma-informed practice. Three-quarters of young justice-involved females and two-thirds of young justice-involved males have been exposed to moderate or severe physical abuse, while 41% and 11%, respectively, report experiencing childhood sexual abuse (King et al., Citation2011). These are likely to be underestimates, especially for males, given the known barriers to disclosure (Rice et al., Citation2022). Adverse childhood experiences can have an additive effect, with each additional event conferring an increased risk for a range of mental disorders, alcohol and other drug misuse, criminal activity, and subsequent recidivism (Folk, Kemp, et al., Citation2021; K. Hughes et al., Citation2017). Trauma-informed care is therefore likely to be warranted for community-based clinicians working with justice-involved young-people. provides key recommendations for clinicians working with justice-involved young people in a trauma-informed manner, based on Levenson and Willis (Citation2019) SHARE framework from custodial settings. Implementing the framework does not require additional training or a structured treatment programme. Rather, it forms the basis of working with justice-involved young people based on their history, needs, and goals (Levenson & Willis, Citation2019).

Table 1. SHARE trauma-informed care recommendations for justice-involved young people.

Enhancing care with the risk-need-responsivity approach

Community mental health services can enhance their care of justice-involved young people by employing elements of the Risk-Need-Responsivity (RNR) approach (Andrews & Bonta, Citation2010b), the leading model of assessment and treatment for people in contact with the criminal justice system (see ). In the RNR framework, mental illness is viewed as a criminality responsivity factor (i.e., the ability of a person/client to change in response to intervention) — but criminality might also be a responsivity factor for mental illness (Morgan et al., Citation2020). Recent data from justice-involved young people in the US (N = 28,255) showed that unmet mental health needs (e.g., substance use, greater severity of anger, vengefulness, irritability) decreased the length of time between release from custody and reincarceration (Li et al., Citation2022). Such results highlight the need for clinicians operating outside of justice settings to be equipped to support justice-involved young people, so that their recovery can be facilitated even while they are not formally involved with the justice-system. While some criminogenic needs are more appropriately addressed by justice services (e.g., antisocial associates), others (e.g., substance misuse) can be addressed by community-based clinicians in coordination with justice services (Armytage & Ogloff, Citation2017a). As with any psychological intervention, treatment must be responsive to a young person’s individual characteristics, including their strengths, motivations, and demographic and socio-cultural profile (Andrews & Bonta, Citation2010b).

Table 2. Risk-need-responsivity model.

Culture- and gender-sensitive care

Justice-involved young people differ from the general population on several important demographic and cultural factors. These factors should be considered responsivity factors when working with justice-involved young people. Since justice-involved young people are likely to belong to groups at increased risk of mental ill-health and suicide, it is imperative that mental health services provide culturally sensitive and gender-informed support.

Culture

Many justice-involved young people come from minority and/or culturally and linguistically diverse (CALD) communities, the members of which experience an increased risk of mental illness and increased barriers to mental health service utilisation/access (Planey et al., Citation2019; Spinney et al., Citation2016). In Australia, Indigenous young people come into contact with youth justice systems at a younger age and are 16 times more likely than non-Indigenous young people to be involved with Australia’s youth justice systems, comprising approximately half of all justice-involved young people (AIHW, Citation2020). Upon contact with the justice system, Indigenous young people are treated more harshly in terms of sentencing and bail conditions than non-Indigenous young people and are subject to racist language and behaviour by police and correctional officers as they move through the justice system (Blagg et al., Citation2005). Indigenous young people are also more than three times as likely to die by suicide than non-Indigenous young people (AIHW, Citation2022). These findings highlight the importance of providing culturally-informed care when working with justice-involved young people.

Systemic racism is also present in the US justice system, such that justice-involvement is more likely and results in harsher legal, social, and health consequences for people of colour, including the incarceration of Black minors in adult facilities (Blankenship et al., Citation2018). Understanding how experiences of systemic racism in the justice-system interact with other social determinants of health (e.g., housing instability, educational inequality) is crucial to developing a collaborative treatment plan with justice-involved youth (Rotter & Compton, Citation2022).

Clinicians working with justice-involved youth from diverse cultural backgrounds should access in-depth training and education regarding the client’s cultural systems of knowledge, beliefs, and values (Durey et al., Citation2014). Culturally informed care is also vital to engaging families in psychoeducation and the development of treatment plans. Where language barriers are present, the use of professional interpreters should be considered. However, the use of clients’ family or friends as interpreters should be avoided, as these individuals may not provide accurate, unbiased translations (Wamwayi et al., Citation2019).

Gender-sensitive care for boys and young men

Approximately 80% of justice-involved people aged <18 years are male (Brown et al., Citation2020), rising to 90% among young people in custody (AIHW, Citation2020), although females are a fast-growing population in the youth justice system (de Vogel & Nicholls, Citation2016). Boys and men tend to prefer a collaborative, transparent, action-oriented, goal-focused treatment style (Rice et al., Citation2018; Seidler et al., Citation2018). Clinicians working with justice-involved boys and young males should consider the impact of masculine socialisation and gender norms on the social and emotional development of young men (Rice et al., Citation2018; Seidler et al., Citation2018). These norms also interact with criminal behaviour. For example, young males often join gangs in an attempt to satisfy basic needs for affiliation, safety, and self-esteem, but ultimately experience poorer mental health as a result (Raby & Jones, Citation2016). Given this, clinicians might explore more adaptive means of meeting these needs with gang-affiliated clients.

Gender-sensitive care for girls and young women

Justice-involved girls and young women differ from their male counterparts in clinically significant ways. For example, a history of trauma is more common, warranting trauma-informed care (see ) and interventions promoting positive social relationships (Wright et al., Citation2012). The available research on gender-sensitive interventions for girls and young women suggests that effective treatment will target the negative cognitions and emotions that result from trauma with the aim of promoting more adaptive social functioning (Thomann et al., Citation2020). However, such research is relatively limited (Thomann et al., Citation2020), and the provision of trauma-informed care must only be made in response to a known trauma history, as girls and young women who do not display gender-typical patterns of risk tend to respond unfavourably to such treatment (Day et al., Citation2015).

Their lower overall risk of justice system involvement (Brown et al., Citation2020) also means that many specialised forensic mental health assessment tools (e.g., for psychopathy) have been predominately validated with male populations and should therefore be used with caution (de Vogel & Nicholls, Citation2016). Some violence-risk assessment tools appear to have greater predictive validity in women, however, notably the Historical, Clinical, Risk Management–20 (HCR-20; Coid et al., Citation2009; Nicholls et al., Citation2004).

Working with youth with substance-disorders

Clinicians working with justice-involved young-people should note the higher rates of substance use in this population (Borschmann et al., Citation2020). Intervention is often opportunistic, as young people rarely present for treatment of a primary substance use disorder, and should use interventions and treatment frameworks that are appropriate for young people with co-occurring substance use and mental disorders e.g., cognitive behavioural therapy for substance use delivered in the same setting by the same clinician as interventions for comorbid disorders (Peters et al., Citation2017). Given the relationship between offending and substance-use, identify and support clients’ motivation to engage in treatment for both substance-use and offending behaviour (Perry et al., Citation2015).

Working with youth with traumatic brain injury and neurodevelopmental disorders

Justice-involved youth also experience higher rates of neurodevelopmental disabilities (e.g., autism spectrum disorder, attention deficit/hyperactivity disorder, learning disabilities, intellectual disability; Hughes et al., Citation2017; Young et al., Citation2018), epilepsy, and traumatic brain injuries (Chitsabesan et al., Citation2015; N. Hughes et al., Citation2015; W. H. Williams et al., Citation2010). These conditions might impact therapeutic engagement within treatment sessions, and deficits in impulse control and emotion regulation might affect regular attendance. Consequently, clinicians might consider referring clients for formal neuropsychological assessment. It is important to have clear questions that guide the neuropsychological referral and assessment, for example (Wills & Sweet, Citation2006):

  1. What is the nature and degree of neuropsychological impairment?

  2. What are cognitive strengths and weaknesses?

  3. What is the underlying aetiology of impairments?

  4. Do the impairments impact on competency to delineate right from wrong?

  5. Given neurocognitive impairments, what strategies might be needed to engage the young person in therapeutic work?

  6. What are the potential long-term consequences of neuropsychological impairments on functioning and recovery?

Conclusion

Justice-involved young people experience significant vulnerabilities that place both themselves and others at risk of harm and adverse outcomes. Opportunities to provide evidence-based mental health intervention to address unmet needs among this group must be prioritised in efforts to better support their transition to attainment of prosocial adult role functioning. Parity of access to, and provision of, high-quality mental health care for all justice-involved young people is an issue of social justice that serves to promote symptomatic recovery and provide a foundation for increased stability and reduced recidivism. The expansion of existing specialised forensic youth mental health services is most certainly necessary, especially for meeting the needs of justice-involved youth with complex and severe presentations. However, they are only one part of a comprehensive system of care for justice-involved young people. Appropriately equipped community-based mental health services can complement specialist services by supporting low-risk justice-involved youth and acting as a referral pathway following specialised treatment.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

No original data were produced for this article.

Additional information

Funding

The work was supported by the National Health and Medical Research Council [APP1158881]; University of Melbourne [Dame Kate Campbell Fellowship]

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