Commentary: Toward an Improved Understanding of Recidivism

In the preamble to their study, Hall and her associates¹ deftly explored the available clinical literature and presented a vast statistical summary of the known static (e.g., demographics and criminal history) and dynamic (e.g., antisocial cognition, values, and behaviors) risk factors for recidivism in the SMI. The therapeutic approaches to manage this phenomenon included a variety of interventions aimed at achieving cognitive restructuring. These interventions should attenuate the impact of mental illness on recidivism.

During a 24-month period, the authors interviewed and worked with 92 percent of a large sample of the carceral population of New York (n = 2005), registered under such variables as demography, criminal history, years of exposure to prison, mental health history, and engagement in transitional programs to the community. The authors measured the number of days between release from prison and both general re-arrest and re-arrest for violence and correlated both to independent variables ranging from demographics to prior psychiatric treatment. They categorized the sample in accordance with their psychiatric needs, from low-intensity intervention (Mental Health Level 1) to Levels 3 and 4, which require clinic-level care. Therapeutic and rehabilitative interventions were provided to the sample, along with ongoing clinical scrutiny and supervision. The sample ranged from an Assertive Community Treatment (ACT) level of care to weekly contact with mental health professionals.

At the conclusion of their study, the researchers established that, “46 percent [of the subjects] were re-arrested during the follow-up period …, but only 11 percent were re-arrested for crimes involving violence” (Ref. 1, p 226). Multivariate statistical analysis producing a Cox regression survival curve measured the impact of the systemic interventions on recidivism rates in comparison with the results of studies mentioned. The authors made a case for addressing the dynamic factors of recidivism with cognitive techniques to break the cycle of recidivism, and they eliminated a pre-existing psychiatric condition as a contributing factor in recidivism.

Although the study by Hall and colleagues helps in appreciating the role of mental health interventions in the reduction of recidivism through a lucid identification of risk factors, it does not offer any insight into the therapeutic dyad of patient-therapist within which conflict resolution is achieved and new cognition is formed. This window was briefly contemplated but not explored. One wonders whether the therapeutic dyad could be explored as a potential independent variable in the reduction of recidivism among SMIs.

The measurements of treatment participation and Parole Supported Treatment Program (PSTP) enrollment were crude yes/no dichotomies. They did not articulate the extent of participation in programs, such as the released individuals' motivation, engagement, active involvement, therapeutic alliance, and insight. In regard to participation, no is a clear response, but yes could encompass wide variability in the extent of the individual's actual involvement and participation in these programs (i.e., just showing up versus being committed to change, feeling a connection with clinicians, and taking active steps toward changing their behavior and attitude). This may explain why treatment participation showed such a weak effect (16%).

It is also worth speculating about the reason that PSTP participation was not measured as a segmented variable, like treatment participation. It was measured only at the time of release, giving no indication about dropout rate.

In general, the authors developed a rather positivistic model, in that most of the variables (all but treatment participation and PSTP enrollment) were historically criminogenic or demographic variables. This is a classic fallacy of psychology and psychiatry, in that we attribute too much variance to the individual and neglect environmental and contextual explanations (e.g., economic disparity, unequal opportunities, unsuitable living environments, race relations, and perceptions of and attitudes toward the criminal justice system) for crime. The authors mention in the second to last sentence of the article: “Moreover, research that focuses on characteristics of individuals and not the environments in which they live is invariably limited in its explanatory power” (Ref. 1, p 230). Further elaboration on this statement would be useful in defining the limiting factors encountered in research today.

The authors did mention the importance of family and community support in reducing the likelihood of re-arrest, an excellent point that should be emphasized. The notion of therapeutic rapport and engagement are key topics that should be highlighted further, stressing the need for the criminal justice and mental health systems to join forces in the recovery efforts of individuals who often overlap the two systems.

Finally, Hall and colleagues note that the active strategy of law enforcement in New York City may explain the heightened re-arrest rates (simply by virtue of their presence and attention to it), but they state that it is less likely to explain the higher odds of re-arrest for violence in the city. However, the brutalization hypothesis² suggests otherwise, that a stronger police presence and enforcement strategies that result in the arrest of an increasing number of members of the community may actually engender greater frustration, alienation, and negative feelings from the community, a formula for disenfranchisement that can lead to ever greater violence.

In other words, violence may beget violence.

• © 2012 American Academy of Psychiatry and the Law