CNS Spectrums (2019), 1–8.

© Cambridge University Press 2019

doi:10.1017/S109285291900141X

REVIEW ARTICLE

Criminogenic risk and mental health: a complicated

relationship
Robert D. Morgan* , Faith Scanlon and Stephanie A. Van Horn

Department of Psychological Sciences, Texas Tech University, Lubbock, Texas, USA

The relationship between criminogenic risk and mental illness in justice involved persons with mental illness is complex
and poorly understood by clinicians, researchers, administrators, and policy makers alike. Historically, when providing
services to justice involved persons with mental illness, clinicians have emphasized mental health recovery
(eg, psychiatric rehabilitation) at the exclusion of treatments targeted at criminogenic risk. More recently, however,
researchers have demonstrated with great clarity that criminogenic risk not only contributes but is likely the leading
factor in the criminal behavior committed by persons with mental illness. Yet, we still do not know the nature of this
criminogenic-mental illness relationship, how this relationship impacts treatment needs, and of ultimate concern, what
this relationship means in terms of individual and societal outcomes. In this paper we briefly define criminogenic risk
and the research that demonstrates the role of criminogenic risk in criminal justice involvement of persons with mental
illness. We also review prevalence rates of persons with mental illness justice involvement, and then discuss important
factors to be considered when assessing risk to include both criminogenic and mental illness risk. We conclude this
paper by reviewing treatment and management strategies for persons with mental illness that are criminal justice
involved particularly reviewing and building off the recommendations put forth by Bartholomew & Morgan.

Received 31 January 2019; Accepted 24 July 2019

Key words: Mental illness, criminal justice, criminogenic risk, recidivism, co-occurring.

Criminogenic Risk and Mental Health: A Complicated
Relationship
The relationship between criminogenic risk and mental
illness in justice involved persons with mental illness
(PMI) is complex and poorly understood. As previously
noted, 1 the general public is misinformed on the nature
of this relationship, erroneously believing that mental
illness causes violence and crime. This perception is
compounded by news reports immediately speculating
about mental illness in response to sensationalized
criminal acts such as mass shootings, as well as in popular
and social media. Of greater concern, however, is when
clinicians, administrators, and policy makers are also
misinformed. Criminal risk includes static (eg, age,
gender) and dynamic (eg, antisocial attitudes, substance
misuse) factors that place an individual at greater risk of
involvement in crime. Criminogenic risk, on the other
hand, refers to dynamic risk factors that directly
* Address correspondence to: Robert Morgan, PhD, Department of
Psychological Sciences, Texas Tech University, PO Box 42051, Lubbock,
TX 79409, USA.
(Email: robert.morgan@ttu.edu)
contribute to criminal behavior and therefore need to
be a focus of intervention (eg, need to reduce antisocial
attitudes, need to reduce substance misuse). Known crim-
inogenic risk factors provide treatment targets for pro-
fessional service providers and decision and policy
makers aiming to reduce crime.
Criminogenic risk is well understood in correctional
settings and often guides the nature of rehabilitative
services.2 Criminogenic risk is less understood in mental
health circles, however, and even when working with
justice involved PMI, mental health professionals often
remain uninformed on the necessity of including crim-
inogenic risk factors in mental health treatments. In fact,
mental health professionals working with incarcerated
PMI have historically emphasized mental health recovery
(eg, reduce symptomatology, medication management)
over, and at times to the exclusion of, criminogenic
risk.3,4 This is particularly problematic given evidence
that targeting criminogenic risk reduces criminal
involvement, including for PMI (see 5 for a thorough
review). Notably, it is the first author’s experience that
when consulting with mental health professionals in cor-
rectional and forensic settings, there remains a belief that

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 2 R. D. MORGAN ET AL.

PMI are involved in the criminal justice system due to lack
of adequate mental health care, and that mental illness is
the primary culprit when it comes to these individual’s
criminal behavior. However, research data clearly refutes
this position such that this naivety and lack of under-
standing of criminogenic risk is inexcusable.
Researchers have clearly demonstrated the link of crim-
inal risk with criminal outcomes for PMI. In fact, a body of
literature now supports the conclusion that mental illness is
not the driving force behind PMI’s criminal justice involve-
ment, but that criminogenic risk (dynamic risk factors
commonly associated with criminal activity) is likely the
primary cause of crime, similar to criminal justice popula-
tions that do not have mental illness (see for example 6-8). In
other words, it is now well understood that the relationship
of mental illness to crime is weak and that other factors,
including criminogenic factors, better account for crime.9
Most compelling in this line of investigation were the results
of a meta-analysis showing that traditional criminogenic
risk factors (eg, antisocial attitudes, antisocial associates,
substance misuse) were better predictors of criminal justice
involvement (ie, recidivism) than were traditional clinical
(ie, mental health) factors for justice involved PMI.10 In
fact, results demonstrated that the variables that best pre-
dicted recidivism for PMI were essentially the same as the
variables that predicted recidivism for offenders without
mental illness. Specifically, this body of research demon-
strates that justice involved PMI exhibit criminal risk factors
similarly to nonmentally ill criminal justice populations
across a variety of criminal justice settings and populations,
including prison inmates,11–13 young jail inmates,14 foren-
sic psychiatric patients15 and justice involved PMI hospital-
ized in acute inpatient psychiatric units.15,16 Nevertheless,
the traditional approach of targeting psychiatric stabiliza-
tion remains the predominant service model used for justice
involved PMI17 without concomitant services targeting
their criminal risk or criminalness. Thus, it is not surprising
that traditional psychiatric services have had limited impact
on criminal justice outcomes.18 To be effective, services for
justice involved PMI must address the co-occurring issues of
mental illness and criminal risk.7,11,18
Although it is clear that criminogenic risk places PMI
at risk for criminal justice involvement, we still do not
know the nature of this criminogenic-mental illness rela-
tionship. Importantly, then, we also do not know how this
relationship impacts treatment needs, and of ultimate
concern, what this relationship means in terms of indi-
vidual and societal outcomes. Bartholomew & Morgan1
proposed that “mental illness and criminalness feed each
other in a continuous loop” (p. 5) as depicted in Figure 1.
If Figure 1 accurately reflects the relationship between
mental illness and criminalness, there would be a com-
plex directionality such that mental illness and criminal-
ness are independent (untreated mental illness results
in increased psychiatric recidivism and untreated
Treating Criminalness
Criminalness Mental Illness
Mental Health Treatment
FIGURE 1. Directionality of mental illness and criminalness.
criminalness results in increased criminal recidivism),
but also multi-directionality such that untreated mental
illness results in increased criminal risk, and vice versa. In
this latter relationship, for example, a PMI experiencing
decompensation in terms of mental health functioning
(eg, increased symptomatology) will experience recipro-
cal decompensation in their cognitive and behavioral
controls that allow them to manage their criminal risk.
From the Risk-Need-Responsivity (RNR) model, the
criminalness-mental illness relationship, as depicted in
Figure 1, suggests that mental illness may be a responsivity
factor for crime, but of equal importance is that criminal-
ness may be a responsivity issue for mental health function-
ing. The nature of this relationship and the
conceptualization of mental illness and criminalness as risk
or responsivity factors will, in our opinion, guide the next
wave of research. Such research will have practical impli-
cations beyond our understanding of this relation with the
potential to significantly alter how we approach the issue of
mental illness across the criminal justice landscape, and
similarly, how we address criminal justice involvement
across the mental health landscape. Even as we write this
narrative discussing both criminal justice and mental health
systems—structured as separate entities in the United
States—we recognize that such research may help break
the artificial silos that now exist, which put justice involved
PMI in a criminal justice or mental health system vacuum.
Applying the Model of Comorbid Mental Illness and
Criminalness in Mental Health Settings
Although criminalness is typically considered in the con-
text of corrections, it is relevant in community mental

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health settings as well. For example, in a sample of
79 men and 63 women in an acute inpatient psychiatric
unit, more than half (n = 74, 52.1%) endorsed previously
being convicted of a crime (misdemeanor and/or fel-
ony).15 This finding is consistent with the rate of criminal
justice involvement in a similar sample of psychiatric
inpatients from another acute inpatient psychiatric unit
where among 61 patients (32 male, 29 female), 55.7%
(n = 34) reported they had been convicted of a crime.19
Compared to inpatient samples, the prevalence of prior
convictions in outpatient mental health care samples
appears to be a little less, with one study showing a
prevalence of about 36%.20
Beyond the prevalence of criminal justice involvement
in mental health samples, there is a need to further
examine the nature of the mental illness–criminalness
relation in community-based psychiatric patients. One
important variable linked to criminalness is antisocial
attitudes, which are attitudes or dispositions that violate
the social norm, including criminal and defiant behavior.
Antisocial attitudes or cognitions are considered a
primary risk factor for predicting crime. In fact, antisocial
cognition is one of the “Central Eight,”5 which consists of
the strongest empirically validated criminal risk factors.
Importantly for purposes of this discussion, antisocial
attitudes are prevalent in justice involved persons with
and without mental illness alike.11 Thus, this provides an
important variable from which to explore the nature of
the mental illness–criminalness relationship.
Among a cross-sectional sample of 61 inpatients men-
tioned above, scores on the Psychological Inventory of
Criminal Thinking Styles21 (PICTS) General Criminal
Thinking scale, an overall self-report measure of criminal
thinking, was significantly associated with a number of the
self-reported Millon Clinical Multiaxial Inventory-III22
(MCMI) scales of psychiatric syndromes, including the
clusters of clinical syndromes scale (Anxiety, Somatoform,
Bipolar, Dysthymic, Alcohol, Drug, and Post-Traumatic
Stress disorder scales; n = 61, β = 0.513, p < 0.001,
R2adj = 0.251), severe clinical syndromes scale (Thought
Disorder, Major Depression, and Delusional Disorder
scales; adjusting for sex, n = 61, β = 0.442, p < 0.001,
R2adj = 0.208), Borderline scale (adjusting for sex, n = 60,
β = 0.477, p < 0.001, R2adj = 0.244), Antisocial scale
(adjusting for relationship status, n = 49, β = 0.732,
p < 0.001, R2adj = 0.517), and an average of the combined
raw MCMI scales which was used as a holistic measure of
mental health symptomology (n = 61, β = 0.604, p < 0.001,
R2adj = 0.354).19 Furthermore, the General Criminal
Thinking scale scores accounted for 20.8 to 51.7% of
the variance in these MCMI scales. This suggests that the
relation between criminal thinking and mental health
symptomology is an appreciable one for justice-involved
PMI, and that criminal thinking may be contributing to a
variety of psychiatric symptoms, thereby interfering with
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CRIMINOGENIC RISK AND MENTAL HEALTH 3
mental health treatment. It should be noted, however, that
due to the cross-sectional nature of this data, it is not
feasible to make causal or temporal conclusions regarding
the relationship of these constructs.
Although criminal thinking, as measured by the
PICTS, was a significant predictor of symptoms associ-
ated with mental illness, criminal risk was not statistically
significantly associated with self-reported length of
psychiatric hospitalization (a behavioral indicator of the
patients’ mental health functioning) in a subsample of
this clinical population. Specifically, neither the PICTS
General Criminal Thinking scale (n = 19, β = 0.071,
p = 0.773, R2adj = –0.054), nor the Criminal Sentiments
Scale–Modified23 (CSSM) Total Score (n = 16, β = 0.068
p = 0.803, R2adj = –0.066) were statistically significantly
associated with current length of hospitalization in the
psychiatric facility. In other words, antisocial cognitions
were related to psychiatric symptoms, but not length of
hospital stay. This finding suggests that criminalness is a
responsivity factor for mental illness given the obtained
relationship with psychiatric symptomatology, but not for
psychiatric recovery as criminalness was not predictive of
length of hospitalization. Given these are correlational
findings from cross-sectional data, more research is
needed to explore the nature of these relationships,
including temporality and causation.
We further examined the mental illness–criminalness
relationship by studying the relationship between psychi-
atric functioning and institutional misconduct. Specifi-
cally, we assessed the extent to which severe psychiatric
symptomology (ie, mania and thought disorders), crimi-
nal attitudes, and the interaction between the two were
related to both violent and nonviolent disciplinary infrac-
tions among an incarcerated population (n = 265).
Among violent infractions, main effects of gender
(β = 2.49, p = < 0.0001), criminal attitudes (β = 0.02,
p = <0.0001), symptoms of mania (β = 0.05, p = 0.001),
and thought disorder (β = –0.04, p = 0.01) were noted. A
model that included all possible interactions between
mania, thought disorder, and criminal attitudes was also
examined. None of the interactions were significant;
however, all previously mentioned main effects remained
significantly related to violent misconduct. When looking
at nonviolent infractions, gender (β = 1.52, p < 0.0001)
and criminal attitudes (β = 0.01, p = 0.04) were statistically
significant contributors to the model; however, the prac-
tical significance of criminal attitudes was negligible. Nei-
ther mania (p = 0.70) nor thought disorder (p = 0.37) were
significantly related to nonviolent infractions.24 Results
from this study again suggest that criminalness and mental
illness play a role in disruptive behavior. Furthermore,
given that mental illness and criminal attitudes were not
related to nonviolent infractions, it is possible that as the
behavior becomes more antisocial, both mental illness
and criminalness factors should be addressed.24 As this
 4 R. D. MORGAN ET AL.
was a retrospective study, conclusions regarding the
causal nature of these relationships cannot be drawn;
however, the results support the hypothesis that criminal-
ness is a responsivity factor when addressing mental
health concerns.
Collectively if these findings are supported by further
research, they suggest that criminalness is a vital, albeit
overlooked factor in the treatment of PMI in community
mental health settings—many of whom have a history of
criminal justice involvement. Furthermore, these find-
ings highlight that criminogenic risk is not only impor-
tant for criminal risk outcomes, but that it is also
entangled in mental health treatment, making psychiatric
symptoms more problematic (ie, criminalness is a respon-
sivity issue for PMI). In other words, the presence of
criminalness (a broader concept than criminogenic risk)
can negatively impact not only an individual’s psychiatric
symptoms, but also motivation, commitment, and sus-
tained efforts toward recovery. For example, a PMI high
in antisocial attitudes may find self-medication for symp-
tom management more convenient with more pleasur-
able psychoactive effects (and fewer negative side-effects)
than working through the complexities and bureaucracy
of the community mental health system to receive their
psychotropic medications. Therefore, in order to improve
outcomes in justice involved persons with mental illness,
it is essential to attend to criminogenic risk not only in
criminal justice settings (eg, corrections), but also in both
forensic and nonforensic psychiatric settings. Given the
conclusion that mental illness and criminalness have an
interactive and reciprocal relationship, these results and
the resulting model (Figure 1) have significant treatment
implications; however, it is first relevant to discuss the
assessment of criminalness broadly, but also specifically
as it pertains to psychiatric patients.
Using Risk Assessments to Inform Psychiatric
Treatment Planning
Risk assessments serve multiple purposes when provid-
ing services to criminal justice involved persons, with the
most common being to inform security and release
decisions. Initially, risk classification was based on clin-
ical judgments (eg, “gut feelings”) that were primarily
informed by unstructured interviews with the justice
involved individual. Overall, these judgments of risk
lacked accuracy, and better methods were needed.25,26
The second generation of risk assessments improved
upon its predecessor by including structured assess-
ments; however, they were not theoretically informed
and mainly assessed for risk factors that were static and
unchangeable (eg, prior criminal history, type of
offense).27 Although this generation of assessments
improved upon the first generation, they were only mar-
ginally useful in predicting future criminal behavior given
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their focus on unchangeable risks.5 The third generation
of risk assessments continued to implement structured
assessments but expanded to include dynamic risk factors
that could be addressed in an attempt to improve risk
estimates. Finally, the fourth generation of risk assess-
ment has attempted to address the difficulty of translating
the information gleaned from these assessments to appro-
priate use for classification and treatment by incorporat-
ing elements of case management.5
Although the use of risk assessment instruments has
increased exponentially over the last decade, there remains
considerable debate regarding how to most effectively com-
municate their results.28 One of the more contentious
topics centers around whether actuarial (ie, statistical
method of estimating risk using risk factors with known
probabilities) or structured professional judgment (SPJ)
instruments (ie, incorporates actuarial information but
estimate of risk is at the discretion of the assessor) yield
more accurate predictions; however, an exploration of the
current issues surrounding violence risk assessment called
attention to two key misunderstandings in this debate.28
First, the assessment of risk is a process and the adminis-
tration of one actuarial instrument cannot be considered a
stand-alone risk assessment.28 Second, people, not instru-
ments, make decisions regarding risk and a risk assessment
that does not address all known risk factors, whether
through actuarial or SPJ methods, is neither comprehen-
sive nor sufficient.28
There are other notable issues regarding the commu-
nication of risk assessment results. Some risk assessment
results are communicated in “categories” of risk (ie, high,
moderate, low); however, studies have shown that clini-
cians’ interpretation of these terms vary widely.28 Other
risk assessment results are communicated in terms of an
individual’s likelihood of reoffending. Studies have shown
that individuals, including highly educated professionals
and clinicians, tend to neglect base rate information when
making individual predictions whether the information is
presented categorically or probabilistically.29,30 Further-
more, some research has found that inclusion of risk
relevant information in narrative form can lead clinicians
to overestimate risk, despite this information having been
included in the estimated probability of re-offense.31 Col-
lectively then, the accuracy of risk assessments means little
if the results are not communicated clearly, interpreted
accurately,28 and effectively used to inform treatment for
justice involved PMI in both criminal justice and mental
health settings.
A variety of measures are available for the prediction of
risk. The Level of Service Inventory-Revised (LSI-R) is the
most commonly used risk assessment worldwide with over
one million official administrations in the year 2010
alone.32 A summary of the meta-analytic studies of the
LSI-R indicated that its average predictive criterion validity
for predicting general recidivism is 0.36, and 0.25 for

predicting violent recidivism.27 Other research has indi-
cated LSI-R scores are also predictive of halfway house
success, parole success, self-reported criminal activity
(as opposed to new arrests or convictions), and institutional
misconduct.33 The LSI-R and its fourth-generation revi-
sion, the Level of Service/Case Management Inventory
(LS/CMI), have been shown to be predictive of reoffending
in a wide range of justice involved persons, including those
with severe mental illness34 and drug offenses.35
A large-scale meta-analysis of other commonly used risk
assessments found overall moderate predictive validity for
violent recidivism for the Historical, Clinical and Risk
Management Violence Risk Assessment Scheme
(HCR-20; r = 0.25), the Psychopathy Checklist-Revised
(PCL-R; r = 0.24), and the Violence Risk Appraisal Guide
(VRAG; r = 0.27).36 Some differences among these mea-
sures were noted in terms of predicting institutional vio-
lence, with the HCR-20 evidencing the strongest predictive
validity (r = 0.31) and the PCL-R evidencing the weakest
(r = 0.15).36 An examination of violence prediction in a
sample of psychiatrically institutionalized justice involved
persons also found that the HCR-20 and PCL-R were sig-
nificant predictors of both verbal and physical aggression.37
Interestingly, findings also indicated the Brief Psychiatric
Rating Scale evidenced a strong relationship with physical
and verbal aggression in this population.37
Clearly, risk assessments can provide invaluable infor-
mation pertaining to security and release decisions; how-
ever, information regarding risk should also be used to
guide treatment.38 Measures that include an examination
of dynamic risk factors can inform treatment planning by
helping clinicians understand important issues to address
in treatment that will ultimately reduce risk and subse-
quently improve public safety.
The LS/CMI33 is an excellent example of a theoreti-
cally driven risk assessment instrument that can function
both as a tool to inform decision-makers regarding risk of
re-offense, and a tool to ensure that the intensity and
targets of treatment are appropriate. Research has con-
tinually shown that the individuals who need the most
intensive services are those with a higher probability of
reoffending.31,38,39 Even more importantly, research has
also shown that providing intensive services to low-risk
individuals can increase their risk of re-offending.38 The
LS/CMI functions as a risk assessment tool by examining
an individual’s risk on each of the Central Eight risk
factors and providing a total score that is associated with
a risk category (ie, low, moderate, high). It functions as a
treatment planning tool when clinicians use the informa-
tion learned about criminogenic risk to prioritize treat-
ment goals. For example, an individual with high scores
on the antisocial attitudes and employment subscales
would best be served by cognitive behavioral therapy to
address criminal thinking, as well as vocational training
and assistance with job placement.
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CRIMINOGENIC RISK AND MENTAL HEALTH 5
Another theoretically grounded, comprehensive risk
assessment instrument that was designed to address treat-
ment needs is the Violence Risk Scale (VRS).40 The VRS
assess 6 static and 20 dynamic risk factors and includes an
assessment of the individual’s treatment readiness on each
dynamic risk factor, as indicated by their stage of change
(for an in-depth discussion, see Reference 41). The inclu-
sion of treatment readiness allows the clinician to choose
appropriate interventions for an individual’s readiness to
change, and when used multiple times during treatment
also allows the VRS to function as a measure of treatment
progress.40 The VRS evidences good predictive validity,
with AUC values ranging from 0.73 (p < 0.001) for any
re-offense at one-year follow-up, to 0.74 (p < 0.001) for any
re-offense at three-year follow-up.40
Although several risk assessments can be used to inform
treatment planning to address criminal risk factors, there
is no widely available assessment that address both crim-
inogenic and psychiatric risk simultaneously. Currently,
treatment providers must use a battery of assessments to
identify the co-occurring needs of justice-involved PMI.
The Services Matching Instrument42 (SMI) is being devel-
oped to meet this need. The SMI is intended as an inte-
grated, theoretically grounded treatment planning tool
designed to identify empirically identified risk factors for
both criminal (eg, criminal history, criminal associates)
and psychiatric recidivism (eg, psychiatric symptomology,
social support). A preliminary examination of the psycho-
metric properties of the SMI suggests the measure evi-
dences good test re-test reliability (r = 0.78 to 0.91),
concurrent validity (r = 0.41 to 0.67), and internal consis-
tency (α = 0.77 to 0.94),43 with additional evaluation of the
measures psychometric properties in progress.
The assessment of risk has evolved significantly in the
last several decades and can be an invaluable tool in
improving public safety; however, risk assessment instru-
ments are under-utilized in terms of improving criminal
rehabilitation. Unfortunately, these instruments fail to
capture how mental illness may affect the presentation
of criminogenic risk factors, and vice versa. More work is
needed to develop measures that integrate these needs for
the growing population of justice-involved PMI, and to
examine the efficacy and accuracy of how risk is inter-
preted by clinicians and communicated to decision-
makers. In addition, more research is needed to better
understand the interaction of criminalness and severity of
mental illness symptomology such that treatment needs
can be more fully conceptualized and prioritized.
Treating Criminalness and Mental Illness
The lead author has written about treating justice
involved PMI and the necessity of targeting mental illness
and criminalness as co-occurring problems;4,11,44
however, these discussions have not fully captured the
 6 R. D. MORGAN ET AL.
complexity of the criminalness–mental illness relation-
ship. It is easy to think of criminalness and mental illness
as univariate constructs with both impacting unique
outcomes of interest (criminalness impacting criminal
recidivism and mental illness impacting psychiatric recid-
ivism) and we often develop treatments accordingly. For
example, recent efforts to modify Cognitive Behavioral
Therapy programs aimed at reducing criminal risk (eg,
Moral Reconation Therapy45) to also address issues of
mental illness,46 are done in this vein. But simply adding
mental health-focused treatment strategies or interven-
tions to programs designed to treat criminalness, and vice
versa, does not account for the complexity of the crim-
inalness–mental illness relationship and risks missing the
treatment mark.
It is commonly understood in health and behavioral
health circles that the more problem areas introduced into
an individual’s life (eg, mental illness, criminalness, sub-
stance abuse, physical disability), the more problematic
(and typically negative) the outcomes.47 There are many
examples of this in educational, medical, psychiatric, and
criminal justice literatures, but one example highlights
this concern specifically for justice involved PMI.
Research examining barriers to employment has dem-
onstrated that a criminal record 48–50 and mental illness
51-53
are significant barriers to employment. Stigma is a
serious concern when it comes to employment for those
involved in the justice system (see Reference 50 for a
thorough review); however, most concerning for justice
involved PMI is that these barriers are compounded when
both mental illness and criminal history are present. In
other words, employers appear least likely to hire indi-
viduals with both a criminal record and mental illness,
compared to those with just a criminal record or PMI who
are not justice involved54,55; multiple areas of concern
result in poorer outcomes.
Given these findings across a range of disciplines, it is
not surprising to find suggestions for treating
co-occurring disorders in a unified treatment protocol
(see for example 56) or a combined/interdisciplinary
approach (see Reference 57). It was in this vein that
Changing Lives and Changing Outcomes58 (CLCO1)
was developed. CLCO is a comprehensive program sys-
tematically developed to meet the unique treatment
needs of individuals with co-occurring mental health
and criminogenic concerns. The aim of this program is
not to cure mental illness or criminalness, but rather to
maximize adaptive behaviors to optimize functioning
while reducing psychiatric relapse and criminal reoffend-
ing. Although CLCO is rooted in cognitive-behavioral
1
Disclaimer that the first author of this paper is also the first author of
this commercially available program; however, the authors of CLCO do
not accept royalties on this program and all proceeds support student
research.
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theory, with a significant psychoeducational component
outlined in a comprehensive and structured treatment
manual, the uniqueness of the program is in the integra-
tion of best mental health practices and best correctional
rehabilitation practices throughout the therapeutic mod-
ules. In other words, consistent with Figure 1, the aim of
CLCO is to treat not only the unique features of mental
illness and the unique criminogenic needs of justice
involved PMI, but to also treat these problems as inte-
grated, with complex ties to both criminal justice and
mental health outcomes of interest. For example, one of
the CLCO modules entitled “Mental Illness and Crimi-
nalness Awareness” is not limited to understanding men-
tal illness. Rather, it also incorporates awareness of one’s
criminal proclivity and how problems in one area (ie,
mental illness or criminalness) can increase problems in
the other domain. Similarly, the Medication Adherence
module not only emphasizes the role of psychotropic
medication in recovery from mental illness, but also as a
responsible life choice that is consistent with achieving
one’s prosocial life goals (ie, a better choice in regard to
criminal justice outcomes than, for example, “self-
medicating” with illicit substances).
We use CLCO not as an example of the best treatment
program available for justice involved PMI, but rather as an
example of how treatments—regardless of one’s treatment
of choice—need to integrate treatments of mental health
and criminogenic risk in treatment work with justice
involved PMI. As the research summarized in this paper
demonstrates, this means going beyond merely adding a
mental health focus to an already effective correctional
program (eg, Thinking for a Change, Moral Reconation
Therapy). Instead, the field should aim to develop and
incorporate treatments that are meaningfully integrated,
to better meet the need of, address, and account for the
complex, interwoven relation of mental illness and crim-
inalness in correctional and psychiatric settings alike.
Although these treatment recommendations histori-
cally have stronger ties in criminal justice settings, these
recommendations are also reflective of changes needed in
forensic and nonforensic psychiatric settings. In forensic
settings, for example, treatments for competency resto-
ration and insanity should not be limited to psychiatric
recovery. This may appear less relevant in the legal con-
text of competency to stand trial, where the emphasis is
typically on abatement of symptoms that impact one’s
ability to factually and rationally understand proceedings
or to assist in one’s defense. Although criminal risk is not
predictive of competency restoration outcomes,59 as
Gowensmith and colleagues60 alluded, failure to inte-
grate a holistic perspective that includes an individual’s
criminogenic risk presents a missed opportunity.
Although competency may be restored with a univariate
focus on mental health functioning, sustained compe-
tency, further psychiatric recovery efforts, and reduced

criminal and psychiatric recidivism outcomes are possibly
missed. In nonforensic settings, it is common to encoun-
ter a significant number of patients with justice involve-
ment (ie, approximately 50% of patients) such that
psychiatric recovery (see for example, Illness Manage-
ment and Recovery61) needs to also account for the crim-
inalness–mental illness relationship. At the very least, it
appears that criminalness is a responsivity factor for
mental illness. Therefore, given the impact of crimino-
genic risk factors on psychiatric symptomatology, recov-
ery efforts that do not account for criminogenic risk will
fall short of treatment goals.
Conclusion
Over the last several decades, researchers, policy makers,
and clinicians alike have developed a growing apprecia-
tion for the complex and nuanced relationship between
mental illness and crime. As a result, there have been
significant clinical advances in the management of justice
involved PMI, such that it is no longer acceptable to
ignore the co-occurring mental health and criminogenic
needs of this high-risk population, be it in terms of assess-
ment or treatment. In order to maintain this momentum,
researchers must continue to examine the nature of the
mental illness–criminalness relationship, how it may
affect treatment needs, and of ultimate concern, how
treatment of these co-occurring needs contribute to both
psychiatric and criminal justice outcomes. In the mean-
time, policy makers, criminal justice administrators, and
clinicians alike must address what we already know about
the complexity of this issue, and develop holistic, wrap-
around policies and clinical strategies to assist justice-
involved PMI to achieve improved quality of life, pro-
longed psychiatric recovery, and improved public safety.
A multi-disciplinary effort to recognize and address this
reciprocal relationship will be required if we have any
hope of achieving these goals.
Acknowledgment
The authors wish to thank Dr. Jeremy Mills for his com-
ments on a previous draft of this manuscript.
Disclosures
Robert Morgan, Faith Scanlon, and Stephanie Van Horn
do not have any disclosures.
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