Incentives and Sanctions andMental Health: Issues toConsiderNADCP 18th Annual Training Conference, OprylandHon. Peggy Fult...
Largest mental hospital in U.S.?             Los Angeles County Jail with 3,000 MI inmates every dayEarley, Pete, Crazy: A...
SMI prevalence in jail/prison 40% of individuals with serious mental  illnesses have been in jail or prison at some  time...
Prevalence of other Dx in Jail Mania, schizophrenia and major  depression were significantly more  prevalent in jails tha...
 72% have co-occurring disorder Only 1/3 men & ¼ women receive  needed services for severe mental  disorders   National...
Co-Occurring Disorder Center
SMI in jail/prison, not hospital More than three times more seriously  mentally ill persons in jails and prisons  than in...
Going backwards       Early 19th C.        reformers fought        for more humane        treatment for        mentally i...
One model of a co-occurring drugtreatment court  Eligibility determined by jail MH staff   and negotiated with DA/PD  In...
Judicial monitoring Vital role Role more subtle and  nuanced than other  P-S courts Informed listening Engagement is k...
Difference? How may depression affect  participation in DTC? Agoraphobia? PTSD? Auditory hallucinations? Medications?...
Incentives & Sanctions:    The Real Issues What behavior do we want to change? What steps will THIS participant need  to...
Mental Illness & Courts: Assumptions about Changing Behavior    Mental illness  criminal behavior    Treatment  crimin...
Typical MHC Client Goals   Achieve/maintain psychiatric stability    ◦ Personal recovery: meaningful life in the      com...
Mental Health Court Model & Assumptions                        Linkage to ID, referral        comprehensive && assessment ...
Does Research Support the MHCModel?Important question: what about MHCs works,  why, and for whom?To date: a few single-sit...
Emerging Research on Jail    Diversion and Probation•   Recidivism and days of incarceration for    people with and withou...
How Can We Get Improved            Criminal Justice Outcomes?                        Linkage to ID, referral        compre...
Questions We Need to Ask  and New TheoriesBefore we get to incentives and sanctions:1. Are people getting the right treatm...
Evidence-Based Services for    MHC Participants Housing Integrated co-occurring disorder  treatment Case management (in...
Treating a Disease vs. Developing a Life    in a Social World   Medical model: Mental illnesses are    biologically based...
Mental health:  The ability to pursue a dynamic  equilibrium between the individual’s  needs and desires – within the fram...
“Treatment” for Criminal Thinking               and Behavior   Criminogenic risks and needs    ◦ Assessment    ◦ Cognitiv...
Court Design & Process   Procedural justice    ◦ Quality of interpersonal treatment      (respect, dignity, empathy)    ◦...
Courts, Mental Illness and      Engagement in Society   Old MHC language: incentives &    sanctions, compliance   New MH...
Motivating Engagement   MHC participants often have impoverished    lives and few successes to celebrate    ◦ Celebrate a...
Court Team Responses to          Engagement & Progress   Recognition: praise,           Certificates for phase    honor ...
Court Team Responses to    Non-Adherence & Non-Engagement   Reprimand, disapproval          More restrictive pretrial  ...
Clinical Responses   NA/AA/Double Trouble       Detox/drug rehab   Clubhouse, other peer      Transfer to different   ...
Essential Element #4    Terms of participation1.   Promote public safety2.   Are clear, individualized and least     rest...
#4, cont. Length should not extend beyond max  period of incarceration or probation  participant could have received Com...
Essential Element #9 Individualized graduated incentives  /sanctions and tx modifications to  promote public safety and p...
#9, cont. Ad hoc praise and rewards helpful and  important incentives Phases should reflect participants’  progress Pub...
Some Strategies to Consider Use jail sparingly so medication  regimes are not compromised Loss of SSI or other benefits...
12 Step, MH, Co-Occurring “A drug is a drug is a drug” People can say anything they want in  a meeting Dual Diagnosis a...
Case Study What expectations are appropriate? What behavior are we trying to  change? Joe:    ◦ Lied to the court about...
Jail Protocols   Turn to the person next to you and    together develop jail protocols for    people with mental health i...
Resources GAINS Center Consensus Project Judicial Leadership Initiative Evidence-Based Practices, Drake, et al.,    “I...
Resources, cont. Bazelon Center for Mental Health Law NJC Co-Occurring Substance and  Mental Health Disorders (9-11-06) ...
Resources, cont.   The Courage to Change: A Guide for    Communities to Create Integrated    Services for People with Co-...
Beyond Sanctions & Incentives in Mental Health Court
Beyond Sanctions & Incentives in Mental Health Court
Beyond Sanctions & Incentives in Mental Health Court
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Beyond Sanctions & Incentives in Mental Health Court

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* Learn information about specific strategies and tactics used by operational Mental Health Courts that help motivate participants to engage in treatment and comply with court-supervised treatment plans
* Learn about factors that have been shown to improve or impair engagement in mental health treatment

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  • Triple bunked in a gym. No cell
  • Beyond Sanctions & Incentives in Mental Health Court

    1. 1. Incentives and Sanctions andMental Health: Issues toConsiderNADCP 18th Annual Training Conference, OprylandHon. Peggy Fulton HoraJudge of the Superior Court (Ret.)NDCI Senior Judicial FellowCarol FislerDirector Mental Health ProgramsCenter for Court Innovation NY
    2. 2. Largest mental hospital in U.S.? Los Angeles County Jail with 3,000 MI inmates every dayEarley, Pete, Crazy: A Fathers Search Through Americas Mental Health Madness (Putnam, 2006)
    3. 3. SMI prevalence in jail/prison 40% of individuals with serious mental illnesses have been in jail or prison at some time in their lives 16% of inmates in jails and prisons have a serious mental illness 1983 it was 6.4% In less than three decades, the percentage of seriously mentally ill prisoners has almost tripledTorrey, E. Fuller, M.D., “More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Survey of the States,” Treatment Advocacy Center (May 2010)
    4. 4. Prevalence of other Dx in Jail Mania, schizophrenia and major depression were significantly more prevalent in jails than the general population Women have 3 xs rate of depression as men in custody Over half of women have substance use disorder
    5. 5.  72% have co-occurring disorder Only 1/3 men & ¼ women receive needed services for severe mental disorders National GAINS Center for People with Co-Occurring Disorders in the Justice System (2002)
    6. 6. Co-Occurring Disorder Center
    7. 7. SMI in jail/prison, not hospital More than three times more seriously mentally ill persons in jails and prisons than in hospitals North Dakota has equal number Arizona and Nevada have almost ten times more mentally ill persons in jails and prisons than in hospitals
    8. 8. Going backwards  Early 19th C. reformers fought for more humane treatment for mentally ill  We’ve gone back to the 1840’s by jailing the mentally ill again Dorthea Dix Torrey, E. Fuller, M.D., “More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Surveyof the States,” Treatment Advocacy Center (May 2010)
    9. 9. One model of a co-occurring drugtreatment court  Eligibility determined by jail MH staff and negotiated with DA/PD  Integrated MH/SA tx  Sanctions sensitive to MH problems  MH specialist both case manager and liaison to judge  Separate court docket Lane Co. (Eugene OR) SAMHSA Jail Diversion Knowledge Dissemination Application Initiative rebecc.mcalexander@co.lane.or.us
    10. 10. Judicial monitoring Vital role Role more subtle and nuanced than other P-S courts Informed listening Engagement is key “The Role of the Judge in Tx Monitoring,” JLI Newsletter 2:1 (2006)
    11. 11. Difference? How may depression affect participation in DTC? Agoraphobia? PTSD? Auditory hallucinations? Medications? 13
    12. 12. Incentives & Sanctions: The Real Issues What behavior do we want to change? What steps will THIS participant need to go through to get to the desired behavior? What will motivate THIS participant to change his/her behavior? What’s really important? ◦ Law-abiding behavior!
    13. 13. Mental Illness & Courts: Assumptions about Changing Behavior  Mental illness  criminal behavior  Treatment  criminal behavior  Criminal justice involvement = opportunity to connect to appropriate treatment  Judicial supervision  treatment retention & outcomes  Treatment and judicial supervision  public safetyPUBLIC INDIVIDUALSAFETY TREATMENTGOALS GOALS
    14. 14. Typical MHC Client Goals Achieve/maintain psychiatric stability ◦ Personal recovery: meaningful life in the community while striving to achieve full potential Achieve/maintain sobriety No new offenses!!! Highly individualized standards for graduation, termination, and progress along the way !!!
    15. 15. Mental Health Court Model & Assumptions Linkage to ID, referral comprehensive && assessment appropriate community services Improved MH outcomes MHC Info-sharingparticipation Improved public safety Judicial monitoring (tx compliance)
    16. 16. Does Research Support the MHCModel?Important question: what about MHCs works, why, and for whom?To date: a few single-site studies, one multi-site study; promising results Recidivism: lower for MHC participants than defendants in traditional courts (even post- graduation) ◦ Biggest predictors of recidivism: # of arrests & # of days incarcerated in 18 months before MHC entry; no MH treatment in 6 months preceding MHC entry ◦ NOT associated with improved CJ outcomes: current charges, most serious prior offense, symptoms, insight, self- reported treatment compliance ◦ Connections to treatment: MHCs do a better job than traditional courts or jails
    17. 17. Emerging Research on Jail Diversion and Probation• Recidivism and days of incarceration for people with and without mental illness is associated with “criminogenic” factors • Criminal history, antisocial behavior, antisocial cognition, antisocial peers, family or marital discord, poor school or work performance, few leisure activities, substance abuse• Diagnosis, symptoms and treatment compliance are not associated with criminal justice outcomesReferences: Almquist & Dodd, Mental Health Courts: A Guide to Research- Informed Policy & Practice (2009); Prins & Draper, Improving Outcomes for People with Mental Illnesses under Community Corrections Supervision: A Guide to Research-Informed Policy and Practice (2009);
    18. 18. How Can We Get Improved Criminal Justice Outcomes? Linkage to ID, referral comprehensive && assessment appropriate ? Improved community services MH outcomes Court ? ? Info-sharing process Improved public safety ? Judicial monitoring (tx compliance)
    19. 19. Questions We Need to Ask and New TheoriesBefore we get to incentives and sanctions:1. Are people getting the right treatment and services?2. Do we have the right MHC design, policies & procedures?3. How important is treatment engagement? What else should participants engage in?
    20. 20. Evidence-Based Services for MHC Participants Housing Integrated co-occurring disorder treatment Case management (incl. ICM, FICM, FACT) Supported employment Trauma interventions Illness management & recovery Cognitive behavioral therapies (esp. for high criminal justice risk)
    21. 21. Treating a Disease vs. Developing a Life in a Social World Medical model: Mental illnesses are biologically based brain disorders ◦ Treatment is fundamentally medical ◦ Mental illnesses are chronic conditions, requiring symptom management ◦ Focus of MHC is treatment adherence Recovery: Development of a person’s full life potential living as independently as possible and in harmony with the community
    22. 22. Mental health: The ability to pursue a dynamic equilibrium between the individual’s needs and desires – within the frame of society’s rules – to fulfill a meaningful life.Mental illness: A person’s temporary inability to pursue a meaningful life due to the presence of psychiatric problems severe enough to interfere with his performance in any one or more of the following spheres: social, labor, and academic
    23. 23. “Treatment” for Criminal Thinking and Behavior Criminogenic risks and needs ◦ Assessment ◦ Cognitive-behavioral interventions (T4C, MRT, R&R) ◦ Accidental cognitive-behavioral treatment?  Court requirements, judicial monitoring, case management “Criminal-justice informed treatment”
    24. 24. Court Design & Process Procedural justice ◦ Quality of interpersonal treatment (respect, dignity, empathy) ◦ Accountability (participants & providers) ◦ Transparency of court process & decisions ◦ Engagement in civic society, social norms Similar factors: treatment engagement
    25. 25. Courts, Mental Illness and Engagement in Society Old MHC language: incentives & sanctions, compliance New MHC language: alliance, motivation & engagement ◦ Ongoing judicial monitoring/relationship to motivate engagement in treatment, prosocial activities and civil society
    26. 26. Motivating Engagement MHC participants often have impoverished lives and few successes to celebrate ◦ Celebrate accomplishments; avoid more failure Lots more carrots than sticks Coordinate judicial & clinical responses Your reward = my punishment! Don’t confuse treatment & services with rewards & punishment Engagement strategies will reflect the style of the judge and the court team
    27. 27. Court Team Responses to Engagement & Progress Recognition: praise,  Certificates for phase honor roll, applause, completion: not rigidly showcase talent (show defined! art work, sing)  Participation in court- Less frequent appts. sponsored events with MHC/monitoring  Less restrictive pretrial staff release conditions Status hearings: voice  Less frequent urine re frequency, priority in testing order or appearance or seating  Granting of privileges (such as travel, later Presents, gift curfew) certificates (usually donated)  Charge
    28. 28. Court Team Responses to Non-Adherence & Non-Engagement Reprimand, disapproval  More restrictive pretrial More frequent appts with release status (contact MHC/monitoring staff supervision, electronic monitoring, etc.) Unannounced visits  Loss of privileges (such More frequent status as travel, curfew) hearings  Community service Penalty box  Bench warrant Writing assignments (journal, letter to judge)  Jail remand (short stays) Workbook assignments  Termination/sentencing
    29. 29. Clinical Responses NA/AA/Double Trouble  Detox/drug rehab Clubhouse, other peer  Transfer to different support provider, but same type Treatment of service (improve “fit”) engagement groups  Transfer to more or less (remand intervention) restrictive housing or Hospitalization treatment program ◦ Voluntary  Other groups (money ◦ Involuntary mgmt, anger mgmt, family relations, etc.)
    30. 30. Essential Element #4 Terms of participation1. Promote public safety2. Are clear, individualized and least restrictive to ensure tx engagement3. Minimize impact of charges on participants’ criminal record4. Support a positive legal outcome
    31. 31. #4, cont. Length should not extend beyond max period of incarceration or probation participant could have received Completion tied to compliance and strength of connection to community tx Withdrawal/dismissal should not reflect negatively on current case
    32. 32. Essential Element #9 Individualized graduated incentives /sanctions and tx modifications to promote public safety and participants’ recovery Imposed “with great care” and w/ input from MH professionals Develop specific protocols for jail as a sanction
    33. 33. #9, cont. Ad hoc praise and rewards helpful and important incentives Phases should reflect participants’ progress Public recognition of progress Number of available incentives should be as broad as sanctions
    34. 34. Some Strategies to Consider Use jail sparingly so medication regimes are not compromised Loss of SSI or other benefits Look for creative alternative to incarceration like set up chairs for group Link volunteer work with something defendant likes to do (work outdoors, work with animals, etc.)
    35. 35. 12 Step, MH, Co-Occurring “A drug is a drug is a drug” People can say anything they want in a meeting Dual Diagnosis and Dual Recovery 17 Step meetings
    36. 36. Case Study What expectations are appropriate? What behavior are we trying to change? Joe: ◦ Lied to the court about employment ◦ Lost his supported housing after staying out all night; won’t acknowledge responsibility (says another resident ratted him out to his PO) ◦ Clean and sober for a year ◦ No new arrests
    37. 37. Jail Protocols Turn to the person next to you and together develop jail protocols for people with mental health issues or co-occurring disorders  Length of time? Medications? Strip search? Segregation?  Other issues?
    38. 38. Resources GAINS Center Consensus Project Judicial Leadership Initiative Evidence-Based Practices, Drake, et al., “Implementing Evidence-Based Practices in Routine Mental Health Service Settings,” Psychiatric Services 52 (2001)
    39. 39. Resources, cont. Bazelon Center for Mental Health Law NJC Co-Occurring Substance and Mental Health Disorders (9-11-06) and Managing Cases with Mental Disabilities (10-18-06)courses Second Generation of Mental Health Courts Redlich, et al., The Second Generation of Mental Health Courts, Psych.Pub.Pol.Law 11(4) 527-538 (2005)
    40. 40. Resources, cont. The Courage to Change: A Guide for Communities to Create Integrated Services for People with Co-Occurring Disorders in the Justice System (National GAINS Center, Dec. 1999) MH webliography/AOD listserv peggyhora@sbcglobal.net

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