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National Council Magazine, 2010 Issue 1


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  • 1. m a g a z i n e NationalCouncilSharing Best Practices in Mental Health & Addictions TREATMENT Published by the National Council for Community Behavioral Healthcare Improving Public Safety and Maximizing Taxpayer Dollars Neal Cash Ending an American Tragedy National Leadership Forum for Behavioral Health/Criminal Justice Services Human Rights at Home: Mental Illness in U.S. Prisons and Jails David Fuller Where Does the Buck Stop? Linda Rosenberg Decriminalizing Mental Illness: Miami Dade County Tackles a Crisis at the Roots Judge Steven Leifman, Tim Coffey Mental Health First Aid Equips Police Officers to De-escalate Crises Richard Leclerc Beyond Bars Mental Health-Addictions and Criminal Justice Collaborations 2 0 1 0 , Issu e 1
  • 2. p.34 From the Field National Council Magazine is published quarterly by the National Council for Community Behavioral Healthcare, 1701 K Street, Suite 400, Washington, DC 20006. Editor-in-Chief: Meena Dayak Specialty Editor, Mental Health-Addictions and Criminal Justice Collaborations: Mohini Venkatesh Editorial Associate: Nathan Sprenger Editorial and advertising queries to or 202.684.7457, ext. 240. PDF available at NationalCouncilM A G A Z I N E 2 What Happened to Me, Not What Was Wrong With Me Tonier Cain 4 Editorial Improving Public Safety and Maximizing Taxpayer Dollars Neal Cash 6 Human Rights at Home: Mental Illness in U.S. Prisons and Jails David Fuller 8 Ending an American Tragedy: Addressing the Needs of Justice-Involved People with Mental Illnesses and Co-Occurring Disorders National Leadership Forum for Behavioral Health/Criminal Justice Services 14 Behavioral Health and Criminal Justice Collaboration: Where Does the Buck Stop? Interview with Linda Rosenberg 18 Decriminalizing Mental Illness: Miami Dade County Tackles a Crisis at the Roots Steven Leifman, Tim Coffey 24 Jails and Prisons, Our New Mental Asylums Interview with Pete Earley 26 Reducing Justice Involvement for People with Mental Illness: Strategies that Work Interview with Fred Osher 28 Funding for Behavioral Health and Criminal Justice Programs Henry J. Steadman, Samantha Califano 30 Back to Basics: Evaluating Opportunities to Serve the Justice-Involved Population in Community Behavioral Health John Petrila 32 Advocate to Give Youth a Second Chance: Juvenile Justice and Delinquency Prevention Reauthorization Act Mohini Venkatesh 34 FROM THE FIELD Center for Health Care Services, Centerstone, Citrus Health Network, Community Partnership of Southern Arizona, Community Psychiatric Clinic, Chrysalis, Hands Across Long Island, John Eachon Re-entry Program, The Kent Center, Mental Health Center of Denver, MHMR Tarrant County, River Edge Behavioral Health Center, River Oak Center for Children, Seacoast Mental Health Center, Spanish Peaks Mental Health Center, Wayne State University Project CARE 52 Double Tragedies: Speaking Out Against the Death Penalty for People with Mental Illness Ron Honberg 54 Reinstating Medicaid Benefits: Life in the Community after Incarceration Alex Blandford 56 Incarceration and Homelessness: Breaking the Tragic and Costly Cycle Andy McMahon 58 Mental Health First Aid Equips Police Officers to De-escalate Crises Richard Leclerc 62 E-learning in Corrections: Viable Training Option in a Tough Economy Diane Geiman 64 Member Spotlight National Council 2010 Awards of Excellence Honorees Beyond Bars Mental Health-Addictions and Criminal Justice Collaborations National Council Magazine, 2010, Issue 1
  • 3. 4 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars Iam a 41-year-old African American woman who has been in and out of prison multiple times; I am a mental health consumer who’s been hospi- talized many times; and I have been in so many substance abuse programs, I can’t even name them all. Most important, I am a trauma survivor. During every incarceration, every institutionaliza- tion, every court-ordered drug treatment program, it was always the same: I was always treated like a hopeless case.All people could see was the way I looked or the way I smelled. It wasn’t until I finally entered a recovery-oriented, trauma-informed treatment program a little more than four years ago, where I felt safe and respected, that I could begin to heal. As a young child, I had a belief system that I was nothing and that I would never amount to anything. I thought that the men whom my mother enter- tained, who touched and hurt me, did it because something was wrong with me and I deserved it. I thought that my mother abused me and didn’t love me because I was a bad child.My eight broth- ers and sisters needed me to protect them. I had to keep the men from hurting them, like they hurt me; I only wished my mother loved me enough to protect me. I spent a long time living with no hope and finding no help in the different systems I entered. Every time I went into jail or prison, I asked for help, but I was told that it was a jail, not rehab.When I was leaving, they said,“See you when you come back, we’ll hold your cell for you.” No one ever said, “I hope you make it this time.” When I was admitted to mental health units, I was told that I had several diagnoses, and I always asked, “How do you know? I’ve been up smoking crack for 7 days.” They never allowed the street drugs to get out of my system before they evalu- ated me. I also went to many substance abuse programs — at one, I was raped by a counselor; others used a “tear you down and build you back up”model,but I was broken down enough already. Even in school, where I was teased because of the way I smelled, no one asked about what was hap- pening to me. I have also been secluded and restrained several times. I am a victim of neglect and abandonment, and one of the worst things that you can do to someone with this type of history is to put them into a seclusion room. When that door was shut, the flashbacks of my mother’s abuse and aban- donment began. When they’d come later with a tray of food, I had been triggered, and so I pushed the tray away from me, but then they restrained me.I was a rape victim,and this restraint triggered me even more. I was also always overmedicated. It’s hard not to lose hope under those circum- stances. Then, after 19 years of drug addiction, alcohol- ism, homelessness, going in and out of prison (83 arrests and 66 convictions), mental health insti- tutions, and substance abuse programs, I finally found the help that I needed to heal. Someone finally asked me“What happened to you?”instead of “What’s wrong with you?” I was in prison and pregnant, and I was terrified that I was about to lose another child: I had al- ready had four kids taken from me,and I could not survive losing another. I was told about a program that would help me heal from my trauma, recover from my addictions, treat my mental illness, and let me keep my baby with me. Well, I didn’t know how they were going to manage all that,but I knew I had to give it a try.What did I have to lose? The first thing my therapist said to me was “Everything that happened to you as a child, hap- pened to you; you didn’t do it to yourself,” and I believed her because her tone was gentle and not judgmental. Then we began the work, and I had to remember and talk about every time I was touched and assaulted as a child. I talked about my issues with my mother,how she never loved me What Happened to Me, Not What Was Wrong With Me Tonier Cain, Consumer Advocate Tonier Cain is a featured “In My Own Words” speaker at the 2010 National Council Conference, March 15-17, Disney World, Florida. “ Tonier Cain has spoken nationally on trauma,incarceration, and recovery. She has served as a member of the Protection and Advocacy for Individuals with a Mental Illness Council. She has also worked as a case manager and director of advocacy services for a private nonprofit in Annapolis, Maryland. She is the team leader for the National Center for Trauma Informed Care, which provides consultation, technical assistance, and training to revolutionize the way in which mental health and human services are organized, delivered, and managed while furthering the understanding of trauma-informed practices through education and outreach. Ms. Cain is the subject of “Healing Neen,” a documentary based on her life as she moved through multiple systems of care.
  • 4. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 5 and never protected me. I began to heal because I started to understand that I am an adult now, and my mother’s lack of love for me, and men’s abuse of me, is a reflection of who they are; it’s not about who I am. Then my therapist told me that we had to start talking about my children, and I shut down. I asked her how I could talk about something that gives me so much pain and suffering every day of my life: How do you heal from having four kids walking the earth when you don’t know how they’re doing, what they look like, or who they are? She said, “You do; you just don’t do it by yourself,” and she was there with me, for weeks of crying and rocking, as I allowed myself to remember them and grieve them. In that program, I felt safe for the first time.The walls had pictures and positive quotes on them.We had our own rooms with nice colors. No one was screaming “medication time”at us or secluding or restraining us. I was asked every day, “How are you feeling today?” Everybody there was trained in trauma, which meant I could talk to any staff member at any time, and they would listen. For the first time in my life, I felt like a person, a human being, and not like the monster I had been treated as in the past. I felt hope. Oh, what a difference it makes when someone asks,“What hap- pened to you?” instead of “What’s wrong with you?” Once I was able to start healing from the trauma in my life, my belief system changed from “I am nothing” to “I am somebody, and I can be anything I want in this world.” All of the earlier treatment and informa- tion that people had tried to give me for years had only reached the surface; it didn’t get down to the foundation of my problems and needs. Since getting trauma treatment in a safe, trauma-informed setting, however, I have been able to heal. I make better deci- sions. I have a healthy, beautiful child whom I simply adore and who is securely attached to me. I do not have the desire to use drugs or alcohol.I am no longer on medication. I am now an advocate in the streets where I once lived, used drugs, and was raped and beaten.I am now a national spokesperson on trauma, I am a homeowner, and I sit on several boards. Five years ago, I was taking hits of crack, in a mental institution, and in and out of prison. Everyone then thought that I would spend the rest of my life going in and out of prisons and mental institutions or that I was going to die in the streets.They were wrong. Where there’s breath, there’s hope, and for me it be- gan with respectful, individualized trauma treatment.” Every time I went into jail or prison, I asked for help, but I was told that it was a jail, not rehab. When I was leaving, they said, “See you when you come back, we’ll hold your cell for you.” Suited for Performance! Contact us today to arrange a 60-minute demonstration on how InfoMC can help you. - performing at the speed of your business! Come Visit Us in Booths 707,709 and 711 at the 2010 National Council Conference. InfoMC, Inc. 101 West Elm Street Suite G10 Conshohocken, PA 19428 phone 484-530-0100 InfoMC - the leading Business Solutions Partner for Behavioral Healthcare Payors InfoMC’s Incedo™ solution allows Employee Assistance / Work-Life Programs (EAPs), Managed Behavioral Healthcare and Disease Management Organizations (MBHOs and DMOs) to enroll and track member eligibility, manage provider networks, do referrals, authorizations and care coordination, and process and pay claims. It also links Providers and Payors via the internet to streamline communications.
  • 5. Editorial 6 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Community behavioral healthcare’s role in pre- venting crime and increasing public safety is one of our country’s best-kept secrets. And that’s a shame. A few months ago, news reports focused on a third straight year of decreased crime rates across the United States, surprising law enforcement officials and other experts who predicted just the opposite, given the high rate of unemployment and the eco- nomic recession. In previous periods of economic stress, crime rates increased.Yet preliminary statis- tics for 2009, released by the FBI in late December, showed that rates for all types of crime had again decreased from the year before. As analysts struggled to explain this anomaly,few to none mentioned the role of community behavioral health services.Yet many of us in the field know how important our efforts have been in this regard — and how much more we can accomplish. Community behavioral healthcare serves as an important partner for the criminal justice system, whether by providing treatment which prevents be- haviors that could bring people into contact with law enforcement; training officers in how to deal with people with mental illness who are in crisis; or preventing recidivism by ensuring continued and coordinated treatment for people involved with the justice system, leaving the justice system, or both. In these difficult financial times, it is especially important that our systems recognize and embrace their interrelatedness and work together to maxi- mize public resources. At the same time, we must educate the public about how effective behavioral health treatment reduces crime, avoids expensive incarceration,helps people remain in or re-enter the community as contributing citizens, and enhances the quality of life of everyone in the community. As reported in the National Leadership Forum on Behavioral Health/Criminal Justice Services Report featured in this issue, the interface between our systems often is frayed, if it exists at all. Yet there are pockets of excellence around the country that provide models for collaboration and cooperation, with promising results in both individual outcomes and taxpayer savings — examples are featured in the From the Field section of this issue.Representa- tives of the Center for Mental Health Services’ Na- tional GAINS Center visited some of these pockets of excellence in fall 2009, including those operated by the Community Partnership of Southern Arizona. Collaboration Is Key As a community-based nonprofit organization, CPSA has a large stake in the quality of life and public safety of the communities it serves — more than 1 million people across five counties. Our work helps prevent crime, reduce recidivism, and divert people with mental illness and substance use issues from incarceration into less expensive, and more effec- tive, community-based treatment. CPSA, the regional behavioral health authority over- seeing publicly funded care in southernArizona,has sought creative ways to collaborate with the crimi- nal justice system.We’ve learned that: >> Any cross-system program or strategy must be built on a firm foundation of mutual respect and understanding and on relationships that both grow out of and are nurtured by the collaboration. >> Planning needs to be deliberate and incremental, with both short- and long-term common goals. >> Processes, strategies, and results should be monitored and evaluated, and improvements should be made on the basis of findings. >> Communication, including sharing and celebrat- ing results, should be structured and ongoing. >> Collaborations must be cost effective and sus- tainable, even in tough times. This is supported by the mutual advocacy and identification of new opportunities that evolve out of collabora- tive relationships, further strengthening commit- ment, and magnifying the impact of strategies and programs. This is basic community development.It can be slow and at times frustrating, but CPSA’s experience has demonstrated that it is worth it — and that no sub- stantive and lasting change can happen without it. CPSA began this journey in the late 1990s by form- ing a work group of behavioral health and criminal justice stakeholders in Tucson/Pima County that sought to identify systemic strategies to decrease the time people with a mental illness were inap- propriately incarcerated.This group evolved into the current Forensic Task Force, which meets quarterly and includes representatives of the court system, law enforcement, jails and corrections, local behav- ioral health providers, crisis services, attorneys, the veterans’ hospital, and other community stakehold- Neal Cash, President and CEO, Community Partnership of Southern Arizona, and Member, Board of Directors, National Council for Commu- nity Behavioral Healthcare Improving Public Safety and Maximizing Taxpayer Dollars Community Behavioral Healthcare’s Best-kept Secret Neal Cash is president and CEO of the Community Part- nership of Southern Arizona, the regional behavioral health authority contracted by the state of Arizona for funding and oversight of the public behavioral health system in five counties. He has a bach- elor’s degree in psychology from Syracuse University and a master’s degree in rehabilitation counseling from the University of Arizona. He is a member of the National Leadership Forum on Behavioral Health/Criminal Justice Services of the National GAINS Center. Participants in the mental health court experienced a 50 percent overall reduction in subsequent criminal charges in the 2 years after being in the program.
  • 6. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 7 ers. The task force, along with collocated behavioral health and criminal justice staff, provides the founda- tion and framework for all strategies and programs. Most of CPSA’s efforts in this collaboration have fallen into two areas: diversion programs and service coordi- nation via information sharing (see article, p. 37). CPSA also helped to establish Arizona’s first mental health court in 1999 in Tucson and has founded ad- ditional mental health courts in the Pima County Su- perior Court and Consolidated Justice Court. It also developed a formal mental health collaboration with every other limited-jurisdiction court in Pima County (six in total). CPSA has developed relationships and tools to allow swift identification of members who have been arrested and appropriate, real-time shar- ing of information while protecting confidentiality. These relationships and tools expedite communica- tion between the community behavioral health treat- ment provider and the jail’s treatment provider,ensur- ing that members receive support in navigating the criminal justice system while maintaining coordina- tion of care. Most recently,CPSA has established an InitialAppear- ance program, which involves community behavioral healthcare staff participation.This program has signif- icantly decreased the likelihood that a CPSA member will be detained in the jail system. CPSA has also be- gun training forensic peer mentors to provide support and advocate for members involved with the criminal justice system and is again offering crisis intervention training to law enforcement in southern Arizona. Participants in the mental health court experienced a 50 percent overall reduction in subsequent criminal charges in the 2 years after being in the program.The most recent annual figures for CPSA’s diversion pro- grams in Tucson City Court and Pima County Justice Court show graduation rates of 97 percent and 92 percent, respectively — a total of 627 CPSA members who avoided incarceration and had charges dropped. “Many people were skeptical about mental health court,”noted the Hon.NanetteWarner,Judge of Supe- rior Court, Division 20, in a recent letter,“but with the leadership and the commitment from CPSA,it became a reality and allayed all concerns...The result has been fewer people with mental illnesses falling through the cracks. They have escaped the revolving door of the criminal justice system and are now experiencing meaningful recovery and success for the first time in their lives. There are innumerable people who have graduated from mental health court, even people the professionals thought would not be successful.” Current Conditions Demand Creativity Collaborations are especially critical now.Federal and state governments face historic budget shortfalls, just as expenditures on corrections across the country are nearing a staggering $70 billion annually, according to the Bureau of Justice Statistics. Some states are releasing inmates early, and many are increasingly relying on community supervision as an alternative to expensive incarceration. At the same time, publicly funded behavioral health services — the very resources that can help ensure the success of these alternative justice approaches — are in grave danger of being cut. With states struggling to cut costs and few lawmak- ers willing to consider new revenue sources,the result could be a mad, self-defeating scramble for funding among different systems and stakeholders. Alter- natively, our industry’s proactive engagement with criminal justice could create collaboration instead of chaos and lead to thoughtful changes and strategies that result in real improvements at both the systems and individual levels — not only to make the best use of dwindling dollars but to create stronger, more efficient, more effective, and more humane systems in the long run. The status quo is being shattered by fiscal realities. We can seize this opportunity to create partnerships with criminal justice and to educate decision makers and the public about community behavioral health- care’s critical role in the safe diversion and release of people with substance use issues and mental illness. We can make real connections between community behavioral healthcare and criminal justice. And by promoting our accomplishments to the larger com- munity, we can emphasize our contribution to public safety. Expenditures on corrections across the country are nearing a staggering $70 billion annually. Some states are releasing inmates early, and many are increasingly relying on community supervision as an alternative to expensive incarceration.At the same time, publicly funded behavioral health services — the very resources that can help ensure the success of these alternative justice approaches — are in grave danger of being cut.
  • 7. 8 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars “Mr. Chairman, Ranking Member Coburn, and dis- tinguished members of this Subcommittee, it is an honor to provide testimony before this body. My purpose in testifying is to bring to light some of the experiences people with mental illness encounter when they enter the criminal justice system and to expose the inhumane treatment they receive. I have also included information on how this travesty in human rights can start to be corrected. With the ability of hindsight, I can say I started to experience depression at an early age. The first twinge of it was in elementary school at the time of Martin Luther King, Jr.’s assassination. I can re- member thinking, “The people in this country will never change. If they could kill a man as good as him what chance do I have?”These thoughts were in the context of experiencing racism through my en- tire life, from times visiting family in the rural south as a young child to going to a majority white school in my native New York from elementary through high school. I think now, and feel seven years old is too young to feel hopelessness, especially in a country that has as much as this country. When I was seventeen I experienced my first arrest. New York City’s Rikers Island at that time was called the “gladiator school” by local youth. I was arrested for illegal gambling because I had betted a few dollars on some numbers and was caught near the “number spot.” Honestly, I used to bet to get a thrill because even at that age, it was hard for me to feel joy or happiness like other young men, so I used to fill that void with thrill seeking and other non goal- producing behaviors like drugs and alcohol use.This charge was considered a misdemeanor in New York City [and] State. In the few days it took for me to post bail I experi- enced suicidal thoughts and was actually stabbed by another inmate for the jacket I was wearing. I was afraid to go to the clinic because I knew they would put me in isolation on suicide watch and I felt punished enough. When I became eighteen years old, things were not getting better for me. I was abusing drugs like heroin and crack cocaine. My family did not know what to do. I was trying to outrun someone I could never outrun, myself. By the time I was twenty-one years old,I had been arrested several times for drug possession/sale and gambling. I was using a large amount of drugs and got caught in a drug den dur- ing a police raid. I was facing a lot of time and was scared to death. My family found me a good attor- ney who eventually got the charges dismissed and suggested that I seek drug treatment. I went to a long-term drug treatment facility in NewYork State.I did not like being there,but I thought maybe I could get help with the problems I had been experiencing. I told my counselor I thought I had more than just a drug problem — that I felt sad and lonely pretty much all the time no matter what I did. I also told him I thought about ending my life quite a bit.When he heard this, he warned me that if I mentioned that again I would be discharged from the program and sent to a mental hospital. I never mentioned it again. I graduated from the program after a year, went back home,picked up drugs again in less than two weeks, and was back in the street like nothing ever changed. Through the next twenty years, I went back and forth to jail. My ability to function was slowly, but steadily, declining. I was arrested at least twenty or thirty times in that time period. I served sentences from ten days to one year.The first six to ten times I would ask my lawyer or the staff in the jail for help with the issues I had, I got the same answer every time — that is if they bothered to answer; that either I went to drug treatment or the mental hospital. I knew one or the other by itself would not work, so I gave up asking for help from the system. Towards the last few years of my suffering, I ex- perienced my first hospitalization for psychiatric reasons; it was after my first suicide attempt. I was there for a couple of months. I went to therapy, and I was put on medication. It helped; I became stable and was discharged from the hospital. I did not have stable housing when I was discharged. I was referred to a“¾ house”to live and it was worse than living on the streets, so that is what I did. I ended up not taking my medication, not participating in therapy, and quickly re-offended. When I went to jail the next time I didn’t stand up for the count. I was written up and put into punitive segregation (“the box”). In segregation, I was put in a cold, dark, barren cell — no TV, no books — where the environment exaggerated my symptoms and I even experienced some new ones like audio hal- Testimony of David Fuller, Certified Psychiatric Rehabilitation Practitioner and Forensic Peer Specialist; a Person with a History of Incarcer- ation and Psychiatric Disability, before the United States Senate Committee on the Judiciary, Subcommittee on Human Rights and the Law, Hearing on “Human Rights at Home: Mental Illness in US Prisons and Jails,” September 15, 2009. Printed with permission of David Fuller Human Rights at Home: Mental Illness in U.S. Prisons and Jails This cycle would repeat itself many more times: get out, no place to live, stop taking my medication, use drugs, become suicidal, then go back to jail.
  • 8. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 9 lucinations. The officers were verbally and physically abusive.There was no point in making an official com- plaint because the officers would just abuse you more and nothing would ever be done about it. This cycle would repeat itself many more times: get out, no place to live, stop taking my medication, use drugs, become suicidal, then go back to jail. I remem- ber I“caught a ticket”in jail one time and before they could send me to the box I tried to hang myself in my cell,my cellmate found me before the officers did and untied the sheet. He did not tell the officers because he knew what would happen.I wept in my cell the rest of the night; I was discharged after two days. There were fights with other inmates almost every time I went to jail. Because of my depression, I would appear to be an easy victim and some of the other inmates would try to steal my food. Most of the time I would win the fight, but lose the battle for my self- esteem and self-respect — fighting for food like a common animal. “There is no HIPAA in jail” because there is really no privacy in regards to your psychiatric care. Either you are on the “Mental Observation Unit” with all the stig- ma and dangers that implies, or you are living in gen- eral population where every time you go for medica- tion or need to see the doctor it is announced through the cell block. When you are getting your medication you are on a line with a hundred other inmates and inmates going back and forth on the other side of the hall. People are buying and selling medication and other illicit drugs. Everybody pretty much knows what the other person is getting.When you go to the“clinic” to see the doctor you have to wait for hours on end and once again, everybody knows what you are there for. You can hear staff talking about other patients when you are meeting someone about yourself, so you think about whether they talk about you when you leave, so you do not share much and do not get the help you need. For 28 years of my life, I struggled with depression and then later [posttraumatic stress disorder]. I used hard drugs most of this period and it seemed like I was always going in and out of jail. Violence was al- ways around me.Through my periods in jail and being homeless I have been stabbed and shot.I was abused by the very people and system that were supposed to be helping me, and keeping me safe. I did not have access to the services I needed; I was alienated from friends and family. I felt isolated and alone. I dwelled in hopelessness, shame, guilt, and fear of the future. I believed God had abandoned me and things would never change. I turned down treatment a few times in the past when I was in jail before because I was never offered a place [where] I could address my psychiatric disabil- ity and my drug addiction at the same time, in the same place.I had been through treatment many times for one or the other at different times and it seemed to never work for me. I am happy to say things did change. The last time I was incarcerated I was offered an opportunity to par- ticipate in a Mentally Ill/Chemically Addicted — resi- dential treatment rather than stay in jail. It turned my life around. I was able to be around people who had similar experiences and I did not feel so alone. I talk- ed to people like me who had recovered and [were] on their way to happy, productive lives. For the first time in a long time, I had real hope for the future. I learned I had to be honest,open-minded,and willing to do the footwork in order to recover. I had to take responsibility for my life. I gained a relationship with a higher power that I choose to call God. I confronted my fears and insecurities and made friends with other people, some like me and some that did not have the same experiences as me. I did not use my past as an excuse to fail; I used it as a source of strength and truth to move me forward.I learned to love again; first myself and then others. I learned to forgive. It set me free. I went back to work with the help of my peers at the Howie T. Harp Advocacy Center, a supportive employ- ment/training center for people with histories similar to my own, got a place to live, and found someone special to share my life with. I learned to be a father, a husband, a citizen — a man! Eight years ago I never thought I would be able to say this, but I am happy, joyous, and free.Today, all things are possible! Through my years of suffering, the government has probably spent about one million dollars (not includ- ing court and law enforcement costs) on incarceration and treatments that just made my life worse and were ineffective in diminishing or eliminating the problem. All my drug use was a desperate attempt to medicate symptoms that I did not understand and that society had made me ashamed and fearful to get help for. All of my arrests were due to my drug use. Why did I have to be punished so severely, for so long, for be- ing sick? Psychiatric disability and substance abuse are chronic illnesses similar to hypertension or diabetes.The last time I checked, people with those illnesses were not being put in jail and shunned by society. People can live with all of these disorders with proper treatment and support. In closing, I encourage everyone to read Ending an American Tragedy: Addressing the Needs of Justice-In- volved People with Mental Illnesses and Co-Occurring Disorders, which I have attached. I believe this document can point this committee in the right direction in changing the way services are given; in a cost-effective and humane way that ben- efits the community as a whole” Sincerely, David L. Fuller David Fuller, CPRP, a consumer in recovery from psychiatric disability, substance abuse, and the criminal justice system, is employed at Kings County Hospital Center in Brooklyn as a peer counselor who coordinates the Adult Outpatient Walk-In Clinic and a group facilitator with its Continuing Day Treatment Program. He is also an outreach and housing coordinator for the Manhattan Outreach Consortium.As an administrator, service provider, and independent consultant, Fuller draws on his personal experiences as a consumer — and his opportunity to overcome many chal- lenges — to fuel his mission to improve access to services for people who have been affected by psychiatric diagnoses and who use the public mental health system. Fuller is also a member of the National Leadership Forum on Behavioral Health/Criminal Justice with the National GAINS Center; an advisory board member of the Peer Integration Project through the Columbia School of Social Work’s Workplace Center; a guest lecturer at the Columbia,Adelphi, and New York Universities Schools of Social Work on trauma and mental health recovery models. Psychiatric disability and substance abuse are chronic illnesses similar to hypertension or diabetes. The last time I checked, people with those illnesses were not being put in jail and shunned by society.
  • 9. 10 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars In 1841, Dorothea Dix was appalled by the conditions she observed in Massachusetts jails and crusaded for more humane responses to the needs of those inmates with mental illnesses. Within a decade her work was translated into therapeutic state run institutions that traded punishment for care. Over the next century, without sustained commitment to Dix’s vision for recovery, these facilities fell into disrepair to the point that today,hundreds of thousands of people with mental illnesses crowd our county jails and state prisons. In 1946, Life Magazine published an exposé detailing cruel and inhumane conditions in State psychi- atric hospitals across the United States.1The article described widespread abuse of patients resulting, in part, from “public neglect and legislative penny pinching;” and was punctuated by a series of haunting photographs depicting desolate and shameful conditions under which people with mental illnesses were being confined, often for years or even decades on end. The author referenced grand jury reports as well as State and Federal investigations documenting widespread abuses and hazard- ous living conditions in State institutions. Citing severely inadequate staffing, substandard treatment, inappropriate use of restraints, and provision of little more than custodial care, the institutions were described as, “…costly monuments to the States’ betrayal of the duty they have assumed to their most helpless wards” Although the population of State psychiatric hospitals continued to grow over the next decade, the publication of this article, along with similar accounts from other media sources, began to expose a crisis that had existed largely hidden from public view for far too long. As more light was shed on the horrific treatment people received in State psychiatric hospitals, along with the hope offered by the availability of new medications, a flurry of federal lawsuits resulted in court decisions leading to substantial reductions in the numbers of people housed in State psychiatric hospitals. Unfortunately, while State hospital beds were shut down by the thousands, the types of comprehensive community-based services and supports promised as a condition of their closing were never developed. Combined with changes in sentencing practices, evolution of quality of life ordinances, and restricted definitions of eligibility for public sector behavioral health services, this has resulted in many individu- A Report of the National Leadership Forum for Behavioral Health/Criminal Justice Services, Co-chaired by Linda Rosenberg, MSW, President and CEO, National Council for Community Behavioral Healthcare and Henry J. Steadman, PhD, President, Policy Research Associates; CMHS National GAINS Center Ending an American Tragedy: Addressing the Needs of Justice-Involved People with Mental Illnesses and Co-Occurring Disorders It is my privilege to co-chair the National Leadership Forum for Behavioral Health/Criminal Justice Services. Ending an American Tragedy: Addressing the Needs of Justice-Involved People With Mental Illnesses and Co-Occurring Disorders is a working document of the NLF.The report is designed as both a call to action, focusing on the crisis in our nation’s jails and prisons — men and women with mental illnesses and addictions incarcerated because they didn’t get the treat- ments they desperately need — and an inspiration — highlighting the possibilities of effective services.We are asking leaders in all communities to come together, pool resources, and work as one. I’m proud of member organizations that are already providing such leadership and you’ll find a small sample of member programs in the “From the Field” section of this issue. National Council members are endlessly creative in overcoming financial, bureaucratic, and cultural barriers and establishing collaborations that solve community problems.And we look forward to the growth and spread of programs and services that offer productive lives to people with mental illnesses and addictions as the alternative to incarceration.” — Linda Rosenberg
  • 10. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 11 als with mental illnesses and co-occurring substance use disorders repeatedly coming into contact with the criminal justice system. Our Nation is once again in the midst of another shameful and costly mental health crisis that has been allowed to fester and grow, largely out of public sight. It is a secret of stunning proportions; in numbers and in harm. Everyday, in every community in the United States, our law enforcement officers, courts, and correctional institutions are witness to a parade of misery brought on by an inadequately funded, antiquated, and frag- mented community mental health system that is un- able to respond to the needs of people with serious mental illnesses. Each year, more than 1.1 million people diagnosed with mental illnesses are arrested and booked into jails in the United States. Roughly three-quarters of these individuals also experience co-occurring substance use disorders, which increase their likelihood of becoming involved in the justice system. On any given day, between 300,000 and 400,000 people with mental illnesses are incarcer- ated in jails and prisons across the United States,and more than 500,000 people with mental illnesses are under correctional control in the community. Overthepast50yearswehavegonefrominstitutional- izing people with mental illnesses, often in subhuman conditions, to incarcerating them at unprecedented and appalling rates — putting recovery out of reach for millions of Americans. These people are not all the same.They are a hetero- geneous group. >> A small subgroup does resemble the State hos- pital patients of yesteryear, and their presence in our jails/prisons is one of the most egregious and disturbing images related to our failed systems of care. The availability of intensive care models, in- cluding hospital care for some, is critical. >> Many other citizens with mental illnesses in our jails have less disabling conditions and with ac- cess to appropriate community treatment and support, will do quite well. >> A third subgroup includes people with mental ill- nesses who have traits that are associated with high arrest and recidivism rates.These individuals would be best served with good treatment and supports, which include interventions targeted to their dynamic risk factors for arrest. As we attempt to respond to the needs of these peo- ple and respect the legitimate public safety concerns of all community members, conditions in these cor- rectional settings, which are designed for detention and not therapeutic purposes, are often far worse than conditions described in the State hospitals of the 1940s. Moreover, when justice-involved persons with co-occurring disorders leave correctional institu- tions, they repeatedly are left adrift only to recycle through the criminal justice system. Furthermore, individuals who become involved in the justice sys- tem often must contend with the additional stigma of criminal records, which make access to basic needs in the community, such as housing, education, and employment, even more difficult to obtain. This national disgrace, kept hidden for too long, represents one area in civil rights where we have actually lost ground.This failed policy has resulted in a terrible misuse of law enforcement, court, and jail resources, reduced public safety, and compromised public health. These conditions have recently resulted in investiga- tionsintothetreatmentofpeoplewithmentalillnesses in institutional settings, only this time the institutions are correctional facilities that were never intended to serve as de facto psychiatric hospitals. Over the past decade alone, the U.S. Department of Justice has issued findings from investigations of mental health conditions in more than 20 jail and prison systems across the United States, with additional investiga- tions currently ongoing. Equally reminiscent of the past, among the more pervasive findings from these investigations are severely inadequate staffing, sub- standard treatment, inappropriate use of restraints, and provision of little more than custodial care. The following excerpts are taken from recent grand jury and Department of Justice reports: >> During our tour, we observed inmate JM hitting her head on the window of her cell and talking with slurred speech. She was housed in a hospital cell under suicide watch. She spoke of seeing angels and said that she was afraid of her cellmate (who was in the advanced stages of pregnancy) was trying to harm her. She had been at [the jail] for approximately one month prior to our visit. JM stated on her intake form that she had previously been treated at a mental hospital in Little Rock and that she had been seen at a local hospital in January 2005 for seeing ‘spiritual things.’ Shortly after her admission to [the jail], she was placed on suicide watch for making statements about going to sleep and not getting up and ‘not caring if she was alive or not.’ Her medical record notes numerous instances of ‘talking wildly’ and ‘talking to herself.’ She told us that she had a history of hypothyroidism and told us the names of various psychiatric medications that she had been taking before being admitted to [the jail].Throughout our tour, we could hear JM moaning and crying and at times screaming. In spite of all this, this inmate was never evaluated by a mental health care pro- vider.We were told that she was not started on any psychiatric medications or sent to the local hos- pital because she did not have the ability to pay. >> Inmate M.K. hung herself on January 5, 2003 af- ter having been admitted on December 4, 2002. Her record contained the following inmate request form dated two days before her death on January 3, 2003.The note indicated the following. ‘I need to see the doctor to get my medicine straightened out. I am not getting my meds that my doctor faxed prior orders for me, and I brought in the medication myself and paid for it. I cannot afford to be treated this way! Please help me! I need my medicine.’ There is no indication that M.K.received her medi- cation before her death. There are no comparable Department of Justice inves- tigations into a lack of community services, because there is no constitutional right to community-based services as there is for persons who are incarcerated. However, by contrast, there are success stories in the community.A recent report by the Health Foundation of Greater Cincinnati offers a number of compelling personal stories from four Forensic Assertive Commu- nity Treatment (FACT) Teams they fund. Clearly, jails and prisons were never intended as a community’s primary setting to provide acute care services to individuals experiencing serious mental illnesses. In most cases they are ill equipped to do so.
  • 11. 12 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars >> “My housing is a lot better. My Social Security just got approved today, so I start receiving that again. They cut it off while I was in prison. I did 18 months in prison. I got [Social Security] back with the help of [the FACT team]. And they’ve been helping me with my housing. And that’s a lot better ‘cause now I can get adjusted to a cer- tain environment.And I don’t have to worry about where I’m going to live, one week to the next for whatever reason.” >> “Well, I was really in bad shape. I didn’t know how to go about getting help.The only thing that I really knew that I had to do was try to care for myself and my habit. And that’s what leads to criminal behavior, which limited me on jobs. I felt like I couldn’t work because of my record. So,I had to keep being a criminal to support my- self and my habit. I didn’t know where to go for help. I didn’t know who to talk to. I was suicidal all the time.And I really hated myself for all the feelings and things that I was doing. I had an apartment but I was evicted because I couldn’t pay the rent.And then,I was just,like,going from place to place and sometimes in homeless shel- ters and sometimes with friends or just wherever. I was in jail all the time. I just spent two years in the penitentiary. I’ve been in the penitentiary 3 times and I’ve been in jail probably 30 to 40 times.” The same consumer, when asked about life after receiving FACT services,reported:“Yeah, I haven’t had any problems.I work at McDonalds full-time.” Clearly, jails and prisons were never intended as a community’s primary setting to provide acute care services to individuals experiencing serious mental illnesses.Inmostcasestheyareillequippedtodoso. When we look at community-based services,we find current policies governing the funding and organiza- tion of community mental health care have resulted in people with more intensive and chronic treat- ment needs being underserved or unserved in typi- cal community-based settings. This is due in large part to rules and regulations that limit flexibility in designing service and reimbursement strategies targeting the specific needs of people with serious mental illnesses. For example, the Substance Abuse and Mental Health Services Administration (SAMH- SA) and the Centers for Medicare and Medicaid Ser- vices (CMS) are two agencies housed within the U.S. Department of Health and Human Services (DHHS). SAMHSA has identified intensive case management, psychosocial rehabilitation,supported employment, and supported housing as evidence-based inter- ventions, consistently yielding positive outcomes for persons with serious mental illnesses. However there are several obstacles to using Medic- aid to pay for these effective services.These include categorical restrictions on eligibility, which exclude many people with serious mental illnesses and co- occurring substance use disorders who have been involved in the criminal justice system, as well as fragmentation in coverage for treatment of medical, mental health,and substance abuse problems.Nar- row criteria for “medical necessity” and definitions of covered services that are often not aligned with what we know about evidence-based practices cre- ate barriers to more effective service delivery and recovery outcomes.As a result,there is an increased demand for services provided in hospitals, emer- gency settings, and the justice system, contributing to extraordinarily high costs for local communities, states, and the Federal government. Furthermore, new practices have been slow to be made available to justice-involved persons with co-occurring disorders. For example, it has now be- come widely accepted that all services for people with serious mental illnesses,particularly those with criminal justice involvement, be trauma-informed. Among both women and men with criminal justice involvement, histories of trauma are nearly univer- sal. Ninety-three percent of 2,000 women and men in federally funded jail diversion programs between 2002 and 2008 reported at least one incident of physical or sexual abuse in their lifetime. Sixty- one percent reported physical or sexual abuse in the last 12 months. Yet few programs, institutional or community-based, offer environments that are trauma informed or trauma specific. Moreover, a recent study found 31 percent of women being booked into local jails with current symptoms of serious mental illness.2This compares with 14 percent of men.These rates exacerbate the issues of providing adequate services for women in predominantly male facilities whose physical plants and staffing are geared to men.Gender-specific ser- vices that reflect a trauma-informed culture must be developed in all institutional and community settings to respond to the frighteningly high rates of mental illness among women in contact with the criminal justice system. In addition, we know that individuals using mental health services — often referred to as“consumers”— have a significant impact on creating recovery-ori- ented mental health and substance abuse services. For people involved in the criminal justice system, forensic peer specialists — those with histories of mental illness and criminal justice system involve- ment — can help pave the way for a successful re- turn to the community. The ability to effectively design, implement, and reimburse treatment providers for delivering high quality services targeting specialized treatment needs is critical to establishing an effective com- munity-based system of care for people who expe- rience serious mental illnesses. In the absence of what are now seen as essential services for peo- ple with mental illnesses living in the community, people will continue to be forced into more costly, deep-end services in hospitals, crisis centers, emer- gency rooms, and the justice system. The result is a recycling of individuals between jails, prisons, shelters, short-term hospitalizations, and homelessness — with public health, public safety, and public administration implications that are staggering. Now more than ever, as we strive to provide health care to our most vulnerable citizens, we must address this serious public health and public safety crisis. It is high time to be open and honest about the deplorable conditions that ex- ist and take steps to address them. We offer four recommendations for immediate action. In the absence of what are now seen as essential services for people with mental illnesses living in the community, people will continue to be forced into more costly, deep-end services in hospitals, crisis centers, emergency rooms, and the justice system.
  • 12. 14 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars u The President should appoint a Special Advisor for Mental Health/Criminal Justice Collaboration. Currently, there is no fixed responsibility within the Federal government to promote effective mental health/criminal justice activities and ensure ac- countability for the use of public dollars.The Special Advisor will serve as an advocate and ombudsman across the wide array of Federal agencies that serve the multiple needs of justice-involved people with mental and substance use disorders. One of his or her tasks will be to implement an immediate re- view of all CMS and SAMHSA regulations to identify conflicts and inconsistencies for people with mental illnesses and co-occurring substance use disorders — particularly those involved in the justice system. u Federal Medicaid policies that limit or discourage access to more effective and cost-efficient health care services for indi- viduals with serious mental illnesses and co-occurring substance use disorders should be reviewed and action taken to create more efficient programs. Congress is encouraged to review Medicaid policies and take action that will enable states to create more effective and appropriate programs target- ing eligible beneficiaries most likely to experience avoidable admissions to acute care settings. Such programs should allow states flexibility in designing and implementing targeted outreach and engage- ment services, coordinated care management, and community support services that are likely to reduce expenditures on deep-end services, and en- gage people in prevention, early intervention, and wellness care in the community. Services provided should reflect evidence-based and promising prac- tices and should be designed around principles of recovery, person-centered planning, and consumer choice. Because of the high rates of co-morbid health care needs among people with serious men- tal illnesses and co-occurring substance use disor- ders, programs should seek to establish more ef- fective integration of primary and behavioral health care service delivery system as well. u All States should create cross-system agencies, commissions, or positions charged with removing barriers and creating incen- tives for cross-agency activity at the State and local level. No one system can solve this problem alone.These cross-system groups or individuals will play a key role in spanning the different administrative struc- tures, funding mechanisms, and treatment philoso- phies of the mental health, substance abuse, and criminal justice systems. States must make clear that collaboration is not only possible but expected. In Montana, for example, the State Department of Corrections and Department of Public Health and Human Services jointly fund a boundary spanner position that facilitates shared planning, communi- cation, resources, and treatment methods between the mental health and criminal justice systems. u Localities must develop and implement core services that comprise an Essential Sys- tem of Care: Recognizing the limited resources often available and the complexities of the cross-system collabora- tions required,the eight components of an Essential System of Care are best approached in two phases. Phase 1 includes less expensive, easier to mount services. Phase 2 includes essential evidence- based practices that are more expensive and more challenging to implement, but are critical to actu- ally increasing positive public safety and public health outcomes. Phase 1 >> Forensic Intensive Case Management >> Supportive Housing >> Peer Support >> Accessible and Appropriate Medication These four services are the ones we believe are minimally necessary to break the cycle of illness, arrest and incarceration, and recidivism.We believe these services — described in brief below — can be implemented quickly, cost-effectively, and with positive results. However, these services can only be effective if the programs that provide them are structured and staffed by people who understand and are prepared to address trauma as a risk fac- tor for both mental health problems and criminal justice involvement.A trauma-informed system that features trauma-specific interventions can help en- sure public health and public safety and transform individuals’ lives. Forensic Intensive Case Management (FICM) is designed for justice-involved people with multiple and complex needs and features services provided when and where they are needed. FICM focuses on brokering rather than providing services directly, making it less expensive than ACT. For a brokered service model to be effective, communities must have adequate and accessible services to which in- dividuals can be linked.What makes these services “forensic” is “criminal justice savvy,”3 that is, pro- viders understand the criminal justice system and the predicaments of their clients involvement in it. Supportive Housing is permanent, affordable hous- ing linked to a broad range of supportive services, including treatment for mental and substance use disorders. Supportive housing can significantly de- crease the chance of recidivism to jails and prisons and is less costly on a daily basis than jail or prison. Unfortunately, affordable housing is in short supply in many communities,and ex-offenders with drugre- lated offenses often have trouble securing public housing assistance. Housing for ex-offenders must balance the needs for supervision and the provision of social services. Peer Support services can expand the continuum of services available to people with mental and substance use disorders and may help them engage in treatment. Forensic peer specialists bring real- world experience with multiple service systems and an ability to relate one-on-one to people struggling to reclaim their lives. The practice of consumer- driven care — as exemplified by the involvement of mental health consumers in service design,delivery, and evaluation — is at the heart of a transformed mental health system. Accessible and Appropriate Medication supports continuity of care for individuals with mental ill- nesses whose treatment often is disrupted when they become involved in the criminal justice system. They may not receive appropriate medication in Recommendations for Immediate Action
  • 13. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 15 jail or prison or adequate follow-up when they return to the community. It is imperative that people with mental illnesses and co-occurring substance use disorders have access to the right medication at the right dosage for their condition, as determined by the individual together with his or her clinician. Phase 2 Clearly, the Phase 1 services are necessary, but not sufficient. Services that support the Essential System of Care include several evidence-based practices for people with serious mental illnesses. These services may be more expensive or difficult to implement than the four listed above, but we encourage States and communities to move toward development of these services by codifying them in policy, supporting them in practice, and rewarding their implementation. Phase 2 services include: >> Integrated Dual Diagnosis Treatment, which provides treatment for mental and substance use dis- orders simultaneously and in the same setting >> Supported Employment, which is an evidence- based practice that helps individuals with mental ill- nesses find, get, and keep competitive work >> Assertive Community Treatment (ACT)/ Foren- sic Assertive Community Treatment (FACT), which is a service delivery model in which treatment is pro- vided by a team of professionals, with services deter- mined by an individual’s needs for as long as required, and >> Cognitive Behavioral Interventions Targeted to Risk Factors specific to offending, are a set of in- terventions, well researched within both institutional settings and community settings, that have a utility when extended to community treatment programs. This list of evidence-based and promising practices is illustrative but not exhaustive. Clearly, however, there is much that can be done to help people with mental and substance use disorders avoid arrest and incar- ceration and return successfully to their communities after jail or prison. We acknowledge that in difficult financial times, new dollars may not be available. However,though new money is not always required for systems change, new ways of thinking are. To meet the public health and public safety needs of our communities demands a fully collaborative campaign involving both the behavioral health and criminal justice systems. Neither system can continue business as usual. The criminal justice system needs to do an adequate job of screening, assessing, and individualizing responses to detainees and inmates identified with mental illness. The behavioral health system needs to refine and deliver evidence-based practices with an awareness of its responsibility to not only improve the quality of life of its clients,but to ad- dress interventions to factors associated with criminal recidivism in these clients and to more directly involve clients as partners in a recovery process that recog- nizes the community’s public safety concerns. Prime examples of this Essential System of Care have been developed within the CMHS TCE Jail Diversion program since 2002. San Antonio, TX, has become a national model with a highly integrated system of care that reflects strong behavioral health and criminal justice partnerships that have resulted in a central- ized police drop-off that directly links persons to case management, medications, housing, and peer sup- port. A medium-size city that has built a comprehen- sive, integrated system around an existing community mental health center is Lincoln, NB.These are but two examples of successfully moving entire communities forward via a jail diversion program to achieve Phase 1 services and move towards Phase 2 implementa- tion. These goals are achievable even in today’s eco- nomic tough times. We must move toward a day when people with men- tal and substance use disorders receive the effec- tive community-based interventions they need and deserve, and jails and prisons no longer are forced to serve as primary, de facto treatment facilities. We know what works to address successfully the needs of people with mental and substance use disorders who come in contact with the criminal justice system; now we have to DO what works. The time for action is now! National Leadership Forum Members Thomas Berger Vietnam Veterans of America Sandra Cannon Ohio Department of Mental Health Neal Cash Community Partnership of Southern Arizona David Fuller Manhattan Outreach Consortium Robert Glover National Association of State Mental Health Program Directors Gilbert Gonzales Bexar County Mental Health Authority Center for Health Care Services Richard Gowdy Missouri Department of Mental Health Jennifer Johnson San Francisco Office of the Public Defender Hon. Steve Leifman Special Advisor on Criminal Justice and Mental Health to Florida Supreme Court Stephanie LeMelle New York State Psychiatric Institute, Columbia University Department of Psychiatry Ginger Martin Oregon Department of Corrections Transitional Services Division John Morris The Technical Assistance Collaborative Fred Osher Council of State Governments Justice Center Linda Rosenberg* National Council for Community Behavioral Healthcare David Shern Mental Health America Henry J. Steadman* Policy Research Associates, CMHS National GAINS Center Carol Wilkins Corporation for Supportive Housing B. Diane Williams Safer Foundation Dee Wilson Texas Department of Criminal Justice Sharon Wise The Gregory Project of Washington D.C. *Co-chair of National Leadership Forum To meet the public health and public safety needs of our communities demands a fully collaborative campaign involving both the behavioral health and criminal justice systems. Neither system can continue business as usual.
  • 14. 16 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Interview Linda Rosenberg, MSW, President & CEO, National Council for Community Behavioral Healthcare, shares her thoughts about the current status of treatment for justice-involved individuals with mental illness and ad- diction. Committed to supporting the efforts of member organizations to address the problems of their communi- ties, Rosenberg has positioned the National Council to promote the expansion of community based alternatives to incarceration. Prior to her position at the National Council, she served as the Senior Deputy Commissioner for the New York State Office of Mental Health, during which time she oversaw the state’s services for justice-in- volved individuals,implementing a network of jail diversion programs including New York’s first mental health court. National Council: What challenges exist in serving justice-involved people with mental illness and addic- tions? Linda: There are many challenges in connecting jus- tice involved consumers with services. We’re talking primarily about people with little money or power and they may have little or no interest in mental health or addictions treatment services. They’ve not found ser- vices useful or relevant and often dislike programs that are highly structured. Our job at the National Council is to identify member organizations that have devel- oped successful services for this population and then to facilitate the member to member spread of these programs. National Council: New York has an assisted outpa- tient treatment law — what is the controversy behind such laws? Linda: Some view these laws as victimizing — blaming — people with mental illness. In a perfect world, court ordered treatment would be unnecessary but in our world the combined power of the court and treatment can mean successful community living for consumers that would otherwise be in and out of hospital or jail. Assisted Outpatient Treatment must be carefully used but when all else fails it can connect people to vital services. But AOT alone isn’t enough — a full array of community services including housing, effective treat- ments, work supports, and general medical care must be available and accessible. Unfortunately passage of AOT is often a political reaction to an unfortunate inci- dent — a law is passed with no financing of the services that are critical if we’re going to keep both individuals with mental illnesses and our communities safe. National Council: As a state official in New York, you were a strong supporter of the state’s first mental health court. What benefits do such courts bring to providers and the individuals they serve? Linda: I’ve seen mental health courts and to an even greater extent, drug courts, emerge as a powerful means through which people access care. In many places the court begins with a judge who has personal and/or professional interest in behavioral health is- sues. Mental health and drug courts aren’t meant to be applied broadly — these courts are alternatives for people with serious mental illnesses and addictions that are on the way to jail or prison.And like AOT, there must be seamless connections to the full continuum of treatment and support services.These problem-solving courts give individuals with serious behavioral health disorders a unique opportunity to engage with a judge around their needs.The courts provide alternatives to people with mental illnesses and addiction — offering services instead of time behind bars. National Council: How can states move forward in creating programs for justice-involved persons in this era of budget cuts? What role do community providers play? Linda:Change is often incremental in our very complex world but it looks like we’ve reached a tipping point in regard to diversion and re-entry. Policy change is often driven by a convergence of ideas and money. States are in tremendous economic distress and can’t con- tinue to build new jails and prisons or support grow- ing numbers of incarcerated individuals. At the same time it’s becoming clear that treatment and services works and are less expensive alternatives. Look at the President’s budget proposal – growth in financing of alternatives to criminal justice involvement. This is an area where there is both new money and potential for re-investment of dollars currently directed to incarcer- ation.And as always leadership is essential — excited by the possibilities, local leaders emerge, enlist others in their vision, and the money follows. National Council: How does the justice-involved population “fall through the cracks?” Linda: The falling through the cracks problem is not unique to justice-involved individuals. Every time we create a new program or service to keep people from falling through the cracks, we are creating another crack for someone to fall through.The system has got- ten so rich and so complicated — multiple programs and services, most under different corporate auspices and each with its unique rules and operating practices — that it’s difficult to navigate it.A person’s treatment is run by one organization, their housing by another, their employment supports by another — and getting all these organizations on the same page and at the same table becomes nearly impossible. It is very, very difficult to coordinate services. National Council:What can be done to support co- ordinated treatment? Linda: I think in the end we need a system where one organization/person is responsible. If everyone is re- sponsible, then no one is responsible. The buck has to stop somewhere and I think it needs to stop with an organization that gets an adequate pot of money and ensures that the consumer gets the services they need and want.With adequate financing, clarity as to what treatments and services are effective and the de- livery of those interventions, use of health information technology, and the ongoing measurement of simple outcomes — hospitalization, incarceration and home- lessness — we can coordinate care and go a long way toward supporting successful community tenure. That doesn’t mean that all justice-involved people will have a straight trajectory to recovery. Some people will be hospitalized and some might be incarcerated or be- come homeless. We can do better but challenges will remain.Our jobs are to address the challenges,always exploring new approaches and refining our efforts to improve lives. Mohini Venkatesh serves as the staff policy liaison to the National Council for Community Behavioral Healthcare’s network of associations throughout the states, conducts federal legislative and policy analysis on an array of issues, and man- ages political engagement activities including an annual Hill Day in Washington, DC. She received a masters in public health from Yale University and a BA in psychology from the University of Massachusetts-Amherst. Nathan Sprenger supports the National Council’s public rela- tions and marketing efforts, leads the social media activities, maintains the website, and serves as editorial assistant for National Council Magazine. He has a masters degree in public communication from American University in Washington DC. Linda Rosenberg, MSW, President & CEO, National Council for Community Behavioral Healthcare, Interviewed by Mohini Venkatesh, Director, Federal and State Policy and Nathan Sprenger, Marketing and Communications Associate — National Council for Community Behavioral Healthcare Behavioral Health and Criminal Justice Collaboration: Where Does the Buck Stop? There must be a single point of accountability. If everyone is respon- sible, then no one is responsible.”
  • 15. VIVITROL... there when they need it. For the treatment of alcohol dependence VIVITROL is a registered trademark of Alkermes, Inc. ©2010 Alkermes, Inc. All rights reserved VIV 981 B January 2010 Printed in U.S.A. Please see brief summary ofViViTrol Prescribing informaTion, including boxedwarning,onThe nexT Page. Naltrexonehasthecapacitytocausehepatocellularinjurywhengiveninexcessivedoses. Naltrexoneiscontraindicatedinacutehepatitisorliverfailure,anditsuseinpatientswithactiveliver diseasemustbecarefullyconsideredinlightofitshepatotoxiceffects. Themarginofseparationbetweentheapparentlysafedoseofnaltrexoneandthedosecausing hepaticinjuryappearstobeonlyfive-foldorless.VIVITROLdoesnotappeartobeahepatotoxinatthe recommendeddoses. Patientsshouldbewarnedoftheriskofhepaticinjuryandadvisedtoseekmedicalattentionifthey experiencesymptomsofacutehepatitis.UseofVIVITROLshouldbediscontinuedintheeventofsymptoms and/orsignsofacutehepatitis. VIVITROLisadministeredasaglutealintramuscularinjection.Inadvertentsubcutaneousinjectionof VIVITROLmayincreasethelikelihoodofsevereinjectionsitereactions.VIVITROLmustbeinjectedusing thecustomizedneedleprovidedinthecarton.Becauseneedlelengthmaynotbeadequateduetobody habitus,eachpatientshouldbeassessedpriortoeachinjectiontoassurethatneedlelengthisadequate forintramuscularadministration.VIVITROLinjectionsitereactionsmaybefollowedbypain,tenderness, induration,swelling,erythema,bruisingorpruritus;however,insomecasesinjectionsitereactionsmaybe verysevere.Injectionsitereactionsnotimprovingmayrequirepromptmedicalattention,includinginsome casessurgicalintervention. Considerthediagnosisofeosinophilicpneumoniaifpatientsdevelopprogressivedyspneaandhypoxemia. InanemergencysituationinpatientsreceivingVIVITROL,suggestionsforpainmanagementincluderegional analgesiaoruseofnon-opioidanalgesics.Alcoholdependentpatients,includingthosetakingVIVITROL, shouldbemonitoredforthedevelopmentofdepressionorsuicidalthoughts.Cautionisrecommendedin administeringVIVITROLtopatientswithmoderatetosevererenalimpairment. ThemostcommonadverseeventsassociatedwithVIVITROLinclinicaltrialswerenausea,vomiting, headache,dizziness,asthenicconditionsandinjectionsitereactions. 1. VIVITROL [full prescribing information]. Waltham, MA: Alkermes, Inc; May 2009. *Eligibility for co-pay assistance: Offer not valid for prescriptions purchased under Medicaid, Medicare, or any federal or state healthcare programs, including any state medical or pharmaceutical assistance program. Offer not valid in Massachusetts. Void where prohibited by law, taxed or restricted. Alkermes, Inc. reserves the right to rescind, revoke or amend these offers without notice. indicaTion1 VIVITROL® isindicatedforthetreatmentofalcoholdependenceinpatientswhoareabletoabstain fromalcoholinanoutpatientsettingpriortoinitiationoftreatmentwithVIVITROL. PatientsshouldnotbeactivelydrinkingatthetimeofinitialVIVITROLadministration. TreatmentwithVIVITROLshouldbepartofacomprehensivemanagementprogramthatincludes psychosocialsupport. imPorTanT safeTy informaTion for ViViTrol1 VIVITROLiscontraindicatedinpatientsreceivingopioidanalgesicsorwithcurrentphysiologic opioiddependence,patientsinacuteopiatewithdrawal,anyindividualwhohasfailedthenaloxone challengetestorhasapositiveurinescreenforopioids,orinpatientswhohavepreviouslyexhibited hypersensitivitytonaltrexone,PLG,carboxymethylcelluloseoranyothercomponentsofthediluent. VIVITROLpatientsmustbeopioidfreeforaminimumof7-10daysbeforetreatment.Attemptstoovercome opioidblockadeduetoVIVITROLmayresultinafataloverdose.Inprioropioidusers,useofopioidsafter discontinuingVIVITROLmayresultinafataloverdosebecausepatientsmaybemoresensitivetolower dosesofopioids.PatientsrequiringreversaloftheVIVITROLblockadeforpainmanagementshouldbe monitoredbyappropriatelytrainedpersonnelinasettingequippedforcardiopulmonaryresuscitation. For more information, call toll-free 1-800-VIVITROL (1-800-848-4876, ext. 2). Tell Your Patients About Our Co-Pay Assistance Program Upto6monthsofmedicationwith potentiallynoout-of-pocketcosts*
  • 16. BRIEF SUMMARY See package insert for full Prescribing Information. INDICATIONS AND USAGE: VIVITROL is indicated for the treatment of alcohol dependence in patients who are able to abstain from alcohol in an outpatient setting prior to initiation of treatment with VIVITROL. Patients should not be actively drinking at the time of initial VIVITROL administration. Treatment with VIVITROL should be part of a comprehensive management program that includes psychosocial support. CONTRAINDICATIONS: VIVITROL is contraindicated in: • Patients receiving opioid analgesics (see PRECAUTIONS). • Patients with current physiologic opioid dependence (see WARNINGS). • Patients in acute opiate withdrawal (see WARNINGS). • Any individual who has failed the naloxone challenge test or has a positive urine screen for opioids. • Patients who have previously exhibited hypersensitivity to naltrexone, PLG, carboxymethylcellulose, or any other components of the diluent. WARNINGS: Hepatotoxicity Eosinophilic pneumonia In clinical trials with VIVITROL, there was one diagnosed case and one suspected case of eosinophilic pneumonia. Both cases required hospitalization, and resolved after treatment with antibiotics and corticosteroids. Should a person receiving VIVITROL develop progressive dyspnea and hypoxemia, the diagnosis of eosinophilic pneumonia should be considered (see ADVERSE REACTIONS). Patients should be warned of the risk of eosinophilic pneumonia, and advised to seek medical attention should they develop symptoms of pneumonia. Clinicians should consider the possibility of eosinophilic pneumonia in patients who do not respond to antibiotics. Unintended Precipitation of Opioid Withdrawal—To prevent occurrence of an acute abstinence syndrome (withdrawal) in patients dependent on opioids, or exacerbation of a pre-existing subclinical abstinence syndrome, patients must be opioid-free for a minimum of 7-10 days before starting VIVITROL treatment. Since the absence of an opioid drug in the urine is often not sufficient proof that a patient is opioid-free, a naloxone challenge test should be employed if the prescribing physician feels there is a risk of precipitating a withdrawal reaction following administration of VIVITROL. Opioid Overdose Following an Attempt to Overcome Opiate Blockade VIVITROL is not indicated for the purpose of opioid blockade or the treatment of opiate dependence. Although VIVITROL is a potent antagonist with a prolonged pharmacological effect, the blockade produced by VIVITROL is surmountable. This poses a potential risk to individuals who attempt, on their own, to overcome the blockade by administering large amounts of exogenous opioids. Indeed, any attempt by a patient to overcome the antagonism by taking opioids is very dangerous and may lead to fatal overdose. Injury may arise because the plasma concentration of exogenous opioids attained immediately following their acute administration may be sufficient to overcome the competitive receptor blockade. As a consequence, the patient may be in immediate danger of suffering life-endangering opioid intoxication (e.g., respiratory arrest, circulatory collapse). Patients should be told of the serious consequences of trying to overcome the opioid blockade (see INFORMATION FOR PATIENTS).There is also the possibility that a patient who had been treated with VIVITROL will respond to lower doses of opioids than previously used. This could result in potentially life-threatening opioid intoxication (respiratory compromise or arrest, circulatory collapse, etc.). Patients should be aware that they may be more sensitive to lower doses of opioids after VIVITROL treatment is discontinued (see INFORMATION FOR PATIENTS). PRECAUTIONS: General—When Reversal of VIVITROL Blockade is Required for Pain Management In an emergency situation in patients receiving VIVITROL, suggestions for pain management include regional analgesia or use of non-opioid analgesics. If opioid therapy is required as part of anesthesia or analgesia, patients should be continuously monitored in an anesthesia care setting, by a person not involved in the conduct of the surgical or diagnostic procedure. The opioid therapy must be provided by an individual specifically trained in the use of anesthetic drugs and the management of the respiratory effects of potent opioids, specifically the establishment and maintenance of a patent airway and assisted ventilator. Depression and Suicidality In controlled clinical trials of VIVITROL, adverse events of a suicidal nature (suicidal ideation, suicide attempts, completed suicides) were infrequent overall, but were more common in patients treated with VIVITROL than in patients treated with placebo (1% vs. 0). In some cases, the suicidal thoughts or behavior occurred after study discontinuation, but were in the context of an episode of depression which began while the patient was on study drug. Two completed suicides occurred, both involving patients treated with VIVITROL. Depression-related events associated with premature discontinuation of study drug were also more common in patients treated with VIVITROL (~1%) than in placebo-treated patients (0). In the 24-week, placebo-controlled pivotal trial, adverse events involving depressed mood were reported by 10% of patients treated with VIVITROL 380 mg, as compared to 5% of patients treated with placebo injections. Alcohol dependent patients, including those taking VIVITROL, should be monitored for the development of depression or suicidal thinking. Families and caregivers of patients being treated with VIVITROL should be alerted to the need to monitor patients for the emergence of symptoms of depression or suicidality, and to report such symptoms to the patient’s healthcare provider. Injection Site Reactions VIVITROL injections may be followed by pain, tenderness, induration, swelling, erythema, bruising or pruritus; however in some cases injection site reactions may be very severe. In the clinical trials, one patient developed an area of induration that continued to enlarge after 4 weeks with subsequent development of necrotic tissue that required surgical excision. In the postmarketing period, additional cases of injection site reaction with features including induration, cellulitis, hematoma, abscess, sterile abscess and necrosis have been reported. Some cases required surgical intervention. VIVITROL is administered as a gluteal intramuscular injection. An inadvertent subcutaneous injection of VIVITROL may increase likelihood of severe injection site reactions. VIVITROL must be injected by the customized needle provided in the carton. Alternate treatment should be considered for those patients whose body habitus precludes a gluteal intramuscular injection with the provided needle. Patients should be informed that any injection site reactions should be brought to the attention of the healthcare provider (see INFORMATION FOR PATIENTS). Patients exhibiting signs of abscess, cellulitis, necrosis or extensive swelling should be evaluated by a physician. Renal Impairment VIVITROL pharmacokinetics have not been evaluated in subjects with moderate and severe renal insufficiency. Because naltrexone and its primary metabolite are excreted primarily in the urine, caution is recommended in administering VIVITROL to patients with moderate to severe renal impairment. Alcohol Withdrawal Use of VIVITROL does not eliminate nor diminish alcohol withdrawal symptoms. Intramuscular injections As with any intramuscular injection, VIVITROL should be administered with caution to patients with thrombocytopenia or any coagulation disorder (e.g., hemophilia and severe hepatic failure). Information for Patients Physicians are advised to consult Full Prescribing Information for information to be discussed with patients for whom they have prescribed VIVITROL. Drug Interactions Patients taking VIVITROL may not benefit from opioid-containing medicines (see PRECAUTIONS, Pain Management). Because naltrexone is not a substrate for CYP drug metabolizing enzymes, inducers or inhibitors of these enzymes are unlikely to change the clearance of VIVITROL. No clinical drug interaction studies have been performed with VIVITROL to evaluate drug interactions, therefore prescribers should weigh the risks and benefits of concomitant drug use. The safety profile of patients treated with VIVITROL concomitantly with antidepressants was similar to that of patients taking VIVITROL without antidepressants. Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenicity studies have not been conducted with VIVITROL. Carcinogenicity studies of oral naltrexone hydrochloride (administered via the diet) have been conducted in rats and mice. In rats, there were small increases in the numbers of testicular mesotheliomas in males and tumors of vascular origin in males and females. The clinical significance of these findings is not known. Naltrexone was negative in the following in vitro genotoxicity studies: bacterial reverse mutation assay (Ames test), the heritable translocation assay, CHO cell sister chromatid exchange assay, and the mouse lymphoma gene mutation assay. Naltrexone was also negative in an in vivo mouse micronucleus assay. In contrast, naltrexone tested positive in the following assays: Drosophila recessive lethal frequency assay, non-specific DNA damage in repair tests with E. coli and WI-38 cells, and urinalysis for methylated histidine residues. Naltrexone given orally caused a significant increase in pseudopregnancy and a decrease in pregnancy rates in rats at 100 mg/kg/day (600 mg/m2 /day). There was no effect on male fertility at this dose level. The relevance of these observations to human fertility is not known. Pregnancy Category C Reproduction and developmental studies have not been conducted for VIVITROL. Studies with naltrexone administered via the oral route have been conducted in pregnant rats and rabbits. Teratogenic Effects Oral naltrexone has been shown to increase the incidence of early fetal loss in rats administered ≥30 mg/kg/day (180 mg/m2 /day) and rabbits administered ≥60 mg/kg/day (720 mg/m2 /day). There are no adequate and well-controlled studies of either naltrexone or VIVITROL in pregnant women. VIVITROL should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Labor and Delivery The potential effect of VIVITROL on duration of labor and delivery in humans is unknown. Nursing Mothers Transfer of naltrexone and 6β-naltrexol into human milk has been reported with oral naltrexone. Because of the potential for tumorigenicity shown for naltrexone in animal studies, and because of the potential for serious adverse reactions in nursing infants from VIVITROL, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. Pediatric Use The safety and efficacy of VIVITROL have not been established in the pediatric population. Geriatric Use In trials of alcohol dependent subjects, 2.6% (n=26) of subjects were >65 years of age, and one patient was >75 years of age. Clinical studies of VIVITROL did not include sufficient numbers of subjects age 65 and over to determine whether they respond differently from younger subjects. ADVERSE REACTIONS: In all controlled and uncontrolled trials during the premarketing development of VIVITROL, more than 900 patients with alcohol and/or opioid dependence have been treated with VIVITROL. Approximately 400 patients have been treated for 6 months or more, and 230 for 1 year or longer. Adverse Events Leading to Discontinuation of Treatment In controlled trials of 6 months or less, 9% of patients treated with VIVITROL discontinued treatment due to an adverse event, as compared to 7% of the patients treated with placebo. Adverse events in the VIVITROL 380-mg group that led to more dropouts were injection site reactions (3%), nausea (2%), pregnancy (1%), headache (1%), and suicide-related events (0.3%). In the placebo group, 1% of patients withdrew due to injection site reactions, and 0% of patients withdrew due to the other adverse events. Common Adverse Events The most common adverse events associated with VIVITROL in clinical trials were nausea, vomiting, headache, dizziness, fatigue, and injection site reactions. For a complete list of adverse events, please refer to the VIVITROL package insert for full Prescribing Information. A majority of patients treated with VIVITROL in clinical studies had adverse events with a maximum intensity of “mild” or “moderate.” Post-marketing Reports—Reports From Other Intramuscular Drug Products Containing Polylactide-co-glycolide (PLG) Microspheres – Not With VIVITROL. Retinal Artery Occlusion Retinal artery occlusion after injection with another drug product containing polylactide- co-glycolide (PLG) microspheres has been reported very rarely during post-marketing surveillance. This event has been reported in the presence of abnormal arteriovenous anastomosis. No cases of retinal artery occlusion have been reported during VIVITROL clinical trials or post-marketing surveillance. VIVITROL should be administered by intramuscular (IM) injection into the gluteal muscle, and care must be taken to avoid inadvertent injection into a blood vessel (see DOSAGE AND ADMINISTRATION). OVERDOSAGE: There is limited experience with overdose of VIVITROL. Single doses up to 784 mg were administered to 5 healthy subjects. There were no serious or severe adverse events. The most common effects were injection site reactions, nausea, abdominal pain, somnolence, and dizziness. There were no significant increases in hepatic enzymes. In the event of an overdose, appropriate supportive treatment should be initiated. This brief summary is based on VIVITROL Prescribing Information (VIV 566C May 2009). Naltrexone has the capacity to cause hepatocellular injury when given in excessive doses. Naltrexone is contraindicated in acute hepatitis or liver failure, and its use in patients with active liver disease must be carefully considered in light of its hepatotoxic effects. The margin of separation between the apparently safe dose of naltrexone and the dose causing hepatic injury appears to be only five-fold or less. VIVITROL does not appear to be a hepatotoxin at the recommended doses. Patients should be warned of the risk of hepatic injury and advised to seek medical attention if they experience symptoms of acute hepatitis. Use of VIVITROL should be discontinued in the event of symptoms and/or signs of acute hepatitis. Alkermes® and VIVITROL® are registered trademarks of Alkermes, Inc. Manufactured and marketed by Alkermes, Inc. ©2009 Alkermes, Inc. VIV 107C July 2009 Printed in U.S.A. All rights reserved.
  • 17. 20 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars Judge Leifman Encounters the Challenge “When I first became a judge,I discovered a situation familiar to many of my colleagues but seldom discussed outside the courtroom — a situation that my legal and judicial training had not prepared me for. Day after day, defendants stood be- fore me, disheveled and distraught. Most were charged with relatively minor offenses such as loitering or panhandling. Some exhibited impulsive behaviors, speaking in pressured, incoherent sentences. Others were guarded and withdrawn, appearing to have little understanding of the circumstances in which they found themselves. Homelessness, substance abuse, and trauma were symptoms of a larger set of personal and social factors contributing to their unfortunate and often repeated involvement in the criminal justice system. These people of many backgrounds shared one thing in common — serious and persistent mental illness. When I first came across defendants experiencing acute men- tal illness, I followed the lead of my fellow judges by appoint- ing experts and ordering psychiatric evaluations to determine their competence to proceed with their court cases.Although these evaluations tended to be very costly and meant that defendants would remain in jail for weeks or possibly even months, the idea of releasing a person in acute psychiatric distress to the streets with nowhere to live and no supports seemed a far more cruel response to the situation. I assumed that once evaluations by mental health experts were complet- ed and the need for treatment was documented, the mental health treatment system would step in, if not voluntarily, then by court order. Before long, I realized my assumptions were wrong. Even though I had expert opinions indicating that people were indeed experiencing severe psychiatric symptoms — and in many cases requiring immediate hospitalization — state law prohibited judges presiding over misdemeanor cases from ordering treatment in the forensic mental health system. In- stead, the law required people to be released to the commu- nity on the condition that they participate in treatment, but there was no mechanism to ensure that treatment,housing,or any other type of support was actually provided. Judge Steven Leifman, Special Advisor on Criminal Justice and Mental Health, Supreme Court of Florida, and Associate Administrative Judge, County Court, Criminal Division, 11th Judicial Circuit of Florida; Tim Coffey, Coordinator, 11th Judicial Circuit, Criminal Mental Health Project Decriminalizing Mental Illness: Miami Dade County Tackles a Crisis at the Roots Miami-Dade County, Florida houses the largest percentage of people with serious mental illness (e.g., schizophrenia, bipolar disorder, major depression) of any urban community in the United States. Roughly 9.1 percent of the population (170,000 adults) experiences serious mental illness, yet only 1 percent (24,000 adults) receives treatment in the public mental health system. By contrast, the number of people accessing mental health services through the Miami-Dade County jail is staggering. Of the roughly 114,000 bookings into the jail this past year, it is estimated that as many as 20,000 people with mental illness required psychiatric treatment during incarceration. On any given day, the county jail houses approximately 1,200 people with mental illness receiving psychotherapeutic medications. This number represents 17 percent of the total inmate population and costs taxpayers more than $50 million annually.The Miami-Dade County jail serves as the largest psychiatric institution in the state of Florida, housing more beds serving people with mental illness than any inpatient hospital in the state and nearly half as many beds as there are in all state civil and forensic mental health hospitals combined. Sadly, these statistics are not unique to south Florida. Findings from a recent study suggest that people with serious mental illness are arrested and booked into jails in the United States more than two million times annually. Roughly three-quarters of these people also have co-occurring substance use disorders that increase their likelihood of becoming involved in the justice system. On the basis of the most recent population data reported by the Department of Justice, it is estimated that currently 400,000 people with mental illnesses are incarcerated in jails and prisons across the country, and nearly 900,000 are on probation or parole in the community.
  • 18. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 21 Most people released under these circumstances never received any type of services on re-entering the community and were quickly rearrested and reappeared in my courtroom, often over and over again. These people accrued lengthy criminal re- cords for offenses that were all too obviously the result of untreated mental illness. This contributed to a revolving door of neglect and despair; caused a huge backlog of cases in the justice system; placed enormous burden on the courts,jails,and law enforce- ment agencies; and left taxpayers to foot the bill. Not wanting to continue to be a witness to the parade of misery passing through my courtroom, I was deter- mined to figure out why and where the system was failing.With the help of many dedicated stakeholders from the community mental health, criminal justice, and social services systems,I set out to learn as much as I could about the community mental health sys- tem and how it intersected with the criminal justice system.” Identifying the Root Cause A 2-day summit was convened in 2000 to review the ways in which the community collectively responded to people with mental illness before and after they became involved in the justice system. What we dis- covered were embarrassingly dysfunctional and frag- mented systems. Before the summit, it was apparent that people with mental illness were over-represented in the justice system. What was not so apparent, however, was the degree to which stakeholders were unwittingly contributing to and perpetuating the problem. Many participants were shocked to find that a single per- son with mental illness was accessing the services and resources of almost every other stakeholder in the room, including law enforcement agencies, emer- gency medical services, mental health crisis units, emergency rooms, hospitals, homeless shelters, jails, and the courts. This happened repeatedly as people revolved through a criminal justice system that was never intended to handle overwhelming numbers of people with serious mental illness and a community mental health system that was ill equipped to provide the level and capacity of care necessary for those ex- periencing the most acute forms of mental illness. Stakeholders were largely disconnected from one an- other and no mechanisms were in place to coordinate resources or services. Everyone was so busy doing his or her job that no one was looking at the bigger pic- ture to see what the impact was on the welfare of the system as a whole or of the people it served.The po- lice were policing, the lawyers were lawyering, and the judges were judging. Treatment providers knew little about what went on when their clients were arrested and had little incentive to learn, because of barriers to accessing information and laws that prohibit reim- bursement for services provided to people who are incarcerated. For people who had no resources to pay for services, crisis units, hospitals, and the jail were often the only options to receive care. Ironically, although many people could not access the most basic prevention and treatment services in the community, they were readily provided some of the most costly levels of institutional care over and over again. The degree of fragmentation in the community not only prevented the mental health and criminal justice systems from responding more effectively to people with mental ill- ness but actually created increased opportunities for people to fall through the cracks. By the conclusion of the summit, we began to realize that people with untreated serious mental illness may be among the most expensive populations in the community, not because of their diagnoses but because of the way they are treated. As we’ve come to better understand the problems and context of people with mental illness involved in the justice system, we learned three critical lessons: >> First, our criminal and juvenile justice systems are in the midst of mental health crises at the local, state, and national levels. The current level of de- mand for deep-end services in settings such as emergency rooms, crisis units, state hospitals, and ultimately jails and prisons is inappropriate and unsustainable and contributes to enormous social, fiscal,and personal tragedies.The backlog of cases in the justice system involving people with mental illness impedes the administration of justice and contributes to needless pain and suffering. >> Second, the problems facing the mental health and, consequently, criminal justice systems in the United States today relate to the fact that the cur- rent community mental health system was devel- oped at a time when most people with severe and disabling forms of mental illness resided in state hospitals. Most community mental health systems were designed around people with more moderate treatment needs, not around the needs of people who experience highly acute and chronic mental illness. Intensive supports necessary to live suc- cessfully in the community are many times in short supply or altogether unavailable. >> Third,state expenditures on mental health services have become disproportionately skewed toward providing expensive, acute-care services such as crisis stabilization and hospitalization in state- funded facilities, not to mention services pro- vided in jails and prisons. Such heavy investment in these kinds of back-end services has come at the cost of being able to adequately invest in a responsive and comprehensive continuum of pri- mary and preventive care in the community. Criminal Mental Health Project Provides Solutions The 11th Judicial Circuit Criminal Mental Health Project was established 10 years ago in an effort to better respond to the needs of people with serious mental illness and co-occurring substance use dis- orders involved in or at risk of becoming involved in the justice system. Initially, the CMHP worked to di- vert misdemeanor offenders from the criminal justice system into community-based treatment and support services.Today, the CMHP has expanded to serve de- fendants arrested for lower level felony offenses and other charges as are determined appropriate. It has developed collaborations with other local problem- solving courts including domestic violence court and drug court and has developed partnerships with community mental health and substance abuse treat- ment providers, housing providers and other social services agencies, consumer and family advocacy groups, countywide criminal justice and law enforce- We began to realize that people with untreated serious mental illness may be among the most expensive popula- tions in the community, not because of their diagnoses but because of the way they are treated.
  • 19. 22 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars ment agencies, and state and federal social welfare agencies. Funding Initial support for the development of the CMHP was provided through a grant from the National GAINS Center that enabled the courts to host the summit meeting in 2000. The GAINS Center provided tech- nical assistance and helped the community map existing resources, identify gaps in services and service delivery, and develop a more integrated ap- proach to coordinating care. Stakeholders included judges and court staff, law enforcement agencies and first responders, attorneys, mental health and substance abuse treatment providers, state and local social service agencies, consumers of mental health and substance abuse treatment services, and family members. Using information generated from the summit, pro- gram operations were initiated on a limited basis. Additional funding was secured from a local phil- anthropic foundation to conduct a planning study of the mental health status and needs of people arrested and booked into the county jail, as well as the processes in place to link people to community- based services and supports. Information from this planning study was used to develop a more formal program design and to secure a 3-year federal tar- geted capacity expansion grant from the Substance Abuse and Mental Health Services Administration, which enabled the CMHP to significantly expand its staffing and operations.At the conclusion of the federal grant period, the county assumed continua- tion of funding for all positions. Because of the pro- gram’s early success and demonstrated outcomes at the misdemeanor level, in 2008 the CMHP was awarded a 3-year grant by the state of Florida to further expand postbooking diversion operations to serve people charged with less serious felonies. Efforts are currently underway to secure long-term sustainability for felony operations and to develop strategies to increase program capacity. Since its inception, the CMHP has received ongo- ing support from the Florida Department of Children and Families.This support has included funding case management positions as well as providing resourc- es to secure housing, medications, and transporta- tion for program participants. Early in its develop- ment, the CMHP also benefited from a partnership established with faculty from Florida International University. This partnership facilitated activities around program planning and evaluation and the preparation and submission of funding proposals. Jail and Forensic Hospital Diversion Programs Today, the CMHP operates a total of four different diversion programs and is working with the county to develop of a first-of-its-kind mental health diver- sion complex. All programs are complemented by support components designed to improve access to basic needs and economic self-sufficiency. Diversion programs and support components in- clude the following elements: Prebooking jail diversion program targeting crisis intervention team training for law enforcement officers Crisis Intervention Team training is designed to educate and prepare law enforcement officers to recognize the signs and symptoms of mental illness and to respond more effectively and appropriately to people in crisis. When appropriate, people are assisted in accessing treatment in lieu of being ar- rested and taken to jail. To date, CIT training has been provided to more than 2,500 officers from 36 law enforcement agencies across the county. Additional CIT-related training courses have been developed or adapted to target emergency dispatch (e.g., 911) call takers, law enforcement crisis ne- gotiators, correctional officers, other nonpolice law enforcement agencies, and executive management of CIT programs. Since the implementation of CIT, significantly fewer people in psychiatric crisis are being arrested and booked into jail, law enforcement agencies are ex- periencing fewer injuries to officers and civilians, fewer instances of use of force involving officers and people with mental illness have occurred, and more people are being linked to appropriate care in the community. Postbooking jail diversion program targeting people arrested for misdemeanor offenses All defendants booked into the jail are screened for signs and symptoms of mental illness by correc- tional officers using an evidence-based screening tool known as the Brief Jail Mental Health Screen. People charged with misdemeanors who meet pro- gram admission criteria are transferred from the jail to a community-based crisis stabilization unit within 24–48 hours of booking. On stabilization, legal charges may be dismissed or modified in ac- cordance with treatment engagement. People who agree to services are linked to a comprehensive array of community-based treatment, support, and housing services that are essential for successful community re-entry and recovery outcomes. Pro- gram participants are monitored by CMHP for up to 1 year after community re-entry to ensure ongoing linkage to necessary supports and services. Most participants (75-80 percent) in the misdemeanor diversion program are homeless at the time of ar- rest and tend to be among the most severely psychi- atrically impaired people served by the CMHP. The misdemeanor diversion program receives around 300 referrals annually, with program recidivism rates of just 22 percent, far below most other re- cidivism estimates. Postbooking jail diversion program targeting people arrested for felony offenses Participants in the felony jail diversion program are referred to the CMHP through a number of sources including the public defender’s office, the state attorney’s office, private attorneys, judges, correc- tions health services, and family members. All par- ticipants must meet diagnostic and legal criteria as well as be eligible to apply for entitlement benefits such as Supplemental Security Income, Social Se- curity Disability Insurance, and Medicaid. At the time a person is accepted into the felony jail di- version program, the state attorney’s office informs the court of the plea the defendant will be offered contingent on successful program completion.Simi- lar to the misdemeanor program, legal charges may be dismissed or modified on the basis of treatment engagement. All program participants are assisted in accessing community-based services and sup- ports, and their progress is monitored and reported back to the court by CMHP staff.To date, the felony diversion program has served roughly 150 people, and participants have demonstrated reductions of roughly 75 percent in both numbers of arrests and days incarcerated after program enrollment. Postbooking forensic hospital diversion program targeting people arrested for felony offenses and adjudicated incompetent to proceed to trial The forensic hospital diversion program was recently implemented as a state-sponsored pilot project to serve people in Florida’s forensic mental health
  • 20. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 23 system and to control growth in demand for services provided in state hos- pitals.People served are charged with third-degree and nonviolent second- degree felonies, have been found incompetent to proceed to trial, and require placement in a state hospital in the absence of a less restrictive al- ternative.The program seeks to provide a more cost-effective alternative to forensic hospitalization, while providing enhanced interventions targeting long-term recovery, reduced recidivism, and successful community living. Admissions for competency restoration in state hospitals in Florida typically result in a length of stay of around 6 months at a cost of $60,000 per indi- vidual. It is estimated that the forensic hospital diversion program can pro- vide a full year of services to program participants — including competency restoration services, recovery services, and community re-entry services — for $32,000 per individual. At current capacity, the program is projected to divert 40 people per year from admission to state hospitals, which is projected to result in a savings to the state of $1.1 million while funding an additional 7,200 days of new community-based treatment services. Mental Health Diversion Complex In support of all diversion programs, Miami-Dade County and the CMHP have been actively working to develop a first-of-its-kind comprehensive mental health diversion, treatment, and community re-entry complex near downtown Miami. Development of this project, which is funded in part through a general obligation bond issue approved by voters, will involve renovating and expanding a former state forensic hospital that has been leased to the county. The complex will consist of programs operated by community-based treat- ment and social services providers to create a full continuum of care and support, including a crisis stabilization unit, a short-term residential treat- ment program, a transitional housing program, day treatment and day ac- tivity programs, intensive case management, specialized services address- ing the unique needs of people with mental illness involved in the justice system (e.g., trauma treatment and treatment for co-occurring disorders), outpatient services,and job training and employment services.All programs will incorporate peer support and peer leadership components. Space will also be provided for agencies and programs that address the comprehen- sive social needs of people served, such as legal services, public welfare and entitlement programs, and immigration services. Since the implementation of Crisis Intervention Team training, significantly fewer people in psy- chiatric crisis are being arrested and booked into jail, law enforcement agencies are experi- encing fewer injuries to officers and civilians, fewer instances of use of force involving officers and people with mental illness have occurred, and more people are being linked to appropri- ate care in the community. Do you need capital to buy, build or renovate a facility, update your IT systems, or refinance existing debt? CHFF Can Help! We are a non-profit loan fund that provides capital to non-profit behavioral healthcare organizations nationwide. o Aggressive interest rates o Flexible terms and structures o Gap and subordinate financing o Loans from $150,000 o Participation with other lenders o Strategic financial planning services The Community Health Facilities Fund is pleased to have provided financial advisory services and/or direct loans to the following organizations in 2009: Ability Beyond Disability Bethel, CT Alternatives Unlimited Whitinsville, MA Cache Employment and Training Center Logan, UT Community Housing Associates Baltimore, MD For more information contact, u Community Health Facilities Fund 6 Landmark Square, 4th Floor, Stamford, CT 06901 Meet us at the National Council Conference Expo Hall, Booth #421 Chris Conley 203-273-4200 Dean Adams 812-273-5198
  • 21. 24 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars In addition to community-based treatment and support services, the complex will house a secure medical unit serving inmates in the custody of the county’s corrections and rehabilitation department who are being evaluated to determine eligibility for diversion.The complex will also include a courtroom to expedite and facilitate legal hearings. The vision for the mental health diversion complex is to create a centralized, coordinated, and seamless continuum of care for people who are diverted from the criminal justice system either before or after booking. By housing a comprehensive array of ser- vices and supports in one location, it is anticipated that many of the barriers and obstacles to navigat- ing traditional community mental health and social services will be removed, and people will be more likely to engage treatment and recovery services. Social Security Benefits All CMHP participants are assisted with individual- ized transition planning and linked to community- based treatment and supports as appropriate. Services provided include supportive housing, supported employment, assertive community treat- ment, illness self-management and recovery (Well- ness Recovery Action Planning), trauma services, and integrated treatment for co-occurring mental illness and substance use disorders. Most people served by the CMHP are indigent and are not receiving entitlement benefits at the time of program entry.As a result, many do not have the necessary resources to access adequate housing, treatment, or support services in the community. To address this barrier and maximize resources, the CMHP developed an innovative plan to improve the ability to transition people from the criminal justice system to the community. On the basis of an agreement established between Miami-Dade County and the Social Security Admin- istration, a gap-funding program was developed to provide assistance for people applying for federal entitlement benefits such as Supplemental Security Income or Social Security Disability Insurance dur- ing the period between application for and approval of benefits.If approved for benefits,people applying for Social Security are compensated retroactively to the date of initial application. Participants applying for benefits and receiving assistance from the CMHP sign an interim assistance reimbursement agree- ment, which allows the county to be reimbursed for housing costs when an individual is approved for Social Security benefits and receives a retroactive payment. In an effort to ensure that program participants who are eligible for entitlement benefits receive them as quickly and efficiently as possible, the CHMP uses a best practice model referred to as SOAR (SSI/SSDI, Outreach,Access and Recovery).This approach was developed as a federal technical assistance initia- tive to expedite access to Social Security entitle- ment benefits for people with mental illness who are homeless. All CMHP participants are screened for eligibility for federal entitlement benefits, with staff initiating applications as early as possible using the SOAR model. Program data demonstrate that 88 percent of the CMHP participants who ap- ply for benefits using SOAR are approved on the initial application. By contrast, the national average across all disability groups for approval on initial application is 37 percent. In addition, the average time to approval for CMHP participants is 62 days. This achievement is remarkable compared with the ordinary approval process, which typically takes 9–12 months or longer. Lessons Learned: Collaboration is Key The CMHP’s success and effectiveness depends on the commitment, consensus, and ongoing efforts of traditional and nontraditional stakeholders through- out the community. In the past, treatment providers regularly talked with other treatment providers and criminal justice agencies regularly talked with other criminal justice agencies; however, treatment pro- viders and criminal justice agencies rarely bridged the gap between their respective systems. In estab- lishing the CMHP, a mental health committee was established within the courts and a local chapter of a statewide advocacy organization known as Florida Partners in Crisis was formed.The purpose of these bodies was to facilitate and encourage communica- tion and information exchange. As a representative of the courts, the CMHP is in a unique position to bring together stakeholders who may otherwise not have opportunities to engage in such problem-solving collaborations. By working together across systems and communities to craft more appropriate, responsive, and coordinated pro- grams and services, it is possible to prevent people from unnecessarily entering the criminal justice sys- tem and to increase opportunities for recovery. The justice system was never intended to serve as the safety net for the public mental health system and is ill equipped to do so.The current shortcom- ings of the community mental health and criminal justice systems did not arise recently. No one cre- ated these problems alone, and no one will be able to solve these problems alone. Miami-Dade County Judge Steven Leifman has served as Special Advisor on Criminal Justice and Mental Health for the Supreme Court of Florida since April 2007. In this capacity, Judge Leifman is responsible for chairing the Court’s Mental Health Subcommittee which authored a ground-breaking report entitled,Transforming Florida’s Mental Health System. Judge Leifman also serves as Chair of the Eleventh Judicial Circuit of Florida’s Mental Health Committee, and is responsible for creating the Eleventh Judicial Circuit Criminal Mental Health Project. Judge Leifman is a former Assistant Public Defender for Miami-Dade County, Florida. Tim Coffey has nearly 20 years of experience in the fields of behavioral health, public health, and social science research and evaluation. Having worked in a variety of healthcare, academic, and government settings, he has been involved in basic and applied research activities addressing mental and behavioral health issues.As coordinator for the Eleventh Judicial Circuit Criminal Mental Health Project, Coffey is respon- sible for the development, implementation, and evaluation of a variety of court-based projects and programs designed around the needs of people with mental illnesses involved in the criminal justice system The forensic hospital diversion program is projected to divert 40 people per year from admission to state hospitals, which is projected to result in a savings to the state of $1.1 million while funding an additional 7,200 days of new community-based treatment services.
  • 22. MHRRG and Negley Associates specialize in providing comprehensive insurance solutions and exclusive loss prevention tools for addiction treatment and mental health providers. 1.800.845.1209 Fax:973.830.8585 Professional Liability General Liability Directors and Officers Liability Property Workers Compensation Excess Auto
  • 23. 26 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Interview National Council Magazine talked to Pete about both the stories he tells in Crazy. NationalCouncil: Pete, why did you choose to tell the two stories? Pete: I was outraged that my son got arrested.I was frustrated that imminent danger laws in Virginia, where I live, kept me from getting my son help and treatment. Then the legal system wanted to punish my son when he wasn’t thinking clearly.It was a ter- rible Catch-22 situation. As a father I couldn’t do much but as a reporter I could. So I wanted to tell two stories. One about the struggles I had in help- ing my son and the other about the state of mental health treatment in this country and I was shocked at what I found in the criminal justice system. NationalCouncil:In Crazy,you tell stories of some persons with mental illness other than your son.Any idea how they’re all doing now? Pete: Sadly, none of them got any better. In fact, their stories have gotten more tragic. The only per- son I profile in my book who ever got better was my son. National Council: What made the difference with your son? Pete: Good case management and good people in the community mental health system that treated him. I had no option but to call the cops when Mike was threatening me one night — my son was shot twice with aTaser and taken away.After that,he was assigned a case manager who was a saint — I give her full credit. She worked with him for three years and he got better. Now Mike is getting trained to go and work in jails,providing peer support.As a parent you are limited — the system doesn’t want to listen to you but you are the one that has to pick up the pieces.This social worker literally saved his life! National Council: What effect did Crazy have on people’s attitudes about mental health? Pete: Not enough since this book was read very little outside the mental health community. It was very well received by those who work in behavioral health, but it didn’t educate many people who like most of us, are ignorant about mental health. The strongest supporters of this book are the parents of those who have mental illness. I was lucky as my son was able to get treatment.I hear from people all the time whose children are dead,in prison,or even on death row because they had a mental illness and committed crimes while suffering from bipolar disorder or schizophrenia.This includes judges and psychiatrists. National Council: What advice would you give to other parents trying to get help for their kids with mental illness? Pete: First, you can’t give up. You have to be a squeaky wheel.You also have to be an advocate for someone who often doesn’t want you involved and in a system that doesn’t want you involved.You have to be willing to have your child hate you at times in order to get them proper treatment. National Council: How did you get into Miami Dade County Jail — the setting for the other story you tell in Crazy? Pete: The only reason I got into the Miami-Dade County Jail was because of Judge Steven Leifman. I found the officers were very frustrated with the con- ditions in the jail. Most of them wanted to do the right thing. They wanted to do their job and their Pete Earley, Journalist and Author Interviewed by Meena Dayak,Vice President, Marketing and Communications; Mohini Venkatesh, Director, Federal and State Policy; and Nathan Sprenger, Marketing and Communications Associate — National Council for Community Behavioral Healthcare Pete Earley with two oil paintings by his son, Mike (the faceless chess player is a self portrait) Pete Earley on Jails and Prisons, Our “New Mental Asylums” Why did National Council Magazine interview Pete Earley, author of Crazy: A Father’s Search Through America’s Mental Health Madness for a criminal- justice focused issue? Pete describes it best in his own words — in his introduction to Crazy at “I had no idea. I’d been a journalist for thirty years and written extensively about crime and punishment and society. But I’d always been on the outside looking in. I had no idea what it was like to be on the inside looking out – until my son, Mike, was declared mentally ill. Suddenly the two of us were thrown headlong into the maze of contradictions, disparities and Catch-22s that make up America’s mental health system. Crazy: A Father’s Search Through America’s Mental Health Madness is a nonfiction book that tells two stories. The first is my son’s.The second describes what I observed during a year-long investigation inside the Miami-Dade County jail, where I was given unrestricted access. I feel more passionately about this book than any I have every written. Our nation’s jails and prisons have become our new mental asylums. I wrote this book as a wake-up call to expose how persons with mental illness are ending up behind bars when what they need is help, not punishment.” We know how to help people — we just aren’t doing it. We just won’t put the necessary funds into community mental health in order to save people.
  • 24. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 27 job was not to take care of people with severe mental illness. The leading advocates for change in how we incarcerate those with mental illness have not been mental health advocates but correctional officers, judges, and those in law enforcement who see how horrible this is. National Council: Did you visit other jails and prisons? Pete: The LA County Jail has been described as the largest public mental health facility and that’s where it started. I was invited to observe the LA County Jail but was asked to leave after three days as they cited legal concerns about the privacy rights of inmates under HIPAA. I then tried Cook County Jail in Chicago and they said no.Then I tried Rikers Island in NewYork and Baltimore and they said no. I tried DC and they said,“Hell, no.” In LA, the corrections officers wanted me out and the mental health staff wanted me in.In Rikers,it was the opposite. In LA, I think it was because the corrections officers knew how deplorable the conditions were and didn’t have the proper training to deal with inmates who had mental illness and in cases where the mental health staff didn’t want me in, I think it was because they weren’t doing much for a variety of reasons. I think fear was the motivating factor behind their op- position to me getting inside these jails. National Council: How did you feel when you first entered the psychiatric unit at the Miami Dade County Jail? Pete: It was barbaric! Nothing prepared me for what I saw.There was severe overcrowding.You had naked people in cells that had nothing in them. Because it was an old system,you had days when the water didn’t work. You had people drinking out of toilets because they couldn’t get anything to drink otherwise.You had people yelling and screaming. The officers at that time had received zero training for dealing with those who had mental illness. Because of a history of abuse by the correctional officers and many lawsuits, all forms of restraint were taken away from the officers — the cells were sealed shut to pre- vent things from being thrown at the officers,and they had no way of controlling the inmates except to beat them or isolate them. Now the officers do receive more training on how to deal with those who have mental illness. National Council: Community mental health orga- nizations often partner with their local corrections systems to address the needs of incarcerated popula- tions. How best can they help? Pete:We are mistakenly putting too much money into corrections instead of into treatment.Without enough funding for community mental health, it doesn’t mat- ter how good your Crisis Intervention Teams training program is.You are going to fail! Real partnerships between corrections and community mental health providers are key, since correctional professionals don’t know how to handle persons with mental illness without the help from those in com- munity mental health,who are on the outside.A prime example of community partnerships is San Antonio, where police are trained to recognize those with seri- ous mental illness — if they arrest such persons, they take them to the local drop off center instead of jail. They’ve convinced their local and state government that it’s much more cost effective to put those with mental illness into the community mental health network — this saves more money than it costs by preventing incarceration and repeat arrests. This is not a case of us not knowing what to do. It’s a case of us not wanting to do it.We know that assertive community treatment works.We know that SamTsem- beris’s Housing First program had an 86% success rate in getting persons with mental illness and addic- tions off the street.We know that peer outreach works and that good case management can help people recover their lives.We know how to help people — we just aren’t doing it. We just won’t put the necessary funds into community mental health in order to save people.You can’t expect case managers with 50 – 60 clients or community mental health centers without temporary hospital beds for those with severe schizo- phrenia to do a good job. NationalCouncil:What barriers do you see to better funding to treat the incarcerated? Pete: We tend to look for short-term solutions. Then there is the issue of civil commitment laws — we have a system now where one has to be an imminent dan- ger before they can be hospitalized. Many states are using the civil rights issue as a sham to not fund good community mental health services. The civil rights is- sue is being twisted to justify denying treatment to those who could benefit from it. I wish there were someone in the mental health community who would try to show that persons with mental illness have a constitutional right to good treatment. I think until we get lawsuits going, we will never have the leverage to get politicians and others to really do what needs to be done to help people! National Council: Given the magnitude of mental health budget cuts that state after state is facing, do you really think criminal justice populations have any hope? Pete: Housing First and good community mental health treatment programs will ultimately save money, but you have to hang in there for the long term. A great way to pay for mental health services would be the cigarette tax, if politicians had enough guts to raise it. Some states have increased it but in Virginia we charge a ridiculously low 30 cents per pack. If we raised that a dime,that would raise $100 million.Why the cigarette tax?A UCLA study showed that 40% of all cigarette sales go to those who have been diagnosed with a mental illness. I think law enforcement and corrections people should be the first ones to step forward and say that jails are not an appropriate place for those with mental illness. Jails are straining to pay for medications for inmates in these times of budget cuts. Behavioral health peo- ple need to make it clear that they can help people with mental illness and addictions if they are given the resources to do so. It needs to be emphasized that incarcerated persons can be helped and that their mental illnesses aren’t their fault. Meena Dayak has more than 15 years of experience in marketing and media relations for nonprofit healthcare organizations. She spearheads branding, PR, social media, member communica- tion, and public education initiatives at the National Council for Community Behavioral Healthcare. Her mission is to help member organizations tell a compelling story so the world will recognize that mental illnesses and addictions are treatable health condi- tions from which persons can recover and lead full lives. Mohini Venkatesh serves as the staff policy liaison to the National Council for Community Behavioral Healthcare’s network of associations throughout the states, conducts federal legislative and policy analysis on an array of issues, and manages political engagement activities including an annual Hill Day in Washington, DC. She received a masters in public health from Yale University and a BA in psychology from the University of Massachusetts- Amherst. Nathan Sprenger supports the National Council’s public relations and marketing efforts, leads the social media activities, maintains the website, and serves as editorial assistant for National Council Magazine. He has a masters degree in public communication from American University in Washington DC.
  • 25. 28 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Interview National Council: What does the latest research show regarding the prevalence of mental illness and addictions among the justice-involved population? Fred: It is important to be aware of the overrepre- sentation of people with behavioral health disorders in the criminal justice system. Recent research has found that about 14.5 percent of men and 31 per- cent of women booked into jails have serious men- tal illnesses.These rates are about three to six times the prevalence rates for the general population. About 70 percent of people admitted into prison meet the criteria for a substance use disorder; and most have co-occurring disorders.The majority have not committed violent crimes and do not pose a threat to public safety. These facts beg for creative responses to prevent those who are unnecessarily in custody from being there, and to link those com- ing out of jails and prisons to effective behavioral health interventions. National Council: What type of interventions can limit the criminal justice involvement of individuals with mental illnesses and addiction disorders? Fred: There are now a number of initiatives that hold a lot of promise in supporting recovery with these populations. For those individuals who are not a public safety risk, we want to divert them to treatment. There are specialized responses geared toward police officers and other first responders in how to deal with those who have serious mental ill- nesses. One of the most common is called Crisis Intervention Teams training, which teaches police officers how to be aware of those with mental ill- nesses and to de-escalate potentially dangerous situations when they encounter someone with a serious behavioral problem on the street.Those are widespread and growing in popularity. Another point of intervention is at jails and other post booking sites where we can appropriately screen for mental illness and drug addiction and work with judges and defense and prosecuting at- torneys to find appropriate treatment options. One of the most likely post booking options is the ap- pearance at specialty courts, such as drug and mental health courts. These courts are becoming more common and are often options that defense attorneys advise their clients to pursue.These courts require treatment as a condition of release and monitor progress with more frequent appearances before the bench.These courts have been shown to be effective in engaging those with mental and ad- diction disorders, and are cost effective. We also have programs for those who are reenter- ing the community after being in jail and prison settings. This has gotten a lot of attention recently with the passage of the Second Chance Act, which focuses on the needs of individuals leaving custody and returning to their home communities. All are concerned that these programs protect public safe- ty while advancing public health outcomes through the integration of best practices in supervision and treatment. We have specialized probation and pa- role initiatives that train community corrections of- ficers about mental health and addiction disorders, and treatment providers about supervision strate- gies and objectives. National Council: What can be done to reduce recidivism? Fred: The factors that influence criminal activity among those with mental illnesses and addiction disorders aren’t that different from the factors that influence those who commit crime in the general population.These criminogenic factors include stat- ic factors such as age at one’s first arrest and basic demographic information.Additionally,there are dy- namic factors that are subject to change over time, such as antisocial patterns of thinking that have been identified as increasing risk of crime; antiso- cial peers that can influence the likelihood of recidi- vism; and mental health and addictions issues that influence one’s decision-making processes. Many justice-involved individuals with mental illness may also have a co-occurring substance use problem. These dynamic factors suggest that the application of evidence-based treatment practices, such as cognitive behavioral therapy, can assist people to make better choices when confronted with certain situations that lead to criminal behavior. One cannot overlook the importance of other envi- ronmental factors that reduce recidivism, such as stable housing and access to meaningful employ- ment and/or education. I haven’t met anyone with mental illness or addictions who wants to be in cus- tody. They key to reducing recidivism is to match effective treatment with essential supportive pro- grams that allow these people to realize their goals. NationalCouncil:What cognitive behavioral treat- ments are known to be effective for justice-involved persons with mental illness? Fred: There are several models that are known to work for those involved in the criminal justice system, such as Thinking for a Change and Moral Reconation Therapy. The key is to utilize models that put people in a well documented and strategic program that provides treatment sessions and gives people the tools and skills they need to advance in their recovery.In NewYork,there is a program called SPECTRM (Sensitizing Providers to the Effects of In- carceration on Treatment and Risk Management) that helps to change the types of behaviors that led inmates into criminal behavior and to prevent recidivism once they are released from prison.While we are starting to see more innovative programs be- ing initiated by community mental health providers, more work needs to be done here. Fred Osher, MD, Director of Health Systems and Services Policy, The Council of State Governments Justice Center, Interviewed by Mohini Venkatesh, Director, Federal and State Policy; Meena Dayak,Vice President, Marketing and Communications; and Nathan Sprenger, Market- ing and Communications Associate — National Council for Community Behavioral Healthcare Reducing Justice Involvement for People with Mental Illness: Strategies that Work
  • 26. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 29 National Council: What are the major barriers that limit collaboration between the criminal justice and treatment systems? Fred:Traditionally, community behavioral health sys- tems have not had a primary focus on public safety is- sues; however, we are now seeing these organizations playing a larger role in this arena.Unfortunately,there are financial barriers that limit the ability of commu- nity behavioral health to be responsive to this need. Many of those in the criminal justice system don’t qualify for the various state mental health funded programs because of their eligibility criteria.While ac- tuarial models that have been developed by the crimi- nal justice field help us to determine who might be more at risk of committing a crime,this information is not frequently used to identify priority populations. National Council: Are there federal initiatives that support behavioral health and criminal justice col- laborations? Fred: Absolutely. The passage of the Mentally Ill Of- fender Treatment Crime Reduction Act (MIOTCRA) pro- vided funding for the Bureau of Justice Assistance to develop the Justice Mental Health Collaboration pro- gram. Grants under this program require the partner- ship of the community mental health and criminal jus- tice systems.We’ve seen the creation of a specialized law enforcement initiative in Philadelphia, a mental health court in Kalamazoo, MI, and specialized com- munity corrections strategies in Portland, ME, with this funding.There are about six dozen grantees that are implementing these types of programs across the country. The Second Chance Act provides a new source of funding for criminal justice and treatment collabo- rations with several grant programs that focus on justice-involved individuals with substance use and co-occurring disorders. Additionally,we’ve seen growing support for justice re- investment work in the states. [Justice Reinvestment is an approach that uses data-driven, fiscally respon- sible policies and practices to increase public safety and reduce recidivism and corrections spending.]This approach gives policymakers options to reduce cor- rections expenditures while enhancing public safety. Justice reinvestment projects stimulate collabora- tion between criminal justice, community behavioral health, and other key partners. On the federal level, the Justice Center has been working with our advo- cacy partners to develop further support for these initiatives. National Council: Why do we need justice reinvest- ment projects? Fred: State spending on corrections has risen faster than any other item in state budgets over the last 20 years. It has increased from $10 billion in 1990 to over $45 billion today. This is occurring in the con- text of significant budgetary pressures related to this recession. Justice reinvestment is an approach that starts with an analysis of the drivers of jail and prison growth in communities and states. One of the more common findings is that the growth is not about new crimes or new arrests; it’s being driven by high rates of revocation of people on probation or parole — peo- ple coming out of prison have a two-third chance of being sent back to prison within three years of their release and most of them return within the first eight months. Often, they are having their parole or proba- tion revoked not for new crimes but for technical vio- lations of their release.The majority of these technical violations are related to behavioral problems such as failure to appear or keep appointments, or continued substance abuse.This has created an opportunity for those in behavioral health to partner with the criminal justice system to slow down this revolving door. NationalCouncil:What role do you see for community behavioral health providers in justice reinvestment? Fred: Community behavioral health providers are an absolutely critical component to the success of jus- tice reinvestment strategies; we need their expertise in providing effective community behavioral health treatments.Their involvement in these initiatives gives them a mechanism to access additional resources and to focus their staff on the needs of justice in- volved persons. For example, we are seeing the be- havioral health community coming to the table and saying, “We can provide the integrated treatment for co-occurring disorders that these people coming out of prison need.” National Council: What advice would you give to states that want to start getting involved in justice reinvestment work? Fred: The first step is to understand what comes from collaboration. One system on its own can’t do everything; all branches of government and all stake- holders — the criminal justice field, community be- havioral health providers, victims’ advocates, families and consumers, and others — need to use the power of collaboration to access different funding streams and more importantly, to be responsive to the needs of persons with mental illness and addictions in the criminal justice system and to the need to create safer communities. Fred Osher, MD, oversees the health components of the Council of State Governments Justice Center’s initiatives. He also provides technical assistance to state and local governments across the country seeking to improve their response to people who have mental health and/or substance use disorders and are involved in the criminal justice system. Before joining the CSG Justice Center, Fred served as the Director of the Center for Behavioral Health, Justice, and Public Policy and as an Associate Professor of Psychiatry at the University of Maryland School of Medicine. He has published extensively in the areas of homelessness, com- munity psychiatry, co-occurring mental and addictive disorders, and effective approaches to persons with behavioral disorders within criminal justice settings. He received his BA from Harvard University and his MD from Wayne State University. Mohini Venkatesh serves as the staff policy liaison to the National Council for Community Behavioral Healthcare’s network of associations throughout the states, conducts federal legislative and policy analysis on an array of issues, and manages several political engagement activities including an annual Hill Day in Washington, DC. She received a masters in public health from Yale University and a BA in psychology from the University of Massachusetts-Amherst. Meena Dayak has more than 15 years of experience in marketing and media relations for nonprofit healthcare organizations. She spearheads branding, PR, social media, member communica- tion, and public education initiatives at the National Council for Community Behavioral Healthcare. Her mission is to help member organizations tell a compelling story so the world will recognize that mental illnesses and addictions are treatable health condi- tions from which persons can recover and lead full lives. Nathan Sprenger supports the National Council’s public relations and marketing efforts, leads the social media activities, maintains the website, and serves as editorial assistant for National Council Magazine. He has a masters degree in public communication from American University in Washington DC. Community behavioral health providers are an absolutely critical component to the success of justice reinvestment strategies; we need their expertise in providing effective community behavioral health treatments. Their involvement in these initiatives gives them a mechanism to access additional resources and to focus their staff on the needs of justice involved persons.
  • 27. 30 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars All is not bleak for finding resources for innovative programs. In both the public and private sectors and at the local, state, and federal levels, there are opportunities worth exploring. Two major federal sources of funding are the Bureau of Justice Assis- tance ( and the Substance Abuse and Mental Health Services Administration ( On the private side, many local foundations fund innovative programs at the interface of behavioral health and criminal justice. Through BJA, behavioral health organizations that partner with local justice agencies on grants to service justice-involved people in their communities can use grant funding to provide services. BJA offers an array of grants to partnerships between justice and mental health agencies. Two grant programs are currently seeking applications for funding, the Justice and Mental Health Collaboration Program, created by the Mentally Ill Offender Treatment and Crime Reduction Act of 2004 and the Second Chance Act of 2007. The third grant program, for which the application deadline has passed, is the Byrne Justice Grant (JAG). Since fiscal year 2006, the BJA has granted joint justice and mental health partnerships funding under the Justice and Mental Health Collaboration Program to plan,implement,or expand a justice and mental health collaboration program.This program’s goal is to increase public safety through mental health and criminal justice collaboration for justice- involved people with mental illness or co-occurring mental health and substance abuse disorders.In FY 2009,BJA received 246 applications seeking a total of $43,401,754 in funding and awarded 43 site- based applicants a total of $7,874,824 in funding. In FY 2010, the Justice and Mental Health Collabo- ration Program will receive an increase of $2 million over FY 2009, for a total of $12 million. The Second ChanceAct of 2007 was signed in 2008 to ensure safe and successful transitions for people from prison,jail,or juvenile residential facilities into the community. The Second Chance Act Adult and Juvenile Offender Reentry Initiative FY 2010 grant is seeking applications from state, local, and tribal governments who have developed a strategic re- entry plan with extensive evidence of partnership and collaboration and have created a Reentry Task Force that includes both justice system and com- munity representatives. Under the FY 2010 spend- ing package, the Second Chance Act will receive $100 million, which is $75 million more than in FY 2009.Applications are due by March 4, 2010, 8:00 p.m. eastern time. Although the deadline for the JAG program passed in January 2010, this program is the primary provider of federal criminal justice funding to state and local jurisdictions.All areas of the criminal justice system, including drug and task forces, crime prevention, courts, treatment programs, and sharing justice information, are supported by this program. In FY 2010, the JAG program will receive $511 million. In addition to BJA, SAMHSA funds grant opportuni- ties for states and local government. In September 2009, SAMHSA awarded a second round of Jail Di- version Trauma Recovery Grantees to support local and statewide expansion of jail diversion programs for people with posttraumatic stress disorder and other trauma-related disorders. A priority for this program is to provide needed services to veterans returning from Iraq and Afghanistan. Awards were given to the states of Florida, North Carolina, New Mexico, Ohio, Rhode Island, and Texas. The first six states to be funded under this grant in 2008 were Colorado, Connecticut, Georgia, Illinois, Massachu- setts, and Vermont. In FY 2010, SAMHSA and the Center for Substance Abuse Treatment, in collaboration with BJA, are of- fering a unique opportunity that blends funding sources. Grantees will receive two separate awards totaling $20 million to enhance the court services, coordination, and substance abuse treatment ca- pacity of adult drug courts. BJA will fund the drug court component, and CSAT will fund the substance abuse treatment component. Up to a total of 31 grants will be awarded. This program allows appli- cants to submit one application to receive blended criminal justice and substance abuse treatment funding. Local health foundations are also available to pro- vide funding to local organizations and government Henry J. Steadman, PhD, President, Policy Research Associates; Samantha Califano, MS, Project Assistant, CMHS National GAINS Center Funding for Behavioral Health and Criminal Justice Programs In FY 2010, SAMHSA and the Center for Substance Abuse Treatment, in collaboration with the Bureau of Justice Assistance, are offering a unique opportunity that blends funding sources. Grantees will receive two separate awards totaling $20 million to enhance the court services, coordination, and substance abuse treatment capacity of adult drug courts. This program allows applicants to submit one application to receive blended criminal justice and substance abuse treatment funding.
  • 28. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 31 agencies in their states.Two local health foundations, for example, are Staunton Farm Foundation in Penn- sylvania and The Health Foundation of Greater Cin- cinnati. These foundations award grants to nonprofit organizations and government agencies in their sur- rounding areas. The Staunton Farm Foundation was founded approxi- mately 70 years ago and focuses on the behavioral health of children, youths, and adults. Rural behav- ioral health and access to behavioral health and criminal justice diversion are the three areas funded by foundation funds. The Staunton Farm Foundation provides grants to organizations in 10 counties in southwestern Pennsylvania. It has provided grants to mental health courts, drug courts, dual-diagnosis treatment programs, and agencies to create new websites and much more with the goal of improving behavioral health treatment. Another local health foundation active in behavioral health services for justice-involved people with mental illness is the Health Foundation of Greater Cincinnati, a social welfare organization whose focus is enhanc- ing community health.In 1997,the foundation refined its focus after conducting an extensive assessment of health issues within its region.The Health Foundation of Greater Cincinnati provides grant funding in Cincin- nati and 20 counties in Indiana, Kentucky, and Ohio. The four areas of focus are community primary care, school-age children’s healthcare, substance use dis- orders,and severe mental illness.Annually,the Health Foundation of Greater Cincinnati awards about $9 million in grants. Seventy-four grants were awarded between 1999 and 2007, focusing on substance use disorders and severe mental illness in the criminal justice system. The Staunton Farm Foundation and the Health Foun- dation of Greater Cincinnati are just two examples of local entities not often thought of in the context of behavioral health–criminal justice issues that are, in fact, very active throughout the United States. So, do not overlook these options in your community. With opportunities available on local, state, federal, and private levels, it is important to think creatively about funding. Many opportunities are available to blend multiple local, state, federal, and private fund- ing sources. Henry J. Steadman is internationally known for his research on interfacing criminal justice and mental health systems. He has been President of Policy Research Associates since he founded it in 1987. Previously, he ran a nationally known research bureau for 17 years for the New York State Office of Mental Health. Dr. Steadman’s major current projects are the National GAINS Center for Evidence-Based Practices in the Justice System; the John D. and Catherine T. MacArthur Foundation Mental Health Court Study; the CMHS Transformation Center; and SAMHSA’s Technical Assistance and Policy Analysis Center for Jail Diversion. Samantha Califano is a project assistant for the CMHS National GAINS Center, which is operated by Policy Research Associates, Inc., in Delmar, NY. She graduate Cum Laude with a bachelor of science in Criminology/Criminal Justice from Keuka College in 2008 and was awarded a master of science in Forensic Mental Health in December 2009 from Sage Graduate School. Congratulations to Anasazi Software customers on their 2010 National Council Awards of Excellence Excellence in Service Innovation Burrell Behavioral Health (Springfield, MO) for the Journey Home Project —— Todd Schaible, CEO — Excellence in Consumer & Family Advocacy Austin Travis County Integral Care (Austin, TX) for their work with the Central Texas African American Family Support Conference — David Evans, CEO — Rose Hill Center Providing four levels of treatment and rehabilitation programs for adults with mental illness Residential Rehabilitation Extended Residential Transitional Living Community Support 866-504-2259 (toll-free) Accredited by The Joint Commission Contact us to find out how you, a family member, or friend may benefit from treatment at Rose Hill Center Design. Develop. Deliver. We help with: • Marketing Repositioning for Parity • Strategic Mapping • Primary Care Integration • Affiliations and ASO’s Criterion Health, Inc. AHP Behavioral Health Consulting Group In partnership with Charles G. Ray (301) 213-6201 Patrick Gauthier (888) 898-3280
  • 29. Beyond Bars 32 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 What are some of the major issues a community behavioral health provider should consider before investing resources in the treatment of people who have entered or may be at risk of entering the criminal justice system? Defining the Population People with mental disorders in the criminal justice system have diverse patterns of offending, di- verse clinical profiles,and diverse needs.Many have co-occurring disorders,others are homeless,and some may have had prior contact with the treatment system. For example, in Florida, 190,000 (or nearly 30%) of the 638,000 people arrested in 2006 had used a behavioral health service paid for by Medicaid or provided in a state licensed facility in the five years prior to arrest.While the fact that a person charged with a crime does not mean that mental illness caused the crime,people with mental illnesses and substance abuse problems often engage in behavior that results in misdemeanor arrests because the behavior is a public nuisance. At the Florida Mental Health Institute we examined four years of crimi- nal justice and treatment involvement for 3,769 people with a serious mental illness arrested in Pinellas County, Florida between July 2003 and June 2004.For a 4-year period,this group generated 17,663 arrests with a mean arrest rate per person of 4.6 arrests over the four years. However, a group of 210 individuals averaged more than 16 arrests, or 4 arrests per year, for the 4-year period, with nearly all arrests for misdemeanors. What was distinctive about this group? In con- trast to other arrestees with serious mental illnesses that we examined, this group was much more likely to be male, have a psy- chotic disorder, and have the lowest rate of outpatient treatment contacts. In addition, 44% had been homeless at some point dur- ing the four years. Policymakers might focus on the group averaging 16 arrests over 4 years; however a treatment provider might or might not consider this an appro- priate group for a treatment intervention. John Petrila, JD, LLM, Director, Florida Mental Health Institute Criminal Justice, Mental Health, and Substance Abuse Technical Assistance Center Back to Basics: Evaluating Opportunities to Serve the Justice-Involved Population in Community Behavioral Health
  • 30. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 33 Defining the Treatment What is treatment supposed to accomplish? Is it focused primarily on behavioral health issues, unrelated to the person’s criminal involvement? Or is it designed to ameliorate risk? And if so, risk to the public, a specific person, or the individual receiving treatment? There is little evidence that most types of treatment have a direct impact on criminal recidivism, even if they relieve symptoms or improve mental status or functioning.Treatments with empirical footing,such as dialectical behavioral therapy for borderline personality disorders, or multisystemic therapy for youth, require significant investments in resources and fidelity to the particular model. Interventions that have proved successful in other contexts,such as assertive com- munity treatment may not have a similar effect with a justice-involved population. An intervention with empirical support for its effect on treatment should not be applied indiscriminately with the assumption that it will have an impact on re- cidivism. A study of North Carolina’s outpatient civil commitment law found that a court order of at least six months duration, combined with treatment of the same duration, had an impact on recidivism and rehospitalization of people with psychotic disorders.However,one without the other did not have this effect,nor did the combination of long-term court order and long-term treatment have the same effect on people with affective disorders. Paying for the Treatment Most people with mental illnesses involved in the criminal justice system are poor. People with Medicaid are less likely to be re-arrested than those without. However, given Medicaid eligibility rules, obtaining and retaining Medicaid eligibility can be difficult. Of 689,000 individuals arrested in Florida during 2006, 66,679 (or 9.7%) had been enrolled in Medicaid at some point during the 365 days prior to arrest. However, only 48,342 (or 7.0%) were still enrolled at the time of arrest. Loss of eli- gibility may occur for a variety of reasons.However,the lack of entitlements creates difficulties in making even the smallest co-pay for medications and other services. In addition, Medicaid is a minor payer for substance abuse services. More than 90% of Florida arrestees who had used a Medicaid reimbursed behavioral health service in the 365 days prior to their arrest used a mental health service,with fewer than 10% using a substance use service.This means that Medicaid is often of little utility in paying for substance use services that may be clinically essential. Public Safety No issue is more important to law enforcement, judges, and prosecutors than public safety. Any provider that works with people referred by the criminal justice system must understand this, and must consider how risk will be assessed and managed.Today, we know a great deal about the relationship between mental ill- ness,substance abuse,and violence.Good instruments also are available to struc- ture the assessment of risk to third parties — some developed for institutional populations, others for com- munity use. However, our knowledge of risk management is more limited. Good treat- ment alone is not enough unless it is targeted to those dynamic factors that re- search has shown are most related to future risk. In addition, providers need to develop and implement clear policies that describe the factors that should be considered if a person misses appointments, stops taking medication, or exhibits other behaviors that conceivably could foreshadow future risk. Such policies are good risk management tools in any practice, but are essential in working with the criminal justice system. Political Alliances One of the most important developments in public mental health in the last de- cade has been the emergence of judges and law enforcement officials as leaders in addressing the needs of people with mental illnesses and substance abuse disorders. This can be uncomfortable for treatment providers, because of some- times quite different perspectives on identifying and solving problems. However, the interest of other leaders provides an opportunity to create local and statewide political alliances that would have been unheard of several years ago.Any provider working with justice-involved people needs to know the local sheriff, the relevant police departments, the state attorney (the prosecutor), and the public defender. These relationships will lead to increased trust between the parties as well as alli- ances that may result in increased investment for services. Many behavioral health providers may be offered or will seek out opportunities to work with people entering services through the criminal justice system. Such work can be rewarding and can place the provider in a larger set of community relationships. However, recognizing the diversity of the population, and the limited impact of most treatments on criminal recidivism and understanding the impor- tance of public safety are essential for any provider to succeed in this rapidly growing market. John Petrila is a professor in the Department of Mental Health Law & Policy and in the USF College of Public Health. He is also the Director of the Florida Mental Health Institute Criminal Justice, Mental Health, and Substance Abuse Technical Assistance Center. Petrila was General Counsel to the New York State Office of Mental Health and the first Director of Forensic Services in the Missouri Department of Mental Hygiene. He has published frequently on mental health law and policy issues, and authored the chapter on confidentiality in the Surgeon General’s Report on Mental Health. He is a member of the MacArthur Foundation Research Network on Mandated Community Care, Past-President of the International Association of Forensic Mental Health Services, and co-editor of Behavioral Sciences and the Law. An intervention with empirical support for its effect on treatment should not be applied indiscriminately with the assumption that it will have an impact on recidivism.
  • 31. 34 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars Mohini Venkatesh, Director, Federal and State Policy, National Council for Community Behavioral Healthcare Advocate to Give Youth a Second Chance Juvenile Justice and Delinquency Prevention Reauthorization Act What is the underlying rationale of state juvenile justice systems? Is it to punish youths who commit crimes or to rehabilitate youths to give them a second chance? Although this perpetual debate plays out similarly for incarcer- ated adults, what is unique to the juvenile justice discussion is the people who are most affected: youths.Yes, they are supposed to be corrected when they do something wrong but, isn’t it also important to invest in them and give them the opportunity to mature and grow into adulthood? When considering factors that contribute to juvenile delinquency, such as mental health and substance use problems, negative environmental influences, or complicated family situations, the role of state juvenile justice systems and community providers becomes clear — to prevent juvenile delinquency whenever possible and to rehabilitate youths who are in the system to give them the best chance to succeed. Studies have indicated that 70 percent or more of youths who are securely detained in a juvenile justice facility have a mental health or related disorder; in contrast,approximately 20 percent of the general youth population have such a disorder. According to a public opinion poll commissioned by the Center for Children’s Law as part of the John D. and Catherine T. MacArthur Foundation’s Model for Change juvenile justice reform initiative, a majority of people polled viewed alternatives to incarceration — such as community mental health treat- ment, mentoring, and vocational training — as effective ways to rehabilitate youths. In addition, 8 out of 10 polled strongly favored taking away some of the money states spend on incarcerating youth offenders and using that funding to pay for counseling, education, and job training. Juvenile Justice and Delinquency Prevention Act In response to widespread abuses in state and local juvenile justice facilities, Congress passed the Juvenile Justice and Delinquency Prevention Act in 1974. The JJDPA serves as the primary federal funding stream for juvenile justice ser- vices to states and territories that voluntarily ascribe to its core requirements. Among other requirements, the JJDPA established rules to ensure that juveniles who commit minor or “status offenses” are not held in secure confinement, protect juveniles from being incarcerated in adult jails or lock-ups for extended periods of time, address the disproportionate contact youths of color have with the juvenile justice continuum, and other protections. Through these core re- quirements, the JJDPA is meant to foster services and supports to prevent juve- nile delinquency and, in cases in which youths enter the juvenile justice system, protections to ensure that they are not unduly exposed to harm or trauma while incarcerated. According to a 2008 survey of the states conducted by the Coalition for Juvenile Justice, 55 of 56 states and territories voluntarily participate in the JJDPA and 85 percent are compliant with all JJDPA core requirements. One of the true benefits of the JJDPA is the federal–state partnership it creates via the U.S. Office of Juvenile Justice and Delinquency Prevention; as a result,states and ter- ritories greatly value the opportunity to receive technical assistance and share successful practices with each other and the OJJDP.Through small investments in successful programs, the federal government is able to offer the opportunity for states and territories to replicate successful programs, the result of which is hoped to be an overall improvement in the way juvenile justice systems respond to youths’ unique needs. Although the principles of the JJDPA are laudable and have created key protec- tions for youths, implementation challenges persist — funding limitations, lack of appropriate staffing and training, and other challenges prevent the realiza- tion of the original vision of the JJDPA. Reauthorization Advocates,including the National Council for Community Behavioral Healthcare, view reauthorization of the JJDPA as an opportunity to address these challenges.
  • 32. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 35 The JJDPA was most recently reauthorized in 2004, and efforts are underway to reauthorize the act in the 111th Congress. After being introduced in the Senate, the Juvenile Justice and Delinquency Prevention Reauthorization Act (S. 678) was approved by the Senate Judiciary Committee, thus sending the bill to the Senate floor for consideration.Although a companion bill has yet to be introduced in the House of Representatives, efforts are underway to push for Senate passage in 2010 to bolster efforts in the House. Among several improvements, S. 678 takes important steps to strengthen the ability of state and territorial juvenile justice systems to meet the substance use and mental health needs of youths by incorporating >> New incentives for improving mental health and substance use screenings, treatment, diversion, and re-entry services. >> An increase of federal authorizations for core juvenile justice programs. >> Reinforcements of the relationship between OJJDP and participating states and territories to facilitate increased compliance with the core requirements of the JJDPA. To achieve reauthorization of the JJDPA in 2010, the National Council, along with an array of advocacy organizations, participates in a national coalition effort: Act4JJ ( this coalition, the National Council joins juvenile justice,child welfare,and youth development organizations with a unified message in support of enhancing the JJDPA. Readers who want to be involved in advocacy for the Justice and Delinquency Prevention Reauthorization Act on a national level are encouraged to sign on to the Act4JJ Statement of Principles and monitor the National Council’s Public Policy Update for notices of our activity on the JJDP Reauthorization Act in 2010. Youths who commit crimes often face an uphill battle to improve their lives, and it is our job as community providers, advocates, and members of our communities to guide them in a manner that protects them from danger and gives them the op- portunity to achieve more.Although reauthorization of the JJDPA won’t resolve all challenges in serving justice-involved youths, it will certainly get us closer. Mohini Venkatesh serves as the staff policy liaison to the National Council for Community Behavioral Healthcare’s network of associations throughout the states, conducts federal legislative and policy analysis on an array of issues, and manages political engagement activities including an annual Hill Day in Washington, DC. She received a masters in public health from Yale University and a BA in psychology from the University of Massachusetts-Amherst. Preview of FY 2011 Federal Budget Appropriations for Criminal Justice >> On February 1, 2010, President Obama released his requests for the Fiscal Year (FY) 2011 federal budget.The release of the President’s budget signifies the official initiation of the Congressional appropria- tions process; both the House and Senate appropriations commit- tees will hold hearings, amend the budget over several months, and approve a final FY 2011 budget. >> Details of the president’s budget help us understand what the Presi- dent’s priorities are and give us a foundation from which to advocate. The following is a snapshot of the President’s FY 2011 budget requests for key criminal justice programs compared with previous fiscal years: >> Treatment drug courts: $56 million, including $5 million for family dependency, treatment drug courts. Increase of $12 million from FY 2010. >> Ex-offender re-entry: $23 million. Increase of $5 million from FY 2010. >> Drug courts: $57 million. Level-funded from FY 2010. >> Second chance re-entry: $100 million. Level-funded from FY 2010. >> Mentally Ill Offender Treatment Crime Reduction Act: None.Although this amount represents a $12 million decrease in funding, it is suspected that the President is attempting to combine MIOTCRA funding into the funding provided for drug and mental health courts. The President’s FY 2009 budget also requested this change, but it was denied by Congress. A detailed budget chart for these and other substance use and mental health-related federal programs is available at (click on Public Policy/Issues and Resources/Federal Budget) to learn more. A majority of people polled viewed alternatives to incarceration — such as community mental health treatment, mentoring, and vocational training — as effective ways to rehabilitate youths.
  • 33. From The Field 36 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 From The Field National Council member organizations across America share stories of collaboration with criminal justice and law enforcement systems to strengthen communities, save taxpayer dollars, and give persons with mental illness and addiction disorders a new life, beyond prison bars.
  • 34. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 37 Gilberto Rendon Gonzales, Director, Communications and Diversion Initiatives,The Center for Health Care Services, Bexar County Mental Health Authority, San Antonio,TX / Bexar County’s Restoration Center Offers Alternatives to Jail and the Streets Addressing the silos dividing substance abuse treat- ment and mental health services is a monumental task. The Restoration Center, started in 2007 by The Center for Healthcare Services, Bexar County’s Mental Health and Mental RetardationAuthority,seeks to ad- dress this problem by providing integrated substance abuse services. In combination with its sister Crisis Care Center,a 24-hour psychiatric emergency unit,the Restoration Center sees 900–1,000 people a month. Working closely with the Crisis Care Center, the Res- toration Center provides law enforcement with quick access to treatment for nonviolent misdemeanor of- fenders with substance abuse problems and also of- fers substance abuse services to homeless persons in the community. In establishing the Restoration Center, CHCS worked closely with local government and public and private stakeholders and drew upon lessons learned from the nationally recognized, award-winning Bexar County Jail Diversion Program,started in 2003.Earlier,stake- holders had sought to address the community’s pub- lic safety needs by developing the Crisis Care Center with medical clearance for law enforcement officers so that drop-offs take about 15 minutes, compared to an 8-14 hour wait in emergency rooms earlier.The Crisis Care Center’s success in returning officers to service prompted community stakeholders to address the gaps in substance abuse treatment through the Restoration Center. The Restoration Center includes a substance abuse court and features three distinct programs: >> The public safety unit, which provides injured prisoner medical clearance and treatment and a sobering unit (40+ person capacity) that enables safe sobering of persons brought in by law enforce- ment for public inebriation. >> The medical detox unit, which provides 27-bed capacity with a 3- to 5-day stay. >> Intensive outpatient substance abuse services — specialized day care treatment with intensive and supportive counseling programs. County Judge Nelson Wolff and business leaders such as Bill Greehey won the support of the Bexar County, Texas, legislative delegation for a special funding ap- propriation to establish the Restoration Center. The Restoration Center is proving to be cost-effective. In its first 180 days of operation, it served 395 home- less people who were diverted from jail, saving tax- payers $766,530. The sobering unit admitted 1,627 individuals in 162 days — 1,158 of them would oth- erwise have been admitted into the municipal court detention area at a cost of $2,657,610.An additional $703,500 was saved when law enforcement officers took 469 people to the Restoration Center instead of to a hospital emergency room before incarceration. Officers are spending less time in emergency room waiting rooms, which allows them to return to com- munity policing. Admissions to the Restoration Center’s detox unit stem from multiple referral sources such as courts, the sobering unit, the crisis care unit, Haven for Hope partners, and walk-ins by people who are homeless. The Restoration Center is a stakeholder partner in the $100 million, 37-acre, 962-bed Haven for Hope homeless facility. Located just across the street from the Restoration Center, Haven for Hope is scheduled to be fully operational in June 2010.The ability to pro- vide 24-hour access to psychiatric crisis assessment, sobering services, minor medical clearance services, pre-employment services, and housing — all in one area — exponentially enhances the possibility of treat- ment success. CHCS President and Chief Executive Officer Leon Evans attributes the Restoration Center’s success to community collaboration. “We were able to accom- plish this because we addressed a compelling need,” he explains. Catherine Jones, director of Addiction Recovery Ser- vices at CHCS says, “We made it a point to provide information to each of our stakeholders, we moni- tored outcomes, we showed our collaborative pro- gram partners what was working and what wasn’t, we showed that we were saving money, and we showed that this approach was a good doorway into treatment as well.” Melanie Lane, director of the Restoration Center, at- tributes success to persistence and staff serving as ef- fective role models. She explains that they were able to introduce real change — in the past, persons could not access substance abuse services unless they were sober but the Center knows you can’t get sober until you get services. Lane, having once been homeless herself, says, “I’m glad someone was willing to take one more chance on me.” 1,158 individuals admitted to the Restoration Center instead of the municipal court detention area saved taxpayers $2,657,610. 469people taken to the Restoration Center instead of to a hospital emergency room before incarceration saved an additional $703,500.
  • 35. From The Field 38 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Linda Grove-Paul, M.S.W., believes that a newly launched re-entry initiative for criminal offenders withaddictionsandco-occurringmentalhealthprob- lems in Indiana can help erase unproductive mis- conceptions about working with the justice system. “Mental health clinicians don’t realize how well-in- formed the judicial system is, in terms of evidence- based practices and outcomes,” said Grove-Paul, director of addiction and forensic services at the nationally prominent behavioral health services organization Centerstone. “Corrections ‘gets it’ that prison is not a place for the seriously mentally ill.” Centerstone of Indiana last week began overseeing the first participants in the Project CARE (Commu- nity and Re-entry Enhancement) initiative.The effort is bound to be watched nationally for several rea- sons. Centerstone is the contractor for a $1.2 mil- lion Substance Abuse and Mental Health Services Administration (SAMHSA) grant for the initiative, a grant awarded to the Indiana Division of Mental Health and Addictions in a highly competitive en- vironment. As a large behavioral health organization formed out of three entities, Centerstone is consistently being looked at as a model for innovative program- ming (see MHW, Dec. 24, 2007).And perhaps most importantly, Project CARE will serve as a significant test case for successful integration, between addic- tion and mental health services as well as between the behavioral health and justice systems. “This initiative really is about breaking down service silos,” Grove-Paul said. Details of initiative A collaboration among SAMHSA, the state behav- ioral health division and the state Department of Corrections, Project CARE will involve pre- and post- release planning for offenders in order to support the provision of behavioral health services and other supports to ease community reintegration and reduce recidivism. The initiative’s reach covers six southern Indiana counties (Bartholomew, Crawford, Harrison,Monroe,Orange andWashington),a region that does not have a re-entry court system. Grove-Paul said that while most of the offenders to be served under the initiative will have a co- occurring mental health issue such as depression or bipolar disorder,all will have a substance depen- dence diagnosis. For each individual potentially eligible for participa- tion,a case manager will complete a comprehensive assessment within the correctional facility, usually several months prior to the offender’s scheduled release date. This process will assist in identifying a wraparound team for each individual, taking into account that person’s potential support system in the with the case manager, a formalized treatment plan will be drawn up within 14 days. The initiative then will emphasize nearly immediate contact with program workers and treatment provid- ers upon an offender’s release. Within one to two business days after release, an individual will be re- quired to attend an appointment with a community provider as well as with a case manager,community corrections officer or parole officer.The individual’s wraparound team will have its first meeting within a week of the offender’s return to the community. Grove-Paul said Project CARE will be needs-driven, emphasizing individualized services in the realms of behavioral health treatment, general health as- sistance, vocational support, housing support and other key areas.There may be times when either the community corrections officer or the offender might deter- mine that the program is not a fit, and there will be an opt-out provision. As reported in Mental Health Weekly,Volume 20, Number 6, February 8, 2010 New Centerstone Initiative Heralds Promise of Work with Justice System This initiative really is about breaking down service silos.” PREVENT FRAUD By utilizing the Corporate Compliance ”Employee Action Line” to support your in-house Corporate Compliance Program, you not only reduce your potential liability, should there be a fine levied against your organization, but you’ll also send a clear message to your Board, employees, and stakeholders that you are serious about the prevention of fraud and compliance with federal guidelines. u The “Employee Action Line” is a “Best Practice” approach to ensure confidentiality and anonymity for employees to report fraud or suspicion without fear of retaliation or reprisal (as required by law). u A confidential report of any incident reported is transcribed and provided via certified mail to your Corporate Compliance Officer within 24 hours for internal investigation of possible violations for early intervention. 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  • 37. From The Field 40 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Citrus Health Network is a federally qualified health center located in Miami-Dade County, Florida and specializing in the integration of primary care and behavioral health services. In 2008, we aggregated and analyzed 4 years of data from our jail diversion program. The results were reported in Psychiatric Services in June 2009. Here, we provide an overview of our treatment model and a summary of results from that data review. Concern regarding the prevalence and inadequate management of people with mental illness within the criminal justice system has generated interest in developing effective diversion programs.In 2000, CHN received funding from the state to develop a jail diversion program, in keeping with a countywide initiative prompted by Judge Steve Leifman,Associ- ate Administrative Judge of the 11th Judicial Circuit in Miami-Dade County. CHN’s jail diversion program is based on two princi- ples geared toward enhancing psychosocial stability and reducing criminal recidivism: a) Facilitating access to integrated medical and psychiatric care. b) Delivering all interventions within the framework of our relationship-based care model, which we developed as a result of our experience in treat- ing people with pronounced difficulty in engage- ment and sustained interpersonal contact. In addition to specific interventional techniques, the RBC model reflects a philosophical approach that pervades all interactions with participants. The model assumes that the empathy, respect, and connectedness inherent in healthy relation- ships can be instrumental in engaging people in therapeutic activities and empowering them to take responsibility for their lives. RBC incorporates elements from other philosophi- cally compatible approaches, such as the low-de- mand model and motivational enhancement thera- py. For example, the principle of “express empathy” directs us to communicate respect and encourage collaboration with staff,who come to be viewed as a blend of supportive companions and knowledgeable consultants.The concept of“rolling with resistance,” from the low-demand model, discourages staff from meeting resistance head on; rather,they try to facili- tate a discrepancy between a person’s perception of the current situation and future aspirations.An end- point objective of RBC is establishing self-efficacy and self-agency, in which people develop a sense that they can change specific behaviors,act on their own behalf,and take responsibility and be account- able for their decisions. To operationalize RBC and facilitate its implemen- tation, we conceptualized the following stages: (a) engagement, (b) stability and commitment, (c) awakening, and (d) growth and differentiation. During engagement, the initial foundation of a re- lationship is established; motivational interviewing techniques are used to mobilize self-interest and encourage the client to choose care. Stability and commitment marks a period of rest and quiescence in which participants begin to feel safe and secure.This second stage consolidates the client’s relationship with staff as evidenced by their accepting physical and mental healthcare,develop- ing trust to rely on others for basic needs, and col- laborating with others to obtain day-to-day stability. We note that although some clients did not progress past this phase, they were nonetheless able to suc- cessfully remain out of jail. Probability for long-term change, however, increases if a person progresses through the next stages. The third stage,awakening,refers to a phenomenon in which clients begin to manifest a desire for more than a day-to-day existence and meeting basic needs. This stage is marked by clients taking in- creased advantage of the therapeutic, educational, and rehabilitation opportunities offered to them through our program. The final stage, growth and differentiation, begins when participants manifest stability, demonstrate new adaptive behaviors, exhibit signs of psychoso- cial flourishing, and ultimately transition into inde- pendent living. For this study, we analyzed data from the Criminal Justice Information System in Miami-Dade County for 151 people consecutively referred to our RBC program and compared them with data for 78 people diverted to other programs in the commu- nity. Number of arrests for each participant was determined during the 1-year period preceding date of diversion, followed by a review of arrests during the year after diversion. Results indicated that the RBC group demonstrated a statistically sig- nificant reduction in postdiversion arrest rates (p < .0001), whereas the rearrest rate for the control group remained nearly identical (p = .398).For both groups, postdiversion arrest rates were significantly correlated with number of arrests before diversion (p < .001). For the RBC group, regression analysis revealed that when number of prior arrests was ex- cluded from the equation, length of participation in the program (p < .045) and number of psychiatric contacts (p < .043) accounted for a significant por- tion of the variance in postadmission arrest rates. The RBC model appears to be effective in reduc- ing criminal recidivism. Length of participation in program and involvement in psychiatric treatment correlates with reduced arrest rates. Rafael A. Rivas-Vazquez, PsyD, Director,Assessment and Emergency Service, and Manual Sarria, LCSW, Administrator,Adult Homeless Programs — Citrus Health Network, Inc., Miami, FL / Citrus Jail Diversion Program Provides Integrated Care in a Relationship-Based Care Model The Relationship-Based Care model assumes that healthy relationships can be instrumental in engaging people in therapeutic activities and empowering them to take responsibility for their lives.
  • 38. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 41 Community Partnership of Southern Arizona has taken a creative, strategic approach to collabo- rating with the criminal justice system — from the establishment of Arizona’s first mental health court 10 years ago to new initiatives that quickly identify and mobilize therapeutic and peer support for CPSA members who have been arrested.CPSA works closely with both the adult and the juvenile justice systems to ensure appropriate diversion,coordinate treatment during incarceration, and plan for continued services after release. Collaboration with criminal justice and other govern- ment systems is built into CPSA’s structure and op- erations. CPSA is a nonprofit, community-based man- aged care organization created 15 years ago by local stakeholders to administer public behavioral health services in five southern Arizona counties. CPSA now oversees these services for more than 1.2 million people. CPSA’s community roots and ability to rein- vest cost savings into services allow it to respond to emerging needs, including the creation of teams that focus on support services such as housing, employ- ment, and wellness. The seven-person criminal justice team is an im- portant part of CPSA’s holistic effort to reintegrate members into the community, maintaining a collabo- ration with law enforcement and courts that benefits all partners.The CJT will be presented with the 2010 SAMHSA’s Center for Mental Health Services National GAINS Center Impact Award at the GAINS national conference in March 2010. This award recognizes programs doing outstanding work in criminal justice and mental health services for adults. CPSA formed the CJT in 1999 as a result of a work- group of behavioral health and criminal justice staff in Tucson/Pima County that sought to identify systemic strategies to decrease the time that a person with mental illness is inappropriately incarcerated. CPSA began mandating that its contracted Comprehensive Service Providers, which coordinate care and provide direct behavioral health services, hire criminal justice specialists to help resolve system-wide and member- specific issues. An ongoing forensic task force also grew out of the workgroup.This collaboration resulted in the development of relationships, processes, and tools that allow timely identification of CPSA members who have been arrested and appropriate, real-time information sharing that protects member confiden- tiality. CPSA’s CJT staff check county booking lists against membership information twice a day. Staff alert the member’s assigned CSP of an arrest and ensure that treatment is coordinated with the jail’s behavioral health treatment provider. Staff from the CSP visit the member in jail within 72 hours of arrest notification, 7 days before the member’s adjudication or hear- ing, and every 30 days thereafter. CPSA, the CSP, and medical personnel from the jail hold staff meetings on select cases each week. On any given day, the CJT monitors 250–300 mem- bers detained in jail and as many as 800 members throughout the criminal justice system.Approximately 65 members are diverted from jail each month as the result of the CJT program, via mental health court or other means,resulting in approximately 17 fewer days of incarceration per member — a savings of more than $84,000 each month. In December 2008, CPSA initiated an effort to ensure CJT representation at its members’ initial court ap- pearances, to help divert these members before jail detention and quickly connect them with community treatment services. This initial appearance compo- nent has significantly decreased the likelihood of incarceration for CPSA members. At initial appearances, the judge informs the member of the charges and determines conditions of release. CJT staff are prepared to obtain the member’s signa- ture on a universal consent form for information shar- ing, assess the member’s ability to transport him- or herself home and to treatment, and share informa- tion with pretrial services and the presiding judge.For people who are eligible but not yet enrolled in the public behavioral health system, CJT staff facilitate enrollment and oversee timely contact with a treat- ment provider. When the member is too unstable to safely leave the jail on his or her own,staff coordinate pickup by a treatment provider or shelter. The initial appearance component has resulted in an approximately 60 percent decrease in the likelihood that a CPSA member will be detained in custody.The approximate number of members remanded for jail time in the component’s first year dropped from 40 per month to 24 per month.This trend has continued in subsequent months. In 2009,CPSA began a peer mentor program in Pima County. In this program, members who graduate from superior mental health court receive extensive train- ing and coaching so they can help incarcerated mem- bers navigate the behavioral health and criminal jus- tice systems. CPSA’s CJT has also provided technical assistance to and become a stakeholder in the newly implemented Veterans Court in Tucson City Court. Success in Tucson/Pima County has led CPSA to establish six more mental health court collaborations across its region. The initial appearance component will be expanded as funding is available. Neal Cash, MS, President and CEO, and Kate K.V. Lawson, MPA, Criminal Justice Manager — Community Partnership of Southern Arizona, Tucson,AZ / CPSA’s Criminal Justice Team Stay in Touch to Reduce Incarceration The Criminal Justice Team diverts approximately 65 members from jail and results in approximately 17 fewer days of incarceration per member — a savings of more than $84,000 each month.
  • 39. From The Field 42 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Shirley Havenga, MA, MPA, CEO, Community Psychiatric Clinic, Seattle,WA / At Community Psychiatric Clinic, Integrated Funding Stream Facilitates Comprehensive Care In 2003,Community Psychiatry Clinic developed its IMPACT program, one of the first co-occurring dis- order programs in the region, providing integrated mental health and chemical dependency services using a single funding source. IMPACT was one of the first programs funded by King County’s Criminal Justice Initiative, which created multiple programs focused on developing alternatives to incarceration and is funded through both the county and state. IMPACT provides services to people referred by sev- eral local mental health and drug diversion court programs. Clients are enrolled in IMPACT for up to 12 months before transitioning to the regular men- tal health treatment provider network for ongoing services. IMPACT serves approximately 100 people annually. The IMPACT program provides evidence-based in- tegrated treatment services, including Integrated Dual-Disorder Treatment and Moral Reconation Therapy for adults with co-occurring mental health and chemical dependency disorders and a history of incarceration. IDDT has been shown to reduce hospitalization, homelessness, and incarceration and improve employment outcomes over time. MRT focuses on changing behavior and personality with a systematic,12-step treatment approach aimed at re-educating clients socially, morally, and behavior- ally and assisting them in developing appropriate values, goals, and motivation. An intensive case management model is strengthened by small case- load size, team-based services, and assertive out- reach to promote client engagement. Program staff include chemical dependency professionals and mental health professionals. Beginning in 2010, the IMPACT program will also include a boundary spanner position to serve as the liaison between the criminal justice system and the treatment team. Coordination with the criminal justice system, com- munity providers, landlords, and family members is a key program component that aids clients in achieving treatment recovery goals and avoiding further incarceration. Staff have developed solid relationships with local resources — housing agents to assist in securing housing for clients who may have significant difficulty with this because of their criminal history; jail health services staff to promote continuity of care for inmates preparing for release, particularly for medication maintenance; court staff to help clients remain in compliance with court orders, and others. In addition, IMPACT staff col- laborate with the State of Washington Department of Corrections in cases in which the client is adju- dicated on a felony and is now on DOC community supervision (state form of probation) for ongoing compliance with DOC sanctions. “One of the most effective components of the IM- PACT program has been the ability to operate with a single funding stream, rather than the traditional siloed mental health and chemical dependency funding sources,” says Shirley Havenga, CPC’s CEO. Other helpful program components have included access to CPC’s extensive housing resources for people with mental illness and funds to assist cli- ents with securing housing; offering intensive treat- ment groups, peer support services, involvement with AA meetings, and individual sessions to help gear clients toward success; and close coordination of treatment with courts and probation. Data from the first 4 years of the program demon- strate that clients have significant reductions in substance abuse when discharged from the pro- gram. Clients showed this reduction irrespective of the referral source. In years 1, 2, 3, and 4 regarding specialty court–referred clients 47 percent, 34 per- cent, 44 percent, and 44 percent, respectively, of clients reduced to ≤1 use per week; in years 1 and 2 regarding King County Jail referrals, 29 percent and 47 percent, respectively, of clients reduced to ≤1 use per week). Tanya Howard, Services Director, Chrysalis Center, Hartford, CT / Chrysalis’ Employment Support Network Improves Job Prospects for Ex-Offenders Chrysalis Center has provided employment servic- es since the mid-1980s.The State of Connecticut DepartmentofMentalHealthandAddictionServices has funded Chrysalis Center to provide the Employ- ment and Recovery Network, an outcomes-driven employment support service for people with mental illness, substance abuse history, or both. The new Employment Support Network began operations in summer 2009,providing a full range of employment services for parolees, many of whom struggle with mental illness, substance abuse, or both. ESN staff include a services director, three employ- ment specialists,and two job developers.Staff have diverse prior work experience, representing criminal justice, behavioral health, employment, and educa- tion. Employment specialists work with participants to assess strengths and deficits, determine career interests, and help develop individual service plans Coordination with the criminal justice system, community providers, landlords, and family members aids clients in achiev- ing treatment recovery goals and avoiding further incarceration.
  • 40. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 43 to help participants work toward their goals. Staff link participants to additional training and education and to appropriate community supports. Staff focus on addressing the needs of the whole person, not just the employment component. They help participants gain access to housing, behavioral health treatment, support groups, legal assistance, driver’s license or identification, child care, and more to help them suc- ceed. Staff counsel people that despite their illness, disability, or life circumstance, each brings with them a host of strengths,experiences,and skills to build on. Job developers work in the community to introduce Chrysalis Center and its services to potential employ- ers and educate them about hiring ex-offenders. Staff work to persuade employers to give an opportunity to ex-offenders and assure employers that partici- pants will continue to receive the supports they need to maintain employment. Job developers make their case by informing employers about tax credits avail- able to businesses that hire people with a criminal background. In addition, they cite research demon- strating that employment is a key factor in reducing recidivism. They emphasize that ex-offenders being employed and paying taxes is of greater benefit to the local economy and to society. Job developers and employment specialists conduct intensive counseling with clients so they are confident when they interview with a potential employer. Staff conduct mock interviews, set up appointments for clients, and drive them to interviews as needed.They assist each person with developing an explanation letter for potential employers,addressing the person’s felony and his or her subsequent remorse and reha- bilitation. Staff provide supports for a maximum of 120 days while participants are on parole. “Some clients walk through the door ready for em- ployment,while others are in need of training,motiva- tion,and other supports,”saysTanna Howard,services director for the project.“We arm clients with the tools they need for success by providing a number of train- ing programs in-house, and linking clients to other services that meet their needs. We make sure par- ticipants understand that gaining employment is their responsibility, and that we are here to support them.” Although ESN is designed to serve 300 participants each year, the project has served more than 200 ex- offenders in its first 4 months of operation. Staff work closely with both parole officers and participants to ensure a successful outcome for each person served. To date, 50 participants have gained employment. Because of their own life experiences, many partici- pants have a strong desire to work with people in recovery from mental illness or substance abuse.Two have completed the Recovery CoachAcademy with the Connecticut Community for Addiction Recovery. One has graduated from the Connecticut Department of Mental Health and Addiction Service’s Recovery Uni- versity, and two are working toward degrees in drug and alcohol counseling. Howard attributes the project’s early success to four factors: employer education, a strong relationship with parole officers, the diversity of experience and passion of ESN staff, and ongoing collaboration with other community providers and stakeholders. Mental illnesses are complicated You probably know someone who has one Your Partners In Mental WellnessYour Partners In Mental Wellness To learn more visitTo learn more visit who has onewho has one complicatedcomplicated
  • 41. From The Field 44 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Ellen M. Healion, MA, Executive Director, Hands Across Long Island, Inc., Central Islip, NY / At Hands Across Long Island, Peers Follow People from Prison to the Community HandsAcross Long Island,a peer-run organization that has been operating for more than 21 years, supports people with severe and persistent mental illness in the criminal justice system. It is not easy for mental health providers to gain ac- cess to the criminal justice system,given safety con- cerns. New York State has led the way to a solution by providing mental health services in a separate unit of Sing Sing Prison in Ossining. HALI has been part of this program since 2002,in addition to work- ing in the county jail.The goals of this program are to prepare inmates for the changes that have taken place in the community since their incarceration; develop their interview skills with respect to parole, housing, and other practitioners; and develop new coping skills to help them remain in the community. It is imperative that inmates understand that the coping skills they’ve acquired in prison or jail will not be an asset to them in the community. Because HALI staff have“been there,done that”and work with inmates for 3 months, they develop posi- tive, trusting relationships. Next, staff help to bridge inmates from prison to the community. Staff meet inmates at the gate on the day of release and ac- company them to parole and a meeting with their case manager and then to a shelter for the evening. To date, no housing programs have been developed to accept inmates on release; therefore,shelters are necessary for approximately 2 weeks to verify home- lessness. To facilitate the transition to the commu- nity, staff continue working with a participant for another three months. A drop-in center was developed to offer support to those people who have completed the program and want continued support.The center is open on “reporting day,” just around the corner from parole. If someone has dropped off the radar, chances are that they can be found at parole on their reporting day.The center also provides a place where people can touch base with the staff who worked with them in prison and with whom they have a relationship. This center required permission of the Parole De- partment to allow felons to congregate as most fel- ons are prohibited from being with other felons. The New York State Office of Mental Health has re- ported that since the inception of these services, the recidivism rate has dropped significantly. On Long Island, HALI recognized the needs of peo- ple being released to the county from prison and from the local jail. In collaboration with the Suffolk County Re-Entry Task Force, HALI developed a Re- Entry House Pilot project to fill a major gap in the recovery process — housing. With a grant from the Department of Criminal Jus- tice and HALI funds, we were able to create an in- tensive program and establish housing.We can ac- commodate four people at any given time.Attached to the house is a studio apartment in which a staff person resides and provides emergency response for the residents. We help people develop routines and attitudes helpful for community integration. The program initially provides intensive supervision and then lifts restrictions as appropriate. Staff ar- rive at the house every morning, inspect the house, and make sure residents are ready before they are transported to their program or appointments. By 3:30 pm, residents are picked up from their work and brought back to the house where they have time for dinner and chores before they head out for a community-based 12-step program (AA or NA). Staff stay with them through the meeting to coach them to participate,meet people,and integrate into the community. They typically return to the house around 10:00 pm. On weekends, staff accompany residents to the grocery store and other errands, and residents participate in some form of exercise and recreation. The goal is to teach the residents how to live a full life in recovery.For many,this is an exhausting process — life in jail or prison is certainly not filled with activity. When the staff and the resident together feel that he or she is ready to have more responsibility,unsuper- vised activities are planned that also take into con- sideration conditions of parole or probation. During this phase, the resident is given more and more freedoms with frequent drug testing, verification of planned activities, and so forth. In addition, plan- ning is done for after the resident graduates from the program. Applications for housing programs, employment programs, recovery programs, and the like are prepared and submitted to the appropri- ate agencies. Although providers, employers, and schools may be hesitant to accept a parolee’s ap- plication, a graduation certificate from the re-entry program provides supporting documentation that attests to the person’s efforts to change his or her life.HALI can also directly communicate with provid- ers to help with their acceptance of the parolee. People with mental illness require intense assis- tance to succeed in returning to the community from prison. HALI gives them the opportunity to live on the outside with others who have done the same and not only survived but created a life worth living. Twenty-eight people from Sing Sing and Suffolk County Jail have crossed our threshold. Of these, 22 are employed or going to school, have reunited with their family, have started a family of their own, or live independently or in a supported housing program — their names line the wall at the re-entry house to give hope to newcomers. Staff help inmates understand that the coping skills they’ve acquired in prison or jail will not be an asset to them outside and work with them after release to support transition to the community.
  • 42. Operating premier mental health crisis response systems for over a decade Including: Mobile crisis teams (both police-based and clinician-based models) 365/24/7 call centers Urgent care centers In-home and family intervention teams CISM Hospital and jail diversion Assisting over 3 million residents during times of crisis For more information about our services and capacities please contact Fred Chanteau at
  • 43. From The Field 46 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Elaine Cooper, MEd, LPC, NCC, Mental Health Therapist, John Eachon Re-Entry Program, Lakewood, CO / John Eachon Re-Entry Program Focuses on Intensive Therapeutic Services The John Eachon Re-Entry Program serves offend- ers who are eligible for community placement or parole. JERP offers intensive residential and nonresidential treatment for offenders with serious mental illnesses and substance abuse disorders. JERP is a collaboration between four major entities: the Colorado Department of Corrections, Jefferson Center for Mental Health (serving Jefferson, Gilpin, and Clear Creek Counties), Intervention Community Correction Services, and Jefferson County Justice Services Division of Criminal Justice Department of Public Safety. Early planning and collaboration began in September 2003, and with a grant from the Bureau of Justice Assistance, doors opened in November 2005. On July 1, 2005, JERP began re- ceiving state funding. The goals and objectives of JERP are to: >> Integrate correctional supervision with community re-entry, mental health treatment, substance abuse treatment, vocational rehabili- tation (education and employment), and social services (housing, benefits, family resources). >> Increase mental health functioning and prosocial behavior. >> Decrease psychiatric hospitalizations (or returns to DOC resulting from psychiatric emergencies or decompensation). >> Increase medication compliance. >> Reduce technical violations and new criminal offenses. >> Reduce community corrections placement failures. Our mission is to offer intensive therapeutic servic- es (individual and group therapy, psychiatric care, medication monitoring) to meet program goals for offenders with co-occurring disorders. Typical diag- noses treated include major depression, bipolar disorder, schizophrenia, schizoaffective disorder, substance abuse disorders, personality disorders, attention deficit hyperactivity disorder, and post- traumatic stress disorder. Much-needed mental health treatment helps to reduce recidivism. While in the JERP program, the clients are able to take part in many Jefferson Center services and programs, including additional group therapy; a wellness program; assistance with transition to other housing; benefits application assistance; peer mentoring and counseling; and case manage- ment to assist in obtaining employment, education, transportation, and other services. A JERP participants remains in the residential pro- gram at ICCS until he or she is deemed ready for nonresidential placement — transition to Jefferson Center housing or other community living.To ensure community readiness, the decision to transition from community corrections to the community is made by an interdisciplinary team of JERP clini- cians, nurse, and supervisor, as well as the ICCS clinical director and staff and the offender’s parole officer.Jefferson Center offers a continuum of hous- ing options to serve as transitional living opportuni- ties for clients who are working to eventually obtain independent living within the community. After completing services at JERP’s inpatient site, clients are offered housing through other Jefferson Center programs or within the community. Clients continue attending weekly individual and group therapy, as well as other therapeutic services.Also, offenders may be able to move from the residen- tial program site at ICCS to other approved living arrangements, such as with family or independent living, with the approval of their parole officer and the JERP team. Jefferson Center offers mental health treatment ser- vices that range from intensive residential services through general outpatient therapy or medication management, and JERP clients are encouraged to maintain services with Jefferson Center even after completion of the JERP program, parole, or both. Preliminary statistics indicate a significant de- crease in JERP clients’ recidivism rate (2–3 times less) compared with that of severe and persistently mentally ill substance-abusing offenders who re- ceive no treatment. The JERP program has identified specific criminogenic factors of severe and persistently mentally ill substance-abusing offenders — focusing on these factors supports recovery and lowers recidivism. Criminogenic factors include l Mental health l Criminal thinking l Antisocial companions l Antisocial personality or temperament l Substance abuse l Family and marital conflict (social supports) l Employment (social supports) l School (social supports) l Leisure and recreation (social supports) Criminogenic Factors
  • 44. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 47 David S. Lauterbach, ACSW, President & CEO,The Kent Center,Warwick, RI / Kent Center’s Court Clinic Bridges Behavioral Health and Criminal Justice Systems Rhode Island — the smallest state in the nation — is not immune to the personal, social, and financial ramifications of the inappropriate incarceration of people with behavioral health challenges. Greater awareness of this issue has slowly come to the fore- front,and one way in which Rhode Island has success- fully prevented many inappropriate incarcerations in favor of treatment is through The Kent Center’s Court Clinic Program. In 1999, the Rhode Island Department of Mental Health, Retardation and Hospitals provided funding to The Kent Center to establish the first court clinic in Rhode Island at the Kent County District Court. Since the program’s inception, we have assisted nearly 2,500 people with outcomes that include diversion from jail,placement in treatment,dropped or reduced charges, and reduced court fees. We have also as- sisted family members by educating them about what happens in court and by referring them to community resources. The Kent Center employs a full-time master’s-level cli- nician whose primary work site is the courthouse.The clinician is present during court hours and is imme- diately available to the judges should they request an assessment of a person who comes before the court. The clinician assesses the person’s behavioral health needs, makes treatment recommendations, and pro- vides follow-up information regarding the person’s compliance with court orders. The prosecuting and defense attorneys, police, family members, or defen- dants themselves may also request an assessment. Our court clinician assesses the person for mental health issues, substance disorders and a history of trauma.The clinician uses the guidelines of a trauma- informed intervention model when making an assess- ment. The clinician — employed by The Kent Center and not the court — serves as an independent and ob- jective advocate. This arrangement fosters significant trust between the clinician and clients and families. Equally as important to the program’s success are the relationships developed over several years between the Kent Center’s court clinician — and, by extension, the Kent Center’s Emergency Services team of which she or he is a member — and all segments of the criminal justice system.We realized early on that one key to success would be a receptive judiciary. One judge in particular,Judge Stephen Erickson,assuaged all concerns. Judge Erickson has a track record of working with people struggling with mental illness and addictive disorders and supported a clinician in the court from the start. Other judges have quickly become supportive as well.A strong rapport has also been established between the court clinician and the prosecution teams of the towns and cities served at the Kent County Court, as well as between the court clinician and police departments. The clinician’s knowledge of the roles of each segment of the crimi- nal justice system, appreciation for the unique cul- tures of all agencies involved,and flexible approach to problem-solving has helped to create an atmosphere of mutual respect between the behavioral health and criminal justice systems in Kent County. One of the most positive outcomes of the Court Clinic Program is the impact it has had on the relationship between the criminal justice system — in particular police departments — and the Kent Center’s 24/7 Emergency Services Department. The court clinician acts as a consultant to police in handling emergency encounters with people in crisis and trains police officers from across the county and state in how to handle emergency encounters with people present- ing with behavioral health symptoms. She is often the point person for police and is called on at any time of day to assist with emergency situations. In turn, she calls in other members of the emergency services team to assist. The relationship between the Kent Center and the criminal justice system continues to grow. Working together, we will divert many more people struggling with behavioral health challenges from inappropriate involvement with the criminal justice system into treat- ment, in order to provide cost savings and the best outcomes for individuals, families, and communities. Before 2006, a young man like JT might not have had much of a chance of escaping his revolving cycle of depression, substance abuse, and repeated incarcerations for multiple misdemeanor violations in the city and county of Denver. Thanks to Court to Community (C2C),a collaborative program of Denver’s criminal justice system and community mental health and service agencies,JT has made dramatic strides in his recovery and hasn’t had a single legal infraction since entering the program. C2C, a jail diversion program, grew out of the vision of the Denver Crime Prevention and Control Commission, Kristi Mock, MSW, LCSW, Adult Recovery Services Director, and Jay Flynn, JD, Deputy Director of Adult Recovery Services — Mental Health Center of Denver, Denver, CO / Mental Health Center of Denver’s Court to Community Program Gets Results The court clinician’s flexible approach to problem solving has helped to create an atmosphere of mutual respect between the behavioral health and criminal justice systems in Kent County.
  • 45. From The Field 48 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 with the mission of creating a flexible and respon- sive system to serve and manage municipal ordi- nance offenders with serious and persistent mental illness. Now entering its fourth year, C2C has proven to be an enormous success for Denver, both in out- comes for its participants and in demonstrating a successful system of cooperation and collaboration between mental health providers and the criminal justice system. With services provided by the Mental Health Center of Denver and the Colorado Coalition for the Home- less, the program serves at least 36 adults at any given time, connecting consumers to court-ordered mental health treatment, substance abuse services, and housing and social support assistance.The pro- gram is funded by the city and county of Denver and the Colorado Health Foundation. C2C’s initial goals included reducing arrests and incarcerations of people with serious and persistent mental health issues by 25 percent. Over the pro- gram’s first year,an 87 percent drop was seen in the cumulative arrest rate. The cumulative number of days spent in jail dropped by 80 percent compared with the year before admission. It is estimated that 5 years after completion, the program saves $3.50 for every dollar spent on a consumer. The program has also shown reductions in psychiatric admis- sions, the need for detoxification services, and sub- stance abuse. C2C uses Assertive Community Treatment in a novel way by providing a clinically sound process for graduating consumers to lower service levels while maintaining their progress in recovery, allowing the C2C team to serve more consumers than with a traditional ACT approach. MHCD also provides integrated dual-disorders treatment and access to dialectic behavioral therapy and trauma recovery empowerment model groups when indicated. Pro- gramming and outcomes are evaluated, monitored, and improved on using sophisticated measurement methods developed by MHCD’s Department of Out- comes and Evaluation. At first, C2C was met with skepticism. According to MHCD Deputy Director of Adult Recovery Services Jay Flynn, the greatest obstacle was the criminal justice system’s initial lack of trust and reluctance to allow consumers to join the program. “It took a lot of communication and collaboration to help the city attorney’s office feel comfortable that people could succeed in the program and not commit fur- ther crimes,” explains Flynn. As a result of C2C’s success, Denver now has a mental health court docket and a judge dedicated to strict review and oversight of consumer partici- pation and progress. The program has made sig- nificant contributions to promoting mental health literacy within the criminal justice system and has provided ample evidence that mental health treat- ment can be cost effective in reducing the use of public funds. C2C’s demonstrated effectiveness has led to a collaborative effort to seek funds to sustain and expand the program. Denver Judge Larry Bohn- ing, who oversees Denver’s weekly mental health docket, was an early skeptic. “Now I’m convinced we’re doing some good,”he says.“We could use 300 more slots.” C2C has been and continues to be a model for the development of a number of similar programs and partnerships targeted at reducing the skyrocketing number of people with severe mental illness, co- occurring substance abuse disorders, and trauma in Denver who are involved in the criminal justice system. Steve Moore, Chief of Police, Hurst Police Department, Fort Worth,TX; Ken Bennett, LCSW, and Courtney Janes, LPC-I, CART — MHMR Tarrant County, Fort Worth,TX / Tarrant County’s Mental Health Law Liaison Project Is On 24/7 MHMR’s Mental Health Law Liaison Project is a jail diversion program that works with all law enforcement agencies in Tarrant County. Program funding is provided by Tarrant County Commission- ers Court and a federal justice assistance grant.The goal is to slow down the “reinstitutionalization” of people with mental illness in prison by diverting them to services appropriate to their needs. The project answers officers’ calls 24/7, to help as- sess the clients’ condition and recommend treat- ment services. Follow-ups include consultation with officers on the phone and at the scene to determine the most appropriate action to take. MHMR also advocates for clients by training officers at local police departments, sheriffs’ departments, and po- lice academies on how to interact with people with mental illness. These trainings include the Mental Health Peace Officers Course, crisis intervention training, and other specialized mental health train- ings on request. On April 11, 2003, the Hurst Police Department re- sponded to a shooting at a condominium complex in the southeast portion of the city. At the scene, the witnesses relayed to officers that a 78-year- old woman, Ms. Locke, had been making threats against another resident in the complex, Ms. Porter. Ms. Porter died of a single gunshot wound inflicted by Ms. Locke. It was discovered that Ms. Locke had been making threats against Ms. Porter because she believed Ms. Porter was having a relationship with a man in Virginia who Ms. Locke believed was her boyfriend. No such relationship actually existed. During the investigation, the department found that they had dealt with Ms. Locke on a couple of occa- sions when she had made threats against city rec- reation staff. The department also discovered that Ms.Locke had been arrested in 1982 for attempted murder and that the case was dismissed for rea- son of insanity. Subsequently, a Tarrant County jury Over the C2C program’s first year, an 87 percent drop was seen in the cumulative arrest rate. It is estimated that 5 years after completion, the program saves $3.50 for every dollar spent on a consumer.
  • 46. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 49 found Ms. Locke incompetent to stand trial for the 2003 murder, and she was sent to the Vernon State Hospital. The Hurst Police Department comes into contact with an increasing number of citizens with mental health issues.Officersoftendealwithfamilymemberswhore- port how well these citizens are when they are on their medication; however,many stop taking their medicine when they feel they are doing better.The Hurst Police Department is unable to solve many of these mental health issues without the assistance of mental health professionals. So, the department started looking for a way to be more proactive and preventive in dealing with clients with mental illness. A proactive approach to dealing with people with mental illness has been partnering with the MHMR Mental Health Law Liaison Project. The Hurst Police Department and the Law Liaison Project have been able to work closely together to identify people in the community with mental health issues and coordinate the appropriate treatment services. This partnership has facilitated effective communication in crisis situ- ations, which has resulted in better outcomes in the community. The partnership also has been instru- mental in reducing calls for services, thus leading to decreased costs for the department. By working together to identify people with special needs early in the process, we’ve been able to decrease the num- ber of people going to hospital or jail and to increase public, officer, and client safety. The Hurst Police Department has created a protocol withinitsagencytoensurethattheproperdocumenta- tion is completed and forwarded to the Mental Health Law Liaison Project.Once this information is received, the Law Liaison Project attempts to follow up with the client to determine the best course of action.The Law Liaison Project also completes follow-ups by riding with trained mental health peace officers and has one designated mental health peace officer who com- municates regularly with MHMR to discuss the status of clients with mental illness within the community.A high percentage of contacts made by the Hurst Police Department and MHMR are health wellness checks to reduce emergency detentions. The Law Liaison Project is also a part of the hostage negotiation team and provides technical assistance to negotiators to make a good diagnostic impression and to determine the best course of action in a cri- sis situation.As a result of the successful partnership between MHMR and the Hurst Police Department,the program has grown exponentially. This proactive ap- proach has been implemented by five departments in Northeast Tarrant County, which include Euless, Bed- ford, Richland Hills, North Richland Hills, and Haltom City Police Departments. In 1998, in an effort to decriminalize people with mental illness and move defendants from jail into treatment, Bibb County law enforcement joined River Edge Behavioral Health Center and other community partners to begin a forensic social services program. In the early days, officers brought inmates of the 930- bed Bibb Law Enforcement Center with significant is- sues to a River Edge site for evaluation. Eventually, River Edge began sending an evaluator to the LEC for at-risk inmates because bringing the inmates to the River Edge facility was deemed expensive, time- consuming, and embarrassing to inmates. River Edge also began providing licensed staff to be available on weekends and holidays for emergency evaluations, along with a psychiatrist who could prescribe medi- cations. Through a contract with Bibb County Government, fi- nancial contribution by River Edge Behavioral Health Center, and donated office space and computer in the LEC, River Edge now provides a full-time licensed clinical social worker, a part-time psychiatrist, and two (male and female) certified addiction counselors available 24/7, on call and onsite. Services provided include case management, psychiatric services, eval- uations, medication management, brief intervention groups for addiction, therapy groups, skills training, parenting classes, and discharge planning. With the sheriff’s financial and political support, the Bibb County LEC has significantly decreased inmates’ assaults on other inmates or staff and suicide at- tempts or referrals for psychiatric hospitalization. During the past fiscal year, only 1 percent of the jail population assaulted another inmate and only nine inmates attempted assaults on staff. In fiscal years 2007, 2008, and 2009, the Bibb County jail had no suicides or referrals for psychiatric hospitalization. Among inmates with ongoing access to treatment and supportive services on release, the rate of recidivism is far lower than average. In 2005, River Edge, the National Alliance on Mental Illness, and the Bibb County sheriff’s office teamed up Tiffany M. Russell, Community Affairs Manager, and Shannon T. Harvey, LCSW, CEO — River Edge Behavioral Health Center, Macon, GA River Edge Combines Services and Training to Lower Recidivism From FY 2007-2009, the Bibb County jail had no suicides or referrals for psychiatric hospitalization. Among inmates with ongoing access to treatment and supportive services on release, the rate of recidivism is far lower than average. By identifying people with special needs early in the process, we’ve been able to decrease the number of people going to hospital or jail and to increase public, officer, and client safety.
  • 47. From The Field 50 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 to provide crisis intervention training to teach pub- lic safety officers and first responders how to more therapeutically intervene with individuals or families experiencing a mental health crisis. In April 2007, a mental health court was initiated in Bibb Superior Court. Persons charged with either a misdemeanor or a felony may participate in the mental health court; however, those charged with homicide or sex crimes cannot yet be served. After an initial referral from jail staff,the defense attorney, LEC medical staff, or the inmate, an assessment for clinical appropriateness is completed. If a referral is received pre-adjudication, most charges can be dropped on graduation from mental health court. If a referral is received from a probation officer, in- mates can be sentenced to program participation. Accordingly, the court can serve both as pretrial di- version and in lieu of incarceration, saving taxpayer dollars on jail beds — approximately $52.00 per inmate bed per day. Referrals are reviewed by the mental health court team, which includes the assistant district attorney, representatives from state and federal probation, the Department of Family and Children Services, River Edge, and the public defender’s office. Once a referral is accepted, the participant is assigned a case manager who works with him or her to deter- mine treatment and resource support needs. It is important to note that mental health court partici- pants receive intensive court supervision, including reporting their progress to the judge every other Thursday. People served typically enter services homeless and quite ill psychiatrically; therefore, program services and monitoring are usually con- tinued for 12–16 months before graduation. Gradu- ates can receive additional services and aftercare. The Bibb County mental health court has been enor- mously successful; the number of graduates has doubled at each graduation. Graduates have only a 1 percent rate of rearrest. Program success can be attributed to visionary leadership and consis- tent,strong collaboration between law enforcement, health professionals, and other supportive services. With more than 30 percent of the population in- carcerated in the Bibb County jail currently entering the facility with a diagnosable mental illness, the need for services is huge. Funding for medication, psychiatric time, and additional supportive services — especially case management and transitional housing with watchful oversight — has been the lim- iting factor in mental health court expansion. It is projected that with the addition of these services, hundreds more could be served and recidivism cut by an additional 20 percent. Mary Hargrave, PhD, CEO, and Stephanie Parmely, PhD, Director MST, River Oak Center for Children, Carmichael, CA River Oak Center Helps Youth on Probation through Multisystemic Therapy River Oak Center for Children adopted the Mul- tisystemic Therapy program in 2003 to address unmet needs for youths in probation with mental health and substance abuse issues. MST is an evidence-based program known to reduce out-of- home placement, criminal behavior, and substance abuse among youths ages 10–17 years. MST works by assessing the multiple systems that contribute to the client’s behaviors and works through the key stakeholders within those systems (parents being the most significant) to increase structure, limit setting, monitoring, warmth, and prosocial peer activities. In Sacramento,CA,MST services are funded through probation grants and mental health funding. Each therapist works intensively with four to six families at a time.Services include 24/7 availability and two to three sessions weekly provided in the home,com- munity,school,and neighborhood to make systemic changes. To ensure quality feedback and maintain model fidelity,staff are required to submit to super- vision, weekly case summaries that include clients’ overarching goals, previous weekly goals, advances toward and barriers to those goals, assessments regarding what has contributed to any problems or successes that week, and new goals for the week ahead. In the weekly supervision group, staff are re- quired to discuss every case.After supervision,there is a weekly consultation group with an MST consul- tant. Each client completes a monthly evaluation of the therapist, and therapists complete evaluations of their supervisor to ensure fidelity. MST is rooted in family systems approaches and cognitive–behavioral, parent management, and solution-focused theories. No intervention is pro- vided until a thorough assessment or sequence of the problem is established with the family, thus en- suring that the therapist avoids a one-size-fits-all approach and encouraging family awareness and participation in the development of interventions. With substance abuse, the therapist does a func- tional assessment with the child and family looking at (a) systemic triggers for the substance use, (b) positive and negative effects of using, and (c) after- effects of use. Research indicates common triggers for youths include parents who use, family conflict, low monitoring, ineffective discipline, peers who use, lack of prosocial activities, truancy, pleasure or escape,boredom,low social support,and perceived benefits of using. With this information, staff work to help the family reduce these triggers, increase positive coping skills, and involve youths in proso- cial activities in which exposure to substance-using peers decreases. The June 2007–June 30,2008,Mentally Ill Offender Crime Reduction Outcome Report reflected River Of youth in the multisytemic therapy program, 93 percent were in school or working and 70 percent showed success in an educational or vocational setting.
  • 48. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 51 Oak client outcomes as follows: >> 6.6 times fewer petitions filed for new law viola- tions (111 days for historical group vs. 18 days). >> 6.9 times fewer sustained new law violations (62 historical vs. 9). >> 6.5 times fewer commits to juvenile hall, ranch, or camp (13 historical vs. 2). >> Fewer days detained in a juvenile hall, ranch, or camp (323 historical vs. 23). >> Three out-of-home placements (vs. 8 historical). >> One admission to an acute psychiatric hospital (vs. 18 people in the historical group with a total of 24 admissions). >> More minors attending school and more days attended (5 of 71). >> No petitions filed or sustained for status offenses (vs. 14 filed and 0 sustained historical). >> 6.1 times fewer people made WIC 602 wards of the juvenile court (43 historical vs. 7). MST outcome data for the same period showed the following: >> 73 percent completed treatment. >> 88 percent showed parenting skills necessary to handle future problems. >> 84 percent showed improved family relations. >> 80 percent showed improved social support networks. >> 93 percent were in school or working. >> 70 percent showed success in an educational or vocational setting. >> 48 percent of youths were involved in prosocial activity. During the time River Oak has been using MST, we’ve learned that: >> With quality supervision, there is high motivation and competence and prevention of burnout among quality staff. >> With quality staff that fit a systemic approach, there are quality outcomes for families. >> With quality outcomes for families, there is support for the program. >> With support for the program, there is funding. >> With funding and quality outcomes, there are fewer clients that fill up our juvenile halls, ranches, and group homes. >> With fewer clients in facilities, there is more money to fund quality programs. Launched in May 2008, Seacoast Mental Health Center’s Community Wellness Court in Portsmouth, New Hampshire, seeks to rehabilitate people charged with crimes who have severe and persistent mental illness. The result of a year-long coordinated planning pro- cess, the program, which recently graduated its first class, involves SMHC, local police departments, the county jail, prosecutors, public defenders, and the court system. According to the director of SMHC’s Community Sup- port Program, Gretchen Estes, the collaborative na- ture of the CWC has been critical to its initial success. “A lot of cross-education has taken place,” says Estes. “It was important [that] we shared our knowledge — they have learned a great deal about how we operate and we have learned how the legal system works. It’s improved the program.” Portsmouth District Judge Sawako Gardner agrees and says the program originated from their initial effort to deal with crimes perpetrated by the city’s homeless population. “We realized pretty quickly the problem was also combined with mental illness so the idea started from there,”says Judge Gardner,who also cited the efforts of Al Wright, superintendent of the Rockingham County House of Corrections, and Mike Magnant, retired Portsmouth police chief, as crucial to CWC’s development. “Without that sort of collab- orative effort, we wouldn’t be in existence,” Judge Gardner added. Offering case management,psychiatric,and therapeu- tic services in addition to vocational and educational supports, the CWC program is based on evidence- based practices found in illness management and recovery and supported employment principles. SMHC’s Debra Braun, team leader for the Intensive Treatment Team within CSP, supervises the program and says its objective is to help participants, more than half of whom have co-occurring substance abuse issues, acquire tangible skills they may use to sta- bilize themselves. Responding to critics who suggest the alternative-sentencing program provides repeat offenders with a free pass, Braun says that CWC re- quires each participant to sign a 1-year contract and actively develop his or her own treatment plan.“It’s a lot of work,” states Braun, who says participants meet with their therapist and case manager at least once a week in addition to seeing a psychiatrist, nurses, and other appropriate personnel as necessary. Judge Gardner adds that she and the city’s public prosecutors and defenders also meet with program participants on a monthly basis to better understand their goals, circumstances, and any stressors in their lives.“The court has to be invested in the process and needs to connect with each participant,” she says. Judge Gardner also notes that the program has sig- nificantly improved the eligibility criteria needed to enter CWC. Rob Levey, MA, Development and Communications, Seacoast Mental Health Center, Portsmouth, NH / Seacoast’s Community Wellness Court Rehabilitates Persons with Serious Mental Illness The recidivism rate for program participants is below 15 percent, and the program has reduced crime on an individual basis and improved overall community safety.
  • 49. From The Field 52 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 “You have to be careful who you choose to be in the program,” said Judge Gardner, who points out that participants’ diagnosed mental illnesses must be deemed substantially responsible for causing the crimes. “It can’t just be that the person has committed a crime and they happen to have a mental illness,” she adds.“That wasn’t on our radar in the beginning of the program, but it is now.” As for program outcomes, the recidivism rate for program participants is below 15 percent, and Judge Gardner anecdotally notes that she believes CWC has reduced crime on an individual basis and has improved overall community safety. According to Portsmouth Prosecutor Karl Durand, participants have also been able to take away an immense amount of pride in themselves.“The court provides incentives for people to address their men- tal health problems that have caused them to react criminally,” he says. “Without this court, they would not have that opportunity. We need to provide in- centives for them to get therapy and be medication compliant.” CWC has also proved to be sustainable; as Estes says, it “works within established models already in place,” although she notes it could benefit from expansion, which would require additional outside funding sources. However, Judge Gardner says she believes the maximum capacity CWC can handle at one time is between 15 and 20 people and cautions against allowing the program to get too big. “We need to connect with participants individually,” she adds.“If the program was any bigger, I don’t think we could do that.” Lisa Rea, MA, LPC, Special Services Program Director, Spanish Peaks Mental Health Center, Pueblo, CO / Spanish Peaks Offers the Alternative to Incarceration — Treatment Beginning in July 2008, Spanish Peaks Mental Health Center in Pueblo, Colorado, received funding through Senate Bill 097 to create a multi- disciplinary community collaboration and to imple- ment programming to provide mental health and co-occurring substance abuse treatment to adult and juvenile offenders in the community.The center specifically enrolls people who would not otherwise have the means to access services.Its first goal was to develop a community collaboration that included leadership from SPMHC,the court,law enforcement, and other criminal justice agencies. We wanted to hear from everyone about how offenders with men- tal illness affect their agencies and how we might work together to divert these offenders into effective treatment rather than incarceration. The Treatment Alternatives Collaboration Program was created in October 2008. In partnership with seven of the area’s law enforcement and judicial and criminal justice agencies,we worked to develop our goals, objectives, and outcome measures and to create a Memorandum of Understanding.TheTAC Program Treatment Team began accepting referrals in October 2008 and is made up of three full-time staff — a mental health clinician,a substance abuse treatment specialist, and a case manager. We re- ceived more than 225 referrals during fiscal year 2008–2009.The TAC Program is able to serve up to 50 people.We offer outpatient individual and group mental health and co-occurring substance abuse treatment. The evidence-based practices that are available to all TAC Program clients, depending on their indi- vidual treatment needs, include Moral Reconation Therapy, Integrated Dual-Disorder Treatment /co- occurring treatment, Dialectical Behavior Therapy, and Assertive Community Treatment. SPMHC also provides comprehensive case management ser- vices that include referrals and linkage to housing resources,prescription assistance,employment and educational resources, and referrals to agencies to apply for any benefits for which clients may qualify. Once the treatment team and the programming were in place, our next goal was to identify and in- tercept offenders with mental illness and increase their access to community treatment. We used the sequential intercept model as a guide in developing our programs and protocols. Initially, it was difficult to decide at which point(s) in the criminal justice process we should try to identify and intercept of- fenders.To really understand our community needs, we elected to accept referrals from all points in the criminal justice system — from initial contact with law enforcement, to diversion in lieu of prosecution, to diversion at sentencing, to people re-entering the community from the jail or Department of Cor- rections. Though ambitious, this has allowed us to really tailor our interventions to our communities’ specific needs. Although theTAC Program has only been in existence for about 18 months, we are already seeing encour- aging outcomes, both clinically and with decreased recidivism — we define recidivism as any return to jail or DOC as a result of a new charge or conviction or revocation of probation or parole. We are also tracking potential cost savings because clients are sentenced to the TAC Program in lieu of sentenc- ing to Colorado DOC.These clients come to the TAC Program with suspended sentences. Between July 1, 2008, and June 30, 2009, the TAC Program served a total of 66 adult clients. In the 12 months preceding their enrollment in the TAC Program, these clients served a combined total of 5,191 jail or DOC days. During their admission to the TAC Program, they served a combined total of only 897 days,a decrease of 4,294 days.This trans- lates into a cost savings of $38,874 for the Pueblo County Jail and a savings of more than $300,000 for DOC. Additionally, between April 1, 2009, and December 1, 2009, the TAC Program accepted nine clients with combined suspended DOC sentences of 22.5 years. The potential cost savings associated with this is $582,480. Between April 1, 2009, and December 1, 2009, the TAC Program accepted nine clients with combined sentences of 22.5 years — the potential cost savings associated with this is $582,480.
  • 50. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 53 Julie Hanna, MSW, Research Assistant,WSU Project CARE, Detroit, MI / In Wayne County, Jail and Community-based Services Work in Tandem To address the issue of co-occurring substance use and mental health disorders in jails, staff from the Wayne County Jail, Detroit-Wayne County Community Mental Health Agency, Detroit Recovery Project, and Wayne State University Project CARE collaborated to form the Co-Occurring Peer Empowerment program.In 2006,WSU staff began facilitating meetings and dis- cussions among involved parties, researching existing models, writing the proposal to obtain block grant funding for the program, and obtaining Institutional Review Board approval from the university and from the jail. On the basis of research on existing models, the COPE Program was developed with three compo- nents: the APIC (Assess, Plan, Identify, Coordinate) model, Dual Recovery Anonymous, and peer support. COPE was implemented in September 2007 to en- hance existing jail-based services, with the mission of “Providing jail and community-based relapse and re- covery services for inmates with co-occurring disorders at the Wayne County Jail” and the goal of “Reducing relapse and the associated behaviors that contribute to the increase in mental health services, substance abuse, and the involvement in criminal activity that lead to recidivism and increased cost.” COPE provides a range of jail-based and community- based services. Initially, DRA groups were established twice a week inside the jail. In 2009, two groups a week were added at a second facility. Peer support specialists facilitate groups. The case manager does intake interviews with new participants, collecting in- formation for their case files and for program evalua- tion.In the community-based component,COPE offers re-entry assistance, DRA groups, participation in peer activities, case management, and peer mentoring. WSU staff reviewed participants’ records on a quar- terly basis to collect relevant information and enter it into an electronic database. Data were triangulated with data provided by the jail and data from the coun- ty’s community mental health database. In the program’s first 2 years,218 people participated in the jail-based DRA groups.The average age was 38 years. Fifty-nine percent were African American, and 32 percent were White. Sixty-four percent reported being unemployed, and 32 percent reported being homeless at the time of arrest.Of all participants,117 were released from jail. Nineteen of those released subsequently followed up with the COPE program in the community. Those who continued in the COPE program after release, as opposed to those who did not continue,tended to beAfricanAmerican,older,un- employed, and homeless, which has implications for program staff in terms of understanding and engaging the target population and tailoring services to their particular needs. In comparing the 19 who followed up with COPE with the 94 who didn’t, we looked at outcomes related to community mental health appointments, inpatient psychiatric hospitalizations, and recidivism. The hy- pothesis was that ongoing contact with COPE would in- crease the likelihood of people making and keeping a community mental health appointment and decrease the incidence of psychiatric hospitalization and recid- ivism. People who followed up with COPE were more likely to have a postrelease community mental health services claim (90 percent vs. 50 percent), get into community mental health services sooner (42 days vs. 74 days from release to first appointment), remain in the community for a longer period of time before being hospitalized (221 days vs.89 days from release to hospitalization),and remain in the community for a longer period before being reincarcerated (247 days vs. 134 days from release to incarceration). COPE participants reported that they liked the jail DRA groups because of the educational as- pect, the facilitation by peer support special- ists, and the linkages to the community after release. Interest in the jail-based DRA groups was surprisingly high,but the rates of community follow-up were not as high as we had anticipated. We discovered that this was in part because of logistics. First, only 54 percent of participants were actually released. Second, the facilities differ in that one mainly houses people awaiting sentencing, and the other houses people who have already been sen- tenced. Following up with the latter was easier be- cause they were more likely to know their release date and less likely to be transported to another facility outside of the county; however, groups did not begin at that facility until 2009,thereby limiting the amount of time for community follow-up at this point. In light of all we have learned, we encourage cre- ative and assertive methods to ensure higher rates of participation in the community, such as providing transportation on release from jail and engaging in assertive community outreach. People who followed up with COPE were more likely to get into community mental health services sooner and remain in the community for a longer period of time before being hospitalized or reincarcerated.
  • 51. 54 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars In 1999, Manny Babbitt, a decorated Vietnam vet- eran diagnosed with schizophrenia and posttrau- matic stress disorder, was executed at San Quentin Prison in California after having been convicted of murder. Manny’s brother Bill, who turned Manny in to the authorities after being promised that the state would not pursue the death penalty, has become a staunch advocate against the death penalty. In 1998, Linda Gregory’s husband, Gene, was shot and killed while responding to a call to assist a man with paranoid schizophrenia who had barricaded himself in his residence with an arsenal of weapons. Since then, Linda has become a leading advocate for better mental health services in Florida. These extraordinary individuals joined many others in San Antonio in October 2008 to begin an unprec- edented conversation about whether persons with severe mental illnesses should be exempt from capital punishment. The participating families dis- covered that they had much in common. Whether families of homicide victims or families of people who had been executed, they all shared common frustrations about problems in the mental health system and common beliefs that executing indi- viduals with severe mental illness only compounded tragedies.These executions serve no useful purpose in deterring crimes. The meeting in San Antonio was organized by Mur- der Victims’ Families for Human Rights (MVFHR), an international organization of relatives of homicide victims and relatives of people who have been ex- ecuted,all of whom oppose the death penalty.NAMI has long opposed the execution of people with se- vere mental illness. Recognizing a commonality of interests, MVFHR Executive Director Renny Cushing conceived the idea for this project and approached NAMI about becoming a partner.“Family opposition to the death penalty is grounded in personal trag- edy,” said Cushing.“In the public debate about the death penalty and how to respond in the aftermath of violent crime, these are the voices that need to be heard.” MVFHR and NAMI have released a report giving voice to the shared concerns of the participants in the San Antonio meeting. Entitled Double Tragedies: Victims Speak Out against the Death Penalty for People with Severe Mental Illness, the report calls the death penalty “inappropriate and unwarranted” for people with severe mental illnesses and “a dis- traction from problems within the mental health system that contributed or even directly led to tragic violence.” The report is based on extensive interviews with 21 family members from 10 states: California, Florida, Georgia, Illinois, Louisiana, Maine, Massachusetts, North Carolina, Tennessee, and Texas. The families represented in these interviews fall into one of two categories: families of victims of homicides at the hands of a person with a severe mental illness and families of persons with severe mental illness who have been convicted of homicides and executed. In certain cases, the person who committed the homi- cide and the victim of the homicide were related. Most state laws list “mental disease and defects” or some variant of this term as a factor that should mitigate against the death penalty.However,studies suggest that defendants with severe mental illness are more likely to be sentenced to death than those without mental illness convicted of similar crimes. At least 100 people with mental illness have been executed in the United States, and hundreds more are currently on death row awaiting execution. In 2002, the U.S. Supreme Court ruled that the ex- ecution of individuals with intellectual disabilities (mental retardation) is unconstitutional and in 2005, the Court further ruled that it is unconstitu- tional to execute people whose crimes were com- mitted when they were juveniles.The court’s rulings in both cases were based on its concern that factors such as impaired judgment, understanding, and im- pulse control reduce the level of culpability in cases involving defendants with intellectual disabilities or juveniles and, therefore, do not justify the most extreme penalty of death. These factors frequently apply as well in capital cases involving severe men- tal illness —raising serious questions about whether the death penalty should be similarly banned for defendants with these illnesses. The Double Tragedies report describes horrendously violent acts but notes that supportive services are the best way to avoid risks.“Most people with men- tal illness are not violent,” said NAMI Executive Di- rector Michael Fitzpatrick. “When violent tragedies occur they are exceptional, because something has gone terribly wrong, usually in the mental health- care system.Tragedies are compounded and all our families suffer.” The report makes four basic recommendations: 1.The death penalty for persons with severe men- tal illness should be banned. Currently,legislation is pending in at least four states to limit or eliminate the execution of people with severe mental illnesses. However, only Connecticut has a law on the books limiting capital punishment for individuals with “significantly impaired mental capacity” and that law is seldom used. Ron Honberg, JD, Director of Policy and Legal Affairs, National Alliance on Mental Illness Reprinted with permission from the Fall 2009 issue of The NAMI Advocate. Double Tragedies: Speaking Out Against the Death Penalty for People with Mental Illness How can a modern, civilized society choose to exterminate its mentally ill citizens rather than treat them? I’ve been waiting 25 years… for people to come together and say that the death penalty is not the answer to the problem of untreated mental illness in our country. Lois Robinson continued on page 55
  • 52. 56 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars It is vital that the significant number of justice- involved persons with mental illness have con- sistent access to healthcare and other supports — both while they are incarcerated and upon re- lease. Given that many people with mental illness rely on Medicaid to access services and that those who are incarcerated likely had their mental illness before incarceration; it follows that they must rely on Medicaid to cover services upon their release. Yet, many offenders with mental illness automati- cally lose their health and social supports because of state policies that terminate rather than suspend benefits on incarceration.A central issue is conflict- ing guidelines across different levels of government and agencies that render the system complex and difficult to navigate. Although federal law prohibits state Medicaid agencies from using federal funds to pay for services while a person is incarcerated, it does not delineate how states should implement this requirement.Termination of Medicaid eligibility is not required, and states have the option of sus- pending eligibility while people are incarcerated. States face a series of barriers that challenge their ability to suspend and reinstate Medicaid eligibility. Suspension or reinstatement of Medicaid require coordination across multiple systems and agencies but in many states, data systems cannot commu- nicate. Other states face restrictions that limit the degree to which information can be shared between jail and prison systems and community agencies. Many states terminate rather than suspend eligibil- ity to ensure that claims are not inadvertently filed for people while they are incarcerated. Another barrier is that the Social Security Adminis- tration provides financial incentives (up to $400 per case) for reporting incarcerated people in receipt of federal benefit payments so that Supplemental Security Income and Social Security Disability In- surance benefits can be suspended or terminated. No incentive is provided to notify SSA when such people are released so that benefit eligibility can be reinstated. This program can be detrimental to inmates with mental illness because Medicaid ben- efits are tied to SSI and SSDI. However,several strategies are being used by states and localities to facilitate access to federal benefits for inmates with mental illness and substance use disorders. Two strategies in particular — legislation for suspension of eligibility and prerelease plan- ning as part of re-entry programs — have recently received attention. Medicaid Suspension Legislation Legislation could be introduced at the federal level to require that states suspend Medicaid eligibil- ity upon incarceration and reinstate on release to ensure continuity of care. Released inmates would then be able to go directly to a Medicaid provider, demonstrate eligibility, and receive services without interrupting access to medications and other treat- ment. Suspension of eligibility is the most desirable approach because it does not require that a new application be filed, and benefits can be restored with minimal delay. In the absence of federal legis- lation, state Medicaid policy could allow incarcer- ated people — where applicable by federal law — to maintain Medicaid eligibility. The most significant recent development at the federal level was the introduction of H.R. 2829, the Recidivism ReductionAct,in June 2009.The bill was subsequently referred to the HouseWays and Means and Energy and Commerce Committees but has not been reported on to date.The bill proposes amend- ments to the Social Security Act >> Requiring the reinstatement of SSI benefits after application, during or following incarceration, and the provision of benefits in the interim, ef- fective the day of release. >> Requiring the reinstatement of Medicaid benefits on release for those with eligibility before incar- ceration unless there is a determination that the person is no longer eligible to be so enrolled. >> Offering financial assistance for states imple- menting Medicaid suspension systems. >> Offering case management services to engage in planning for services after a person’s release. >> Requiring that to receive the incentive payments from the SSA described earlier, jails and prisons must participate in a prerelease agreement with the SSA. Another example of federal legislative action is the inclusion of section 1729 in H.R. 3962, the Afford- able Health Care for America Act, which requires states to suspend, rather than terminate, Medic- aid eligibility for incarcerated people age 18 and younger. With regard to state activity, several states have passed legislation to bridge the gap between fed- eral and state funding.States with policies and laws for the suspension of Medicaid include Colorado, Florida, Indiana, Ohio, Maryland, Maine, Michigan, North Carolina, New York, and Oregon.The example of New York State highlights what states can do to Alex Blandford, Project Coordinator, Institute for Evaluation Health Science in Community Health, Graduate School of Public Health, University of Pittsburgh Reinstating Medicaid Benefits: Life in the Community after Incarceration Many offenders with mental illness automatically lose their health and social supports because of state policies that terminate rather than suspend benefits on in- carceration. A central issue is conflicting guidelines across different levels of government and agencies that render the system complex and difficult to navigate.
  • 53. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 57 address the barriers they face. New York was one of the first states to pass legislation requiring that Med- icaid eligibility for inmates be suspended (April 2008) and that the effort be a shared responsibility be- tween state and local departments of social services. Although the law clearly requires the suspension of eligibility, the reinstatement process is less explicit and requires clarification. For people to have their benefits reinstated on release, the state must be able to check whose Medicaid eligibility was suspended against who is released from jail. Although state law requires coordination between the Department of Corrections and the Office of Temporary and Disability Assistance to identify offenders who need Medicaid suspended on entering correctional facilities, many states, including New York, do not require that correc- tional facilities report an inmate’s release to the state, thus rendering information about incarcerated people incomplete and hindering reinstatement of Medicaid coverage. Many state agencies issue a memorandum of understanding that specifies requirements and re- sponsibilities for information exchange between the two entities. This approach, however, is largely rela- tionship based and can be problematic. Prerelease Planning for Re-entry For inmates whose benefits were terminated or who were not previously enrolled, a desirable option is to ensure that an application for Medicaid,SSI,and oth- er benefits is submitted well in advance of release (at least 1–3 months) so that assistance is available upon release.A variety of federal,state,and local funds and grants support enrollment in public programs as part of the discharge planning process. Prerelease plan- ning varies by the length of incarceration, the size of the correctional facility, and the resources available. Planning programs can include ensuring that the in- mate has identification cards (for Medicaid), a supply of medications, and community resource supports (food stamps, cash assistance, and housing) upon release.Collocating relevant specialized staff (trained social workers) or local SSA staff at the institution to facilitate the process is advisable. In Allegheny County, Pennsylvania, comprehensive re-entry planning (including providing access to benefits) is provided in jail as part of the Allegheny County Jail Collaborative, a joint effort of the Allegh- eny County Jail, the Allegheny County Department of Human Services, and the Allegheny County Health Department. As part of transition planning, intensive case management is offered during incarceration and after release to construct a service plan to coordinate services and apply for assistance while the offender is still in jail. Case managers help people connect with existing supports (e.g., family support) and in devel- oping other supports in the community through peer, provider, and other community organizations. The fact that suspension of Medicaid benefits for the incarcerated has garnered more attention on the lo- cal and state levels, and more recently on the federal level, is encouraging but much remains to be done. In the absence of enacted federal legislation, states should adopt legislation to suspend, rather than ter- minate, the Medicaid benefits of eligible people dur- ing incarceration. They should also seek or continue to seek funding to create and sustain re-entry initia- tives. This issue is extremely complex, and federal benefit enrollment is only one part of the solution. However, people should not leave jail or prison with- out immediate access to vital care and support in the community, which can be achieved in part by access to Medicaid. Alex M. Blandford is Project Coordinator for the Institute for Evaluation Health Science in Community Health, housed in the Graduate School of Public Health at the University of Pittsburgh, Pennsylvania. Her areas of research interest include integrated care and criminal justice issues for justice involved individuals with mental illness, particularly the effective provision of care and services across fragmented systems using collaborative ap- proaches. Blandford received a masters in Public Health from the University of Pittsburgh and BA in psychology from Pennsylvania State University. She is a former National Council Public Policy intern. Most people with mental illness are not violent. When violent tragedies occur they are exceptional, because something has gone terribly wrong, usually in the mental healthcare system. Michael Fitzpatrick continued from page 52 2. Mental health systems need to be reformed to more effectively provide treatment and supportive services to individuals with severe mental illnesses before they reach the point of crisis. NAMI’s Grading the States 2009 report contains a number of recommendations for improving mental health systems and services, including strategies for responding effectively to individuals with severe mental illness who are most at risk and have difficulty adhering to treatment regimens. 3.Recognize the needs of families of murder victims through rights to information and participation in criminal and mental health proceedings. 4. Recognize that families of individuals who are executed are victims themselves and provide as- sistance to these families due to any victims of traumatic loss. Lois and Ken Robison of Texas became activists against the death penalty after their son Larry — diag- nosed with paranoid schizophrenia — was executed in 2000.The Robisons struggled for years to get help for their son prior to the crimes that led to his execu- tion. At the meeting in San Antonio, Lois posed the question“How can a modern,civilized society choose to exterminate its mentally ill citizens rather than treat them? I’ve been waiting 25 years…for people to come together and say that the death penalty is not the answer to the problem of untreated mental illness in our country.” NAMI hopes The Double Tragedies report is the start of this process. Ron Honberg oversees NAMI’s federal advocacy agenda and the NAMI Law and Criminal Justice Action Center. In recent years, he has worked on issues affecting people with mental illnesses involved with criminal justice systems, and more. Before joining NAMI in 1988, Honberg worked as a Vocational Rehabilitation Counselor for the State of Maryland and in a variety of direct ser- vice positions in the mental illness and developmental disabilities fields. Honberg has a Juris Doctor degree from the University of Maryland School of Law and master’s degree in education from the University of Maryland.
  • 54. 58 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars Lavelle Conner, 46, estimates he’s been arrested 150 times. While struggling with schizophrenia, depression, and drug addiction during his 12 years of homelessness, he slept in abandoned buildings and ate out of garbage cans.With little, if any, sup- port from the community, Lavelle faced one dead end after another. “The drugs helped my pain, so I kept taking things that weren’t mine, to support my habit.” Lavelle’s story is not unusual. Every year, U.S. pris- ons and jails release almost 10 million people. Like Lavelle, many return to impoverished neighbor- hoods and are trapped in a cycle of homelessness, incarceration, and health and mental health crises. More often than not, these people find themselves right back in prison or jail for parole violations and quality-of-life crimes.Taxpayer dollars are wasted as the cycle continues and people’s lives spiral of out control. In addition to the mind-boggling costs in terms of lost human potential, productivity, child and fam- ily stability, and public safety, states and cities are spending billions as a result of failed policies. Among the 20,000 parolees with mental illness exiting California prisons each year, about 3,500 become homeless.Ninety-four percent of those who are homeless return to prison within 24 months.This alarming recidivism rate results in an equally shock- ing expense to the state — the average annual cost of housing an inmate with mental illness in Califor- nia is $110,000. Keeping someone incarcerated in a Chicago jail or at New York’s Rikers Island is simi- larly expensive and averages more than $47,000 a year, without considering the added costs of mental health treatment.The nation’s jails and prisons are now de facto mental health institutions — and the Los Angeles County Jail; Cook County, Illinois, Jail; and Rikers Island in New York are this country’s three largest such facilities. Of all the issues facing parolees re-entering com- munities, studies suggest that none is more imme- diate than the need to find a place to live.Without stable housing, returning to jail or prison is almost a given in a system in which people find themselves arrested again and again for violations related to homelessness, untreated mental illnesses, and ad- diction. An Opportunity to Succeed With the right help, Lavelle was able to turn his life around. He became a permanent supportive housing tenant through Thresholds, a Chicago-area nonprofit. Since obtaining housing, counseling, and other support services, he has been living success- fully in the community for almost 4 years. Lavelle no longer abuses drugs and has remained out of trouble. He has served as president of the tenant council and as a consumer advocate for a Thresh- olds’jail diversion program,working with judges and the district attorney. Of his new life, Lavelle says,“I have three children and six grandchildren. Before Thresholds, years and years passed before I could see them — at one point I couldn’t even knock at my family’s door.Now that they’ve opened up their door to me, I learned how to be a grandfather.” Supportive Housing Works Supportive housing — permanent, affordable hous- ing linked with services that meet the needs of individuals and families — has emerged as a real solution that works.Services are tailored and coordi- nated and provide health, mental health, substance use, vocational services and benefits advocacy, and other supports necessary to help people stabilize their lives. Successful programs often begin to en- gage participants and provide services while they are still incarcerated. The Corporation for Supportive Housing’s Return- ing Home Initiative, funded primarily by the Robert Wood Johnson Foundation and the Open Society Institute, aims to end the cycle of incarceration and homelessness.The initiative focuses on engag- ing criminal justice systems and integrating the ef- forts of housing, behavioral health, corrections, and other agencies to better serve people with a history of homelessness and incarceration by placing them into supportive housing. Returning Home has ad- vanced efforts in nearly a dozen jurisdictions across the country, all focused on reducing the number of people with histories of homelessness, behavioral health issues, and incarceration who are inappro- priately languishing in U.S. jails and prisons. Jurisdictions Leading the Way Nationwide, more and more cities, counties, and states are investing in supportive housing for people re-entering their communities from jails and pris- ons. Highlighted next are examples of real work on the ground that is proving successful in ending the cycle of homelessness and incarceration for people with serious behavioral and other health issues. Frequent Users Service Enhancement Initiative — New York City The New York City Department of Correction, Home- less Services, and CSH, with assistance from the Human Resources Administration, the Department of Health and Mental Hygiene, Housing Preserva- Incarceration and Homelessness: Breaking the Tragic and Costly Cycle Andy McMahon, Associate Director for Innovations and Research, Corporation for Supportive Housing
  • 55. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 59 tion and Development, and the New York City Hous- ing Authority are implementing the FUSE Initiative. This groundbreaking initiative has placed more than 150 people with long histories of incarceration and homelessness into permanent supportive housing — breaking their institutional circuit among jail, shelter, emergency health, and other public systems. As the program’s name implies, it is targeted to fre- quent users of public services. Eligible participants are identified through an administrative data match between the Department of Corrections and New York City Homeless Services, and recruitment and enroll- ment often begin while people are still incarcerated. Participants are provided with an initial, intensive burst of services as outreach is done, housing is se- cured, and they begin to stabilize in the community. FUSE is funded with a blend of federal, state, local, and private philanthropic resources. Housing for the program is funded using a combination of Section 8 rental subsidies from the NYCHA and funds from New York City departments, including the DOHMH and DHS. NYCHA granted a criminal justice waiver for sponsor-based vouchers that are linked with stabiliza- tion and support services that promote public safety and tenant success. Funds for service enhancements have been provided by the New York DOC and DHS, CSH, and the Justice, Equality, Human Dignity, and Tolerance Foundation. The first round of FUSE has been extremely success- ful in helping people maintain housing and avoid returning to homelessness. An evaluation conducted by John Jay College, of the first year after placement, demonstrates >> 91 percent housing retention. >> 53 percent reduction of jail days used. >> 92 percent reduction of shelter days used. When results are viewed next to those of a matched comparison group, FUSE participants showed signifi- cantly increased resilience,extended time in the com- munity, and a reduced rate of cycling between DOC and DHS, showing cost offsets to those systems of $2,953 per person per year. Returning Home — Ohio The Ohio Department of Rehabilitation and Correc- tions has invested in a supportive housing program targeted to parolees at risk of homelessness. The program links and integrates the efforts of the cor- rections system with housing, mental and behavioral health, and other agencies to more effectively and efficiently transition people back into the community from prison. Priority placement within the program is given to people identified as being most likely to require hous- ing linked to support services to maintain housing. Through this pilot, ODRC and CSH are working with select nonprofit organizations to demonstrate how supportive housing can reduce an offender’s return to the criminal justice system and prevent homelessness. Over the course of the pilot, ODRC is providing more than $3.8 million, which will be used for rental sub- sidies,tenant assistance,case management,program evaluation, and project management. Providers use a mix of scattered-site and single-site housing and also coordinate with community-based organizations for additional behavioral health and other services. CSH, in collaboration with the Ohio Housing Finance Agency,has also established a rental subsidy program to assist Returning Home tenants who may require rental subsidy for an indeterminate amount of time beyond the pilot period. The first of 92 participants was accepted into housing in March 2007. As of March 2009, 51 people (55%) were in housing, 20 (22%) had exited with posi- tive outcomes, 11 (12%) had been terminated with negative outcomes, and 5 (5%) had exited for other reasons (e.g., death, to participate in a treatment program, placement in a nursing home). The Returning Home pilot includes an evaluation component, which is being conducted by the Urban Institute’s Justice Policy Center in Washington, DC. An interim report can be viewed at publications/411869.html. The Way Forward Too many people like LaVelle languish in a cycle of homelessness and incarceration, using immense amounts of public resources with little or no ben- efit. This cycle wastes money and lives, but solu- tions exist. Efforts like the ones in New York, Ohio, and other communities across the country dem- onstrate that we can more efficiently invest our scarce public resources and more effectively serve people with histories of homelessness and incar- ceration. Some lessons learned and strategies that are working are captured in a systems change re- port the Urban Institute recently completed for CSH ( Reentry/UI-RHI-After3Yrs-Nov09.pdf). In short, communities need to >> Identify the scale and scope of this problem in their own communities. >> Develop the interagency collaborations needed among criminal justice,housing,behavioral health, and other agencies. >> Create in-reach and outreach programs that are linked to a network of supportive housing providers. >> Direct housing and support services resources to effectively serve this population, including rein- vestment of criminal justice funds. >> Support data-driven evaluation that documents the costsandimpactsonindividualsandthecommunity. We can do better — and cities and states across the country are proving it. Andy McMahon leads Returning Home, the Corporation for Supportive Housing’s national initiative focused on engaging cor- rections and criminal justice systems to create supportive housing and end the cycle of homelessness and incarceration that so many people face. He also is responsible for providing strategic direction for Returning Home in its three primary sites — Los Angeles, New York City, and Chicago — and leads CSH’s national efforts to increase investment in re-entry supportive housing and change public policy to better integrate efforts among corrections, human service, and housing agencies at all levels of government. New York’s FUSE program, which places people with a history of incarceration in permanent supportive housing, has resulted in 91 percent housing retention, 53 percent reduction of jail days used, and 92 percent reduction of shelter days used. FUSE participants showed significantly increased resilience and extended time in the community, yielding cost offsets of $2,953 per person per year.
  • 56. 60 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars Mental Health First Aid USA Equips Police Officers to De-escalate Crises Richard H. Leclerc, President, Gateway Healthcare Gateway Healthcare in Pawtucket, Rhode Island was a pilot site for the rollout of Mental Health First Aid USA training.As Gateway staff were trained and certified to offer the 12-hour Mental Health First Aid program to the public, local police depart- ments in Rhode Island were seeking to broaden of- ficers’ response options during incidents involving citizens with serious mental illness. This fostered a strong partnership that now has mental health pro- fessionals and law enforcement officers speaking a common language. Police officers have become priority recipients of Mental Health First Aid training in Rhode Island, with eight training courses having been offered at the state’s Municipal Police Academy since spring 2008. Representatives from both Gateway and the law enforcement community say the effort has suc- ceeded largely because the course offers much practical information on mental illness and a police lieutenant helps officers figure out how to apply this new knowledge on their beat. “Law enforcement is a pretty tight-knit group, and bringing in an outsider to do this training alone would be kind of tough,” says Carole Bernardo, a certified Mental Health First Aid instructor at Gate- way who serves as training coordinator for the community mental health organization’s LifeWatch EmployeeAssistance Program.“I co-train with an of- ficer, Lt. Joe Coffey of the Warwick police. I basically present the mental health information,and Joe puts it in their world.” “Carole covers the signs and symptoms of mental illness, and I interject examples of scenarios and engagements that the officers might see,” says Cof- fey. “Then I talk about the response side. We talk about giving the officer discretion in what to do,and offering ideas that are outside the box.” Bernardo recalls that she was observing another training at the Municipal Police Academy when she informed the training coordinator, Captain David Ricciarelli, that she was becoming certified as a trainer for the innovative 12-hour Mental Health First Aid course. They agreed to follow up later and came up with plans for a jointly taught class that has become one of the academy’s most popular of- ferings. “Officers certainly need to know about the signs and symptoms and the definitions of what constitutes a mental illness,”Coffey says.“As first line responders, this is key for them.” It has become clear to Bernardo from the first course she facilitated at the academy that officers prefer a practical learning approach that empha- sizes examples of options for defusing potentially harmful situations involving people with mental ill- ness.Both Bernardo and Coffey emphasize that they do not ask participating officers to change the way they do their jobs; officers are simply acquiring new tools with which to respond to potential crises. Just as police departments have acquired new methods for applying non-deadly force in danger- ous situations, the knowledge acquired in Mental Health First Aid training gives officers strategies for trying to prevent a situation on the street from es- calating, Coffey says.The training became available to municipal departments shortly after a number of highly publicized incidents in the state that ended tragically with an officer’s use of deadly force on a suspect with mental illness. “The officers have seen these behaviors, and now they can understand people with mental illness,and they can respond without compromising safety,” he continued on page 60
  • 57. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 61 MentalHealthFirstAidisdeliveredtomembersof the public through an interactive 12-hour course, which introduces participants to risk factors and warning signs of mental health problems, builds understanding of their impact, and overviews common treatments. Participants learn a 5-step action plan encompassing the skills, resources and knowledge to help an individual in crisis connect with appropriate professional, peer, social, and self-help care. The course also pro- vides participants with an understanding of the prevalence of various mental health disorders in the U.S.and the need for reduced stigma in their communities. The 12-hour Mental Health First Aid course has been offered to a variety of audiences and key professions, including police/corrections staff/ first responders/security personnel; educators/ school administrators; human resources profes- sionals;membersoffaithcommunities;homeless shelters workers; nurses/physician assistants/ primary care workers; social workers; consumers and family members; and caring citizens. Mental Health First Aid was created in 2001 by Professor Tony Jorm, a respected mental health literacy professor, and Betty Kitchener, a nurse specializing in health education,and is auspiced at the University of Melbourne. Five published studies in Australia show that the program saves lives,expands knowledge of mental illnesses and their treatments,increases the services provided, and reduces overall stigma by improving mental health literacy. In the USA, Mental Health First Aid is coordinated by three national authorities — the National Council for Community Behavioral Healthcare, the Maryland State Department of Mental Hygiene, and the Missouri Department of Mental Health. The national authorities certify instructors to im- plement Mental Health First Aid in communities throughout the United Sates.Each Mental Health First Aid site develops individualized plans to reach its community, but undergoes tight cre- dentialing to guarantee fidelity to the original, tested model. About Mental Health First Aid USA To learn more and find a Mental Health First Aid course near you or to find out how you can become a certified instructor, visit or contact Susan Partain at 202.684.3732 or Mental Health FirstAid is the initial help given to a person showing symptoms of mental illness or in a mental health crisis (severe depression, psychosis, panic attack, suicidal thoughts and behaviors…) until appropriate professional or other help, including peer and family support, can be engaged. By the Numbers > 6,000+ Mental Health First Aiders trained > 700 instructors certified > 1,000,000+ media impressions
  • 58. 62 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars says. “We don’t try to minimize or alter the safety factor in what we present.” Nor do they convey that there will never be a situation in which use of force will need to occur. Mental Health First Aid training has also helped officers overcome challenges in negotiating the mental health system.They realize that just as they experience frustration with the long waits they may encounter when they take an individual to a hos- pital emergency room, mental health professionals also get frustrated in their efforts to get people the help they need. This realization has forged greater mutual respect between the mental health and law enforcement communities. “We’re trying to get everyone talking the same lan- guage,” Bernardo says, adding that employees at all sites at which a person with serious mental illness might appear should possess the same basic knowl- edge of mental illness. With 25 officers participating in each Mental Health First Aid course, the program has already reached most of the state’s police departments. Bernardo says officers’ evaluations of the training have praised the team approach to instruction. Although Coffey says a formal evaluation of the pro- gram’s impact in terms of street response has not yet taken place, he knows from anecdotal informa- tion that officers are applying the skills creatively and effectively. He cites a recent example from his own police jurisdiction to support this. Police in the city of Warwick reported to an apart- ment building where a man with schizophrenia had barricaded himself in his residence after having bro- ken into a neighbor’s house. Coffey says the typical response to such a call would have been a tactical one triggered by the alleged breaking and entering. But the neighbor’s knowledge of the individual’s ill- ness, combined with the fact that a responding of- ficer had taken the Mental Health First Aid course, triggered an entirely different set of responses. Coffey says the officers at the scene were able to contact the man’s family members, who communi- cated key information. Within an hour, police were able to defuse the situation. Instead of transporting the man to the police department cell block, where trouble in calming him would likely have occurred, he was sent directly to a hospital for evaluation. In what was perhaps the most surprising devel- opment of all, Coffey says, the bail commissioner agreed to conduct necessary paperwork at the hos- pital so that the man could receive needed services with no delays.“That’s unheard of,” Coffey says. This anecdote is one example of how greater men- tal health awareness and reduction of stigma can change a community’s mindset. “We kind of open their hearts a little bit,”Coffey says of the participat- ing officers. Some participants are encouraged by their local chief to enroll in the course, but many volunteer to participate in what has become one of the acad- emy’s most appreciated course offerings. “This is absolutely working,” Coffey says. Perhaps the biggest eye opener for all participating officers is the course’s use of technology that simu- lates the auditory hallucinations that plague many people with a psychotic illness.When asked to com- plete an exercise while listening to the simulator, the officers experience obvious frustration — and begin to understand what a suspect with serious mental illness might face when trying to respond to an officer’s commands. “That is the single most persuasive method we have,” Coffey says. Richard Leclerc is the President and CEO of Gateway Health- care, overseeing all operations of over 700 employees within the organization. He is on the Board of Directors of the National Council for Community Behavioral Healthcare and the Rhode Island Council of Community Mental Health Organizations. He chairs the Rhode Island Governor’s Council on Behavioral Health. Leclerc is a member of the Academy of Certified Social Workers and the Association of Mental Health Administrators and also a Licensed Independent Clinical Social Worker. Join the Gateway Healthcare team and the National Council for in-depth workshops on Mental Health First Aid training and applications for law enforcement and corrections communities at the National Council’s 40th Annual Mental Health and Addictions Conference & Expo (March 15-17, Disney World, FL), the National GAINS Center Conference (March 17-19, 2010, Disney World, FL), and the International Crisis Intervention Team Conference 2010 (June 1-3, 2010, San Antonio,TX) continued from page 58 Just as police departments have acquired new methods for applying non-deadly force in dangerous situations, the knowledge acquired in Mental Health First Aid training gives officers strategies for trying to prevent a situation on the street from escalating. The training became available to police officers in Rhode Island shortly after a number of highly publicized incidents in the state that ended tragically with an officer’s use of deadly force on a suspect with mental illness.
  • 59. Your Voice Matters Joinus in Washington, DC In-person visits from constituents have more influence on Congress than any other type of communication! Join hundreds of your colleagues from around the country on visits to elected officials to advocate for policies that protect and expand access to adequately funded, effective MENTAL HEALTH and ADDICTIONS services. Register, record Hill appointments, get briefing materials, and reserve discounted hotel rooms at Questions? Email or call 202.684.3735. Bring a team—board members, medical directors, local law enforcement allies, state legislators, county commissioners, consumers, and family members. HILL DAY National Council 6th Annual JUNE 29 – 30, 2010
  • 60. 64 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars In December 2008, the American Correctional As- sociation surveyed state departments of correc- tions and juvenile justice and asked them to identify specific areas of operations designated for budget cuts. The top three areas for adult agencies were staffing, non–education-related offender programs, and training. Juvenile justice agencies designated similar areas. These results are not surprising. Nearly every day, the media announce more company layoffs, and executives talk about cutting budgets to survive the economic downturn. “Vulnerable sectors, notably retail and the government are cutting back on train- ing,” notes Susan Vardoe, president of Ninth House, an e-learning company. She says,“One government agency told me they are too busy buying gasoline and bullets. It’s all they can afford to do.” The financial struggle in most states and counties means that correctional training departments are confronted with the challenge of training staff at all levels with fewer dollars. Corporations faced with this same dilemma are able to scale back or drop programs deemed a luxury or unprofitable. In cor- rections, however, training is not a luxury — it’s a necessity.Yet there is good news.Unlike their corpo- rate counterparts who are often forced to deal with the bottom line, correctional trainers have the op- portunity not only to deliver training but also to de- velop staff even during the worst economic times. The solution to the dilemma is to leverage technol- ogy to an organization’s advantage.The most easily available, cost-effective technology is e-learning or online training. “E-learning offers many advantages that are even more compelling in a tough economy,” points out Stephen Flavin,executive director of Bab- son Executive Education. There are many benefits to e-learning: >> Consistency: Even when trainers use the same lesson plans, delivery of the training varies from class to class simply because no two people are alike. For instance, trainers have different deliv- ery styles and may emphasize different sections of the content. Similarly, they have varying levels of experience that influence the training. Online training, in contrast, provides the same training to all staff — there are no obvious or subtle dif- ferences. The state of Iowa launched an inter- nally built online system in 2009.Terri Schuster, Training Specialist II (or “e-trainer”), emphasizes that online training ensures the agency is deliv- ering “one clear, consistent message.” >> Centralization: All documentation can be main- tained in one location. Staff progress can be monitored on a daily basis,and reports are read- ily available to document completion of training. >> Cost effectiveness: In many cases, online train- ing costs less than traditional learning,and more staff can be trained for fewer dollars.The Florida Department of Juvenile Justice offers nearly 200 department-specific courses online. Mike Mc- Caffrey, director of staff development and train- ing, says that online training is “definitely a cost benefit during these economic times,” and it has saved the department “a lot of money.” He pro- vides a good example of the potential savings. If 25staffarebroughttoTallahassee,thecentralof- ficelocation,for1weekoftraining,thecostwould be approximately $25,000. Teaching the same material online would cost considerably less. >> Time effectiveness: Online training removes geographical barriers because staff can take the courses at various locations throughout an area. It also solves the problem of trying to get staff and trainers in one place at one time. As Terri Schuster points out, online training allevi- ates the problem of “having to find half a day or several days to relieve staff for training.” In addition, learning time is often reduced. Online courses can be designed in shorter time blocks or staff can work on longer courses in 1-hour or longer time blocks. Yet, the quality of the training material does not need to be sacrificed.Well-designed online courses can be as effective as classroom training and, at times, more effective. Some researchers believe that learning retention is higher for online training E-learning for Corrections: Viable Training Option in a Tough Economy Diane Geiman, Manager, Online Corrections Academy,American Correctional Association
  • 61. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 65 than for traditional classroom training. A well-designed course is one that is created according to strict standards. As Stephen Flavin reminds us, “Informa- tion is not instruction.”An interactive course must engage learners throughout and include proper testing or evalu- ation. Flavin cautions wisely that “effective e-learning is not taking existing course material from a classroom,put- ting it on the web and rolling it out and calling it a day.” However, you can convert that valuable material to online courses. ACA believes that online training is one part of an overall correctional training program.The association relies on its many years of training and correctional experience when assisting correctional agencies and facilities in navigating the e-learning landscape. An agency’s needs, both learn- ing and monetary, are priorities throughout the process. ACA has partnered with Essential Learning, the largest e-learning provider in human services online training, to offer a vast library of courses tailored to corrections professionals — including behavioral health courses ac- credited by national organizations — through the Online CorrectionsAcademy.As a result,the OCA now offers more than 70 corrections-specific courses to meet agency train- ing requirements and national standards. Topics include supervision,management,leadership,ethics,medical and mental health, security, and special management offend- ers (e.g., women and elderly people). New correctional courses will be added on a regular basis,through the joint efforts of ACA and Essential Learning. Non-corrections-specific courses are also offered and focus on topics such as workplace issues (e.g., commu- nication and problem solving), Occupational Safety and HealthAdministration compliance,and computer skills.All the academy’s courses may be used by certified correc- tions professionals for recertification. All ACA-developed courses are approved by the Commission onAccreditation for Corrections for preservice and in-service training. Online training is a tool that your correctional agency can use regardless of its budget, and it can be implemented painlessly. Classroom training is being supplemented, not supplanted. Diane Geiman is the Online Corrections Academy Manager at the American Correctional Association. She also serves as the Academy’s instructional curriculum developer. Geiman has more than 20 years of experience in developing training programs for criminal justice profes- sionals. She has received numerous awards for both print curricula and comprehensive video programs on topics such as criminal and juvenile justice, medical and mental health, supervision, management, and law. Essential Learning has partnered with American Correctional Association and its On- line Corrections Academy to provide a full range of e-learning solutions to meet the specific training needs of adult and juvenile correctional agencies.Courses are offered for pre-service and in-service training ; compliance with legislation, ACA accreditation, professional licensing, and ACA re-certification; and agency-specific training. The corrections library includes courses such as The complete Corrections Course Library is available at H Corrections and Mental Illness: An Overview for Corrections Officers H Supervising Mentally Ill Offenders H Overview of Suicide Prevention for Corrections Professionals H Crisis Management for Corrections Professionals H Disciplining Offenders: Enforcing Rules and Regulations H Working with Incarcerated Persons: An Overview for Corrections Professionals H Working with Incarcerated Persons: Best Practices in Treatment H Disciplining Offenders: Report Writing H Professional Ethics in Corrections H The Transition to Correctional Supervisor H Ethical Behavior in Corrections: Best Practices H Fire Safety in Corrections H Security and Offender Management: Escorting and Transporting Offenders H Supervising Offenders in Segregation Units H Overview of Suicide Prevention for Corrections Professionals H Nursing Health Assessment in Corrections H Security and Offender Management: Using Force in the Correctional Environment H Co-Occurring Disorders: An Overview for Corrections Professionals H Introduction to Mental Health Issues for Correctional Officers H Managing Offender Resistance H Ethical Standards for Corrections Supervisors H Sexual Abuse and Assault Intervention (PREA) H Intoxication and Withdrawal for Corrections Officers H Grief and Loss in the Corrections Setting H Understanding Addiction: An Overview for Corrections Professionals H Legal Issues and Women Offenders H Mental and Physical Health Issues for Older Inmates H Overview of Substance Abuse for Corrections Officers H Supervising Mentally Ill Offenders H Security and Offender Management: Supervising Offenders in Programs and on Work Details H Corrections and Mental Illness: An Overview for Corrections Officers H Security and Offender Management: Preventing and Responding to Emergencies H Women Offenders and the Correctional Environment H Security and Offender Management: Preventing Escapes H Understanding Mental Health Treatment in the Corrections Setting H Maintaining Security Part 1 H Suicide Prevention in Juvenile Correctional Facilities H Co-Occurring Disorders: An Overview for Corrections Professionals H Motivational Interviewing for Corrections Professionals H Disciplining Offenders: Report Writing Sample E-learning Corrections Courses
  • 62. Member Spotlight 66 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 A National Council publication featuring members in action March 2010 NationalCouncilMemberSpotlight National Council for Community Behavioral Healthcare Congratulating the 2010 Awards of Excellence Honorees Excellence In Service Innovation Supported by a grant from Mental Health Weekly Burrell Behavioral Health, Springfield, MO The Journey Home Project Programs of Significance Mental Health Center of Denver, Denver, CO Court to Community Treatment Program Community Partnership of Southern Arizona,Tucson,AZ Criminal Justice Team Touchstone Mental Health, Minneapolis, MN Intentional Communities Excellence In Health Information Technology Supported by a grant from Qualifacts Systems, Inc Northern Arizona Regional Behavioral Health Authority, Flagstaff, AZ NARBHAnet Telemedicine Network Programs of Significance Behavioral Health Link,Atlanta, GA Tracking delays and improved coordination associated with crisis lines Colorado Behavioral Healthcare Council, Denver, CO Health information technology program that united the state of Colorado Excellence In Risk Management Supported by a grant from the Mental Health Risk Retention Group and Negley Associates Institute for Community Living, New York, NY Assessment and intervention program for clinical risk in a multi-service behavioral healthcare network Programs of Significance Beech Brook, Cleveland, OH Advancing the emotional well being of children Southwest Behavioral Health Services, Phoenix,AZ Managing risk from a strengths-based perspective
  • 63. Member Spotlight 68 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 March 2010 Excellence In Addictions Treatment & Prevention Hartford Dispensary, Manchester, CT Continuum of recovery-based services in an opioid treatment program Programs of Significance San Luis Valley Mental Health Center,Alamosa, CO Preventing child substance abuse, delinquency and behavioral issues Threshold Services, Inc., Silver Spring, MD Integrating dual disorders treatment and supported housing EXCELLENCE IN CONSUMER AND FAMILY ADVOCACY Supported by a grant from Qualifacts Systems, Inc Austin Travis County Integral Care, Austin, TX Central Texas African American Family Support Conference Programs of Significance Turn-A-Frown-Around Foundation, Freehold, NJ Improving the lives of persons who have lost hope May Farr, Pacific Clinics,Arcadia, CA Improving the behavioral healthcare system EXCELLENCE IN GRASSROOTS ADVOCACY (STATE) Association for Behavioral Healthcare, Natick, MA Campaign for Addiction Prevention, Treatment and Recovery EXCELLENCE IN GRASSROOTS ADVOCACY (LOCAL) Colorado West Regional Mental Health Center, Glenwood Springs, CO Grassroots advocacy program to retire debt UP & COMING LEADERSHIP Rosa M. West, Vice President for Specialty Programs and New Initiatives, Meridian Behavioral Healthcare, Inc., Gainesville, FL VISIONARY LEADERSHIP Mary Anderson, Board Member, Newaygo County Mental Health Services, White Cloud, MI Howard Bracco, PhD, CBHE, President & CEO, Seven Counties, Inc., Louisville, KY David Guth, CEO, Centerstone of America, Nashville, TN Jay Reeve, President & CEO, Apalachee Center, Tallahassee FL Richard Van Horn, President Emeritus, Mental Health America of Los Angeles, Los Angeles, CA EXCELLENCE IN PUBLIC SERVICE Pamela Greenberg, President and CEO, Association for Behavioral Health and Wellness, Washington, DC Carol McDaid, Principal, Capitol Decisions, Inc., Washington, DC The National Council for Community Behavioral Healthcare thanks all our affiliate members for outstanding service to the behavioral health industry. H Anasazi Software H Askesis Development Group H Credible Behavioral Healthcare Software H Defran Systems H Echo Group H eHana H Essential Learning H Foothold Technology H Genoa Healthcare H Hazelden Publishing H Mental Health Risk Retention Group H Negley Associates H Netsmart H Peter and Elizabeth C. Tower Foundation H Qualifacts H UNI/CARE Affiliate Members
  • 64. Contact Susan Partain at the National Council, or 202.684.3732 to ask how we can bring training to a location near you. Mental Health First Aid USA is coordinated by the National Council for Community Behavioral Healthcare, the Maryland Department of Health and Mental Hygiene, and the Missouri Department of Mental Health. Mental Health First Aid USA is taking communities across the country by storm, 6,000+ people trained and more added every day! Do you want to be a pioneer in your community? To raise awareness of mental health and treatment resources? Apply today to become an instructor. Mental Health First Aid USA is a highly interactive, 12-hour program, delivered to small groups by certified instructors who complete a 5-day training and meet other certification requirements. Instructors offer the 12-hour program to diverse audiences such as schools, workplaces, law enforcement, primary care, and faith communities. Apply today at for a 5-day Instructor Training in 2010 Blue Bell, PA (outside of Philadelphia) May 3-7 Denver, CO May 10 – 14 Washington, DC Jun 28 – Jul 2 Houston,TX Jul 12 – 16 Chicago, IL Aug 2 – 6 San Francisco, CA Sept 13 – 17 Atlanta, GA Sept 27 – Oct 1 Don’t miss the Mental Health First Aid USA Workshop at the 40th National Council Conference, Tuesday March 16, 4:00 – 5:30 pm, Fiesta 7/8, Coronado Springs Convention Center. The initial help given to a person showing symptoms of mental illness or in a mental health crisis until appropriate professional or other help, including peer and family support, can be engaged. Mental Health First Aid = Save Lives and Build Stronger Communities Become a Mental Health First Aid USA Instructor
  • 65. Better Business Processes… Better Clinical Outcomes… … A Better Bottom Line The SPQM Services Suite is brought to you by the National Council for Community Behavioral Healthcare and MTM Services RESULTS Community behavioral health organizations have achieved: $200,000 in annual savings per organization through access to care efficiencies. 40% reduction in client wait times — with greater engagement and reduced no-shows. 37% reduction in access to care staff time costs. 450 hours of additional services, without additional staff. Documentation time savings of up to 9 hours a week per direct care staff. To replicate the results in your organization, schedule an SPQM test drive with David Lloyd and his team. Contact Jeannie Campbell at 202.684.7457 or STRATEGIES The SPQM team has implemented winning change concepts in 500+ community behavioral health organizations: SPQM Dashboards Enhancing Revenue Streamlining Documentation Improving Access and Retention Leadership and Workforce Development Clinical Assessment Tools
  • 66. For more information, please call 866-386-6755 | or e-mail | or visit thankyou! We want to thank our customers—new and old—forchoosing Qualifacts as your provider for Web-basedelectronic health records and practice management systems. Because of you, Qualifacts is celebrating record growthin 2009. Despite a difficult economic climate, a recordnumber of providers across the country have selected andsuccessfully implemented CareLogic™ over the past year. If you’re not already a customer, call today to learn howyour agency can “Go-Live” with Qualifacts in less thansix months! J