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  • 1. 2010, iSSUe 1 Published by the National Council for Community Behavioral Healthcare nationalCouncil magazine Sharing BeSt PracticeS in Mental health & addictionS treatMent www.thenationalcouncil.org Beyond Bars Mental Health-Addictions and Criminal Justice Collaborations 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
  • 2. PDF available at www.TheNationalCouncil.org nationalCouncil M 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 National Council Magazine, 2010, Issue 1 Neal Cash 6 Human Rights at Home: Mental Illness in U.S. Prisons and Jails Beyond Bars David Fuller Mental health-addictions and 8 Ending an American Tragedy: Addressing the Needs of Justice-Involved People with Mental Illnesses and Co-Occurring Disorders criminal Justice collaborations 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 p.34 From the Field 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 National Council Magazine is published quarterly by the 54 Reinstating Medicaid Benefits: Life in the Community after Incarceration National Council for Community Behavioral Healthcare, Alex Blandford 1701 K Street, Suite 400, Washington, DC 20006. 56 Incarceration and Homelessness: Breaking the Tragic and Costly Cycle www.TheNationalCouncil.org Andy McMahon Editor-in-Chief: Meena Dayak 58 Mental Health First Aid Equips Police Officers to De-escalate Crises Specialty Editor, Mental Health-Addictions and Richard Leclerc Criminal Justice Collaborations: Mohini Venkatesh 62 E-learning in Corrections: Viable Training Option in a Tough Economy Editorial Associate: Nathan Sprenger Diane Geiman Editorial and advertising queries to Communications@thenationalcouncil.org or 64 MEMbEr SpotligHt 202.684.7457, ext. 240. National Council 2010 Awards of Excellence Honorees
  • 3. Beyond Bars What Happened to Me, Not What Was Wrong With Me “I am a 41-year-old African American woman who has been in and out of prison multiple times; I up” model, but I was broken down enough already. Even in school, where I was teased because of the am a mental health consumer who’s been hospi- way I smelled, no one asked about what was hap- talized many times; and I have been in so many pening to me. substance abuse programs, I can’t even name I have also been secluded and restrained several them all. Most important, I am a trauma survivor. times. I am a victim of neglect and abandonment, During every incarceration, every institutionaliza- and one of the worst things that you can do to tion, every court-ordered drug treatment program, someone with this type of history is to put them it was always the same: I was always treated like a into a seclusion room. When that door was shut, hopeless case. All people could see was the way I the flashbacks of my mother’s abuse and aban- Tonier Cain, Consumer Advocate looked or the way I smelled. It wasn’t until I finally donment began. When they’d come later with a entered a recovery-oriented, trauma-informed tray of food, I had been triggered, and so I pushed Tonier Cain has spoken nationally on trauma, incarceration, and recovery. She has served as a member of the treatment program a little more than four years the tray away from me, but then they restrained Protection and Advocacy for Individuals with a Mental ago, where I felt safe and respected, that I could me. I was a rape victim, and this restraint triggered Illness Council. She has also worked as a case manager begin to heal. me even more. I was also always overmedicated. and director of advocacy services for a private nonprofit As a young child, I had a belief system that I was It’s hard not to lose hope under those circum- in Annapolis, Maryland. She is the team leader for the nothing and that I would never amount to anything. stances. National Center for Trauma Informed Care, which provides I thought that the men whom my mother enter- Then, after 19 years of drug addiction, alcohol- consultation, technical assistance, and training to ism, homelessness, going in and out of prison (83 tained, who touched and hurt me, did it because revolutionize the way in which mental health and human something was wrong with me and I deserved it. arrests and 66 convictions), mental health insti- services are organized, delivered, and managed while I thought that my mother abused me and didn’t tutions, and substance abuse programs, I finally furthering the understanding of trauma-informed practices love me because I was a bad child. My eight broth- found the help that I needed to heal. Someone through education and outreach. Ms. Cain is the subject ers and sisters needed me to protect them. I had finally asked me “What happened to you?” instead of “Healing Neen,” a documentary based on her life as to keep the men from hurting them, like they hurt of “What’s wrong with you?” she moved through multiple systems of care. me; I only wished my mother loved me enough to I was in prison and pregnant, and I was terrified protect me. that I was about to lose another child: I had al- I spent a long time living with no hope and finding ready had four kids taken from me, and I could not no help in the different systems I entered. Every survive losing another. I was told about a program time I went into jail or prison, I asked for help, but that would help me heal from my trauma, recover I was told that it was a jail, not rehab. When I was from my addictions, treat my mental illness, and leaving, they said, “See you when you come back, let me keep my baby with me. Well, I didn’t know we’ll hold your cell for you.” No one ever said, “I how they were going to manage all that, but I knew hope you make it this time.” I had to give it a try. What did I have to lose? When I was admitted to mental health units, I was The first thing my therapist said to me was told that I had several diagnoses, and I always “Everything that happened to you as a child, hap- Tonier Cain is a featured asked, “How do you know? I’ve been up smoking pened to you; you didn’t do it to yourself,” and “In My Own Words” speaker at crack for 7 days.” They never allowed the street I believed her because her tone was gentle and the 2010 National Council Conference, drugs to get out of my system before they evalu- not judgmental. Then we began the work, and I March 15-17, Disney World, Florida. ated me. I also went to many substance abuse had to remember and talk about every time I was www.TheNationalCouncil.org/Conference programs — at one, I was raped by a counselor; touched and assaulted as a child. I talked about others used a “tear you down and build you back my issues with my mother, how she never loved me 4 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 4. and never protected me. I began to heal because I every time i went into jail or prison, i asked for help, but i was started to understand that I am an adult now, and my mother’s lack of love for me, and men’s abuse of me, told that it was a jail, not rehab. When i was leaving, they said, is a reflection of who they are; it’s not about who I am. “See you when you come back, we’ll hold your cell for you.” Then my therapist told me that we had to start talking about my children, and I shut down. I asked her how could talk to any staff member at any time, and they sions. I have a healthy, beautiful child whom I simply I could talk about something that gives me so much would listen. For the first time in my life, I felt like a adore and who is securely attached to me. I do not pain and suffering every day of my life: How do you person, a human being, and not like the monster I have the desire to use drugs or alcohol. I am no longer heal from having four kids walking the earth when you had been treated as in the past. I felt hope. Oh, what on medication. I am now an advocate in the streets don’t know how they’re doing, what they look like, or a difference it makes when someone asks, “What hap- where I once lived, used drugs, and was raped and who they are? She said, “You do; you just don’t do it pened to you?” instead of “What’s wrong with you?” beaten. I am now a national spokesperson on trauma, by yourself,” and she was there with me, for weeks of Once I was able to start healing from the trauma in I am a homeowner, and I sit on several boards. crying and rocking, as I allowed myself to remember my life, my belief system changed from “I am nothing” Five years ago, I was taking hits of crack, in a mental them and grieve them. to “I am somebody, and I can be anything I want in institution, and in and out of prison. Everyone then In that program, I felt safe for the first time. The walls this world.” All of the earlier treatment and informa- thought that I would spend the rest of my life going had pictures and positive quotes on them. We had our tion that people had tried to give me for years had in and out of prisons and mental institutions or that I own rooms with nice colors. No one was screaming only reached the surface; it didn’t get down to the was going to die in the streets. They were wrong. “medication time” at us or secluding or restraining us. foundation of my problems and needs. Since getting Where there’s breath, there’s hope, and for me it be- I was asked every day, “How are you feeling today?” trauma treatment in a safe, trauma-informed setting, gan with respectful, individualized trauma treatment.” Everybody there was trained in trauma, which meant I however, I have been able to heal. I make better deci- Suited for Performance! 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. Contact us today to arrange a 60-minute demonstration on how InfoMC can help you. InfoMC, Inc. - performing at the speed of your business! 101 West Elm Street Suite G10 Conshohocken, PA 19428 phone 484-530-0100 Come Visit Us in Booths 707,709 and 711 at the 2010 National Council Conference. www.infomc.com NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 5
  • 5. Editorial Improving Public Safety and Maximizing Taxpayer Dollars Community Behavioral Healthcare’s Best-kept Secret neal cash, President and ceo, Community Partnership of Southern Arizona, and Member, Board of Directors, National Council for Commu- nity Behavioral Healthcare Neal Cash is president and In these difficult financial times, it is especially >> Any cross-system program or strategy must be CEO of the Community Part- important that our systems recognize and embrace built on a firm foundation of mutual respect and nership of Southern Arizona, their interrelatedness and work together to maxi- understanding and on relationships that both the regional behavioral health authority contracted by the mize public resources. At the same time, we must grow out of and are nurtured by the collaboration. state of Arizona for funding educate the public about how effective behavioral >> Planning needs to be deliberate and incremental, and oversight of the public health treatment reduces crime, avoids expensive with both short- and long-term common goals. behavioral health system in incarceration, helps people remain in or re-enter the five counties. He has a bach- community as contributing citizens, and enhances >> Processes, strategies, and results should be elor’s degree in psychology monitored and evaluated, and improvements from Syracuse University and a master’s degree in rehabilitation the quality of life of everyone in the community. should be made on the basis of findings. counseling from the University of Arizona. He is a member of As reported in the National Leadership Forum on the National Leadership Forum on Behavioral Health/Criminal Behavioral Health/Criminal Justice Services Report >> Communication, including sharing and celebrat- Justice Services of the National GAINS Center. ing results, should be structured and ongoing. featured in this issue, the interface between our systems often is frayed, if it exists at all. Yet there >> Collaborations must be cost effective and sus- C ommunity 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 are pockets of excellence around the country that provide models for collaboration and cooperation, tainable, even in tough times. This is supported by the mutual advocacy and identification of with promising results in both individual outcomes new opportunities that evolve out of collabora- shame. and taxpayer savings — examples are featured in tive relationships, further strengthening commit- A few months ago, news reports focused on a third the From the Field section of this issue. Representa- ment, and magnifying the impact of strategies straight year of decreased crime rates across the tives of the Center for Mental Health Services’ Na- and programs. United States, surprising law enforcement officials tional GAINS Center visited some of these pockets This is basic community development. It can be slow and other experts who predicted just the opposite, of excellence in fall 2009, including those operated and at times frustrating, but CPSA’s experience has given the high rate of unemployment and the eco- by the Community Partnership of Southern Arizona. nomic recession. In previous periods of economic stress, crime rates increased. Yet preliminary statis- tics for 2009, released by the FBI in late December, Participants in the mental health court showed that rates for all types of crime had again experienced a 50 percent overall reduction in subsequent decreased from the year before. criminal charges in the 2 years after being in the program. As analysts struggled to explain this anomaly, few to none mentioned the role of community behavioral collaBoration iS Key demonstrated that it is worth it — and that no sub- health services. Yet many of us in the field know how As a community-based nonprofit organization, CPSA stantive and lasting change can happen without it. important our efforts have been in this regard — and has a large stake in the quality of life and public CPSA began this journey in the late 1990s by form- how much more we can accomplish. safety of the communities it serves — more than 1 ing a work group of behavioral health and criminal Community behavioral healthcare serves as an million people across five counties. Our work helps justice stakeholders in Tucson/Pima County that important partner for the criminal justice system, prevent crime, reduce recidivism, and divert people sought to identify systemic strategies to decrease whether by providing treatment which prevents be- with mental illness and substance use issues from the time people with a mental illness were inap- haviors that could bring people into contact with incarceration into less expensive, and more effec- propriately incarcerated. This group evolved into the law enforcement; training officers in how to deal tive, community-based treatment. current Forensic Task Force, which meets quarterly with people with mental illness who are in crisis; CPSA, the regional behavioral health authority over- and includes representatives of the court system, or preventing recidivism by ensuring continued and seeing publicly funded care in southern Arizona, has law enforcement, jails and corrections, local behav- coordinated treatment for people involved with the sought creative ways to collaborate with the crimi- ioral health providers, crisis services, attorneys, the justice system, leaving the justice system, or both. nal justice system. We’ve learned that: veterans’ hospital, and other community stakehold- 6 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 6. ers. The task force, along with collocated behavioral graduated from mental health court, even people the use of dwindling dollars but to create stronger, more health and criminal justice staff, provides the founda- professionals thought would not be successful.” efficient, more effective, and more humane systems tion and framework for all strategies and programs. in the long run. cUrrent conditionS deMand creativity Most of CPSA’s efforts in this collaboration have fallen Collaborations are especially critical now. Federal and The status quo is being shattered by fiscal realities. into two areas: diversion programs and service coordi- state governments face historic budget shortfalls, just We can seize this opportunity to create partnerships nation via information sharing (see article, p. 37). as expenditures on corrections across the country are with criminal justice and to educate decision makers CPSA also helped to establish Arizona’s first mental nearing a staggering $70 billion annually, according and the public about community behavioral health- health court in 1999 in Tucson and has founded ad- to the Bureau of Justice Statistics. Some states are care’s critical role in the safe diversion and release of ditional mental health courts in the Pima County Su- releasing inmates early, and many are increasingly people with substance use issues and mental illness. perior Court and Consolidated Justice Court. It also relying on community supervision as an alternative to We can make real connections between community developed a formal mental health collaboration with expensive incarceration. behavioral healthcare and criminal justice. And by every other limited-jurisdiction court in Pima County promoting our accomplishments to the larger com- At the same time, publicly funded behavioral health (six in total). CPSA has developed relationships and munity, we can emphasize our contribution to public services — the very resources that can help ensure the tools to allow swift identification of members who safety. success of these alternative justice approaches — are have been arrested and appropriate, real-time shar- in grave danger of being cut. ing of information while protecting confidentiality. With states struggling to cut costs and few lawmak- These relationships and tools expedite communica- ers willing to consider new revenue sources, the result tion between the community behavioral health treat- could be a mad, self-defeating scramble for funding ment provider and the jail’s treatment provider, ensur- among different systems and stakeholders. Alter- ing that members receive support in navigating the natively, our industry’s proactive engagement with criminal justice system while maintaining coordina- criminal justice could create collaboration instead of tion of care. chaos and lead to thoughtful changes and strategies Most recently, CPSA has established an Initial Appear- that result in real improvements at both the systems ance program, which involves community behavioral and individual levels — not only to make the best 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 Expenditures on corrections and advocate for members involved with the criminal across the country are nearing a staggering justice system and is again offering crisis intervention $70 billion annually. Some states are training to law enforcement in southern Arizona. releasing inmates early, and many are Participants in the mental health court experienced a 50 percent overall reduction in subsequent criminal increasingly relying on community charges in the 2 years after being in the program. The supervision as an alternative most recent annual figures for CPSA’s diversion pro- to expensive incarceration. At grams in Tucson City Court and Pima County Justice Court show graduation rates of 97 percent and 92 the same time, publicly funded percent, respectively — a total of 627 CPSA members behavioral health services — who avoided incarceration and had charges dropped. the very resources that can “Many people were skeptical about mental health help ensure the success of court,” noted the Hon. Nanette Warner, Judge of Supe- these alternative justice rior Court, Division 20, in a recent letter, “but with the leadership and the commitment from CPSA, it became approaches — are in grave a reality and allayed all concerns...The result has been danger of being cut. 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 NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 7
  • 7. Beyond Bars Human Rights at Home: Mental Illness in U.S. Prisons and Jails Printed with permission of David Fuller 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. “Mr. Chairman, Ranking Member Coburn, and dis- tinguished members of this Subcommittee, it is an In the few days it took for me to post bail I experi- enced suicidal thoughts and was actually stabbed This cycle would honor to provide testimony before this body. My by another inmate for the jacket I was wearing. I repeat itself many more purpose in testifying is to bring to light some of the was afraid to go to the clinic because I knew they experiences people with mental illness encounter would put me in isolation on suicide watch and I felt times: get out, no place to live, when they enter the criminal justice system and to punished enough. stop taking my medication, expose the inhumane treatment they receive. I have also included information on how this travesty in When I became eighteen years old, things were use drugs, become suicidal, not getting better for me. I was abusing drugs like human rights can start to be corrected. heroin and crack cocaine. My family did not know then go back to jail. With the ability of hindsight, I can say I started what to do. I was trying to outrun someone I could thirty times in that time period. I served sentences to experience depression at an early age. The first never outrun, myself. By the time I was twenty-one from ten days to one year. The first six to ten times I twinge of it was in elementary school at the time years old, I had been arrested several times for drug would ask my lawyer or the staff in the jail for help of Martin Luther King, Jr.’s assassination. I can re- possession/sale and gambling. I was using a large with the issues I had, I got the same answer every member thinking, “The people in this country will amount of drugs and got caught in a drug den dur- time — that is if they bothered to answer; that either never change. If they could kill a man as good as ing a police raid. I was facing a lot of time and was I went to drug treatment or the mental hospital. I him what chance do I have?” These thoughts were in scared to death. My family found me a good attor- knew one or the other by itself would not work, so I the context of experiencing racism through my en- ney who eventually got the charges dismissed and gave up asking for help from the system. tire life, from times visiting family in the rural south suggested that I seek drug treatment. I went to a as a young child to going to a majority white school long-term drug treatment facility in New York State. I Towards the last few years of my suffering, I ex- in my native New York from elementary through high did not like being there, but I thought maybe I could perienced my first hospitalization for psychiatric school. I think now, and feel seven years old is too get help with the problems I had been experiencing. reasons; it was after my first suicide attempt. I was young to feel hopelessness, especially in a country I told my counselor I thought I had more than just there for a couple of months. I went to therapy, and that has as much as this country. a drug problem — that I felt sad and lonely pretty I was put on medication. It helped; I became stable much all the time no matter what I did. I also told and was discharged from the hospital. I did not When I was seventeen I experienced my first arrest. him I thought about ending my life quite a bit. When have stable housing when I was discharged. I was New York City’s Rikers Island at that time was called he heard this, he warned me that if I mentioned referred to a “¾ house” to live and it was worse than the “gladiator school” by local youth. I was arrested that again I would be discharged from the program living on the streets, so that is what I did. I ended for illegal gambling because I had betted a few and sent to a mental hospital. I never mentioned it up not taking my medication, not participating in dollars on some numbers and was caught near the again. I graduated from the program after a year, therapy, and quickly re-offended. “number spot.” Honestly, I used to bet to get a thrill because even at that age, it was hard for me to feel went back home, picked up drugs again in less than When I went to jail the next time I didn’t stand up joy or happiness like other young men, so I used to two weeks, and was back in the street like nothing for the count. I was written up and put into punitive fill that void with thrill seeking and other non goal- ever changed. segregation (“the box”). In segregation, I was put in producing behaviors like drugs and alcohol use. This Through the next twenty years, I went back and a cold, dark, barren cell — no TV, no books — where charge was considered a misdemeanor in New York forth to jail. My ability to function was slowly, but the environment exaggerated my symptoms and I City [and] State. steadily, declining. I was arrested at least twenty or even experienced some new ones like audio hal- 8 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 8. lucinations. The officers were verbally and physically in hopelessness, shame, guilt, and fear of the future. special to share my life with. I learned to be a father, abusive. There was no point in making an official com- I believed God had abandoned me and things would a husband, a citizen — a man! plaint because the officers would just abuse you more never change. Eight years ago I never thought I would be able to say and nothing would ever be done about it. I turned down treatment a few times in the past when this, but I am happy, joyous, and free. Today, all things This cycle would repeat itself many more times: get I was in jail before because I was never offered a are possible! out, no place to live, stop taking my medication, use place [where] I could address my psychiatric disabil- Through my years of suffering, the government has drugs, become suicidal, then go back to jail. I remem- ity and my drug addiction at the same time, in the probably spent about one million dollars (not includ- ber I “caught a ticket” in jail one time and before they same place. I had been through treatment many times ing court and law enforcement costs) on incarceration could send me to the box I tried to hang myself in my for one or the other at different times and it seemed and treatments that just made my life worse and were cell, my cellmate found me before the officers did and to never work for me. ineffective in diminishing or eliminating the problem. untied the sheet. He did not tell the officers because I am happy to say things did change. The last time I All my drug use was a desperate attempt to medicate he knew what would happen. I wept in my cell the rest was incarcerated I was offered an opportunity to par- symptoms that I did not understand and that society of the night; I was discharged after two days. ticipate in a Mentally Ill/Chemically Addicted — resi- had made me ashamed and fearful to get help for. There were fights with other inmates almost every dential treatment rather than stay in jail. It turned my All of my arrests were due to my drug use. Why did I time I went to jail. Because of my depression, I would life around. I was able to be around people who had have to be punished so severely, for so long, for be- appear to be an easy victim and some of the other ing sick? inmates would try to steal my food. Most of the time Psychiatric disability and substance abuse are chronic I would win the fight, but lose the battle for my self- illnesses similar to hypertension or diabetes. The last esteem and self-respect — fighting for food like a time I checked, people with those illnesses were not common animal. Psychiatric disability being put in jail and shunned by society. People can “There is no HIPAA in jail” because there is really no and substance abuse live with all of these disorders with proper treatment privacy in regards to your psychiatric care. Either you are chronic illnesses similar to and support. are on the “Mental Observation Unit” with all the stig- hypertension or diabetes. The last In closing, I encourage everyone to read Ending an ma and dangers that implies, or you are living in gen- American Tragedy: Addressing the Needs of Justice-In- time I checked, people with those eral population where every time you go for medica- volved People with Mental Illnesses and Co-Occurring tion or need to see the doctor it is announced through illnesses were not being put in jail Disorders, which I have attached. the cell block. When you are getting your medication and shunned by society. you are on a line with a hundred other inmates and I believe this document can point this committee in inmates going back and forth on the other side of the the right direction in changing the way services are hall. People are buying and selling medication and given; in a cost-effective and humane way that ben- other illicit drugs. Everybody pretty much knows what similar experiences and I did not feel so alone. I talk- efits the community as a whole” the other person is getting. When you go to the “clinic” ed to people like me who had recovered and [were] Sincerely, to see the doctor you have to wait for hours on end on their way to happy, productive lives. For the first time in a long time, I had real hope for the future. David L. Fuller and once again, everybody knows what you are there for. You can hear staff talking about other patients I learned I had to be honest, open-minded, and willing David Fuller, CPRP, a consumer in recovery from psychiatric when you are meeting someone about yourself, so to do the footwork in order to recover. I had to take disability, substance abuse, and the criminal justice system, is you think about whether they talk about you when you responsibility for my life. I gained a relationship with employed at Kings County Hospital Center in Brooklyn as a peer leave, so you do not share much and do not get the a higher power that I choose to call God. I confronted counselor who coordinates the Adult Outpatient Walk-In Clinic and help you need. my fears and insecurities and made friends with other a group facilitator with its Continuing Day Treatment Program. He is also an outreach and housing coordinator for the Manhattan For 28 years of my life, I struggled with depression people, some like me and some that did not have Outreach Consortium. As an administrator, service provider, and and then later [posttraumatic stress disorder]. I used the same experiences as me. I did not use my past independent consultant, Fuller draws on his personal experiences as an excuse to fail; I used it as a source of strength as a consumer — and his opportunity to overcome many chal- hard drugs most of this period and it seemed like I lenges — to fuel his mission to improve access to services for was always going in and out of jail. Violence was al- and truth to move me forward. I learned to love again; people who have been affected by psychiatric diagnoses and who ways around me. Through my periods in jail and being first myself and then others. I learned to forgive. It use the public mental health system. Fuller is also a member of homeless I have been stabbed and shot. I was abused set me free. the National Leadership Forum on Behavioral Health/Criminal Justice with the National GAINS Center; an advisory board by the very people and system that were supposed to I went back to work with the help of my peers at the member of the Peer Integration Project through the Columbia be helping me, and keeping me safe. I did not have Howie T. Harp Advocacy Center, a supportive employ- School of Social Work’s Workplace Center; a guest lecturer at the Columbia, Adelphi, and New York Universities Schools of Social access to the services I needed; I was alienated from ment/training center for people with histories similar Work on trauma and mental health recovery models. friends and family. I felt isolated and alone. I dwelled to my own, got a place to live, and found someone NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 9
  • 9. Beyond Bars Ending an American Tragedy: Addressing the Needs of Justice-Involved People with Mental Illnesses and Co-Occurring Disorders 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 It is my privilege to co-chair the National Leadership Forum for Behavioral Health/Criminal I n 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 Justice Services. Ending an American Tragedy: care. Over the next century, without sustained commitment to Dix’s vision for recovery, these facilities Addressing the Needs of Justice-Involved People fell into disrepair to the point that today, hundreds of thousands of people with mental illnesses crowd With Mental Illnesses and Co-Occurring Disorders our county jails and state prisons. is a working document of the NLF. The report is designed as both a call to action, focusing on the In 1946, Life Magazine published an exposé detailing cruel and inhumane conditions in State psychi- crisis in our nation’s jails and prisons — men and atric hospitals across the United States.1 The article described widespread abuse of patients resulting, women with mental illnesses and addictions in part, from “public neglect and legislative penny pinching;” and was punctuated by a series of incarcerated because they didn’t get the treat- haunting photographs depicting desolate and shameful conditions under which people with mental ments they desperately need — and an inspiration illnesses were being confined, often for years or even decades on end. The author referenced grand — highlighting the possibilities of effective jury reports as well as State and Federal investigations documenting widespread abuses and hazard- services. We are asking leaders in all communities ous living conditions in State institutions. Citing severely inadequate staffing, substandard treatment, to come together, pool resources, and work as inappropriate use of restraints, and provision of little more than custodial care, the institutions were one. I’m proud of member organizations that are described as, “…costly monuments to the States’ betrayal of the duty they have assumed to their already providing such leadership and you’ll find most helpless wards” a small sample of member programs in the “From Although the population of State psychiatric hospitals continued to grow over the next decade, the the Field” section of this issue. National Council publication of this article, along with similar accounts from other media sources, began to expose members are endlessly creative in overcoming a crisis that had existed largely hidden from public view for far too long. As more light was shed on financial, bureaucratic, and cultural barriers and the horrific treatment people received in State psychiatric hospitals, along with the hope offered by establishing collaborations that solve community the availability of new medications, a flurry of federal lawsuits resulted in court decisions leading to problems. And we look forward to the growth and substantial reductions in the numbers of people housed in State psychiatric hospitals. spread of programs and services that offer Unfortunately, while State hospital beds were shut down by the thousands, the types of comprehensive productive lives to people with mental illnesses community-based services and supports promised as a condition of their closing were never developed. and addictions as the alternative to incarceration.” Combined with changes in sentencing practices, evolution of quality of life ordinances, and restricted — Linda Rosenberg definitions of eligibility for public sector behavioral health services, this has resulted in many individu- 10 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 10. als with mental illnesses and co-occurring substance ple and respect the legitimate public safety concerns on suicide watch for making statements about use disorders repeatedly coming into contact with of all community members, conditions in these cor- going to sleep and not getting up and ‘not caring the criminal justice system. Our Nation is once again rectional settings, which are designed for detention if she was alive or not.’ Her medical record notes in the midst of another shameful and costly mental and not therapeutic purposes, are often far worse numerous instances of ‘talking wildly’ and ‘talking health crisis that has been allowed to fester and grow, than conditions described in the State hospitals of to herself.’ She told us that she had a history of largely out of public sight. It is a secret of stunning the 1940s. Moreover, when justice-involved persons hypothyroidism and told us the names of various proportions; in numbers and in harm. with co-occurring disorders leave correctional institu- psychiatric medications that she had been taking Everyday, in every community in the United States, tions, they repeatedly are left adrift only to recycle before being admitted to [the jail]. Throughout our our law enforcement officers, courts, and correctional through the criminal justice system. Furthermore, tour, we could hear JM moaning and crying and at institutions are witness to a parade of misery brought individuals who become involved in the justice sys- times screaming. In spite of all this, this inmate on by an inadequately funded, antiquated, and frag- tem often must contend with the additional stigma of was never evaluated by a mental health care pro- mented community mental health system that is un- criminal records, which make access to basic needs vider. We were told that she was not started on any able to respond to the needs of people with serious in the community, such as housing, education, and psychiatric medications or sent to the local hos- mental illnesses. Each year, more than 1.1 million employment, even more difficult to obtain. pital because she did not have the ability to pay. people diagnosed with mental illnesses are arrested This national disgrace, kept hidden for too long, >> Inmate M.K. hung herself on January 5, 2003 af- and booked into jails in the United States. Roughly represents one area in civil rights where we have ter having been admitted on December 4, 2002. three-quarters of these individuals also experience actually lost ground. This failed policy has resulted in Her record contained the following inmate request co-occurring substance use disorders, which increase a terrible misuse of law enforcement, court, and jail form dated two days before her death on January their likelihood of becoming involved in the justice resources, reduced public safety, and compromised 3, 2003. The note indicated the following. system. On any given day, between 300,000 and public health. ‘I need to see the doctor to get my medicine 400,000 people with mental illnesses are incarcer- These conditions have recently resulted in investiga- straightened out. I am not getting my meds ated in jails and prisons across the United States, and tions into the treatment of people with mental illnesses that my doctor faxed prior orders for me, and more than 500,000 people with mental illnesses are in institutional settings, only this time the institutions I brought in the medication myself and paid under correctional control in the community. are correctional facilities that were never intended to for it. I cannot afford to be treated this way! Over the past 50 years we have gone from institutional- serve as de facto psychiatric hospitals. Over the past Please help me! I need my medicine.’ izing people with mental illnesses, often in subhuman decade alone, the U.S. Department of Justice has There is no indication that M.K. received her medi- conditions, to incarcerating them at unprecedented issued findings from investigations of mental health cation before her death. and appalling rates — putting recovery out of reach conditions in more than 20 jail and prison systems for millions of Americans. across the United States, with additional investiga- There are no comparable Department of Justice inves- tions currently ongoing. Equally reminiscent of the tigations into a lack of community services, because These people are not all the same. They are a hetero- there is no constitutional right to community-based geneous group. past, among the more pervasive findings from these investigations are severely inadequate staffing, sub- services as there is for persons who are incarcerated. >> A small subgroup does resemble the State hos- standard treatment, inappropriate use of restraints, However, by contrast, there are success stories in the pital patients of yesteryear, and their presence in and provision of little more than custodial care. community. A recent report by the Health Foundation our jails/prisons is one of the most egregious and of Greater Cincinnati offers a number of compelling disturbing images related to our failed systems of The following excerpts are taken from recent grand personal stories from four Forensic Assertive Commu- care. The availability of intensive care models, in- jury and Department of Justice reports: nity Treatment (FACT) Teams they fund. cluding hospital care for some, is critical. >> During our tour, we observed inmate JM hitting her >> Many other citizens with mental illnesses in our head on the window of her cell and talking with jails have less disabling conditions and with ac- slurred speech. She was housed in a hospital cell cess to appropriate community treatment and under suicide watch. She spoke of seeing angels Clearly, jails and prisons were support, will do quite well. and said that she was afraid of her cellmate (who never intended as a community’s was in the advanced stages of pregnancy) was >> A third subgroup includes people with mental ill- primary setting to provide acute trying to harm her. She had been at [the jail] for nesses who have traits that are associated with approximately one month prior to our visit. JM care services to individuals high arrest and recidivism rates. These individuals stated on her intake form that she had previously experiencing serious mental would be best served with good treatment and been treated at a mental hospital in Little Rock supports, which include interventions targeted to illnesses. In most cases they and that she had been seen at a local hospital in their dynamic risk factors for arrest. January 2005 for seeing ‘spiritual things.’ Shortly are ill equipped to do so. As we attempt to respond to the needs of these peo- after her admission to [the jail], she was placed NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 11
  • 11. Beyond Bars 2002 and 2008 reported at least one incident of In the absence of what are now seen as essential services physical or sexual abuse in their lifetime. Sixty- one percent reported physical or sexual abuse in for people with mental illnesses living in the community, the last 12 months. Yet few programs, institutional people will continue to be forced into more costly, deep-end or community-based, offer environments that are services in hospitals, crisis centers, emergency rooms, and trauma informed or trauma specific. the justice system. Moreover, a recent study found 31 percent of women being booked into local jails with current >> “My housing is a lot better. My Social Security cal community-based settings. This is due in large symptoms of serious mental illness.2 This compares just got approved today, so I start receiving that part to rules and regulations that limit flexibility with 14 percent of men. These rates exacerbate the again. They cut it off while I was in prison. I did in designing service and reimbursement strategies issues of providing adequate services for women in 18 months in prison. I got [Social Security] back targeting the specific needs of people with serious predominantly male facilities whose physical plants with the help of [the FACT team]. And they’ve mental illnesses. For example, the Substance Abuse and staffing are geared to men. Gender-specific ser- been helping me with my housing. And that’s a and Mental Health Services Administration (SAMH- vices that reflect a trauma-informed culture must lot better ‘cause now I can get adjusted to a cer- SA) and the Centers for Medicare and Medicaid Ser- be developed in all institutional and community tain environment. And I don’t have to worry about vices (CMS) are two agencies housed within the U.S. settings to respond to the frighteningly high rates where I’m going to live, one week to the next for Department of Health and Human Services (DHHS). of mental illness among women in contact with the whatever reason.” SAMHSA has identified intensive case management, criminal justice system. >> “Well, I was really in bad shape. I didn’t know psychosocial rehabilitation, supported employment, In addition, we know that individuals using mental how to go about getting help. The only thing that and supported housing as evidence-based inter- health services — often referred to as “consumers”— I really knew that I had to do was try to care ventions, consistently yielding positive outcomes for have a significant impact on creating recovery-ori- for myself and my habit. And that’s what leads persons with serious mental illnesses. ented mental health and substance abuse services. to criminal behavior, which limited me on jobs. However there are several obstacles to using Medic- For people involved in the criminal justice system, I felt like I couldn’t work because of my record. aid to pay for these effective services. These include forensic peer specialists — those with histories of So, I had to keep being a criminal to support my- categorical restrictions on eligibility, which exclude mental illness and criminal justice system involve- self and my habit. I didn’t know where to go for many people with serious mental illnesses and co- ment — can help pave the way for a successful re- help. I didn’t know who to talk to. I was suicidal occurring substance use disorders who have been turn to the community. all the time. And I really hated myself for all the involved in the criminal justice system, as well as The ability to effectively design, implement, and feelings and things that I was doing. I had an fragmentation in coverage for treatment of medical, reimburse treatment providers for delivering high apartment but I was evicted because I couldn’t mental health, and substance abuse problems. Nar- quality services targeting specialized treatment pay the rent. And then, I was just, like, going from row criteria for “medical necessity” and definitions needs is critical to establishing an effective com- place to place and sometimes in homeless shel- of covered services that are often not aligned with munity-based system of care for people who expe- ters and sometimes with friends or just wherever. what we know about evidence-based practices cre- rience serious mental illnesses. In the absence of I was in jail all the time. I just spent two years ate barriers to more effective service delivery and what are now seen as essential services for peo- in the penitentiary. I’ve been in the penitentiary recovery outcomes. As a result, there is an increased ple with mental illnesses living in the community, 3 times and I’ve been in jail probably 30 to 40 demand for services provided in hospitals, emer- people will continue to be forced into more costly, times.” The same consumer, when asked about gency settings, and the justice system, contributing deep-end services in hospitals, crisis centers, emer- life after receiving FACT services, reported: “Yeah, to extraordinarily high costs for local communities, gency rooms, and the justice system. I haven’t had any problems. I work at McDonalds states, and the Federal government. The result is a recycling of individuals between jails, full-time.” Furthermore, new practices have been slow to be prisons, shelters, short-term hospitalizations, and Clearly, jails and prisons were never intended as a made available to justice-involved persons with homelessness — with public health, public safety, community’s primary setting to provide acute care co-occurring disorders. For example, it has now be- and public administration implications that are services to individuals experiencing serious mental come widely accepted that all services for people staggering. Now more than ever, as we strive to illnesses. In most cases they are ill equipped to do so. with serious mental illnesses, particularly those with provide health care to our most vulnerable citizens, When we look at community-based services, we find criminal justice involvement, be trauma-informed. we must address this serious public health and current policies governing the funding and organiza- Among both women and men with criminal justice public safety crisis. It is high time to be open and tion of community mental health care have resulted involvement, histories of trauma are nearly univer- honest about the deplorable conditions that ex- in people with more intensive and chronic treat- sal. Ninety-three percent of 2,000 women and men ist and take steps to address them. We offer four ment needs being underserved or unserved in typi- in federally funded jail diversion programs between recommendations for immediate action. 12 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 12. Beyond Bars tal illnesses and co-occurring substance use disor- be effective if the programs that provide them are ders, programs should seek to establish more ef- structured and staffed by people who understand fective integration of primary and behavioral health and are prepared to address trauma as a risk fac- recoMMendationS care service delivery system as well. tor for both mental health problems and criminal justice involvement. A trauma-informed system that For iMMediate action u All States should create cross-system features trauma-specific interventions can help en- agencies, commissions, or positions charged with removing barriers and creating incen- sure public health and public safety and transform tives for cross-agency activity at the State individuals’ lives. and local level. Forensic Intensive Case Management (FICM) is u The President should appoint a Special No one system can solve this problem alone. These designed for justice-involved people with multiple Advisor for Mental Health/Criminal Justice cross-system groups or individuals will play a key and complex needs and features services provided Collaboration. role in spanning the different administrative struc- when and where they are needed. FICM focuses on Currently, there is no fixed responsibility within the brokering rather than providing services directly, tures, funding mechanisms, and treatment philoso- Federal government to promote effective mental making it less expensive than ACT. For a brokered phies of the mental health, substance abuse, and health/criminal justice activities and ensure ac- service model to be effective, communities must criminal justice systems. States must make clear countability for the use of public dollars. The Special have adequate and accessible services to which in- that collaboration is not only possible but expected. Advisor will serve as an advocate and ombudsman dividuals can be linked. What makes these services In Montana, for example, the State Department of across the wide array of Federal agencies that serve “forensic” is “criminal justice savvy,”3 that is, pro- Corrections and Department of Public Health and the multiple needs of justice-involved people with viders understand the criminal justice system and Human Services jointly fund a boundary spanner mental and substance use disorders. One of his or the predicaments of their clients involvement in it. position that facilitates shared planning, communi- her tasks will be to implement an immediate re- cation, resources, and treatment methods between Supportive Housing is permanent, affordable hous- view of all CMS and SAMHSA regulations to identify the mental health and criminal justice systems. ing linked to a broad range of supportive services, conflicts and inconsistencies for people with mental u Localities must develop and implement including treatment for mental and substance use illnesses and co-occurring substance use disorders core services that comprise an Essential Sys- disorders. Supportive housing can significantly de- — particularly those involved in the justice system. tem of Care: crease the chance of recidivism to jails and prisons u Federal Medicaid policies that limit or and is less costly on a daily basis than jail or prison. discourage access to more effective and Recognizing the limited resources often available and the complexities of the cross-system collabora- Unfortunately, affordable housing is in short supply cost-efficient health care services for indi- tions required, the eight components of an Essential in many communities, and ex-offenders with drugre- viduals with serious mental illnesses and System of Care are best approached in two phases. lated offenses often have trouble securing public co-occurring substance use disorders should Phase 1 includes less expensive, easier to mount housing assistance. Housing for ex-offenders must be reviewed and action taken to create more services. Phase 2 includes essential evidence- balance the needs for supervision and the provision efficient programs. based practices that are more expensive and more of social services. Congress is encouraged to review Medicaid policies challenging to implement, but are critical to actu- Peer Support services can expand the continuum and take action that will enable states to create ally increasing positive public safety and public of services available to people with mental and more effective and appropriate programs target- health outcomes. substance use disorders and may help them engage ing eligible beneficiaries most likely to experience in treatment. Forensic peer specialists bring real- avoidable admissions to acute care settings. Such PhasE 1 world experience with multiple service systems and programs should allow states flexibility in designing and implementing targeted outreach and engage- >> Forensic Intensive Case Management an ability to relate one-on-one to people struggling to reclaim their lives. The practice of consumer- ment services, coordinated care management, >> Supportive Housing driven care — as exemplified by the involvement of and community support services that are likely to >> Peer Support mental health consumers in service design, delivery, reduce expenditures on deep-end services, and en- gage people in prevention, early intervention, and >> Accessible and Appropriate Medication and evaluation — is at the heart of a transformed mental health system. wellness care in the community. Services provided These four services are the ones we believe are should reflect evidence-based and promising prac- minimally necessary to break the cycle of illness, Accessible and Appropriate Medication supports tices and should be designed around principles of arrest and incarceration, and recidivism. We believe continuity of care for individuals with mental ill- recovery, person-centered planning, and consumer these services — described in brief below — can nesses whose treatment often is disrupted when choice. Because of the high rates of co-morbid be implemented quickly, cost-effectively, and with they become involved in the criminal justice system. health care needs among people with serious men- positive results. However, these services can only They may not receive appropriate medication in 14 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 13. 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 To meet the public health and public safety needs disorders have access to the right medication at the of our communities demands a fully collaborative right dosage for their condition, as determined by the individual together with his or her clinician. campaign involving both the behavioral health PhasE 2 and criminal justice systems. Neither system can Clearly, the Phase 1 services are necessary, but not continue business as usual. 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 NaTioNaL LeaDeRSHip FoRum memBeRS the four listed above, but we encourage States and business as usual. The criminal justice system needs Thomas Berger to do an adequate job of screening, assessing, and Vietnam Veterans of America communities to move toward development of these individualizing responses to detainees and inmates Sandra Cannon services by codifying them in policy, supporting them Ohio Department of Mental Health in practice, and rewarding their implementation. identified with mental illness. The behavioral health Neal Cash system needs to refine and deliver evidence-based Community Partnership of Southern Arizona Phase 2 services include: practices with an awareness of its responsibility to not David Fuller Manhattan Outreach Consortium >> Integrated Dual Diagnosis Treatment, which only improve the quality of life of its clients, but to ad- Robert Glover provides treatment for mental and substance use dis- dress interventions to factors associated with criminal National Association of State Mental Health Program orders simultaneously and in the same setting recidivism in these clients and to more directly involve Directors clients as partners in a recovery process that recog- Gilbert Gonzales >> Supported Employment, which is an evidence- Bexar County Mental Health Authority Center for Health based practice that helps individuals with mental ill- nizes the community’s public safety concerns. Care Services nesses find, get, and keep competitive work Prime examples of this Essential System of Care have Richard Gowdy Missouri Department of Mental Health >> Assertive Community Treatment (ACT)/ Foren- been developed within the CMHS TCE Jail Diversion Jennifer Johnson sic Assertive Community Treatment (FACT), which program since 2002. San Antonio, TX, has become a San Francisco Office of the Public Defender is a service delivery model in which treatment is pro- national model with a highly integrated system of care Hon. Steve Leifman Special Advisor on Criminal Justice and Mental Health to vided by a team of professionals, with services deter- that reflects strong behavioral health and criminal Florida Supreme Court mined by an individual’s needs for as long as required, justice partnerships that have resulted in a central- Stephanie LeMelle and ized police drop-off that directly links persons to case New York State Psychiatric Institute, Columbia University Department of Psychiatry management, medications, housing, and peer sup- >> Cognitive Behavioral Interventions Targeted to port. A medium-size city that has built a comprehen- Ginger Martin Oregon Department of Corrections Transitional Services Risk Factors specific to offending, are a set of in- sive, integrated system around an existing community Division terventions, well researched within both institutional mental health center is Lincoln, NB. These are but two John Morris settings and community settings, that have a utility examples of successfully moving entire communities The Technical Assistance Collaborative when extended to community treatment programs. Fred Osher forward via a jail diversion program to achieve Phase Council of State Governments Justice Center This list of evidence-based and promising practices is 1 services and move towards Phase 2 implementa- Linda Rosenberg* illustrative but not exhaustive. Clearly, however, there tion. These goals are achievable even in today’s eco- National Council for Community Behavioral Healthcare is much that can be done to help people with mental nomic tough times. David Shern Mental Health America and substance use disorders avoid arrest and incar- We must move toward a day when people with men- Henry J. Steadman* ceration and return successfully to their communities tal and substance use disorders receive the effec- Policy Research Associates, CMHS National GAINS Center after jail or prison. We acknowledge that in difficult tive community-based interventions they need and Carol Wilkins Corporation for Supportive Housing financial times, new dollars may not be available. deserve, and jails and prisons no longer are forced B. Diane Williams However, though new money is not always required for to serve as primary, de facto treatment facilities. We Safer Foundation systems change, new ways of thinking are. know what works to address successfully the needs Dee Wilson Texas Department of Criminal Justice To meet the public health and public safety needs of people with mental and substance use disorders Sharon Wise of our communities demands a fully collaborative who come in contact with the criminal justice system; The Gregory Project of Washington D.C. campaign involving both the behavioral health and now we have to DO what works. The time for action *Co-chair of National Leadership Forum criminal justice systems. Neither system can continue is now! NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 15
  • 14. Interview Behavioral Health and Criminal Justice Collaboration: Where Does the Buck Stop? 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 Linda Rosenberg, MSW, President & CEO, National National Council: As a state official in New York, there must be a single point of Council for Community Behavioral Healthcare, shares her thoughts about the current status of treatment for you were a strong supporter of the state’s first mental accountability. if everyone is respon- health court. What benefits do such courts bring to sible, then no one is responsible.” justice-involved individuals with mental illness and ad- providers and the individuals they serve? diction. Committed to supporting the efforts of member organizations to address the problems of their communi- Linda: I’ve seen mental health courts and to an even crack for someone to fall through. The system has got- ties, Rosenberg has positioned the National Council to greater extent, drug courts, emerge as a powerful ten so rich and so complicated — multiple programs promote the expansion of community based alternatives means through which people access care. In many and services, most under different corporate auspices to incarceration. Prior to her position at the National places the court begins with a judge who has personal and each with its unique rules and operating practices Council, she served as the Senior Deputy Commissioner and/or professional interest in behavioral health is- — that it’s difficult to navigate it. A person’s treatment for the New York State Office of Mental Health, during sues. Mental health and drug courts aren’t meant to is run by one organization, their housing by another, which time she oversaw the state’s services for justice-in- be applied broadly — these courts are alternatives for their employment supports by another — and getting volved individuals, implementing a network of jail diversion people with serious mental illnesses and addictions all these organizations on the same page and at the programs including New York’s first mental health court. that are on the way to jail or prison. And like AOT, there same table becomes nearly impossible. It is very, very must be seamless connections to the full continuum of National Council: What challenges exist in serving treatment and support services. These problem-solving difficult to coordinate services. justice-involved people with mental illness and addic- tions? courts give individuals with serious behavioral health National Council: What can be done to support co- disorders a unique opportunity to engage with a judge ordinated treatment? Linda: There are many challenges in connecting jus- around their needs. The courts provide alternatives to tice involved consumers with services. We’re talking Linda: I think in the end we need a system where one people with mental illnesses and addiction — offering organization/person is responsible. If everyone is re- primarily about people with little money or power and services instead of time behind bars. they may have little or no interest in mental health or sponsible, then no one is responsible. The buck has addictions treatment services. They’ve not found ser- National Council: How can states move forward in to stop somewhere and I think it needs to stop with vices useful or relevant and often dislike programs that creating programs for justice-involved persons in this an organization that gets an adequate pot of money are highly structured. Our job at the National Council era of budget cuts? What role do community providers and ensures that the consumer gets the services they is to identify member organizations that have devel- play? need and want. With adequate financing, clarity as to oped successful services for this population and then what treatments and services are effective and the de- Linda: Change is often incremental in our very complex livery of those interventions, use of health information to facilitate the member to member spread of these world but it looks like we’ve reached a tipping point in programs. technology, and the ongoing measurement of simple regard to diversion and re-entry. Policy change is often outcomes — hospitalization, incarceration and home- National Council: New York has an assisted outpa- driven by a convergence of ideas and money. States lessness — we can coordinate care and go a long way tient treatment law — what is the controversy behind are in tremendous economic distress and can’t con- toward supporting successful community tenure. That such laws? tinue to build new jails and prisons or support grow- doesn’t mean that all justice-involved people will have ing numbers of incarcerated individuals. At the same a straight trajectory to recovery. Some people will be Linda: Some view these laws as victimizing — blaming time it’s becoming clear that treatment and services hospitalized and some might be incarcerated or be- — people with mental illness. In a perfect world, court works and are less expensive alternatives. Look at the come homeless. We can do better but challenges will ordered treatment would be unnecessary but in our President’s budget proposal – growth in financing of remain. Our jobs are to address the challenges, always world the combined power of the court and treatment alternatives to criminal justice involvement. This is an exploring new approaches and refining our efforts to can mean successful community living for consumers area where there is both new money and potential for improve lives. that would otherwise be in and out of hospital or jail. re-investment of dollars currently directed to incarcer- Assisted Outpatient Treatment must be carefully used ation. And as always leadership is essential — excited Mohini Venkatesh serves as the staff policy liaison to the but when all else fails it can connect people to vital by the possibilities, local leaders emerge, enlist others National Council for Community Behavioral Healthcare’s services. But AOT alone isn’t enough — a full array of network of associations throughout the states, conducts federal in their vision, and the money follows. legislative and policy analysis on an array of issues, and man- community services including housing, effective treat- ages political engagement activities including an annual Hill ments, work supports, and general medical care must National Council: How does the justice-involved Day in Washington, DC. She received a masters in public health be available and accessible. Unfortunately passage of population “fall through the cracks?” from Yale University and a BA in psychology from the University AOT is often a political reaction to an unfortunate inci- of Massachusetts-Amherst. dent — a law is passed with no financing of the services Linda: The falling through the cracks problem is not Nathan Sprenger supports the National Council’s public rela- unique to justice-involved individuals. Every time we tions and marketing efforts, leads the social media activities, that are critical if we’re going to keep both individuals maintains the website, and serves as editorial assistant for with mental illnesses and our communities safe. create a new program or service to keep people from National Council Magazine. He has a masters degree in public falling through the cracks, we are creating another communication from American University in Washington DC. 16 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 15. For the treatment of alcohol dependence VIVITROL... there when they need it. Tell Your Patients About Our Co-Pay Assistance Program Up to 6 months of medication with potentially no out-of-pocket costs* For more information, call toll-free 1-800-VIVITROL (1-800-848-4876, ext. 2). * 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 Naltrexone has the capacity to cause hepatocellular injury when given in excessive doses. in Massachusetts. Void where prohibited by law, taxed or restricted. Alkermes, Inc. reserves the right to rescind, Naltrexone is contraindicated in acute hepatitis or liver failure, and its use in patients with active liver revoke or amend these offers without notice. disease must be carefully considered in light of its hepatotoxic effects. indicaTion1 The margin of separation between the apparently safe dose of naltrexone and the dose causing VIVITROL is indicated for the treatment of alcohol dependence in patients who are able to abstain ® hepatic injury appears to be only five-fold or less. VIVITROL does not appear to be a hepatotoxin at the from alcohol in an outpatient setting prior to initiation of treatment with VIVITROL. recommended doses. Patients should not be actively drinking at the time of initial VIVITROL administration. 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 Treatment with VIVITROL should be part of a comprehensive management program that includes and/or signs of acute hepatitis. psychosocial support. imPorTanT safeTy informaTion for ViViTrol1 VIVITROL is administered as a gluteal intramuscular injection. Inadvertent subcutaneous injection of VIVITROL may increase the likelihood of severe injection site reactions. VIVITROL must be injected using VIVITROL is contraindicated in patients receiving opioid analgesics or with current physiologic the customized needle provided in the carton. Because needle length may not be adequate due to body opioid dependence, patients in acute opiate withdrawal, any individual who has failed the naloxone habitus, each patient should be assessed prior to each injection to assure that needle length is adequate challenge test or has a positive urine screen for opioids, or in patients who have previously exhibited for intramuscular administration. VIVITROL injection site reactions may be followed by pain, tenderness, hypersensitivity to naltrexone, PLG, carboxymethylcellulose or any other components of the diluent. induration, swelling, erythema, bruising or pruritus; however, in some cases injection site reactions may be VIVITROL patients must be opioid free for a minimum of 7-10 days before treatment. Attempts to overcome very severe. Injection site reactions not improving may require prompt medical attention, including in some opioid blockade due to VIVITROL may result in a fatal overdose. In prior opioid users, use of opioids after cases surgical intervention. discontinuing VIVITROL may result in a fatal overdose because patients may be more sensitive to lower Consider the diagnosis of eosinophilic pneumonia if patients develop progressive dyspnea and hypoxemia. doses of opioids. Patients requiring reversal of the VIVITROL blockade for pain management should be In an emergency situation in patients receiving VIVITROL, suggestions for pain management include regional monitored by appropriately trained personnel in a setting equipped for cardiopulmonary resuscitation. analgesia or use of non-opioid analgesics. Alcohol dependent patients, including those taking VIVITROL, should be monitored for the development of depression or suicidal thoughts. Caution is recommended in administering VIVITROL to patients with moderate to severe renal impairment. The most common adverse events associated with VIVITROL in clinical trials were nausea, vomiting, Please see brief summary of ViViTrol Prescribing informaTion, headache, dizziness, asthenic conditions and injection site reactions. including boxed warning, on The nexT Page. 1. VIVITROL [full prescribing information]. Waltham, MA: Alkermes, Inc; May 2009. VIVITROL is a registered trademark of Alkermes, Inc. ©2010 Alkermes, Inc. All rights reserved VIV 981 B January 2010 Printed in U.S.A. www.vivitrol.com
  • 16. BRIEF SUMMARY See package insert for full Prescribing Information. intramuscular injection with the provided needle. Patients should be informed that any injection site INDICATIONS AND USAGE: VIVITROL is indicated for the treatment of alcohol dependence in patients reactions should be brought to the attention of the healthcare provider (see INFORMATION FOR PATIENTS). who are able to abstain from alcohol in an outpatient setting prior to initiation of treatment with Patients exhibiting signs of abscess, cellulitis, necrosis or extensive swelling should be evaluated by a VIVITROL. Patients should not be actively drinking at the time of initial VIVITROL administration. physician. Renal Impairment VIVITROL pharmacokinetics have not been evaluated in subjects with Treatment with VIVITROL should be part of a comprehensive management program that includes moderate and severe renal insufficiency. Because naltrexone and its primary metabolite are excreted psychosocial support. CONTRAINDICATIONS: VIVITROL is contraindicated in: • Patients receiving primarily in the urine, caution is recommended in administering VIVITROL to patients with moderate to opioid analgesics (see PRECAUTIONS). • Patients with current physiologic opioid dependence (see severe renal impairment. Alcohol Withdrawal Use of VIVITROL does not eliminate nor diminish alcohol WARNINGS). • Patients in acute opiate withdrawal (see WARNINGS). • Any individual who has failed withdrawal symptoms. Intramuscular injections As with any intramuscular injection, VIVITROL should the naloxone challenge test or has a positive urine screen for opioids. • Patients who have previously be administered with caution to patients with thrombocytopenia or any coagulation disorder (e.g., exhibited hypersensitivity to naltrexone, PLG, carboxymethylcellulose, or any other components of the hemophilia and severe hepatic failure). Information for Patients Physicians are advised to consult Full diluent. 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 WARNINGS: Hepatotoxicity 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, Naltrexone has the capacity to cause hepatocellular injury when given in excessive doses. 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 Naltrexone is contraindicated in acute hepatitis or liver failure, and its use in patients with active liver taking VIVITROL without antidepressants. Carcinogenesis, Mutagenesis, Impairment of Fertility disease must be carefully considered in light of its hepatotoxic effects. Carcinogenicity studies have not been conducted with VIVITROL. Carcinogenicity studies of oral naltrexone The margin of separation between the apparently safe dose of naltrexone and the dose causing hydrochloride (administered via the diet) have been conducted in rats and mice. In rats, there were small hepatic injury appears to be only five-fold or less. VIVITROL does not appear to be a hepatotoxin at the increases in the numbers of testicular mesotheliomas in males and tumors of vascular origin in males and recommended doses. females. The clinical significance of these findings is not known. Naltrexone was negative in the following Patients should be warned of the risk of hepatic injury and advised to seek medical attention if they in vitro genotoxicity studies: bacterial reverse mutation assay (Ames test), the heritable translocation experience symptoms of acute hepatitis. Use of VIVITROL should be discontinued in the event of symptoms assay, CHO cell sister chromatid exchange assay, and the mouse lymphoma gene mutation assay. and/or signs of acute hepatitis. 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 Eosinophilic pneumonia In clinical trials with VIVITROL, there was one diagnosed case and one mg/kg/day (600 mg/m2/day). There was no effect on male fertility at this dose level. The relevance of these suspected case of eosinophilic pneumonia. Both cases required hospitalization, and resolved after observations to human fertility is not known. Pregnancy Category C Reproduction and developmental treatment with antibiotics and corticosteroids. Should a person receiving VIVITROL develop progressive studies have not been conducted for VIVITROL. Studies with naltrexone administered via the oral route dyspnea and hypoxemia, the diagnosis of eosinophilic pneumonia should be considered (see ADVERSE have been conducted in pregnant rats and rabbits. Teratogenic Effects Oral naltrexone has been shown REACTIONS). Patients should be warned of the risk of eosinophilic pneumonia, and advised to seek to increase the incidence of early fetal loss in rats administered ≥30 mg/kg/day (180 mg/m2/day) and medical attention should they develop symptoms of pneumonia. Clinicians should consider the possibility rabbits administered ≥60 mg/kg/day (720 mg/m2/day). There are no adequate and well-controlled studies of eosinophilic pneumonia in patients who do not respond to antibiotics. Unintended Precipitation of of either naltrexone or VIVITROL in pregnant women. VIVITROL should be used during pregnancy only if Opioid Withdrawal—To prevent occurrence of an acute abstinence syndrome (withdrawal) in the potential benefit justifies the potential risk to the fetus. Labor and Delivery The potential effect of patients dependent on opioids, or exacerbation of a pre-existing subclinical abstinence syndrome, VIVITROL on duration of labor and delivery in humans is unknown. Nursing Mothers Transfer of naltrexone patients must be opioid-free for a minimum of 7-10 days before starting VIVITROL treatment. Since and 6β-naltrexol into human milk has been reported with oral naltrexone. Because of the potential for the absence of an opioid drug in the urine is often not sufficient proof that a patient is opioid-free, tumorigenicity shown for naltrexone in animal studies, and because of the potential for serious adverse a naloxone challenge test should be employed if the prescribing physician feels there is a risk reactions in nursing infants from VIVITROL, a decision should be made whether to discontinue nursing or of precipitating a withdrawal reaction following administration of VIVITROL. Opioid Overdose to discontinue the drug, taking into account the importance of the drug to the mother. Pediatric Use The Following an Attempt to Overcome Opiate Blockade VIVITROL is not indicated for the purpose of safety and efficacy of VIVITROL have not been established in the pediatric population. Geriatric Use In opioid blockade or the treatment of opiate dependence. Although VIVITROL is a potent antagonist with trials of alcohol dependent subjects, 2.6% (n=26) of subjects were >65 years of age, and one patient was a prolonged pharmacological effect, the blockade produced by VIVITROL is surmountable. This poses >75 years of age. Clinical studies of VIVITROL did not include sufficient numbers of subjects age 65 and a potential risk to individuals who attempt, on their own, to overcome the blockade by administering over to determine whether they respond differently from younger subjects. ADVERSE REACTIONS: In all large amounts of exogenous opioids. Indeed, any attempt by a patient to overcome the antagonism by controlled and uncontrolled trials during the premarketing development of VIVITROL, more than 900 patients taking opioids is very dangerous and may lead to fatal overdose. Injury may arise because the plasma with alcohol and/or opioid dependence have been treated with VIVITROL. Approximately 400 patients concentration of exogenous opioids attained immediately following their acute administration may be have been treated for 6 months or more, and 230 for 1 year or longer. Adverse Events Leading to sufficient to overcome the competitive receptor blockade. As a consequence, the patient may be in Discontinuation of Treatment In controlled trials of 6 months or less, 9% of patients treated with VIVITROL immediate danger of suffering life-endangering opioid intoxication (e.g., respiratory arrest, circulatory discontinued treatment due to an adverse event, as compared to 7% of the patients treated with placebo. collapse). Patients should be told of the serious consequences of trying to overcome the opioid blockade Adverse events in the VIVITROL 380-mg group that led to more dropouts were injection site reactions (3%), (see INFORMATION FOR PATIENTS).There is also the possibility that a patient who had been treated with nausea (2%), pregnancy (1%), headache (1%), and suicide-related events (0.3%). In the placebo group, 1% VIVITROL will respond to lower doses of opioids than previously used. This could result in potentially of patients withdrew due to injection site reactions, and 0% of patients withdrew due to the other adverse life-threatening opioid intoxication (respiratory compromise or arrest, circulatory collapse, etc.). Patients events. Common Adverse Events The most common adverse events associated with VIVITROL in clinical should be aware that they may be more sensitive to lower doses of opioids after VIVITROL treatment is trials were nausea, vomiting, headache, dizziness, fatigue, and injection site reactions. For a complete list discontinued (see INFORMATION FOR PATIENTS). PRECAUTIONS: General—When Reversal of VIVITROL of adverse events, please refer to the VIVITROL package insert for full Prescribing Information. A majority of Blockade is Required for Pain Management In an emergency situation in patients receiving VIVITROL, patients treated with VIVITROL in clinical studies had adverse events with a maximum intensity of “mild” suggestions for pain management include regional analgesia or use of non-opioid analgesics. If opioid or “moderate.” Post-marketing Reports—Reports From Other Intramuscular Drug Products therapy is required as part of anesthesia or analgesia, patients should be continuously monitored in an Containing Polylactide-co-glycolide (PLG) Microspheres – Not With VIVITROL. Retinal Artery anesthesia care setting, by a person not involved in the conduct of the surgical or diagnostic procedure. Occlusion Retinal artery occlusion after injection with another drug product containing polylactide- The opioid therapy must be provided by an individual specifically trained in the use of anesthetic drugs co-glycolide (PLG) microspheres has been reported very rarely during post-marketing surveillance. and the management of the respiratory effects of potent opioids, specifically the establishment and This event has been reported in the presence of abnormal arteriovenous anastomosis. No cases maintenance of a patent airway and assisted ventilator. Depression and Suicidality In controlled clinical of retinal artery occlusion have been reported during VIVITROL clinical trials or post-marketing trials of VIVITROL, adverse events of a suicidal nature (suicidal ideation, suicide attempts, completed surveillance. VIVITROL should be administered by intramuscular (IM) injection into the gluteal suicides) were infrequent overall, but were more common in patients treated with VIVITROL than in muscle, and care must be taken to avoid inadvertent injection into a blood vessel (see DOSAGE patients treated with placebo (1% vs. 0). In some cases, the suicidal thoughts or behavior occurred after AND ADMINISTRATION). OVERDOSAGE: There is limited experience with overdose of VIVITROL. Single study discontinuation, but were in the context of an episode of depression which began while the patient doses up to 784 mg were administered to 5 healthy subjects. There were no serious or severe adverse was on study drug. Two completed suicides occurred, both involving patients treated with VIVITROL. events. The most common effects were injection site reactions, nausea, abdominal pain, somnolence, and Depression-related events associated with premature discontinuation of study drug were also more dizziness. There were no significant increases in hepatic enzymes. In the event of an overdose, appropriate common in patients treated with VIVITROL (~1%) than in placebo-treated patients (0). In the 24-week, supportive treatment should be initiated. This brief summary is based on VIVITROL Prescribing Information placebo-controlled pivotal trial, adverse events involving depressed mood were reported by 10% of (VIV 566C May 2009). 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 Alkermes® and VIVITROL® are registered trademarks of Alkermes, Inc. site reactions. VIVITROL must be injected by the customized needle provided in the carton. Alternate Manufactured and marketed by Alkermes, Inc. treatment should be considered for those patients whose body habitus precludes a gluteal ©2009 Alkermes, Inc. VIV 107C July 2009 Printed in U.S.A. All rights reserved.
  • 17. Beyond Bars Decriminalizing Mental Illness: Miami Dade County Tackles a Crisis at the Roots 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 JUdge leiFMan encoUnterS the challenge Miami-Dade County, Florida houses the largest percentage of people “When I first became a judge, I discovered a situation familiar with serious mental illness (e.g., schizophrenia, bipolar disorder, major to many of my colleagues but seldom discussed outside the courtroom — a situation that my legal and judicial training depression) of any urban community in the United States. Roughly had not prepared me for. Day after day, defendants stood be- 9.1 percent of the population (170,000 adults) experiences serious fore me, disheveled and distraught. Most were charged with mental illness, yet only 1 percent (24,000 adults) receives treatment relatively minor offenses such as loitering or panhandling. in the public mental health system. By contrast, the number of people Some exhibited impulsive behaviors, speaking in pressured, incoherent sentences. Others were guarded and withdrawn, accessing mental health services through the Miami-Dade County jail appearing to have little understanding of the circumstances is staggering. Of the roughly 114,000 bookings into the jail this past in which they found themselves. Homelessness, substance year, it is estimated that as many as 20,000 people with mental abuse, and trauma were symptoms of a larger set of personal illness required psychiatric treatment during incarceration. and social factors contributing to their unfortunate and often repeated involvement in the criminal justice system. These On any given day, the county jail houses approximately 1,200 people people of many backgrounds shared one thing in common — with mental illness receiving psychotherapeutic medications. This serious and persistent mental illness. number represents 17 percent of the total inmate population and When I first came across defendants experiencing acute men- costs taxpayers more than $50 million annually. The Miami-Dade tal illness, I followed the lead of my fellow judges by appoint- County jail serves as the largest psychiatric institution in the state ing experts and ordering psychiatric evaluations to determine their competence to proceed with their court cases. Although of Florida, housing more beds serving people with mental illness these evaluations tended to be very costly and meant that than any inpatient hospital in the state and nearly half as many beds defendants would remain in jail for weeks or possibly even as there are in all state civil and forensic mental health hospitals months, the idea of releasing a person in acute psychiatric combined. distress to the streets with nowhere to live and no supports seemed a far more cruel response to the situation. I assumed Sadly, these statistics are not unique to south Florida. Findings from that once evaluations by mental health experts were complet- a recent study suggest that people with serious mental illness are ed and the need for treatment was documented, the mental arrested and booked into jails in the United States more than two health treatment system would step in, if not voluntarily, then by court order. million times annually. Roughly three-quarters of these people also Before long, I realized my assumptions were wrong. Even have co-occurring substance use disorders that increase their though I had expert opinions indicating that people were likelihood of becoming involved in the justice system. On the basis indeed experiencing severe psychiatric symptoms — and in of the most recent population data reported by the Department of many cases requiring immediate hospitalization — state law Justice, it is estimated that currently 400,000 people with mental prohibited judges presiding over misdemeanor cases from ordering treatment in the forensic mental health system. In- illnesses are incarcerated in jails and prisons across the country, stead, the law required people to be released to the commu- and nearly 900,000 are on probation or parole in the community. 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. 20 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 18. Most people released under these circumstances ture to see what the impact was on the welfare of the never received any type of services on re-entering system as a whole or of the people it served. The po- the community and were quickly rearrested and lice were policing, the lawyers were lawyering, and the We began to realize that reappeared in my courtroom, often over and over judges were judging. Treatment providers knew little people with untreated serious again. These people accrued lengthy criminal re- about what went on when their clients were arrested cords for offenses that were all too obviously the and had little incentive to learn, because of barriers mental illness may be among result of untreated mental illness. This contributed to accessing information and laws that prohibit reim- the most expensive popula- to a revolving door of neglect and despair; caused bursement for services provided to people who are tions in the community, not a huge backlog of cases in the justice system; placed incarcerated. enormous burden on the courts, jails, and law enforce- For people who had no resources to pay for services, because of their diagnoses ment agencies; and left taxpayers to foot the bill. crisis units, hospitals, and the jail were often the only but because of the way they Not wanting to continue to be a witness to the parade options to receive care. Ironically, although many are treated. of misery passing through my courtroom, I was deter- people could not access the most basic prevention mined to figure out why and where the system was and treatment services in the community, they were failing. With the help of many dedicated stakeholders readily provided some of the most costly levels of from the community mental health, criminal justice, institutional care over and over again. The degree of who experience highly acute and chronic mental and social services systems, I set out to learn as much fragmentation in the community not only prevented illness. Intensive supports necessary to live suc- as I could about the community mental health sys- the mental health and criminal justice systems from cessfully in the community are many times in short tem and how it intersected with the criminal justice responding more effectively to people with mental ill- supply or altogether unavailable. system.” ness but actually created increased opportunities for >> Third, state expenditures on mental health services identiFying the root caUSe people to fall through the cracks. By the conclusion have become disproportionately skewed toward A 2-day summit was convened in 2000 to review the of the summit, we began to realize that people with providing expensive, acute-care services such as ways in which the community collectively responded untreated serious mental illness may be among the crisis stabilization and hospitalization in state- to people with mental illness before and after they most expensive populations in the community, not funded facilities, not to mention services pro- became involved in the justice system. What we dis- because of their diagnoses but because of the way vided in jails and prisons. Such heavy investment covered were embarrassingly dysfunctional and frag- they are treated. in these kinds of back-end services has come at mented systems. As we’ve come to better understand the problems and the cost of being able to adequately invest in a Before the summit, it was apparent that people with context of people with mental illness involved in the responsive and comprehensive continuum of pri- mental illness were over-represented in the justice justice system, we learned three critical lessons: mary and preventive care in the community. system. What was not so apparent, however, was >> First, our criminal and juvenile justice systems are criMinal Mental health ProJect the degree to which stakeholders were unwittingly in the midst of mental health crises at the local, ProvideS SolUtionS contributing to and perpetuating the problem. Many state, and national levels. The current level of de- The 11th Judicial Circuit Criminal Mental Health participants were shocked to find that a single per- mand for deep-end services in settings such as Project was established 10 years ago in an effort to son with mental illness was accessing the services emergency rooms, crisis units, state hospitals, and better respond to the needs of people with serious and resources of almost every other stakeholder in ultimately jails and prisons is inappropriate and mental illness and co-occurring substance use dis- the room, including law enforcement agencies, emer- unsustainable and contributes to enormous social, orders involved in or at risk of becoming involved in gency medical services, mental health crisis units, fiscal, and personal tragedies. The backlog of cases the justice system. Initially, the CMHP worked to di- emergency rooms, hospitals, homeless shelters, jails, in the justice system involving people with mental vert misdemeanor offenders from the criminal justice and the courts. This happened repeatedly as people illness impedes the administration of justice and system into community-based treatment and support revolved through a criminal justice system that was contributes to needless pain and suffering. services. Today, the CMHP has expanded to serve de- never intended to handle overwhelming numbers of >> Second, the problems facing the mental health fendants arrested for lower level felony offenses and people with serious mental illness and a community and, consequently, criminal justice systems in the other charges as are determined appropriate. It has mental health system that was ill equipped to provide United States today relate to the fact that the cur- developed collaborations with other local problem- the level and capacity of care necessary for those ex- rent community mental health system was devel- solving courts including domestic violence court periencing the most acute forms of mental illness. oped at a time when most people with severe and and drug court and has developed partnerships with Stakeholders were largely disconnected from one an- disabling forms of mental illness resided in state community mental health and substance abuse treat- other and no mechanisms were in place to coordinate hospitals. Most community mental health systems ment providers, housing providers and other social resources or services. Everyone was so busy doing his were designed around people with more moderate services agencies, consumer and family advocacy or her job that no one was looking at the bigger pic- treatment needs, not around the needs of people groups, countywide criminal justice and law enforce- NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 21
  • 19. Beyond Bars ment agencies, and state and federal social welfare University. This partnership facilitated activities within 24–48 hours of booking. On stabilization, agencies. around program planning and evaluation and the legal charges may be dismissed or modified in ac- preparation and submission of funding proposals. cordance with treatment engagement. People who FUnding agree to services are linked to a comprehensive Initial support for the development of the CMHP was Jail and ForenSic hoSPital array of community-based treatment, support, and provided through a grant from the National GAINS diverSion PrograMS housing services that are essential for successful Center that enabled the courts to host the summit Today, the CMHP operates a total of four different community re-entry and recovery outcomes. Pro- meeting in 2000. The GAINS Center provided tech- diversion programs and is working with the county gram participants are monitored by CMHP for up to nical assistance and helped the community map to develop of a first-of-its-kind mental health diver- 1 year after community re-entry to ensure ongoing existing resources, identify gaps in services and sion complex. All programs are complemented by linkage to necessary supports and services. Most service delivery, and develop a more integrated ap- support components designed to improve access to participants (75-80 percent) in the misdemeanor proach to coordinating care. Stakeholders included basic needs and economic self-sufficiency. diversion program are homeless at the time of ar- judges and court staff, law enforcement agencies Diversion programs and support components in- rest and tend to be among the most severely psychi- and first responders, attorneys, mental health and clude the following elements: atrically impaired people served by the CMHP. The substance abuse treatment providers, state and Prebooking jail diversion program targeting crisis misdemeanor diversion program receives around local social service agencies, consumers of mental intervention team training for law enforcement 300 referrals annually, with program recidivism health and substance abuse treatment services, officers rates of just 22 percent, far below most other re- and family members. Crisis Intervention Team training is designed to cidivism estimates. Using information generated from the summit, pro- educate and prepare law enforcement officers to Postbooking jail diversion program targeting gram operations were initiated on a limited basis. recognize the signs and symptoms of mental illness people arrested for felony offenses Additional funding was secured from a local phil- and to respond more effectively and appropriately Participants in the felony jail diversion program are anthropic foundation to conduct a planning study to people in crisis. When appropriate, people are referred to the CMHP through a number of sources of the mental health status and needs of people assisted in accessing treatment in lieu of being ar- including the public defender’s office, the state arrested and booked into the county jail, as well as rested and taken to jail. To date, CIT training has attorney’s office, private attorneys, judges, correc- the processes in place to link people to community- been provided to more than 2,500 officers from tions health services, and family members. All par- based services and supports. Information from this 36 law enforcement agencies across the county. ticipants must meet diagnostic and legal criteria as planning study was used to develop a more formal Additional CIT-related training courses have been well as be eligible to apply for entitlement benefits program design and to secure a 3-year federal tar- developed or adapted to target emergency dispatch such as Supplemental Security Income, Social Se- geted capacity expansion grant from the Substance (e.g., 911) call takers, law enforcement crisis ne- curity Disability Insurance, and Medicaid. At the Abuse and Mental Health Services Administration, gotiators, correctional officers, other nonpolice law time a person is accepted into the felony jail di- which enabled the CMHP to significantly expand enforcement agencies, and executive management version program, the state attorney’s office informs its staffing and operations. At the conclusion of the of CIT programs. the court of the plea the defendant will be offered federal grant period, the county assumed continua- Since the implementation of CIT, significantly fewer contingent on successful program completion. Simi- tion of funding for all positions. Because of the pro- people in psychiatric crisis are being arrested and lar to the misdemeanor program, legal charges may gram’s early success and demonstrated outcomes booked into jail, law enforcement agencies are ex- be dismissed or modified on the basis of treatment at the misdemeanor level, in 2008 the CMHP was periencing fewer injuries to officers and civilians, engagement. All program participants are assisted awarded a 3-year grant by the state of Florida to fewer instances of use of force involving officers and in accessing community-based services and sup- further expand postbooking diversion operations people with mental illness have occurred, and more ports, and their progress is monitored and reported to serve people charged with less serious felonies. people are being linked to appropriate care in the back to the court by CMHP staff. To date, the felony Efforts are currently underway to secure long-term community. diversion program has served roughly 150 people, sustainability for felony operations and to develop and participants have demonstrated reductions of strategies to increase program capacity. Postbooking jail diversion program targeting roughly 75 percent in both numbers of arrests and Since its inception, the CMHP has received ongo- people arrested for misdemeanor offenses days incarcerated after program enrollment. ing support from the Florida Department of Children All defendants booked into the jail are screened for signs and symptoms of mental illness by correc- Postbooking forensic hospital diversion program and Families. This support has included funding case tional officers using an evidence-based screening targeting people arrested for felony offenses and management positions as well as providing resourc- tool known as the Brief Jail Mental Health Screen. adjudicated incompetent to proceed to trial es to secure housing, medications, and transporta- People charged with misdemeanors who meet pro- The forensic hospital diversion program was recently tion for program participants. Early in its develop- gram admission criteria are transferred from the implemented as a state-sponsored pilot project ment, the CMHP also benefited from a partnership jail to a community-based crisis stabilization unit to serve people in Florida’s forensic mental health established with faculty from Florida International 22 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 20. Do you need capital to buy, build or renovate a facility, update your IT systems, or Since the implementation of Crisis Intervention refinance existing debt? Team training, significantly fewer people in psy- chiatric crisis are being arrested and booked into jail, law enforcement agencies are experi- CHFF Can Help! encing fewer injuries to officers and civilians, We are a non-profit loan fund that fewer instances of use of force involving officers provides capital to non-profit behavioral healthcare and people with mental illness have occurred, organizations nationwide. and more people are being linked to appropri- o Aggressive interest rates ate care in the community. o Flexible terms and structures system and to control growth in demand for services provided in state hos- o Gap and subordinate financing pitals. People served are charged with third-degree and nonviolent second- o Loans from $150,000 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- o Participation with other lenders ternative. The program seeks to provide a more cost-effective alternative to o Strategic financial planning services forensic hospitalization, while providing enhanced interventions targeting long-term recovery, reduced recidivism, and successful community living. The Community Health Facilities Fund is pleased to Admissions for competency restoration in state hospitals in Florida typically have provided financial advisory services and/or direct result in a length of stay of around 6 months at a cost of $60,000 per indi- loans to the following organizations in 2009: vidual. It is estimated that the forensic hospital diversion program can pro- Ability Beyond Disability vide a full year of services to program participants — including competency Bethel, CT restoration services, recovery services, and community re-entry services — for $32,000 per individual. At current capacity, the program is projected Alternatives Unlimited to divert 40 people per year from admission to state hospitals, which is Whitinsville, MA 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. Cache Employment and Training Center Logan, UT Mental health diverSion coMPlex In support of all diversion programs, Miami-Dade County and the CMHP Community Housing Associates have been actively working to develop a first-of-its-kind comprehensive Baltimore, MD 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- For more information contact, ment program, a transitional housing program, day treatment and day ac- Chris Conley Dean Adams tivity programs, intensive case management, specialized services address- 203-273-4200 812-273-5198 ing the unique needs of people with mental illness involved in the justice cconley@chffloan.org dadams@chffloan.org system (e.g., trauma treatment and treatment for co-occurring disorders), outpatient services, and job training and employment services. All programs www.chffloan.org u info@chffloan.org will incorporate peer support and peer leadership components. Space will Community Health Facilities Fund also be provided for agencies and programs that address the comprehen- 6 Landmark Square, 4th Floor, Stamford, CT 06901 sive social needs of people served, such as legal services, public welfare and entitlement programs, and immigration services. Meet us at the National Council Conference Expo Hall, Booth #421 NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 23
  • 21. Beyond Bars In addition to community-based treatment and ment, which allows the county to be reimbursed for grams and services, it is possible to prevent people support services, the complex will house a secure housing costs when an individual is approved for from unnecessarily entering the criminal justice sys- medical unit serving inmates in the custody of the Social Security benefits and receives a retroactive tem and to increase opportunities for recovery. county’s corrections and rehabilitation department payment. The justice system was never intended to serve as who are being evaluated to determine eligibility for In an effort to ensure that program participants who the safety net for the public mental health system diversion. The complex will also include a courtroom are eligible for entitlement benefits receive them as and is ill equipped to do so. The current shortcom- to expedite and facilitate legal hearings. quickly and efficiently as possible, the CHMP uses a ings of the community mental health and criminal The vision for the mental health diversion complex is best practice model referred to as SOAR (SSI/SSDI, justice systems did not arise recently. No one cre- to create a centralized, coordinated, and seamless Outreach, Access and Recovery). This approach was ated these problems alone, and no one will be able continuum of care for people who are diverted from developed as a federal technical assistance initia- to solve these problems alone. the criminal justice system either before or after tive to expedite access to Social Security entitle- booking. By housing a comprehensive array of ser- ment benefits for people with mental illness who vices and supports in one location, it is anticipated are homeless. All CMHP participants are screened The forensic hospital diversion that many of the barriers and obstacles to navigat- for eligibility for federal entitlement benefits, with ing traditional community mental health and social staff initiating applications as early as possible program is projected to divert services will be removed, and people will be more using the SOAR model. Program data demonstrate 40 people per year from likely to engage treatment and recovery services. that 88 percent of the CMHP participants who ap- ply for benefits using SOAR are approved on the admission to state hospitals, Social SecUrity BeneFitS initial application. By contrast, the national average All CMHP participants are assisted with individual- which is projected to result across all disability groups for approval on initial ized transition planning and linked to community- application is 37 percent. In addition, the average in a savings to the state based treatment and supports as appropriate. time to approval for CMHP participants is 62 days. Services provided include supportive housing, of $1.1 million while This achievement is remarkable compared with the supported employment, assertive community treat- funding an additional ordinary approval process, which typically takes ment, illness self-management and recovery (Well- 9–12 months or longer. ness Recovery Action Planning), trauma services, 7,200 days of new and integrated treatment for co-occurring mental leSSonS learned: collaBoration community-based illness and substance use disorders. iS Key Most people served by the CMHP are indigent and The CMHP’s success and effectiveness depends on treatment services. are not receiving entitlement benefits at the time the commitment, consensus, and ongoing efforts of of program entry. As a result, many do not have the traditional and nontraditional stakeholders through- necessary resources to access adequate housing, out the community. In the past, treatment providers treatment, or support services in the community. regularly talked with other treatment providers and Miami-Dade County Judge Steven Leifman has served as criminal justice agencies regularly talked with other Special Advisor on Criminal Justice and Mental Health for the To address this barrier and maximize resources, the Supreme Court of Florida since April 2007. In this capacity, CMHP developed an innovative plan to improve the criminal justice agencies; however, treatment pro- Judge Leifman is responsible for chairing the Court’s Mental ability to transition people from the criminal justice viders and criminal justice agencies rarely bridged Health Subcommittee which authored a ground-breaking report system to the community. the gap between their respective systems. In estab- entitled, Transforming Florida’s Mental Health System. Judge Leifman also serves as Chair of the Eleventh Judicial Circuit lishing the CMHP, a mental health committee was On the basis of an agreement established between of Florida’s Mental Health Committee, and is responsible for established within the courts and a local chapter of creating the Eleventh Judicial Circuit Criminal Mental Health Miami-Dade County and the Social Security Admin- a statewide advocacy organization known as Florida Project. Judge Leifman is a former Assistant Public Defender for istration, a gap-funding program was developed to Partners in Crisis was formed. The purpose of these Miami-Dade County, Florida. provide assistance for people applying for federal bodies was to facilitate and encourage communica- Tim Coffey has nearly 20 years of experience in the fields of entitlement benefits such as Supplemental Security tion and information exchange. behavioral health, public health, and social science research Income or Social Security Disability Insurance dur- and evaluation. Having worked in a variety of healthcare, As a representative of the courts, the CMHP is in a academic, and government settings, he has been involved ing the period between application for and approval in basic and applied research activities addressing mental of benefits. If approved for benefits, people applying unique position to bring together stakeholders who and behavioral health issues. As coordinator for the Eleventh for Social Security are compensated retroactively to may otherwise not have opportunities to engage in Judicial Circuit Criminal Mental Health Project, Coffey is respon- the date of initial application. Participants applying such problem-solving collaborations. By working sible for the development, implementation, and evaluation of a variety of court-based projects and programs designed around for benefits and receiving assistance from the CMHP together across systems and communities to craft the needs of people with mental illnesses involved in the sign an interim assistance reimbursement agree- more appropriate, responsive, and coordinated pro- criminal justice system 24 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 22. www.jjnegley.com www.MHRRG.com 1.800.845.1209 Fax:973.830.8585 MHRRG and Negley Associates Professional Liability specialize in providing comprehensive General Liability insurance solutions and exclusive loss Directors and Officers Liability prevention tools for addiction treatment Property and mental health providers. Workers Compensation Excess Auto
  • 23. Interview Pete Earley on Jails and Prisons, Our “New Mental Asylums” 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) Why did National Council Magazine interview Pete National Council Magazine talked to Pete about to you but you are the one that has to pick up the Earley, author of Crazy: A Father’s Search Through both the stories he tells in Crazy. pieces. This social worker literally saved his life! America’s Mental Health Madness for a criminal- justice focused issue? Pete describes it best in National Council: Pete, why did you choose to tell National Council: What effect did Crazy have on his own words — in his introduction to Crazy at the two stories? people’s attitudes about mental health? www.peteearley.com. Pete: I was outraged that my son got arrested. I was Pete: Not enough since this book was read very “I had no idea. I’d been a journalist for thirty frustrated that imminent danger laws in Virginia, little outside the mental health community. It was years and written extensively about crime and where I live, kept me from getting my son help and very well received by those who work in behavioral punishment and society. But I’d always been on the outside looking in. I had no idea what it was treatment. Then the legal system wanted to punish health, but it didn’t educate many people who like like to be on the inside looking out – until my son, my son when he wasn’t thinking clearly. It was a ter- most of us, are ignorant about mental health. The Mike, was declared mentally ill. Suddenly the rible Catch-22 situation. As a father I couldn’t do strongest supporters of this book are the parents two of us were thrown headlong into the maze much but as a reporter I could. So I wanted to tell of those who have mental illness. I was lucky as my of contradictions, disparities and Catch-22s that two stories. One about the struggles I had in help- son was able to get treatment. I hear from people all make up America’s mental health system. Crazy: A ing my son and the other about the state of mental the time whose children are dead, in prison, or even Father’s Search Through America’s Mental Health health treatment in this country and I was shocked on death row because they had a mental illness Madness is a nonfiction book that tells two stories. at what I found in the criminal justice system. and committed crimes while suffering from bipolar The first is my son’s. The second describes what disorder or schizophrenia. This includes judges and I observed during a year-long investigation inside National Council: In Crazy, you tell stories of some psychiatrists. the Miami-Dade County jail, where I was given persons with mental illness other than your son. Any unrestricted access. I feel more passionately idea how they’re all doing now? National Council: What advice would you give to about this book than any I have every written. Our other parents trying to get help for their kids with nation’s jails and prisons have become our new Pete: Sadly, none of them got any better. In fact, mental illness? mental asylums. I wrote this book as a wake-up their stories have gotten more tragic. The only per- call to expose how persons with mental illness are son I profile in my book who ever got better was Pete: First, you can’t give up. You have to be a ending up behind bars when what they need is my son. squeaky wheel. You also have to be an advocate for help, not punishment.” someone who often doesn’t want you involved and National Council: What made the difference with in a system that doesn’t want you involved. You have your son? to be willing to have your child hate you at times in Pete: Good case management and good people in order to get them proper treatment. the community mental health system that treated We know how to help people — him. I had no option but to call the cops when Mike National Council: How did you get into Miami Dade County Jail — the setting for the other story we just aren’t doing it. We just was threatening me one night — my son was shot you tell in Crazy? twice with a Taser and taken away. After that, he was won’t put the necessary funds assigned a case manager who was a saint — I give Pete: The only reason I got into the Miami-Dade her full credit. She worked with him for three years County Jail was because of Judge Steven Leifman. I into community mental health and he got better. Now Mike is getting trained to go found the officers were very frustrated with the con- in order to save people. and work in jails, providing peer support. As a parent ditions in the jail. Most of them wanted to do the you are limited — the system doesn’t want to listen right thing. They wanted to do their job and their 26 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 24. job was not to take care of people with severe mental National Council: Community mental health orga- try to show that persons with mental illness have a illness. The leading advocates for change in how we nizations often partner with their local corrections constitutional right to good treatment. I think until we incarcerate those with mental illness have not been systems to address the needs of incarcerated popula- get lawsuits going, we will never have the leverage to mental health advocates but correctional officers, tions. How best can they help? get politicians and others to really do what needs to judges, and those in law enforcement who see how be done to help people! horrible this is. Pete: We are mistakenly putting too much money into corrections instead of into treatment. Without enough National Council: Given the magnitude of mental National Council: Did you visit other jails and funding for community mental health, it doesn’t mat- health budget cuts that state after state is facing, do prisons? ter how good your Crisis Intervention Teams training you really think criminal justice populations have any program is. You are going to fail! hope? Pete: The LA County Jail has been described as the largest public mental health facility and that’s where Real partnerships between corrections and community Pete: Housing First and good community mental it started. I was invited to observe the LA County Jail mental health providers are key, since correctional health treatment programs will ultimately save money, but was asked to leave after three days as they cited professionals don’t know how to handle persons with but you have to hang in there for the long term. legal concerns about the privacy rights of inmates mental illness without the help from those in com- munity mental health, who are on the outside. A prime A great way to pay for mental health services would under HIPAA. I then tried Cook County Jail in Chicago be the cigarette tax, if politicians had enough guts to and they said no. Then I tried Rikers Island in New York example of community partnerships is San Antonio, where police are trained to recognize those with seri- raise it. Some states have increased it but in Virginia and Baltimore and they said no. I tried DC and they we charge a ridiculously low 30 cents per pack. If we said, “Hell, no.” ous mental illness — if they arrest such persons, they take them to the local drop off center instead of jail. raised that a dime, that would raise $100 million. Why In LA, the corrections officers wanted me out and the They’ve convinced their local and state government the cigarette tax? A UCLA study showed that 40% of all mental health staff wanted me in. In Rikers, it was the that it’s much more cost effective to put those with cigarette sales go to those who have been diagnosed opposite. In LA, I think it was because the corrections mental illness into the community mental health with a mental illness. officers knew how deplorable the conditions were and network — this saves more money than it costs by I think law enforcement and corrections people should didn’t have the proper training to deal with inmates preventing incarceration and repeat arrests. be the first ones to step forward and say that jails are who had mental illness and in cases where the mental not an appropriate place for those with mental illness. health staff didn’t want me in, I think it was because 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 Jails are straining to pay for medications for inmates they weren’t doing much for a variety of reasons. I in these times of budget cuts. Behavioral health peo- think fear was the motivating factor behind their op- community treatment works. We know that Sam Tsem- beris’s Housing First program had an 86% success ple need to make it clear that they can help people position to me getting inside these jails. with mental illness and addictions if they are given rate in getting persons with mental illness and addic- the resources to do so. It needs to be emphasized National Council: How did you feel when you first tions off the street. We know that peer outreach works that incarcerated persons can be helped and that entered the psychiatric unit at the Miami Dade and that good case management can help people recover their lives. We know how to help people — we their mental illnesses aren’t their fault. County Jail? just aren’t doing it. We just won’t put the necessary Pete: It was barbaric! Nothing prepared me for what funds into community mental health in order to save Meena Dayak has more than 15 years of experience in marketing I saw. There was severe overcrowding. You had naked and media relations for nonprofit healthcare organizations. She people. You can’t expect case managers with 50 – 60 people in cells that had nothing in them. Because it spearheads branding, PR, social media, member communica- clients or community mental health centers without tion, and public education initiatives at the National Council for was an old system, you had days when the water didn’t temporary hospital beds for those with severe schizo- Community Behavioral Healthcare. Her mission is to help member work. You had people drinking out of toilets because organizations tell a compelling story so the world will recognize phrenia to do a good job. they couldn’t get anything to drink otherwise. You had that mental illnesses and addictions are treatable health condi- tions from which persons can recover and lead full lives. people yelling and screaming. National Council: What barriers do you see to better Mohini Venkatesh serves as the staff policy liaison to the National The officers at that time had received zero training for funding to treat the incarcerated? Council for Community Behavioral Healthcare’s network of dealing with those who had mental illness. Because Pete: We tend to look for short-term solutions. Then associations throughout the states, conducts federal legislative of a history of abuse by the correctional officers and and policy analysis on an array of issues, and manages political there is the issue of civil commitment laws — we have engagement activities including an annual Hill Day in Washington, many lawsuits, all forms of restraint were taken away a system now where one has to be an imminent dan- DC. She received a masters in public health from Yale University from the officers — the cells were sealed shut to pre- ger before they can be hospitalized. Many states are and a BA in psychology from the University of Massachusetts- vent things from being thrown at the officers, and they using the civil rights issue as a sham to not fund good Amherst. had no way of controlling the inmates except to beat community mental health services. The civil rights is- Nathan Sprenger supports the National Council’s public relations them or isolate them. Now the officers do receive and marketing efforts, leads the social media activities, maintains sue is being twisted to justify denying treatment to the website, and serves as editorial assistant for National Council more training on how to deal with those who have those who could benefit from it. I wish there were Magazine. He has a masters degree in public communication mental illness. someone in the mental health community who would from American University in Washington DC. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 27
  • 25. Interview Reducing Justice Involvement for People with Mental Illness: Strategies that Work 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 National Council: What does the latest research screen for mental illness and drug addiction and been identified as increasing risk of crime; antiso- show regarding the prevalence of mental illness and work with judges and defense and prosecuting at- cial peers that can influence the likelihood of recidi- addictions among the justice-involved population? torneys to find appropriate treatment options. One vism; and mental health and addictions issues that of the most likely post booking options is the ap- influence one’s decision-making processes. Many Fred: It is important to be aware of the overrepre- pearance at specialty courts, such as drug and justice-involved individuals with mental illness may sentation of people with behavioral health disorders mental health courts. These courts are becoming also have a co-occurring substance use problem. in the criminal justice system. Recent research has more common and are often options that defense These dynamic factors suggest that the application found that about 14.5 percent of men and 31 per- attorneys advise their clients to pursue. These courts of evidence-based treatment practices, such as cent of women booked into jails have serious men- require treatment as a condition of release and cognitive behavioral therapy, can assist people to tal illnesses. These rates are about three to six times monitor progress with more frequent appearances make better choices when confronted with certain the prevalence rates for the general population. before the bench. These courts have been shown to situations that lead to criminal behavior. About 70 percent of people admitted into prison be effective in engaging those with mental and ad- meet the criteria for a substance use disorder; and One cannot overlook the importance of other envi- diction disorders, and are cost effective. ronmental factors that reduce recidivism, such as most have co-occurring disorders. The majority have not committed violent crimes and do not pose a We also have programs for those who are reenter- stable housing and access to meaningful employ- threat to public safety. These facts beg for creative ing the community after being in jail and prison ment and/or education. I haven’t met anyone with responses to prevent those who are unnecessarily settings. This has gotten a lot of attention recently mental illness or addictions who wants to be in cus- in custody from being there, and to link those com- with the passage of the Second Chance Act, which tody. They key to reducing recidivism is to match ing out of jails and prisons to effective behavioral focuses on the needs of individuals leaving custody effective treatment with essential supportive pro- health interventions. and returning to their home communities. All are grams that allow these people to realize their goals. concerned that these programs protect public safe- National Council: What type of interventions can ty while advancing public health outcomes through National Council: What cognitive behavioral treat- limit the criminal justice involvement of individuals the integration of best practices in supervision and ments are known to be effective for justice-involved with mental illnesses and addiction disorders? treatment. We have specialized probation and pa- persons with mental illness? role initiatives that train community corrections of- Fred: There are several models that are known Fred: There are now a number of initiatives that ficers about mental health and addiction disorders, hold a lot of promise in supporting recovery with to work for those involved in the criminal justice and treatment providers about supervision strate- system, such as Thinking for a Change and Moral these populations. For those individuals who are gies and objectives. Reconation Therapy. The key is to utilize models not a public safety risk, we want to divert them to that put people in a well documented and strategic treatment. There are specialized responses geared National Council: What can be done to reduce program that provides treatment sessions and gives toward police officers and other first responders in recidivism? how to deal with those who have serious mental ill- people the tools and skills they need to advance in nesses. One of the most common is called Crisis Fred: The factors that influence criminal activity their recovery. In New York, there is a program called Intervention Teams training, which teaches police among those with mental illnesses and addiction SPECTRM (Sensitizing Providers to the Effects of In- officers how to be aware of those with mental ill- disorders aren’t that different from the factors that carceration on Treatment and Risk Management) nesses and to de-escalate potentially dangerous influence those who commit crime in the general that helps to change the types of behaviors that situations when they encounter someone with a population. These criminogenic factors include stat- led inmates into criminal behavior and to prevent serious behavioral problem on the street. Those are ic factors such as age at one’s first arrest and basic recidivism once they are released from prison. While widespread and growing in popularity. demographic information. Additionally, there are dy- we are starting to see more innovative programs be- namic factors that are subject to change over time, ing initiated by community mental health providers, Another point of intervention is at jails and other such as antisocial patterns of thinking that have more work needs to be done here. post booking sites where we can appropriately 28 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 26. National Council: What are the major barriers that Community behavioral health providers are an limit collaboration between the criminal justice and absolutely critical component to the success of justice reinvestment treatment systems? strategies; we need their expertise in providing effective community Fred: Traditionally, community behavioral health sys- behavioral health treatments. Their involvement in these initiatives tems have not had a primary focus on public safety is- gives them a mechanism to access additional resources and to sues; however, we are now seeing these organizations focus their staff on the needs of justice involved persons. playing a larger role in this arena. Unfortunately, there are financial barriers that limit the ability of commu- cacy partners to develop further support for these National Council: What advice would you give to nity behavioral health to be responsive to this need. initiatives. states that want to start getting involved in justice Many of those in the criminal justice system don’t reinvestment work? qualify for the various state mental health funded National Council: Why do we need justice reinvest- programs because of their eligibility criteria. While ac- ment projects? Fred: The first step is to understand what comes from collaboration. One system on its own can’t do tuarial models that have been developed by the crimi- Fred: State spending on corrections has risen faster everything; all branches of government and all stake- nal justice field help us to determine who might be than any other item in state budgets over the last 20 holders — the criminal justice field, community be- more at risk of committing a crime, this information is years. It has increased from $10 billion in 1990 to havioral health providers, victims’ advocates, families not frequently used to identify priority populations. over $45 billion today. This is occurring in the con- and consumers, and others — need to use the power text of significant budgetary pressures related to this National Council: Are there federal initiatives that recession. Justice reinvestment is an approach that of collaboration to access different funding streams support behavioral health and criminal justice col- and more importantly, to be responsive to the needs starts with an analysis of the drivers of jail and prison of persons with mental illness and addictions in the laborations? growth in communities and states. One of the more criminal justice system and to the need to create Fred: Absolutely. The passage of the Mentally Ill Of- common findings is that the growth is not about new safer communities. fender Treatment Crime Reduction Act (MIOTCRA) pro- crimes or new arrests; it’s being driven by high rates vided funding for the Bureau of Justice Assistance to of revocation of people on probation or parole — peo- Fred Osher, MD, oversees the health components of the Council of develop the Justice Mental Health Collaboration pro- ple coming out of prison have a two-third chance of State Governments Justice Center’s initiatives. He also provides gram. Grants under this program require the partner- being sent back to prison within three years of their technical assistance to state and local governments across the ship of the community mental health and criminal jus- release and most of them return within the first eight country seeking to improve their response to people who have mental health and/or substance use disorders and are involved tice systems. We’ve seen the creation of a specialized months. Often, they are having their parole or proba- in the criminal justice system. Before joining the CSG Justice law enforcement initiative in Philadelphia, a mental tion revoked not for new crimes but for technical vio- Center, Fred served as the Director of the Center for Behavioral Health, Justice, and Public Policy and as an Associate Professor health court in Kalamazoo, MI, and specialized com- lations of their release. The majority of these technical of Psychiatry at the University of Maryland School of Medicine. munity corrections strategies in Portland, ME, with violations are related to behavioral problems such as He has published extensively in the areas of homelessness, com- this funding. There are about six dozen grantees that failure to appear or keep appointments, or continued munity psychiatry, co-occurring mental and addictive disorders, and effective approaches to persons with behavioral disorders are implementing these types of programs across the substance abuse. This has created an opportunity for within criminal justice settings. He received his BA from Harvard country. those in behavioral health to partner with the criminal University and his MD from Wayne State University. justice system to slow down this revolving door. Mohini Venkatesh serves as the staff policy liaison to the National The Second Chance Act provides a new source of Council for Community Behavioral Healthcare’s network of funding for criminal justice and treatment collabo- rations with several grant programs that focus on National Council: What role do you see for community associations throughout the states, conducts federal legislative and policy analysis on an array of issues, and manages several behavioral health providers in justice reinvestment? political engagement activities including an annual Hill Day in justice-involved individuals with substance use and Washington, DC. She received a masters in public health from co-occurring disorders. Fred: Community behavioral health providers are an Yale University and a BA in psychology from the University of absolutely critical component to the success of jus- Massachusetts-Amherst. Additionally, we’ve seen growing support for justice re- tice reinvestment strategies; we need their expertise Meena Dayak has more than 15 years of experience in marketing investment work in the states. [Justice Reinvestment and media relations for nonprofit healthcare organizations. She in providing effective community behavioral health is an approach that uses data-driven, fiscally respon- spearheads branding, PR, social media, member communica- treatments. Their involvement in these initiatives gives tion, and public education initiatives at the National Council for sible policies and practices to increase public safety them a mechanism to access additional resources Community Behavioral Healthcare. Her mission is to help member and reduce recidivism and corrections spending.] This organizations tell a compelling story so the world will recognize and to focus their staff on the needs of justice in- approach gives policymakers options to reduce cor- that mental illnesses and addictions are treatable health condi- volved persons. For example, we are seeing the be- tions from which persons can recover and lead full lives. rections expenditures while enhancing public safety. havioral health community coming to the table and Nathan Sprenger supports the National Council’s public relations Justice reinvestment projects stimulate collabora- saying, “We can provide the integrated treatment for and marketing efforts, leads the social media activities, maintains tion between criminal justice, community behavioral the website, and serves as editorial assistant for National Council co-occurring disorders that these people coming out health, and other key partners. On the federal level, Magazine. He has a masters degree in public communication of prison need.” from American University in Washington DC. the Justice Center has been working with our advo- NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 29
  • 27. Beyond Bars Funding for Behavioral Health and Criminal Justice Programs henry J. Steadman, Phd, President, Policy Research Associates; Samantha califano, MS, Project Assistant, CMHS National GAINS Center A ll 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 In FY 2010, SAMHSA and the Center for Substance Abuse Treatment, in opportunities worth exploring. Two major federal collaboration with the Bureau of sources of funding are the Bureau of Justice Assis- Justice Assistance, are offering a tance (www.ojp.usdoj.gov/BJA/) and the Substance Abuse and Mental Health Services Administration unique opportunity that blends (www.samhsa.gov/Grants/). On the private side, funding sources. Grantees will receive many local foundations fund innovative programs two separate awards totaling $20 million at the interface of behavioral health and criminal justice. to enhance the court services, coordination, Through BJA, behavioral health organizations that and substance abuse treatment capacity of adult drug courts. This partner with local justice agencies on grants to program allows applicants to submit one application to receive service justice-involved people in their communities blended criminal justice and substance abuse treatment funding. can use grant funding to provide services. BJA offers an array of grants to partnerships between justice and mental health agencies. Two grant programs from prison, jail, or juvenile residential facilities into and statewide expansion of jail diversion programs are currently seeking applications for funding, the the community. The Second Chance Act Adult and for people with posttraumatic stress disorder and Justice and Mental Health Collaboration Program, Juvenile Offender Reentry Initiative FY 2010 grant other trauma-related disorders. A priority for this created by the Mentally Ill Offender Treatment is seeking applications from state, local, and tribal program is to provide needed services to veterans and Crime Reduction Act of 2004 and the Second governments who have developed a strategic re- returning from Iraq and Afghanistan. Awards were Chance Act of 2007. The third grant program, for entry plan with extensive evidence of partnership given to the states of Florida, North Carolina, New which the application deadline has passed, is the and collaboration and have created a Reentry Task Mexico, Ohio, Rhode Island, and Texas. The first six Byrne Justice Grant (JAG). Force that includes both justice system and com- states to be funded under this grant in 2008 were munity representatives. Under the FY 2010 spend- Colorado, Connecticut, Georgia, Illinois, Massachu- Since fiscal year 2006, the BJA has granted joint ing package, the Second Chance Act will receive setts, and Vermont. justice and mental health partnerships funding $100 million, which is $75 million more than in FY In FY 2010, SAMHSA and the Center for Substance under the Justice and Mental Health Collaboration 2009. Applications are due by March 4, 2010, 8:00 Abuse Treatment, in collaboration with BJA, are of- Program to plan, implement, or expand a justice and p.m. eastern time. fering a unique opportunity that blends funding mental health collaboration program. This program’s goal is to increase public safety through mental Although the deadline for the JAG program passed in sources. Grantees will receive two separate awards health and criminal justice collaboration for justice- January 2010, this program is the primary provider totaling $20 million to enhance the court services, involved people with mental illness or co-occurring of federal criminal justice funding to state and local coordination, and substance abuse treatment ca- mental health and substance abuse disorders. In FY jurisdictions. All areas of the criminal justice system, pacity of adult drug courts. BJA will fund the drug 2009, BJA received 246 applications seeking a total including drug and task forces, crime prevention, court component, and CSAT will fund the substance of $43,401,754 in funding and awarded 43 site- courts, treatment programs, and sharing justice abuse treatment component. Up to a total of 31 based applicants a total of $7,874,824 in funding. information, are supported by this program. In FY grants will be awarded. This program allows appli- In FY 2010, the Justice and Mental Health Collabo- 2010, the JAG program will receive $511 million. cants to submit one application to receive blended ration Program will receive an increase of $2 million In addition to BJA, SAMHSA funds grant opportuni- criminal justice and substance abuse treatment over FY 2009, for a total of $12 million. ties for states and local government. In September funding. The Second Chance Act of 2007 was signed in 2008 2009, SAMHSA awarded a second round of Jail Di- Local health foundations are also available to pro- to ensure safe and successful transitions for people version Trauma Recovery Grantees to support local vide funding to local organizations and government 30 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 28. agencies in their states. Two local health foundations, illness is the Health Foundation of Greater Cincinnati, not overlook these options in your community. for example, are Staunton Farm Foundation in Penn- a social welfare organization whose focus is enhanc- With opportunities available on local, state, federal, sylvania and The Health Foundation of Greater Cin- ing community health. In 1997, the foundation refined and private levels, it is important to think creatively cinnati. These foundations award grants to nonprofit its focus after conducting an extensive assessment of about funding. Many opportunities are available to organizations and government agencies in their sur- health issues within its region. The Health Foundation blend multiple local, state, federal, and private fund- rounding areas. of Greater Cincinnati provides grant funding in Cincin- ing sources. The Staunton Farm Foundation was founded approxi- nati and 20 counties in Indiana, Kentucky, and Ohio. mately 70 years ago and focuses on the behavioral The four areas of focus are community primary care, Henry J. Steadman is internationally known for his research on health of children, youths, and adults. Rural behav- school-age children’s healthcare, substance use dis- interfacing criminal justice and mental health systems. He has ioral health and access to behavioral health and orders, and severe mental illness. Annually, the Health been President of Policy Research Associates since he founded it criminal justice diversion are the three areas funded Foundation of Greater Cincinnati awards about $9 in 1987. Previously, he ran a nationally known research bureau million in grants. Seventy-four grants were awarded for 17 years for the New York State Office of Mental Health. Dr. by foundation funds. The Staunton Farm Foundation Steadman’s major current projects are the National GAINS Center provides grants to organizations in 10 counties in between 1999 and 2007, focusing on substance use for Evidence-Based Practices in the Justice System; the John southwestern Pennsylvania. It has provided grants disorders and severe mental illness in the criminal D. and Catherine T. MacArthur Foundation Mental Health Court justice system. Study; the CMHS Transformation Center; and SAMHSA’s Technical to mental health courts, drug courts, dual-diagnosis Assistance and Policy Analysis Center for Jail Diversion. treatment programs, and agencies to create new The Staunton Farm Foundation and the Health Foun- Samantha Califano is a project assistant for the CMHS National websites and much more with the goal of improving dation of Greater Cincinnati are just two examples of GAINS Center, which is operated by Policy Research Associates, behavioral health treatment. local entities not often thought of in the context of Inc., in Delmar, NY. She graduate Cum Laude with a bachelor of science in Criminology/Criminal Justice from Keuka College in Another local health foundation active in behavioral behavioral health–criminal justice issues that are, in 2008 and was awarded a master of science in Forensic Mental health services for justice-involved people with mental fact, very active throughout the United States. So, do Health in December 2009 from Sage Graduate School. Criterion Health, Inc. In partnership with Congratulations AHP Behavioral Health Consulting Group to Anasazi Software customers Design. Develop. Deliver. We help with: on their 2010 National Council • Marketing Repositioning for Parity Awards of Excellence • Strategic Mapping • Primary Care Integration • Affiliations and ASO’s Excellence in Service Innovation Burrell Behavioral Health (Springfield, MO) Charles G. Ray (301) 213-6201 Patrick Gauthier (888) 898-3280 charlesr@criterionhealth.net pgauthier@ahpnet.com for the Journey Home Project www.criterionhealth.net www.ahpnet.com — Todd Schaible, CEO — Excellence in Consumer & Family Advocacy Rose Hill Center Austin Travis County Integral Care (Austin, TX) Providing four levels of treatment for their work with the Central Texas and rehabilitation programs for adults with mental illness African American Family Support Conference — David Evans, CEO — Residential Rehabilitation Extended Residential Transitional Living Community Support 866-504-2259 (toll-free) www.rosehillcenter.org Contact us to find out how you, a family member, or friend may benefit Accredited by from treatment at Rose Hill Center The Joint Commission NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 31
  • 29. Beyond Bars Back to Basics: Evaluating Opportunities to Serve the Justice-Involved Population in Community Behavioral Health John Petrila, Jd, llM, Director, Florida Mental Health Institute Criminal Justice, Mental Health, and Substance Abuse Technical Assistance Center W hat 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. 32 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 30. 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. deFining the treatMent ture the assessment of risk What is treatment supposed to accomplish? Is it focused primarily on behavioral to third parties — some health issues, unrelated to the person’s criminal involvement? Or is it designed to developed for institutional ameliorate risk? And if so, risk to the public, a specific person, or the individual populations, others for com- receiving treatment? There is little evidence that most types of treatment have a munity use. However, our knowledge of direct impact on criminal recidivism, even if they relieve symptoms or improve risk management is more limited. Good treat- mental status or functioning. Treatments with empirical footing, such as dialectical ment alone is not enough unless it is targeted to those dynamic factors that re- behavioral therapy for borderline personality disorders, or multisystemic therapy search has shown are most related to future risk. In addition, providers need to for youth, require significant investments in resources and fidelity to the particular develop and implement clear policies that describe the factors that should be model. considered if a person misses appointments, stops taking medication, or exhibits other behaviors that conceivably could foreshadow future risk. Such policies are Interventions that have proved successful in other contexts, such as assertive com- good risk management tools in any practice, but are essential in working with the munity treatment may not have a similar effect with a justice-involved population. criminal justice system. 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- Political allianceS cidivism. A study of North Carolina’s outpatient civil commitment law found that One of the most important developments in public mental health in the last de- a court order of at least six months duration, combined with treatment of the cade has been the emergence of judges and law enforcement officials as leaders same duration, had an impact on recidivism and rehospitalization of people with in addressing the needs of people with mental illnesses and substance abuse psychotic disorders. However, one without the other did not have this effect, nor did disorders. This can be uncomfortable for treatment providers, because of some- the combination of long-term court order and long-term treatment have the same times quite different perspectives on identifying and solving problems. However, effect on people with affective disorders. 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 Paying For the treatMent working with justice-involved people needs to know the local sheriff, the relevant Most people with mental illnesses involved in the criminal justice system are poor. police departments, the state attorney (the prosecutor), and the public defender. People with Medicaid are less likely to be re-arrested than those without. However, These relationships will lead to increased trust between the parties as well as alli- given Medicaid eligibility rules, obtaining and retaining Medicaid eligibility can be ances that may result in increased investment for services. 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. Many behavioral health providers may be offered or will seek out opportunities However, only 48,342 (or 7.0%) were still enrolled at the time of arrest. Loss of eli- to work with people entering services through the criminal justice system. Such gibility may occur for a variety of reasons. However, the lack of entitlements creates work can be rewarding and can place the provider in a larger set of community difficulties in making even the smallest co-pay for medications and other services. relationships. However, recognizing the diversity of the population, and the limited In addition, Medicaid is a minor payer for substance abuse services. More than impact of most treatments on criminal recidivism and understanding the impor- 90% of Florida arrestees who had used a Medicaid reimbursed behavioral health tance of public safety are essential for any provider to succeed in this rapidly service in the 365 days prior to their arrest used a mental health service, with fewer growing market. 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. 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, PUBlic SaFety Mental Health, and Substance Abuse Technical Assistance Center. Petrila was General Counsel to No issue is more important to law enforcement, judges, and prosecutors than 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, public safety. Any provider that works with people referred by the criminal justice and authored the chapter on confidentiality in the Surgeon General’s Report on Mental Health. system must understand this, and must consider how risk will be assessed and 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 managed. Today, we know a great deal about the relationship between mental ill- Behavioral Sciences and the Law. ness, substance abuse, and violence. Good instruments also are available to struc- NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 33
  • 31. Beyond Bars Advocate to Give Youth a Second Chance Juvenile Justice and Delinquency Prevention Reauthorization Act Mohini venkatesh, Director, Federal and State Policy, National Council for Community Behavioral Healthcare W hat 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- 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, ated adults, what is unique to the juvenile justice discussion is the people who protect juveniles from being incarcerated in adult jails or lock-ups for extended are most affected: youths. Yes, they are supposed to be corrected when they do periods of time, address the disproportionate contact youths of color have with something wrong but, isn’t it also important to invest in them and give them the the juvenile justice continuum, and other protections. Through these core re- opportunity to mature and grow into adulthood? When considering factors that quirements, the JJDPA is meant to foster services and supports to prevent juve- contribute to juvenile delinquency, such as mental health and substance use nile delinquency and, in cases in which youths enter the juvenile justice system, problems, negative environmental influences, or complicated family situations, protections to ensure that they are not unduly exposed to harm or trauma while the role of state juvenile justice systems and community providers becomes incarcerated. clear — to prevent juvenile delinquency whenever possible and to rehabilitate According to a 2008 survey of the states conducted by the Coalition for Juvenile youths who are in the system to give them the best chance to succeed. Justice, 55 of 56 states and territories voluntarily participate in the JJDPA and Studies have indicated that 70 percent or more of youths who are securely 85 percent are compliant with all JJDPA core requirements. One of the true detained in a juvenile justice facility have a mental health or related disorder; benefits of the JJDPA is the federal–state partnership it creates via the U.S. in contrast, approximately 20 percent of the general youth population have such Office of Juvenile Justice and Delinquency Prevention; as a result, states and ter- a disorder. According to a public opinion poll commissioned by the Center for ritories greatly value the opportunity to receive technical assistance and share Children’s Law as part of the John D. and Catherine T. MacArthur Foundation’s successful practices with each other and the OJJDP. Through small investments Model for Change juvenile justice reform initiative, a majority of people polled in successful programs, the federal government is able to offer the opportunity viewed alternatives to incarceration — such as community mental health treat- for states and territories to replicate successful programs, the result of which is ment, mentoring, and vocational training — as effective ways to rehabilitate hoped to be an overall improvement in the way juvenile justice systems respond youths. In addition, 8 out of 10 polled strongly favored taking away some of the to youths’ unique needs. money states spend on incarcerating youth offenders and using that funding to Although the principles of the JJDPA are laudable and have created key protec- pay for counseling, education, and job training. tions for youths, implementation challenges persist — funding limitations, lack JUvenile JUStice and delinqUency of appropriate staffing and training, and other challenges prevent the realiza- Prevention act tion of the original vision of the JJDPA. In response to widespread abuses in state and local juvenile justice facilities, reaUthorization Congress passed the Juvenile Justice and Delinquency Prevention Act in 1974. Advocates, including the National Council for Community Behavioral Healthcare, The JJDPA serves as the primary federal funding stream for juvenile justice ser- view reauthorization of the JJDPA as an opportunity to address these challenges. 34 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 32. 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. The JJDPA was most recently reauthorized in 2004, and efforts are underway to Preview of FY 2011 reauthorize the act in the 111th Congress. After being introduced in the Senate, the Juvenile Justice and Delinquency Prevention Reauthorization Act (S. 678) was Federal Budget Appropriations approved by the Senate Judiciary Committee, thus sending the bill to the Senate for Criminal Justice floor for consideration. Although a companion bill has yet to be introduced in the >> On February 1, 2010, President Obama released his requests for the House of Representatives, efforts are underway to push for Senate passage in Fiscal Year (FY) 2011 federal budget. The release of the President’s 2010 to bolster efforts in the House. budget signifies the official initiation of the Congressional appropria- Among several improvements, S. 678 takes important steps to strengthen the tions process; both the House and Senate appropriations commit- ability of state and territorial juvenile justice systems to meet the substance use tees will hold hearings, amend the budget over several months, and and mental health needs of youths by incorporating approve a final FY 2011 budget. >> New incentives for improving mental health and substance use screenings, >> Details of the president’s budget help us understand what the Presi- treatment, diversion, and re-entry services. dent’s priorities are and give us a foundation from which to advocate. >> An increase of federal authorizations for core juvenile justice programs. The following is a snapshot of the President’s FY 2011 budget requests >> Reinforcements of the relationship between OJJDP and participating states and for key criminal justice programs compared with previous fiscal years: territories to facilitate increased compliance with the core requirements of the >> Treatment drug courts: $56 million, including $5 million for family JJDPA. dependency, treatment drug courts. Increase of $12 million from FY To achieve reauthorization of the JJDPA in 2010, the National Council, along with 2010. an array of advocacy organizations, participates in a national coalition effort: Act4JJ (www.act4jj.org). Through this coalition, the National Council joins juvenile >> Ex-offender re-entry: $23 million. Increase of $5 million justice, child welfare, and youth development organizations with a unified message from FY 2010. in support of enhancing the JJDPA. Readers who want to be involved in advocacy >> Drug courts: $57 million. Level-funded from FY 2010. 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 >> Second chance re-entry: $100 million. Level-funded from National Council’s Public Policy Update for notices of our activity on the JJDP FY 2010. Reauthorization Act in 2010. >> Mentally Ill Offender Treatment Crime Reduction Act: None. Although Youths who commit crimes often face an uphill battle to improve their lives, and it this amount represents a $12 million decrease in funding, it is is our job as community providers, advocates, and members of our communities suspected that the President is attempting to combine MIOTCRA to guide them in a manner that protects them from danger and gives them the op- funding into the funding provided for drug and mental health courts. portunity to achieve more. Although reauthorization of the JJDPA won’t resolve all The President’s FY 2009 budget also requested this change, but it was challenges in serving justice-involved youths, it will certainly get us closer. denied by Congress. A detailed budget chart for these and other substance use and mental 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 health-related federal programs is available analysis on an array of issues, and manages political engagement activities including an annual Hill at www.TheNationalCouncil.org (click on Public Policy/Issues and Day in Washington, DC. She received a masters in public health from Yale University and a BA in Resources/Federal Budget) to learn more. psychology from the University of Massachusetts-Amherst. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 35
  • 33. From The Field 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. 36 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 34. Bexar County’s Restoration Center Offers Alternatives to Jail and the Streets gilberto rendon gonzales, Director, Communications and Diversion Initiatives, The Center for Health Care Services, Bexar County Mental Health Authority, San Antonio, TX / ggonzales@chcsbc.org In establishing the Restoration Center, CHCS worked Officers are spending less time in emergency room closely with local government and public and private waiting rooms, which allows them to return to com- 1,158 stakeholders and drew upon lessons learned from the nationally recognized, award-winning Bexar County munity policing. individuals admitted to the Admissions to the Restoration Center’s detox unit Jail Diversion Program, started in 2003. Earlier, stake- stem from multiple referral sources such as courts, Restoration Center instead holders had sought to address the community’s pub- the sobering unit, the crisis care unit, Haven for Hope of the municipal court lic safety needs by developing the Crisis Care Center partners, and walk-ins by people who are homeless. with medical clearance for law enforcement officers detention area saved The Restoration Center is a stakeholder partner in so that drop-offs take about 15 minutes, compared the $100 million, 37-acre, 962-bed Haven for Hope taxpayers $2,657,610. to an 8-14 hour wait in emergency rooms earlier. The homeless facility. Located just across the street from Crisis Care Center’s success in returning officers to the Restoration Center, Haven for Hope is scheduled 469 people taken to the service prompted community stakeholders to address the gaps in substance abuse treatment through the to be fully operational in June 2010. The ability to pro- Restoration Center instead of vide 24-hour access to psychiatric crisis assessment, Restoration Center. sobering services, minor medical clearance services, to a hospital emergency room The Restoration Center includes a substance abuse pre-employment services, and housing — all in one before incarceration saved an court and features three distinct programs: area — exponentially enhances the possibility of treat- additional $703,500. ment success. >> The public safety unit, which provides injured prisoner medical clearance and treatment and a CHCS President and Chief Executive Officer Leon sobering unit (40+ person capacity) that enables Evans attributes the Restoration Center’s success to safe sobering of persons brought in by law enforce- community collaboration. “We were able to accom- ment for public inebriation. plish this because we addressed a compelling need,” he explains. >> The medical detox unit, which provides 27-bed Catherine Jones, director of Addiction Recovery Ser- capacity with a 3- to 5-day stay. vices at CHCS says, “We made it a point to provide >> Intensive outpatient substance abuse services — information to each of our stakeholders, we moni- specialized day care treatment with intensive and tored outcomes, we showed our collaborative pro- supportive counseling programs. gram partners what was working and what wasn’t, we A ddressing the silos dividing substance abuse treat- ment and mental health services is a monumental task. The Restoration Center, started in 2007 by The County Judge Nelson Wolff and business leaders such as Bill Greehey won the support of the Bexar County, showed that we were saving money, and we showed that this approach was a good doorway into treatment as well.” Center for Healthcare Services, Bexar County’s Mental Texas, legislative delegation for a special funding ap- Health and Mental Retardation Authority, seeks to ad- propriation to establish the Restoration Center. Melanie Lane, director of the Restoration Center, at- dress this problem by providing integrated substance tributes success to persistence and staff serving as ef- The Restoration Center is proving to be cost-effective. fective role models. She explains that they were able abuse services. In combination with its sister Crisis In its first 180 days of operation, it served 395 home- Care Center, a 24-hour psychiatric emergency unit, the to introduce real change — in the past, persons could less people who were diverted from jail, saving tax- not access substance abuse services unless they were Restoration Center sees 900–1,000 people a month. payers $766,530. The sobering unit admitted 1,627 Working closely with the Crisis Care Center, the Res- sober but the Center knows you can’t get sober until individuals in 162 days — 1,158 of them would oth- you get services. toration Center provides law enforcement with quick erwise have been admitted into the municipal court access to treatment for nonviolent misdemeanor of- detention area at a cost of $2,657,610. An additional Lane, having once been homeless herself, says, “I’m fenders with substance abuse problems and also of- $703,500 was saved when law enforcement officers glad someone was willing to take one more chance fers substance abuse services to homeless persons in on me.” took 469 people to the Restoration Center instead of the community. to a hospital emergency room before incarceration. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 37
  • 35. From The Field New Centerstone Initiative Heralds Promise of Work with Justice System As reported in Mental Health Weekly, Volume 20, Number 6, February 8, 2010 For each individual potentially eligible for participa- tion, a case manager will complete a comprehensive assessment within the correctional facility, usually This initiative really several months prior to the offender’s scheduled release date. This process will assist in identifying is about breaking a wraparound team for each individual, taking into account that person’s potential support system in down service silos.” 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- L inda Grove-Paul, M.S.W., believes that a newly launched re-entry initiative for criminal offenders with addictions and co-occurring mental health prob- DETAILS OF INITIATIVE A collaboration among SAMHSA, the state behav- ers upon an offender’s release. Within one to two business days after release, an individual will be re- ioral health division and the state Department of quired to attend an appointment with a community lems in Indiana can help erase unproductive mis- provider as well as with a case manager, community Corrections, Project CARE will involve pre- and post- conceptions about working with the justice system. corrections officer or parole officer. The individual’s release planning for offenders in order to support “Mental health clinicians don’t realize how well-in- the provision of behavioral health services and wraparound team will have its first meeting within a formed the judicial system is, in terms of evidence- other supports to ease community reintegration and week of the offender’s return to the community. based practices and outcomes,” said Grove-Paul, reduce recidivism. The initiative’s reach covers six Grove-Paul said Project CARE will be needs-driven, director of addiction and forensic services at the southern Indiana counties (Bartholomew, Crawford, emphasizing individualized services in the realms nationally prominent behavioral health services Harrison, Monroe, Orange and Washington), a region of behavioral health treatment, general health as- organization Centerstone. “Corrections ‘gets it’ that that does not have a re-entry court system. sistance, vocational support, housing support and prison is not a place for the seriously mentally ill.” other key areas. There may be times when either the Grove-Paul said that while most of the offenders Centerstone of Indiana last week began overseeing to be served under the initiative will have a co- community corrections officer or the offender might the first participants in the Project CARE (Commu- occurring mental health issue such as depression deter- mine that the program is not a fit, and there nity and Re-entry Enhancement) initiative. The effort or bipolar disorder, all will have a substance depen- will be an opt-out provision. is bound to be watched nationally for several rea- dence diagnosis. sons. Centerstone is the contractor for a $1.2 mil- lion Substance Abuse and Mental Health Services PREVENT FRAUD Administration (SAMHSA) grant for the initiative, a By utilizing the Corporate Compliance ”Employee Action Line” to support your in-house Corporate grant awarded to the Indiana Division of Mental Compliance Program, you not only reduce your potential liability, should there be a fine levied against Health and Addictions in a highly competitive en- your organization, but you’ll also send a clear message to your Board, employees, and stakeholders vironment. 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 As a large behavioral health organization formed for employees to report fraud or suspicion without fear of retaliation or reprisal (as required by law). out of three entities, Centerstone is consistently u A confidential report of any incident reported is transcribed and provided via certified mail to your being looked at as a model for innovative program- Corporate Compliance Officer within 24 hours for internal investigation of possible violations for ming (see MHW, Dec. 24, 2007). And perhaps most early intervention. Whistleblowers are not identified; importantly, Project CARE will serve as a significant u The Employee Action Line is professionally staffed test case for successful integration, between addic- from 8:30 a.m. to 8:30 p.m. Monday through Friday, EST; tion and mental health services as well as between u In-house posters promoting awareness of the behavioral health and justice systems. the Employee Action Line are also provided. For additional information, contact Rhonda Willhight at “This initiative really is about breaking down service 1-800-495-6786. silos,” Grove-Paul said. 38 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 36. Ask yourself these questions today. Does you partner p r technol ogy Are you equipped to with all o rovide yo u provide quality care capabiliti f the esse ntial in an environment of es for you constant change? future su r ccess? With Netsmart, the answer is yes!  Certified EHR  Solutions to achieve Meaningful Use  Fast clinical implementation  e-Prescribing designed for Behavioral Health Reduce your risk.  Consumer Web portal Prepare for the future.  HIE connectivity Ensure your success.  SaaS and licensed software options  Support from 350,000 peer providers of care Visit us at Booth #303 at the National Council’s 40th Annual National Mental Health and Addictions Conference & Expo. Or visit www.ntst.com or call us at 1.800.421.7503, Option 6 to discuss how we can help you meet your organization’s goals TODAY. www.ntst.com | 1.800.421.7503, option 6
  • 37. From The Field Citrus Jail Diversion Program Provides Integrated Care in a Relationship-Based Care Model rafael a. rivas-vazquez, Psyd, Director, Assessment and Emergency Service, and Manual Sarria, lcSW, Administrator, Adult Homeless Programs — Citrus Health Network, Inc., Miami, FL / rrv@citrushealth.com C itrus Health Network is a federally qualified health center located in Miami-Dade County, Florida and specializing in the integration of primary The Relationship-Based Care model assumes that care and behavioral health services. In 2008, we healthy relationships can be instrumental in engaging aggregated and analyzed 4 years of data from our jail diversion program. The results were reported in people in therapeutic activities and empowering them Psychiatric Services in June 2009. Here, we provide to take responsibility for their lives. an overview of our treatment model and a summary of results from that data review. blend of supportive companions and knowledgeable needs. This stage is marked by clients taking in- Concern regarding the prevalence and inadequate consultants. The concept of “rolling with resistance,” creased advantage of the therapeutic, educational, management of people with mental illness within from the low-demand model, discourages staff from and rehabilitation opportunities offered to them the criminal justice system has generated interest meeting resistance head on; rather, they try to facili- through our program. in developing effective diversion programs. In 2000, tate a discrepancy between a person’s perception of The final stage, growth and differentiation, begins CHN received funding from the state to develop a the current situation and future aspirations. An end- when participants manifest stability, demonstrate jail diversion program, in keeping with a countywide point objective of RBC is establishing self-efficacy new adaptive behaviors, exhibit signs of psychoso- initiative prompted by Judge Steve Leifman, Associ- and self-agency, in which people develop a sense cial flourishing, and ultimately transition into inde- ate Administrative Judge of the 11th Judicial Circuit that they can change specific behaviors, act on their pendent living. in Miami-Dade County. own behalf, and take responsibility and be account- able for their decisions. For this study, we analyzed data from the Criminal CHN’s jail diversion program is based on two princi- Justice Information System in Miami-Dade County ples geared toward enhancing psychosocial stability To operationalize RBC and facilitate its implemen- for 151 people consecutively referred to our RBC and reducing criminal recidivism: tation, we conceptualized the following stages: (a) program and compared them with data for 78 a) Facilitating access to integrated medical and engagement, (b) stability and commitment, (c) people diverted to other programs in the commu- psychiatric care. awakening, and (d) growth and differentiation. nity. Number of arrests for each participant was b) Delivering all interventions within the framework During engagement, the initial foundation of a re- determined during the 1-year period preceding of our relationship-based care model, which we lationship is established; motivational interviewing date of diversion, followed by a review of arrests developed as a result of our experience in treat- techniques are used to mobilize self-interest and during the year after diversion. Results indicated ing people with pronounced difficulty in engage- encourage the client to choose care. that the RBC group demonstrated a statistically sig- ment and sustained interpersonal contact. In Stability and commitment marks a period of rest nificant reduction in postdiversion arrest rates (p addition to specific interventional techniques, and quiescence in which participants begin to feel < .0001), whereas the rearrest rate for the control the RBC model reflects a philosophical approach safe and secure. This second stage consolidates the group remained nearly identical (p = .398). For both that pervades all interactions with participants. client’s relationship with staff as evidenced by their groups, postdiversion arrest rates were significantly The model assumes that the empathy, respect, accepting physical and mental healthcare, develop- correlated with number of arrests before diversion and connectedness inherent in healthy relation- ing trust to rely on others for basic needs, and col- (p < .001). For the RBC group, regression analysis ships can be instrumental in engaging people in laborating with others to obtain day-to-day stability. revealed that when number of prior arrests was ex- therapeutic activities and empowering them to We note that although some clients did not progress cluded from the equation, length of participation in take responsibility for their lives. past this phase, they were nonetheless able to suc- the program (p < .045) and number of psychiatric cessfully remain out of jail. Probability for long-term contacts (p < .043) accounted for a significant por- RBC incorporates elements from other philosophi- tion of the variance in postadmission arrest rates. cally compatible approaches, such as the low-de- change, however, increases if a person progresses mand model and motivational enhancement thera- through the next stages. The RBC model appears to be effective in reduc- py. For example, the principle of “express empathy” The third stage, awakening, refers to a phenomenon ing criminal recidivism. Length of participation in directs us to communicate respect and encourage in which clients begin to manifest a desire for more program and involvement in psychiatric treatment collaboration with staff, who come to be viewed as a than a day-to-day existence and meeting basic correlates with reduced arrest rates. 40 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 38. CPSA’s Criminal Justice Team Stay in Touch to Reduce Incarceration neal cash, MS, President and CEO, and Kate K.v. lawson, MPa, Criminal Justice Manager — Community Partnership of Southern Arizona, Tucson, AZ / kate.lawson@cpsa-rbha.org C ommunity Partnership of Southern Arizona has taken a creative, strategic approach to collabo- rating with the criminal justice system — from the in the development of relationships, processes, and tools that allow timely identification of CPSA members who have been arrested and appropriate, real-time 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 establishment of Arizona’s first mental health court information sharing that protects member confiden- approximate number of members remanded for jail 10 years ago to new initiatives that quickly identify tiality. time in the component’s first year dropped from 40 and mobilize therapeutic and peer support for CPSA CPSA’s CJT staff check county booking lists against per month to 24 per month. This trend has continued members who have been arrested. CPSA works closely membership information twice a day. Staff alert the in subsequent months. with both the adult and the juvenile justice systems member’s assigned CSP of an arrest and ensure that In 2009, CPSA began a peer mentor program in Pima to ensure appropriate diversion, coordinate treatment treatment is coordinated with the jail’s behavioral County. In this program, members who graduate from during incarceration, and plan for continued services health treatment provider. Staff from the CSP visit the superior mental health court receive extensive train- after release. member in jail within 72 hours of arrest notification, ing and coaching so they can help incarcerated mem- Collaboration with criminal justice and other govern- 7 days before the member’s adjudication or hear- bers navigate the behavioral health and criminal jus- ment systems is built into CPSA’s structure and op- ing, and every 30 days thereafter. CPSA, the CSP, and tice systems. CPSA’s CJT has also provided technical erations. CPSA is a nonprofit, community-based man- medical personnel from the jail hold staff meetings on assistance to and become a stakeholder in the newly aged care organization created 15 years ago by local select cases each week. implemented Veterans Court in Tucson City Court. stakeholders to administer public behavioral health On any given day, the CJT monitors 250–300 mem- Success in Tucson/Pima County has led CPSA to services in five southern Arizona counties. CPSA now bers detained in jail and as many as 800 members establish six more mental health court collaborations oversees these services for more than 1.2 million throughout the criminal justice system. Approximately across its region. The initial appearance component people. CPSA’s community roots and ability to rein- 65 members are diverted from jail each month as the will be expanded as funding is available. vest cost savings into services allow it to respond to result of the CJT program, via mental health court or emerging needs, including the creation of teams that other means, resulting in approximately 17 fewer days focus on support services such as housing, employ- of incarceration per member — a savings of more than ment, and wellness. $84,000 each month. The Criminal Justice The seven-person criminal justice team is an im- portant part of CPSA’s holistic effort to reintegrate In December 2008, CPSA initiated an effort to ensure Team diverts approximately CJT representation at its members’ initial court ap- members into the community, maintaining a collabo- pearances, to help divert these members before jail 65 members from jail and ration with law enforcement and courts that benefits detention and quickly connect them with community all partners. The CJT will be presented with the 2010 results in approximately 17 treatment services. This initial appearance compo- SAMHSA’s Center for Mental Health Services National nent has significantly decreased the likelihood of fewer days of incarceration GAINS Center Impact Award at the GAINS national incarceration for CPSA members. conference in March 2010. This award recognizes per member — a savings of programs doing outstanding work in criminal justice At initial appearances, the judge informs the member and mental health services for adults. of the charges and determines conditions of release. more than $84,000 each CJT staff are prepared to obtain the member’s signa- CPSA formed the CJT in 1999 as a result of a work- ture on a universal consent form for information shar- month. group of behavioral health and criminal justice staff in ing, assess the member’s ability to transport him- or Tucson/Pima County that sought to identify systemic herself home and to treatment, and share informa- strategies to decrease the time that a person with tion with pretrial services and the presiding judge. For mental illness is inappropriately incarcerated. CPSA people who are eligible but not yet enrolled in the began mandating that its contracted Comprehensive public behavioral health system, CJT staff facilitate Service Providers, which coordinate care and provide enrollment and oversee timely contact with a treat- direct behavioral health services, hire criminal justice ment provider. When the member is too unstable to specialists to help resolve system-wide and member- safely leave the jail on his or her own, staff coordinate specific issues. An ongoing forensic task force also pickup by a treatment provider or shelter. grew out of the workgroup. This collaboration resulted NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 41
  • 39. From The Field At Community Psychiatric Clinic, Integrated Funding Stream Facilitates Comprehensive Care Shirley havenga, Ma, MPa, CEO, Community Psychiatric Clinic, Seattle, WA / shavenga@cpcwa.org I n 2003, Community Psychiatry Clinic developed its IMPACT program, one of the first co-occurring dis- order programs in the region, providing integrated load size, team-based services, and assertive out- reach to promote client engagement. Program staff include chemical dependency professionals and Coordination with the criminal mental health and chemical dependency services mental health professionals. Beginning in 2010, justice system, community using a single funding source. IMPACT was one of the IMPACT program will also include a boundary providers, landlords, and family the first programs funded by King County’s Criminal spanner position to serve as the liaison between the Justice Initiative, which created multiple programs criminal justice system and the treatment team. members aids clients in achiev- focused on developing alternatives to incarceration Coordination with the criminal justice system, com- ing treatment recovery goals and and is funded through both the county and state. munity providers, landlords, and family members avoiding further incarceration. IMPACT provides services to people referred by sev- is a key program component that aids clients in eral local mental health and drug diversion court achieving treatment recovery goals and avoiding programs. Clients are enrolled in IMPACT for up to further incarceration. Staff have developed solid Other helpful program components have included 12 months before transitioning to the regular men- relationships with local resources — housing agents access to CPC’s extensive housing resources for tal health treatment provider network for ongoing to assist in securing housing for clients who may people with mental illness and funds to assist cli- services. IMPACT serves approximately 100 people have significant difficulty with this because of their ents with securing housing; offering intensive treat- annually. criminal history; jail health services staff to promote ment groups, peer support services, involvement continuity of care for inmates preparing for release, with AA meetings, and individual sessions to help The IMPACT program provides evidence-based in- particularly for medication maintenance; court staff gear clients toward success; and close coordination tegrated treatment services, including Integrated to help clients remain in compliance with court of treatment with courts and probation. Dual-Disorder Treatment and Moral Reconation Therapy for adults with co-occurring mental health orders, and others. In addition, IMPACT staff col- Data from the first 4 years of the program demon- and chemical dependency disorders and a history laborate with the State of Washington Department strate that clients have significant reductions in of incarceration. IDDT has been shown to reduce of Corrections in cases in which the client is adju- substance abuse when discharged from the pro- hospitalization, homelessness, and incarceration dicated on a felony and is now on DOC community gram. Clients showed this reduction irrespective of and improve employment outcomes over time. MRT supervision (state form of probation) for ongoing the referral source. In years 1, 2, 3, and 4 regarding focuses on changing behavior and personality with compliance with DOC sanctions. specialty court–referred clients 47 percent, 34 per- a systematic, 12-step treatment approach aimed at “One of the most effective components of the IM- cent, 44 percent, and 44 percent, respectively, of re-educating clients socially, morally, and behavior- PACT program has been the ability to operate with clients reduced to ≤1 use per week; in years 1 and ally and assisting them in developing appropriate a single funding stream, rather than the traditional 2 regarding King County Jail referrals, 29 percent values, goals, and motivation. An intensive case siloed mental health and chemical dependency and 47 percent, respectively, of clients reduced to management model is strengthened by small case- funding sources,” says Shirley Havenga, CPC’s CEO. ≤1 use per week). Chrysalis’ Employment Support Network Improves Job Prospects for Ex-Offenders tanya howard, Services Director, Chrysalis Center, Hartford, CT / thoward@chrysaliscenterct.org C hrysalis Center has provided employment servic- es since the mid-1980s. The State of Connecticut Department of Mental Health and Addiction Services illness, substance abuse history, or both. The new Employment Support Network began operations in summer 2009, providing a full range of employment ment specialists, and two job developers. Staff have diverse prior work experience, representing criminal justice, behavioral health, employment, and educa- has funded Chrysalis Center to provide the Employ- services for parolees, many of whom struggle with tion. Employment specialists work with participants ment and Recovery Network, an outcomes-driven mental illness, substance abuse, or both. to assess strengths and deficits, determine career employment support service for people with mental ESN staff include a services director, three employ- interests, and help develop individual service plans 42 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 40. to help participants work toward their goals. Staff link recidivism. They emphasize that ex-offenders being responsibility, and that we are here to support them.” participants to additional training and education and employed and paying taxes is of greater benefit to the Although ESN is designed to serve 300 participants to appropriate community supports. Staff focus on local economy and to society. each year, the project has served more than 200 ex- addressing the needs of the whole person, not just Job developers and employment specialists conduct offenders in its first 4 months of operation. Staff work the employment component. They help participants intensive counseling with clients so they are confident closely with both parole officers and participants to gain access to housing, behavioral health treatment, when they interview with a potential employer. Staff ensure a successful outcome for each person served. support groups, legal assistance, driver’s license or conduct mock interviews, set up appointments for To date, 50 participants have gained employment. identification, child care, and more to help them suc- clients, and drive them to interviews as needed. They Because of their own life experiences, many partici- ceed. Staff counsel people that despite their illness, assist each person with developing an explanation pants have a strong desire to work with people in disability, or life circumstance, each brings with them letter for potential employers, addressing the person’s recovery from mental illness or substance abuse. Two a host of strengths, experiences, and skills to build on. felony and his or her subsequent remorse and reha- have completed the Recovery Coach Academy with the Job developers work in the community to introduce bilitation. Staff provide supports for a maximum of Connecticut Community for Addiction Recovery. One Chrysalis Center and its services to potential employ- 120 days while participants are on parole. has graduated from the Connecticut Department of ers and educate them about hiring ex-offenders. Staff “Some clients walk through the door ready for em- Mental Health and Addiction Service’s Recovery Uni- work to persuade employers to give an opportunity ployment, while others are in need of training, motiva- versity, and two are working toward degrees in drug to ex-offenders and assure employers that partici- tion, and other supports,” says Tanna Howard, services and alcohol counseling. pants will continue to receive the supports they need director for the project. “We arm clients with the tools Howard attributes the project’s early success to four to maintain employment. Job developers make their they need for success by providing a number of train- factors: employer education, a strong relationship case by informing employers about tax credits avail- ing programs in-house, and linking clients to other with parole officers, the diversity of experience and able to businesses that hire people with a criminal services that meet their needs. We make sure par- passion of ESN staff, and ongoing collaboration with background. In addition, they cite research demon- ticipants understand that gaining employment is their other community providers and stakeholders. strating that employment is a key factor in reducing Mental illnesses are complicated You probably know someone who has one To learn more visit www.MentalWellnessToday.com Your Partners In Mental Wellness NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 43
  • 41. From The Field At Hands Across Long Island, Peers Follow People from Prison to the Community ellen M. healion, Ma, Executive Director, Hands Across Long Island, Inc., Central Islip, NY / ellen@hali88.org H ands Across Long Island, a peer-run organization that has been operating for more than 21 years, supports people with severe and persistent mental ons are prohibited from being with other felons. The New York State Office of Mental Health has re- staff help inmates ported that since the inception of these services, illness in the criminal justice system. the recidivism rate has dropped significantly. understand that the coping It is not easy for mental health providers to gain ac- On Long Island, HALI recognized the needs of peo- skills they’ve acquired in cess to the criminal justice system, given safety con- ple being released to the county from prison and prison or jail will not be an cerns. New York State has led the way to a solution from the local jail. In collaboration with the Suffolk by providing mental health services in a separate asset to them outside and County Re-Entry Task Force, HALI developed a Re- unit of Sing Sing Prison in Ossining. HALI has been Entry House Pilot project to fill a major gap in the work with them after release part of this program since 2002, in addition to work- recovery process — housing. to support transition to the ing in the county jail. The goals of this program are to prepare inmates for the changes that have taken With a grant from the Department of Criminal Jus- community. place in the community since their incarceration; tice and HALI funds, we were able to create an in- develop their interview skills with respect to parole, tensive program and establish housing. We can ac- housing, and other practitioners; and develop new commodate four people at any given time. Attached coping skills to help them remain in the community. to the house is a studio apartment in which a staff It is imperative that inmates understand that the person resides and provides emergency response coping skills they’ve acquired in prison or jail will for the residents. We help people develop routines not be an asset to them in the community. and attitudes helpful for community integration. freedoms with frequent drug testing, verification of The program initially provides intensive supervision planned activities, and so forth. In addition, plan- Because HALI staff have “been there, done that” and ning is done for after the resident graduates from work with inmates for 3 months, they develop posi- and then lifts restrictions as appropriate. Staff ar- rive at the house every morning, inspect the house, the program. Applications for housing programs, tive, trusting relationships. Next, staff help to bridge employment programs, recovery programs, and the inmates from prison to the community. Staff meet and make sure residents are ready before they are transported to their program or appointments. By like are prepared and submitted to the appropri- inmates at the gate on the day of release and ac- ate agencies. Although providers, employers, and company them to parole and a meeting with their 3:30 pm, residents are picked up from their work and brought back to the house where they have schools may be hesitant to accept a parolee’s ap- case manager and then to a shelter for the evening. plication, a graduation certificate from the re-entry To date, no housing programs have been developed time for dinner and chores before they head out for a community-based 12-step program (AA or NA). program provides supporting documentation that to accept inmates on release; therefore, shelters are attests to the person’s efforts to change his or her necessary for approximately 2 weeks to verify home- Staff stay with them through the meeting to coach them to participate, meet people, and integrate into life. HALI can also directly communicate with provid- lessness. To facilitate the transition to the commu- ers to help with their acceptance of the parolee. nity, staff continue working with a participant for the community. They typically return to the house another three months. around 10:00 pm. On weekends, staff accompany People with mental illness require intense assis- residents to the grocery store and other errands, tance to succeed in returning to the community A drop-in center was developed to offer support and residents participate in some form of exercise from prison. HALI gives them the opportunity to live to those people who have completed the program and recreation. The goal is to teach the residents on the outside with others who have done the same and want continued support. The center is open on how to live a full life in recovery. For many, this is an and not only survived but created a life worth living. “reporting day,” just around the corner from parole. exhausting process — life in jail or prison is certainly If someone has dropped off the radar, chances are Twenty-eight people from Sing Sing and Suffolk not filled with activity. County Jail have crossed our threshold. Of these, that they can be found at parole on their reporting day. The center also provides a place where people When the staff and the resident together feel that he 22 are employed or going to school, have reunited can touch base with the staff who worked with them or she is ready to have more responsibility, unsuper- with their family, have started a family of their own, in prison and with whom they have a relationship. vised activities are planned that also take into con- or live independently or in a supported housing This center required permission of the Parole De- sideration conditions of parole or probation. During program — their names line the wall at the re-entry partment to allow felons to congregate as most fel- this phase, the resident is given more and more house to give hope to newcomers. 44 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 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 www.thesantegroup.org For more information about our services and capacities please contact Fred Chanteau at fchanteau@santegroup.org
  • 43. From The Field John Eachon Re-Entry Program Focuses on Intensive Therapeutic Services elaine cooper, Med, lPc, ncc, Mental Health Therapist, John Eachon Re-Entry Program, Lakewood, CO / ElaineC@jcmh.org T he John Eachon Re-Entry Program serves offend- ers who are eligible for community placement or parole. JERP offers intensive residential and While in the JERP program, the clients are able to take part in many Jefferson Center services and programs, including additional group therapy; a CRIMINOGENIC FACTORS nonresidential treatment for offenders with serious wellness program; assistance with transition to The JERP program has identified mental illnesses and substance abuse disorders. other housing; benefits application assistance; specific criminogenic factors of JERP is a collaboration between four major entities: peer mentoring and counseling; and case manage- severe and persistently mentally the Colorado Department of Corrections, Jefferson ment to assist in obtaining employment, education, Center for Mental Health (serving Jefferson, Gilpin, transportation, and other services. ill substance-abusing offenders — and Clear Creek Counties), Intervention Community A JERP participants remains in the residential pro- focusing on these factors supports Correction Services, and Jefferson County Justice gram at ICCS until he or she is deemed ready for recovery and lowers recidivism. Services Division of Criminal Justice Department nonresidential placement — transition to Jefferson of Public Safety. Early planning and collaboration Center housing or other community living. To ensure Criminogenic factors include began in September 2003, and with a grant from community readiness, the decision to transition the Bureau of Justice Assistance, doors opened in from community corrections to the community is l Mental health November 2005. On July 1, 2005, JERP began re- made by an interdisciplinary team of JERP clini- ceiving state funding. l Criminal thinking cians, nurse, and supervisor, as well as the ICCS The goals and objectives of JERP are to: clinical director and staff and the offender’s parole l Antisocial companions >> Integrate correctional supervision with officer. Jefferson Center offers a continuum of hous- ing options to serve as transitional living opportuni- l Antisocial personality or community re-entry, mental health treatment, ties for clients who are working to eventually obtain temperament substance abuse treatment, vocational rehabili- independent living within the community. tation (education and employment), and social l Substance abuse services (housing, benefits, family resources). After completing services at JERP’s inpatient site, clients are offered housing through other Jefferson l Family and marital conflict >> Increase mental health functioning and prosocial behavior. Center programs or within the community. Clients (social supports) continue attending weekly individual and group >> Decrease psychiatric hospitalizations (or therapy, as well as other therapeutic services. Also, l Employment (social supports) returns to DOC resulting from psychiatric offenders may be able to move from the residen- l School (social supports) emergencies or decompensation). tial program site at ICCS to other approved living >> Increase medication compliance. arrangements, such as with family or independent l Leisure and recreation >> Reduce technical violations and new criminal living, with the approval of their parole officer and (social supports) offenses. the JERP team. Jefferson Center offers mental health treatment ser- >> Reduce community corrections placement failures. vices that range from intensive residential services through general outpatient therapy or medication Our mission is to offer intensive therapeutic servic- management, and JERP clients are encouraged to es (individual and group therapy, psychiatric care, maintain services with Jefferson Center even after medication monitoring) to meet program goals for completion of the JERP program, parole, or both. offenders with co-occurring disorders. Typical diag- Preliminary statistics indicate a significant de- noses treated include major depression, bipolar crease in JERP clients’ recidivism rate (2–3 times disorder, schizophrenia, schizoaffective disorder, less) compared with that of severe and persistently substance abuse disorders, personality disorders, mentally ill substance-abusing offenders who re- attention deficit hyperactivity disorder, and post- ceive no treatment. traumatic stress disorder. Much-needed mental health treatment helps to reduce recidivism. 46 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 44. Kent Center’s Court Clinic Bridges Behavioral Health and Criminal Justice Systems david S. lauterbach, acSW, President & CEO, The Kent Center, Warwick, RI / astoltz@thekentcenter.org R hode Island — the smallest state in the nation — is not immune to the personal, social, and financial ramifications of the inappropriate incarceration of The court clinician’s flexible approach to problem solving has helped to create an atmosphere of mutual respect between people with behavioral health challenges. Greater awareness of this issue has slowly come to the fore- the behavioral health and criminal justice systems in Kent County. front, and one way in which Rhode Island has success- Our court clinician assesses the person for mental nal justice system, appreciation for the unique cul- fully prevented many inappropriate incarcerations in health issues, substance disorders and a history of tures of all agencies involved, and flexible approach to favor of treatment is through The Kent Center’s Court trauma. The clinician uses the guidelines of a trauma- problem-solving has helped to create an atmosphere Clinic Program. informed intervention model when making an assess- of mutual respect between the behavioral health and In 1999, the Rhode Island Department of Mental ment. The clinician — employed by The Kent Center criminal justice systems in Kent County. Health, Retardation and Hospitals provided funding and not the court — serves as an independent and ob- One of the most positive outcomes of the Court Clinic to The Kent Center to establish the first court clinic in jective advocate. This arrangement fosters significant Program is the impact it has had on the relationship Rhode Island at the Kent County District Court. Since trust between the clinician and clients and families. between the criminal justice system — in particular the program’s inception, we have assisted nearly Equally as important to the program’s success are the police departments — and the Kent Center’s 24/7 2,500 people with outcomes that include diversion relationships developed over several years between Emergency Services Department. The court clinician from jail, placement in treatment, dropped or reduced the Kent Center’s court clinician — and, by extension, acts as a consultant to police in handling emergency charges, and reduced court fees. We have also as- the Kent Center’s Emergency Services team of which encounters with people in crisis and trains police sisted family members by educating them about what she or he is a member — and all segments of the officers from across the county and state in how to happens in court and by referring them to community criminal justice system. We realized early on that one handle emergency encounters with people present- resources. key to success would be a receptive judiciary. One ing with behavioral health symptoms. She is often the The Kent Center employs a full-time master’s-level cli- judge in particular, Judge Stephen Erickson, assuaged point person for police and is called on at any time nician whose primary work site is the courthouse. The all concerns. Judge Erickson has a track record of of day to assist with emergency situations. In turn, clinician is present during court hours and is imme- working with people struggling with mental illness she calls in other members of the emergency services diately available to the judges should they request an and addictive disorders and supported a clinician in team to assist. assessment of a person who comes before the court. the court from the start. Other judges have quickly The relationship between the Kent Center and the The clinician assesses the person’s behavioral health become supportive as well. A strong rapport has also criminal justice system continues to grow. Working needs, makes treatment recommendations, and pro- been established between the court clinician and the together, we will divert many more people struggling vides follow-up information regarding the person’s prosecution teams of the towns and cities served at with behavioral health challenges from inappropriate compliance with court orders. The prosecuting and the Kent County Court, as well as between the court involvement with the criminal justice system into treat- defense attorneys, police, family members, or defen- clinician and police departments. The clinician’s ment, in order to provide cost savings and the best dants themselves may also request an assessment. knowledge of the roles of each segment of the crimi- outcomes for individuals, families, and communities. Mental Health Center of Denver’s Court to Community Program Gets Results 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 / kaylynn.dougall@MHCD.org B efore 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 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 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 incarcerations for multiple misdemeanor violations and service agencies, JT has made dramatic strides in the Denver Crime Prevention and Control Commission, NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 47
  • 45. From The Field Over the C2C program’s first year, an 87 percent drop was seen in the to allow consumers to join the program. “It took a lot of communication and collaboration to help the cumulative arrest rate. It is estimated that 5 years after completion, city attorney’s office feel comfortable that people the program saves $3.50 for every dollar spent on a consumer. could succeed in the program and not commit fur- ther crimes,” explains Flynn. with the mission of creating a flexible and respon- with the year before admission. It is estimated that As a result of C2C’s success, Denver now has a sive system to serve and manage municipal ordi- 5 years after completion, the program saves $3.50 mental health court docket and a judge dedicated nance offenders with serious and persistent mental for every dollar spent on a consumer. The program to strict review and oversight of consumer partici- illness. Now entering its fourth year, C2C has proven has also shown reductions in psychiatric admis- pation and progress. The program has made sig- to be an enormous success for Denver, both in out- sions, the need for detoxification services, and sub- nificant contributions to promoting mental health comes for its participants and in demonstrating a stance abuse. literacy within the criminal justice system and has successful system of cooperation and collaboration C2C uses Assertive Community Treatment in a novel provided ample evidence that mental health treat- between mental health providers and the criminal way by providing a clinically sound process for ment can be cost effective in reducing the use of justice system. graduating consumers to lower service levels while public funds. C2C’s demonstrated effectiveness has With services provided by the Mental Health Center maintaining their progress in recovery, allowing led to a collaborative effort to seek funds to sustain of Denver and the Colorado Coalition for the Home- the C2C team to serve more consumers than with and expand the program. Denver Judge Larry Bohn- less, the program serves at least 36 adults at any a traditional ACT approach. MHCD also provides ing, who oversees Denver’s weekly mental health given time, connecting consumers to court-ordered integrated dual-disorders treatment and access to docket, was an early skeptic. “Now I’m convinced mental health treatment, substance abuse services, dialectic behavioral therapy and trauma recovery we’re doing some good,” he says. “We could use 300 and housing and social support assistance. The pro- empowerment model groups when indicated. Pro- more slots.” gram is funded by the city and county of Denver and gramming and outcomes are evaluated, monitored, C2C has been and continues to be a model for the the Colorado Health Foundation. and improved on using sophisticated measurement development of a number of similar programs and C2C’s initial goals included reducing arrests and methods developed by MHCD’s Department of Out- partnerships targeted at reducing the skyrocketing incarcerations of people with serious and persistent comes and Evaluation. number of people with severe mental illness, co- mental health issues by 25 percent. Over the pro- At first, C2C was met with skepticism. According to occurring substance abuse disorders, and trauma gram’s first year, an 87 percent drop was seen in the MHCD Deputy Director of Adult Recovery Services in Denver who are involved in the criminal justice cumulative arrest rate. The cumulative number of Jay Flynn, the greatest obstacle was the criminal system. days spent in jail dropped by 80 percent compared justice system’s initial lack of trust and reluctance Tarrant County’s Mental Health Law Liaison Project Is On 24/7 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 / Ramey.Heddins@mhmrtc.org M HMR’s Mental Health Law Liaison Project is a jail diversion program that works with all law enforcement agencies in Tarrant County. Program advocates for clients by training officers at local police departments, sheriffs’ departments, and po- lice academies on how to interact with people with 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 funding is provided by Tarrant County Commission- mental illness. These trainings include the Mental she believed Ms. Porter was having a relationship ers Court and a federal justice assistance grant. The Health Peace Officers Course, crisis intervention with a man in Virginia who Ms. Locke believed was goal is to slow down the “reinstitutionalization” of training, and other specialized mental health train- her boyfriend. No such relationship actually existed. people with mental illness in prison by diverting ings on request. During the investigation, the department found that them to services appropriate to their needs. On April 11, 2003, the Hurst Police Department re- they had dealt with Ms. Locke on a couple of occa- The project answers officers’ calls 24/7, to help as- sponded to a shooting at a condominium complex sions when she had made threats against city rec- sess the clients’ condition and recommend treat- in the southeast portion of the city. At the scene, reation staff. The department also discovered that ment services. Follow-ups include consultation with the witnesses relayed to officers that a 78-year- Ms. Locke had been arrested in 1982 for attempted officers on the phone and at the scene to determine old woman, Ms. Locke, had been making threats murder and that the case was dismissed for rea- the most appropriate action to take. MHMR also against another resident in the complex, Ms. Porter. son of insanity. Subsequently, a Tarrant County jury 48 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 46. found Ms. Locke incompetent to stand trial for the community. The partnership also has been instru- 2003 murder, and she was sent to the Vernon State mental in reducing calls for services, thus leading Hospital. to decreased costs for the department. By working By identifying people with The Hurst Police Department comes into contact with together to identify people with special needs early special needs early in the an increasing number of citizens with mental health in the process, we’ve been able to decrease the num- issues. Officers often deal with family members who re- ber of people going to hospital or jail and to increase process, we’ve been able to public, officer, and client safety. port how well these citizens are when they are on their decrease the number of medication; however, many stop taking their medicine The Hurst Police Department has created a protocol when they feel they are doing better. The Hurst Police within its agency to ensure that the proper documenta- people going to hospital or Department is unable to solve many of these mental tion is completed and forwarded to the Mental Health jail and to increase public, health issues without the assistance of mental health Law Liaison Project. Once this information is received, professionals. So, the department started looking for the Law Liaison Project attempts to follow up with the officer, and client safety. a way to be more proactive and preventive in dealing client to determine the best course of action. The Law with clients with mental illness. Liaison Project also completes follow-ups by riding A proactive approach to dealing with people with with trained mental health peace officers and has to negotiators to make a good diagnostic impression mental illness has been partnering with the MHMR one designated mental health peace officer who com- and to determine the best course of action in a cri- Mental Health Law Liaison Project. The Hurst Police municates regularly with MHMR to discuss the status sis situation. As a result of the successful partnership Department and the Law Liaison Project have been of clients with mental illness within the community. A between MHMR and the Hurst Police Department, the able to work closely together to identify people in the high percentage of contacts made by the Hurst Police program has grown exponentially. This proactive ap- community with mental health issues and coordinate Department and MHMR are health wellness checks to proach has been implemented by five departments in the appropriate treatment services. This partnership reduce emergency detentions. Northeast Tarrant County, which include Euless, Bed- has facilitated effective communication in crisis situ- The Law Liaison Project is also a part of the hostage ford, Richland Hills, North Richland Hills, and Haltom ations, which has resulted in better outcomes in the negotiation team and provides technical assistance City Police Departments. River Edge Combines Services and Training to Lower Recidivism tiffany M. russell, Community Affairs Manager, and Shannon t. harvey, lcSW, CEO — River Edge Behavioral Health Center, Macon, GA sharvey@river-edge.org I n 1998, in an effort to decriminalize people with mental illness and move defendants from jail into treatment, Bibb County law enforcement joined River also began providing licensed staff to be available on weekends and holidays for emergency evaluations, along with a psychiatrist who could prescribe medi- uations, medication management, brief intervention groups for addiction, therapy groups, skills training, parenting classes, and discharge planning. Edge Behavioral Health Center and other community cations. With the sheriff’s financial and political support, the partners to begin a forensic social services program. Through a contract with Bibb County Government, fi- Bibb County LEC has significantly decreased inmates’ In the early days, officers brought inmates of the 930- nancial contribution by River Edge Behavioral Health assaults on other inmates or staff and suicide at- bed Bibb Law Enforcement Center with significant is- Center, and donated office space and computer in tempts or referrals for psychiatric hospitalization. sues to a River Edge site for evaluation. Eventually, the LEC, River Edge now provides a full-time licensed During the past fiscal year, only 1 percent of the jail River Edge began sending an evaluator to the LEC clinical social worker, a part-time psychiatrist, and population assaulted another inmate and only nine for at-risk inmates because bringing the inmates to two (male and female) certified addiction counselors inmates attempted assaults on staff. In fiscal years the River Edge facility was deemed expensive, time- available 24/7, on call and onsite. Services provided 2007, 2008, and 2009, the Bibb County jail had no consuming, and embarrassing to inmates. River Edge include case management, psychiatric services, eval- suicides or referrals for psychiatric hospitalization. Among inmates with ongoing access to treatment and From Fy 2007-2009, the Bibb County jail had no suicides or supportive services on release, the rate of recidivism referrals for psychiatric hospitalization. Among inmates with ongoing is far lower than average. access to treatment and supportive services on release, the rate of In 2005, River Edge, the National Alliance on Mental recidivism is far lower than average. Illness, and the Bibb County sheriff’s office teamed up NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 49
  • 47. From The Field to provide crisis intervention training to teach pub- dollars on jail beds — approximately $52.00 per The Bibb County mental health court has been enor- lic safety officers and first responders how to more inmate bed per day. mously successful; the number of graduates has therapeutically intervene with individuals or families Referrals are reviewed by the mental health court doubled at each graduation. Graduates have only experiencing a mental health crisis. team, which includes the assistant district attorney, a 1 percent rate of rearrest. Program success can In April 2007, a mental health court was initiated representatives from state and federal probation, be attributed to visionary leadership and consis- in Bibb Superior Court. Persons charged with either the Department of Family and Children Services, tent, strong collaboration between law enforcement, a misdemeanor or a felony may participate in the River Edge, and the public defender’s office. Once health professionals, and other supportive services. mental health court; however, those charged with a referral is accepted, the participant is assigned a With more than 30 percent of the population in- homicide or sex crimes cannot yet be served. After case manager who works with him or her to deter- carcerated in the Bibb County jail currently entering an initial referral from jail staff, the defense attorney, mine treatment and resource support needs. It is the facility with a diagnosable mental illness, the LEC medical staff, or the inmate, an assessment for important to note that mental health court partici- need for services is huge. Funding for medication, clinical appropriateness is completed. If a referral pants receive intensive court supervision, including psychiatric time, and additional supportive services is received pre-adjudication, most charges can be reporting their progress to the judge every other — especially case management and transitional dropped on graduation from mental health court. Thursday. People served typically enter services housing with watchful oversight — has been the lim- If a referral is received from a probation officer, in- homeless and quite ill psychiatrically; therefore, iting factor in mental health court expansion. It is mates can be sentenced to program participation. program services and monitoring are usually con- projected that with the addition of these services, Accordingly, the court can serve both as pretrial di- tinued for 12–16 months before graduation. Gradu- hundreds more could be served and recidivism cut version and in lieu of incarceration, saving taxpayer ates can receive additional services and aftercare. by an additional 20 percent. River Oak Center Helps Youth on Probation through Multisystemic Therapy Mary hargrave, Phd, CEO, and Stephanie Parmely, Phd, Director MST, River Oak Center for Children, Carmichael, CA mhargrave@riveroak.org R iver Oak Center for Children adopted the Mul- tisystemic Therapy program in 2003 to address unmet needs for youths in probation with mental toward and barriers to those goals, assessments regarding what has contributed to any problems or successes that week, and new goals for the week Of youth in the multisytemic health and substance abuse issues. MST is an ahead. In the weekly supervision group, staff are re- therapy program, 93 percent evidence-based program known to reduce out-of- quired to discuss every case. After supervision, there home placement, criminal behavior, and substance is a weekly consultation group with an MST consul- were in school or working abuse among youths ages 10–17 years. MST works tant. Each client completes a monthly evaluation of by assessing the multiple systems that contribute the therapist, and therapists complete evaluations and 70 percent showed to the client’s behaviors and works through the key of their supervisor to ensure fidelity. success in an educational stakeholders within those systems (parents being MST is rooted in family systems approaches and the most significant) to increase structure, limit cognitive–behavioral, parent management, and or vocational setting. setting, monitoring, warmth, and prosocial peer solution-focused theories. No intervention is pro- activities. vided until a thorough assessment or sequence of In Sacramento, CA, MST services are funded through the problem is established with the family, thus en- low monitoring, ineffective discipline, peers who probation grants and mental health funding. Each suring that the therapist avoids a one-size-fits-all use, lack of prosocial activities, truancy, pleasure or therapist works intensively with four to six families approach and encouraging family awareness and escape, boredom, low social support, and perceived at a time. Services include 24/7 availability and two participation in the development of interventions. benefits of using. With this information, staff work to three sessions weekly provided in the home, com- With substance abuse, the therapist does a func- to help the family reduce these triggers, increase munity, school, and neighborhood to make systemic tional assessment with the child and family looking positive coping skills, and involve youths in proso- changes. To ensure quality feedback and maintain at (a) systemic triggers for the substance use, (b) cial activities in which exposure to substance-using model fidelity, staff are required to submit to super- positive and negative effects of using, and (c) after- peers decreases. vision, weekly case summaries that include clients’ effects of use. Research indicates common triggers The June 2007–June 30, 2008, Mentally Ill Offender overarching goals, previous weekly goals, advances for youths include parents who use, family conflict, Crime Reduction Outcome Report reflected River 50 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 48. Oak client outcomes as follows: (vs. 14 filed and 0 sustained historical). During the time River Oak has been using MST, we’ve >> 6.6 times fewer petitions filed for new law viola- >> 6.1 times fewer people made WIC 602 wards of learned that: tions (111 days for historical group vs. 18 days). the juvenile court (43 historical vs. 7). >> With quality supervision, there is high >> 6.9 times fewer sustained new law violations (62 MST outcome data for the same period showed the motivation and competence and prevention of historical vs. 9). following: burnout among quality staff. >> 6.5 times fewer commits to juvenile hall, ranch, or >> 73 percent completed treatment. >> With quality staff that fit a systemic approach, camp (13 historical vs. 2). there are quality outcomes for families. >> 88 percent showed parenting skills necessary to >> Fewer days detained in a juvenile hall, ranch, or handle future problems. >> With quality outcomes for families, there is camp (323 historical vs. 23). support for the program. >> 84 percent showed improved family relations. >> Three out-of-home placements (vs. 8 historical). >> With support for the program, there is funding. >> 80 percent showed improved social support >> One admission to an acute psychiatric hospital networks. >> With funding and quality outcomes, there are (vs. 18 people in the historical group with a total fewer clients that fill up our juvenile halls, >> 93 percent were in school or working. ranches, and group homes. of 24 admissions). >> 70 percent showed success in an educational >> With fewer clients in facilities, there is more >> More minors attending school and more days or vocational setting. attended (5 of 71). money to fund quality programs. >> 48 percent of youths were involved in prosocial >> No petitions filed or sustained for status offenses activity. Seacoast’s Community Wellness Court Rehabilitates Persons with Serious Mental Illness rob levey, Ma, Development and Communications, Seacoast Mental Health Center, Portsmouth, NH / rlevey@smhc-nh.org L aunched in May 2008, Seacoast Mental Health Center’s Community Wellness Court in Portsmouth, New Hampshire, seeks to rehabilitate people charged The recidivism rate for program participants is below 15 percent, and the program has reduced crime on an individual basis and with crimes who have severe and persistent mental improved overall community safety. illness. problem was also combined with mental illness so the bilize themselves. Responding to critics who suggest The result of a year-long coordinated planning pro- idea started from there,” says Judge Gardner, who also the alternative-sentencing program provides repeat cess, the program, which recently graduated its first cited the efforts of Al Wright, superintendent of the offenders with a free pass, Braun says that CWC re- class, involves SMHC, local police departments, the Rockingham County House of Corrections, and Mike quires each participant to sign a 1-year contract and county jail, prosecutors, public defenders, and the Magnant, retired Portsmouth police chief, as crucial actively develop his or her own treatment plan. “It’s a court system. to CWC’s development. “Without that sort of collab- lot of work,” states Braun, who says participants meet According to the director of SMHC’s Community Sup- orative effort, we wouldn’t be in existence,” Judge with their therapist and case manager at least once a port Program, Gretchen Estes, the collaborative na- Gardner added. week in addition to seeing a psychiatrist, nurses, and ture of the CWC has been critical to its initial success. Offering case management, psychiatric, and therapeu- other appropriate personnel as necessary. “A lot of cross-education has taken place,” says Estes. tic services in addition to vocational and educational Judge Gardner adds that she and the city’s public “It was important [that] we shared our knowledge — supports, the CWC program is based on evidence- prosecutors and defenders also meet with program they have learned a great deal about how we operate based practices found in illness management and participants on a monthly basis to better understand and we have learned how the legal system works. It’s recovery and supported employment principles. their goals, circumstances, and any stressors in their improved the program.” lives. “The court has to be invested in the process and SMHC’s Debra Braun, team leader for the Intensive Portsmouth District Judge Sawako Gardner agrees Treatment Team within CSP, supervises the program needs to connect with each participant,” she says. and says the program originated from their initial and says its objective is to help participants, more Judge Gardner also notes that the program has sig- effort to deal with crimes perpetrated by the city’s than half of whom have co-occurring substance abuse nificantly improved the eligibility criteria needed to homeless population. “We realized pretty quickly the issues, acquire tangible skills they may use to sta- enter CWC. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 51
  • 49. From The Field “You have to be careful who you choose to be in Judge Gardner anecdotally notes that she believes CWC has also proved to be sustainable; as Estes the program,” said Judge Gardner, who points out CWC has reduced crime on an individual basis and says, it “works within established models already that participants’ diagnosed mental illnesses must has improved overall community safety. in place,” although she notes it could benefit from be deemed substantially responsible for causing According to Portsmouth Prosecutor Karl Durand, expansion, which would require additional outside the crimes. participants have also been able to take away an funding sources. “It can’t just be that the person has committed a immense amount of pride in themselves. “The court However, Judge Gardner says she believes the crime and they happen to have a mental illness,” provides incentives for people to address their men- maximum capacity CWC can handle at one time is she adds. “That wasn’t on our radar in the beginning tal health problems that have caused them to react between 15 and 20 people and cautions against of the program, but it is now.” criminally,” he says. “Without this court, they would allowing the program to get too big. “We need to As for program outcomes, the recidivism rate for not have that opportunity. We need to provide in- connect with participants individually,” she adds. “If program participants is below 15 percent, and centives for them to get therapy and be medication the program was any bigger, I don’t think we could compliant.” do that.” Spanish Peaks Offers the Alternative to Incarceration — Treatment lisa rea, Ma, lPc, Special Services Program Director, Spanish Peaks Mental Health Center, Pueblo, CO / LisaR@spmhc.org B eginning in July 2008, Spanish Peaks Mental Health Center in Pueblo, Colorado, received funding through Senate Bill 097 to create a multi- The evidence-based practices that are available to all TAC Program clients, depending on their indi- vidual treatment needs, include Moral Reconation Between april 1, 2009, and december 1, 2009, the TAC disciplinary community collaboration and to imple- Therapy, Integrated Dual-Disorder Treatment /co- Program accepted nine clients with ment programming to provide mental health and occurring treatment, Dialectical Behavior Therapy, combined sentences of 22.5 years — co-occurring substance abuse treatment to adult and Assertive Community Treatment. SPMHC also the potential cost savings associated and juvenile offenders in the community. The center provides comprehensive case management ser- with this is $582,480. specifically enrolls people who would not otherwise vices that include referrals and linkage to housing have the means to access services. Its first goal was resources, prescription assistance, employment and aging outcomes, both clinically and with decreased to develop a community collaboration that included educational resources, and referrals to agencies to recidivism — we define recidivism as any return to leadership from SPMHC, the court, law enforcement, apply for any benefits for which clients may qualify. jail or DOC as a result of a new charge or conviction and other criminal justice agencies. We wanted to Once the treatment team and the programming or revocation of probation or parole. We are also hear from everyone about how offenders with men- were in place, our next goal was to identify and in- tracking potential cost savings because clients are tal illness affect their agencies and how we might tercept offenders with mental illness and increase sentenced to the TAC Program in lieu of sentenc- work together to divert these offenders into effective their access to community treatment. We used the ing to Colorado DOC. These clients come to the TAC treatment rather than incarceration. sequential intercept model as a guide in developing Program with suspended sentences. The Treatment Alternatives Collaboration Program our programs and protocols. Initially, it was difficult Between July 1, 2008, and June 30, 2009, the TAC was created in October 2008. In partnership with to decide at which point(s) in the criminal justice Program served a total of 66 adult clients. In the seven of the area’s law enforcement and judicial process we should try to identify and intercept of- 12 months preceding their enrollment in the TAC and criminal justice agencies, we worked to develop fenders. To really understand our community needs, Program, these clients served a combined total of our goals, objectives, and outcome measures and we elected to accept referrals from all points in the 5,191 jail or DOC days. During their admission to to create a Memorandum of Understanding. The TAC criminal justice system — from initial contact with the TAC Program, they served a combined total of Program Treatment Team began accepting referrals law enforcement, to diversion in lieu of prosecution, only 897 days, a decrease of 4,294 days. This trans- in October 2008 and is made up of three full-time to diversion at sentencing, to people re-entering lates into a cost savings of $38,874 for the Pueblo staff — a mental health clinician, a substance abuse the community from the jail or Department of Cor- County Jail and a savings of more than $300,000 treatment specialist, and a case manager. We re- rections. Though ambitious, this has allowed us to for DOC. Additionally, between April 1, 2009, and ceived more than 225 referrals during fiscal year really tailor our interventions to our communities’ December 1, 2009, the TAC Program accepted nine 2008–2009. The TAC Program is able to serve up to specific needs. clients with combined suspended DOC sentences of 50 people. We offer outpatient individual and group Although the TAC Program has only been in existence 22.5 years. The potential cost savings associated mental health and co-occurring substance abuse for about 18 months, we are already seeing encour- with this is $582,480. treatment. 52 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 50. In Wayne County, Jail and Community-based Services Work in Tandem Julie hanna, MSW, Research Assistant, WSU Project CARE, Detroit, MI / jhann@med.wayne.edu T o address the issue of co-occurring substance use and mental health disorders in jails, staff from the Wayne County Jail, Detroit-Wayne County Community 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 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 Mental Health Agency, Detroit Recovery Project, and the community. Those who continued in the COPE of participation in the community, such as providing Wayne State University Project CARE collaborated to program after release, as opposed to those who did transportation on release from jail and engaging in form the Co-Occurring Peer Empowerment program. In not continue, tended to be African American, older, un- assertive community outreach. 2006, WSU staff began facilitating meetings and dis- employed, and homeless, which has implications for cussions among involved parties, researching existing program staff in terms of understanding and engaging models, writing the proposal to obtain block grant the target population and tailoring services to their People who followed up with funding for the program, and obtaining Institutional particular needs. Review Board approval from the university and from In comparing the 19 who followed up with COPE with COPE were more likely to get the jail. On the basis of research on existing models, the 94 who didn’t, we looked at outcomes related to into community mental health the COPE Program was developed with three compo- community mental health appointments, inpatient nents: the APIC (Assess, Plan, Identify, Coordinate) psychiatric hospitalizations, and recidivism. The hy- services sooner and remain in model, Dual Recovery Anonymous, and peer support. pothesis was that ongoing contact with COPE would in- the community for a longer period COPE was implemented in September 2007 to en- crease the likelihood of people making and keeping a of time before being hospitalized hance existing jail-based services, with the mission of community mental health appointment and decrease “Providing jail and community-based relapse and re- the incidence of psychiatric hospitalization and recid- or reincarcerated. covery services for inmates with co-occurring disorders ivism. People who followed up with COPE were more at the Wayne County Jail” and the goal of “Reducing likely to have a postrelease community mental health relapse and the associated behaviors that contribute services claim (90 percent vs. 50 percent), get into to the increase in mental health services, substance community mental health services sooner (42 days abuse, and the involvement in criminal activity that vs. 74 days from release to first appointment), remain lead to recidivism and increased cost.” in the community for a longer period of time before COPE provides a range of jail-based and community- being hospitalized (221 days vs. 89 days from release based services. Initially, DRA groups were established to hospitalization), and remain in the community for a twice a week inside the jail. In 2009, two groups a longer period before being reincarcerated (247 days week were added at a second facility. Peer support vs. 134 days from release to incarceration). specialists facilitate groups. The case manager does COPE participants reported that they liked the intake interviews with new participants, collecting in- jail DRA groups because of the educational as- formation for their case files and for program evalua- pect, the facilitation by peer support special- tion. In the community-based component, COPE offers ists, and the linkages to the community after re-entry assistance, DRA groups, participation in peer release. Interest in the jail-based DRA groups activities, case management, and peer mentoring. was surprisingly high, but the rates of community WSU staff reviewed participants’ records on a quar- follow-up were not as high as we had anticipated. terly basis to collect relevant information and enter We discovered that this was in part because of it into an electronic database. Data were triangulated logistics. First, only 54 percent of participants were with data provided by the jail and data from the coun- actually released. Second, the facilities differ in that ty’s community mental health database. one mainly houses people awaiting sentencing, and the other houses people who have already been sen- In the program’s first 2 years, 218 people participated tenced. Following up with the latter was easier be- in the jail-based DRA groups. The average age was 38 cause they were more likely to know their release date years. Fifty-nine percent were African American, and and less likely to be transported to another facility 32 percent were White. Sixty-four percent reported outside of the county; however, groups did not begin being unemployed, and 32 percent reported being at that facility until 2009, thereby limiting the amount NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 53
  • 51. Beyond Bars Double Tragedies: Speaking Out Against the Death Penalty for People with Mental Illness 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. How can a modern, civilized I n 1999, Manny Babbitt, a decorated Vietnam vet- eran diagnosed with schizophrenia and posttrau- matic stress disorder, was executed at San Quentin of violent crime, these are the voices that need to be heard.” society choose to exterminate its mentally ill citizens rather than treat MVFHR and NAMI have released a report giving Prison in California after having been convicted of them? I’ve been waiting 25 years… voice to the shared concerns of the participants in murder. Manny’s brother Bill, who turned Manny in the San Antonio meeting. Entitled Double Tragedies: for people to come together and to the authorities after being promised that the state Victims Speak Out against the Death Penalty for say that the death penalty is not the would not pursue the death penalty, has become a People with Severe Mental Illness, the report calls answer to the problem of untreated staunch advocate against the death penalty. the death penalty “inappropriate and unwarranted” mental illness in our country. In 1998, Linda Gregory’s husband, Gene, was shot for people with severe mental illnesses and “a dis- and killed while responding to a call to assist a man traction from problems within the mental health Lois Robinson with paranoid schizophrenia who had barricaded system that contributed or even directly led to himself in his residence with an arsenal of weapons. tragic violence.” Since then, Linda has become a leading advocate The report is based on extensive interviews with 21 for better mental health services in Florida. pulse control reduce the level of culpability in cases family members from 10 states: California, Florida, involving defendants with intellectual disabilities These extraordinary individuals joined many others Georgia, Illinois, Louisiana, Maine, Massachusetts, or juveniles and, therefore, do not justify the most in San Antonio in October 2008 to begin an unprec- North Carolina, Tennessee, and Texas. The families extreme penalty of death. These factors frequently edented conversation about whether persons with represented in these interviews fall into one of two apply as well in capital cases involving severe men- severe mental illnesses should be exempt from categories: families of victims of homicides at the tal illness — raising serious questions about whether capital punishment. The participating families dis- hands of a person with a severe mental illness and the death penalty should be similarly banned for covered that they had much in common. Whether families of persons with severe mental illness who defendants with these illnesses. families of homicide victims or families of people have been convicted of homicides and executed. In who had been executed, they all shared common certain cases, the person who committed the homi- The Double Tragedies report describes horrendously frustrations about problems in the mental health cide and the victim of the homicide were related. violent acts but notes that supportive services are system and common beliefs that executing indi- the best way to avoid risks. “Most people with men- Most state laws list “mental disease and defects” tal illness are not violent,” said NAMI Executive Di- viduals with severe mental illness only compounded or some variant of this term as a factor that should tragedies. These executions serve no useful purpose rector Michael Fitzpatrick. “When violent tragedies mitigate against the death penalty. However, studies occur they are exceptional, because something has in deterring crimes. suggest that defendants with severe mental illness gone terribly wrong, usually in the mental health- The meeting in San Antonio was organized by Mur- are more likely to be sentenced to death than those care system. Tragedies are compounded and all our der Victims’ Families for Human Rights (MVFHR), an without mental illness convicted of similar crimes. families suffer.” international organization of relatives of homicide At least 100 people with mental illness have been victims and relatives of people who have been ex- executed in the United States, and hundreds more The report makes four basic recommendations: ecuted, all of whom oppose the death penalty. NAMI are currently on death row awaiting execution. 1. The death penalty for persons with severe men- has long opposed the execution of people with se- In 2002, the U.S. Supreme Court ruled that the ex- tal illness should be banned. vere mental illness. Recognizing a commonality of ecution of individuals with intellectual disabilities Currently, legislation is pending in at least four states interests, MVFHR Executive Director Renny Cushing (mental retardation) is unconstitutional and in to limit or eliminate the execution of people with conceived the idea for this project and approached 2005, the Court further ruled that it is unconstitu- severe mental illnesses. However, only Connecticut NAMI about becoming a partner. “Family opposition tional to execute people whose crimes were com- has a law on the books limiting capital punishment to the death penalty is grounded in personal trag- mitted when they were juveniles. The court’s rulings for individuals with “significantly impaired mental edy,” said Cushing. “In the public debate about the in both cases were based on its concern that factors capacity” and that law is seldom used. death penalty and how to respond in the aftermath such as impaired judgment, understanding, and im- continued on page 55 54 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 52. Beyond Bars Reinstating Medicaid Benefits: Life in the Community after Incarceration alex Blandford, Project Coordinator, Institute for Evaluation Health Science in Community Health, Graduate School of Public Health, University of Pittsburgh I t is vital that the significant number of justice- involved persons with mental illness have con- sistent access to healthcare and other supports be reinstated. This program can be detrimental to inmates with mental illness because Medicaid ben- efits are tied to SSI and SSDI. Many offenders with mental illness automatically lose — both while they are incarcerated and upon re- However, several strategies are being used by states their health and social lease. Given that many people with mental illness and localities to facilitate access to federal benefits supports because of state rely on Medicaid to access services and that those who are incarcerated likely had their mental illness for inmates with mental illness and substance use policies that terminate rather disorders. Two strategies in particular — legislation before incarceration; it follows that they must rely for suspension of eligibility and prerelease plan- than suspend benefits on in- on Medicaid to cover services upon their release. ning as part of re-entry programs — have recently carceration. A central issue is Yet, many offenders with mental illness automati- received attention. conflicting guidelines across cally lose their health and social supports because of state policies that terminate rather than suspend Medicaid SUSPenSion legiSlation different levels of government benefits on incarceration. A central issue is conflict- Legislation could be introduced at the federal level and agencies that render the ing guidelines across different levels of government to require that states suspend Medicaid eligibil- system complex and difficult and agencies that render the system complex and ity upon incarceration and reinstate on release to difficult to navigate. Although federal law prohibits ensure continuity of care. Released inmates would to navigate. state Medicaid agencies from using federal funds then be able to go directly to a Medicaid provider, to pay for services while a person is incarcerated, demonstrate eligibility, and receive services without it does not delineate how states should implement interrupting access to medications and other treat- person is no longer eligible to be so enrolled. this requirement. Termination of Medicaid eligibility ment. Suspension of eligibility is the most desirable >> Offering financial assistance for states imple- is not required, and states have the option of sus- approach because it does not require that a new menting Medicaid suspension systems. pending eligibility while people are incarcerated. application be filed, and benefits can be restored with minimal delay. In the absence of federal legis- >> Offering case management services to engage in States face a series of barriers that challenge their planning for services after a person’s release. lation, state Medicaid policy could allow incarcer- ability to suspend and reinstate Medicaid eligibility. ated people — where applicable by federal law — to >> Requiring that to receive the incentive payments Suspension or reinstatement of Medicaid require maintain Medicaid eligibility. from the SSA described earlier, jails and prisons coordination across multiple systems and agencies but in many states, data systems cannot commu- The most significant recent development at the must participate in a prerelease agreement with nicate. Other states face restrictions that limit the federal level was the introduction of H.R. 2829, the the SSA. degree to which information can be shared between Recidivism Reduction Act, in June 2009. The bill was Another example of federal legislative action is the jail and prison systems and community agencies. subsequently referred to the House Ways and Means inclusion of section 1729 in H.R. 3962, the Afford- Many states terminate rather than suspend eligibil- and Energy and Commerce Committees but has not able Health Care for America Act, which requires ity to ensure that claims are not inadvertently filed been reported on to date. The bill proposes amend- states to suspend, rather than terminate, Medic- for people while they are incarcerated. ments to the Social Security Act aid eligibility for incarcerated people age 18 and Another barrier is that the Social Security Adminis- >> Requiring the reinstatement of SSI benefits after younger. tration provides financial incentives (up to $400 per application, during or following incarceration, With regard to state activity, several states have case) for reporting incarcerated people in receipt and the provision of benefits in the interim, ef- passed legislation to bridge the gap between fed- of federal benefit payments so that Supplemental fective the day of release. eral and state funding. States with policies and laws Security Income and Social Security Disability In- >> Requiring the reinstatement of Medicaid benefits for the suspension of Medicaid include Colorado, surance benefits can be suspended or terminated. on release for those with eligibility before incar- Florida, Indiana, Ohio, Maryland, Maine, Michigan, No incentive is provided to notify SSA when such ceration unless there is a determination that the North Carolina, New York, and Oregon. The example people are released so that benefit eligibility can of New York State highlights what states can do to 56 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 53. address the barriers they face. New York was one of ensure that an application for Medicaid, SSI, and oth- oping other supports in the community through peer, the first states to pass legislation requiring that Med- er benefits is submitted well in advance of release (at provider, and other community organizations. icaid eligibility for inmates be suspended (April 2008) least 1–3 months) so that assistance is available upon The fact that suspension of Medicaid benefits for the and that the effort be a shared responsibility be- release. A variety of federal, state, and local funds and incarcerated has garnered more attention on the lo- tween state and local departments of social services. grants support enrollment in public programs as part cal and state levels, and more recently on the federal Although the law clearly requires the suspension of of the discharge planning process. Prerelease plan- level, is encouraging but much remains to be done. eligibility, the reinstatement process is less explicit ning varies by the length of incarceration, the size of In the absence of enacted federal legislation, states and requires clarification. For people to have their the correctional facility, and the resources available. should adopt legislation to suspend, rather than ter- benefits reinstated on release, the state must be able Planning programs can include ensuring that the in- minate, the Medicaid benefits of eligible people dur- to check whose Medicaid eligibility was suspended mate has identification cards (for Medicaid), a supply ing incarceration. They should also seek or continue against who is released from jail. Although state law of medications, and community resource supports to seek funding to create and sustain re-entry initia- requires coordination between the Department of (food stamps, cash assistance, and housing) upon tives. This issue is extremely complex, and federal Corrections and the Office of Temporary and Disability release. Collocating relevant specialized staff (trained benefit enrollment is only one part of the solution. Assistance to identify offenders who need Medicaid social workers) or local SSA staff at the institution to However, people should not leave jail or prison with- suspended on entering correctional facilities, many facilitate the process is advisable. out immediate access to vital care and support in the states, including New York, do not require that correc- In Allegheny County, Pennsylvania, comprehensive community, which can be achieved in part by access tional facilities report an inmate’s release to the state, re-entry planning (including providing access to to Medicaid. thus rendering information about incarcerated people benefits) is provided in jail as part of the Allegheny incomplete and hindering reinstatement of Medicaid County Jail Collaborative, a joint effort of the Allegh- Alex M. Blandford is Project Coordinator for the Institute for coverage. Many state agencies issue a memorandum eny County Jail, the Allegheny County Department of Evaluation Health Science in Community Health, housed in the of understanding that specifies requirements and re- Human Services, and the Allegheny County Health Graduate School of Public Health at the University of Pittsburgh, Pennsylvania. Her areas of research interest include integrated sponsibilities for information exchange between the Department. As part of transition planning, intensive care and criminal justice issues for justice involved individuals two entities. This approach, however, is largely rela- case management is offered during incarceration and with mental illness, particularly the effective provision of care tionship based and can be problematic. after release to construct a service plan to coordinate and services across fragmented systems using collaborative ap- proaches. Blandford received a masters in Public Health from the services and apply for assistance while the offender is PrereleaSe Planning For re-entry still in jail. Case managers help people connect with University of Pittsburgh and BA in psychology from Pennsylvania State University. She is a former National Council Public Policy For inmates whose benefits were terminated or who existing supports (e.g., family support) and in devel- intern. were not previously enrolled, a desirable option is to continued from page 52 2. Mental health systems need to be reformed to Lois and Ken Robison of Texas became activists more effectively provide treatment and supportive against the death penalty after their son Larry — diag- Most people with mental services to individuals with severe mental illnesses nosed with paranoid schizophrenia — was executed illness are not violent. When before they reach the point of crisis. in 2000. The Robisons struggled for years to get help violent tragedies occur they NAMI’s Grading the States 2009 report contains a for their son prior to the crimes that led to his execu- are exceptional, because number of recommendations for improving mental tion. At the meeting in San Antonio, Lois posed the health systems and services, including strategies question “How can a modern, civilized society choose something has gone terribly for responding effectively to individuals with severe to exterminate its mentally ill citizens rather than wrong, usually in the mental mental illness who are most at risk and have difficulty treat them? I’ve been waiting 25 years…for people healthcare system. adhering to treatment regimens. to come together and say that the death penalty is not the answer to the problem of untreated mental Michael Fitzpatrick 3. Recognize the needs of families of murder victims through rights to information and participation in illness in our country.” criminal and mental health proceedings. NAMI hopes The Double Tragedies report is the start involved with criminal justice systems, and more. Before joining 4. Recognize that families of individuals who are of this process. NAMI in 1988, Honberg worked as a Vocational Rehabilitation Counselor for the State of Maryland and in a variety of direct ser- executed are victims themselves and provide as- vice positions in the mental illness and developmental disabilities sistance to these families due to any victims of Ron Honberg oversees NAMI’s federal advocacy agenda and the fields. Honberg has a Juris Doctor degree from the University of NAMI Law and Criminal Justice Action Center. In recent years, Maryland School of Law and master’s degree in education from traumatic loss. he has worked on issues affecting people with mental illnesses the University of Maryland. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 57
  • 54. Beyond Bars Incarceration and Homelessness: Breaking the Tragic and Costly Cycle andy McMahon, Associate Director for Innovations and Research, Corporation for Supportive Housing L avelle Conner, 46, estimates he’s been arrested 150 times. While struggling with schizophrenia, depression, and drug addiction during his 12 years 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 nated and provide health, mental health, substance use, vocational services and benefits advocacy, and other supports necessary to help people stabilize of homelessness, he slept in abandoned buildings three largest such facilities. their lives. Successful programs often begin to en- and ate out of garbage cans. With little, if any, sup- Of all the issues facing parolees re-entering com- gage participants and provide services while they port from the community, Lavelle faced one dead munities, studies suggest that none is more imme- are still incarcerated. end after another. “The drugs helped my pain, so diate than the need to find a place to live. Without The Corporation for Supportive Housing’s Return- I kept taking things that weren’t mine, to support stable housing, returning to jail or prison is almost ing Home Initiative, funded primarily by the Robert my habit.” a given in a system in which people find themselves Wood Johnson Foundation and the Open Society Lavelle’s story is not unusual. Every year, U.S. pris- arrested again and again for violations related to Institute, aims to end the cycle of incarceration ons and jails release almost 10 million people. homelessness, untreated mental illnesses, and ad- and homelessness. The initiative focuses on engag- Like Lavelle, many return to impoverished neighbor- diction. ing criminal justice systems and integrating the ef- hoods and are trapped in a cycle of homelessness, forts of housing, behavioral health, corrections, and incarceration, and health and mental health crises. an oPPortUnity to SUcceed other agencies to better serve people with a history With the right help, Lavelle was able to turn his More often than not, these people find themselves of homelessness and incarceration by placing them life around. He became a permanent supportive right back in prison or jail for parole violations and into supportive housing. Returning Home has ad- housing tenant through Thresholds, a Chicago-area quality-of-life crimes. Taxpayer dollars are wasted as vanced efforts in nearly a dozen jurisdictions across nonprofit. Since obtaining housing, counseling, and the cycle continues and people’s lives spiral of out the country, all focused on reducing the number of other support services, he has been living success- control. people with histories of homelessness, behavioral fully in the community for almost 4 years. Lavelle In addition to the mind-boggling costs in terms of health issues, and incarceration who are inappro- no longer abuses drugs and has remained out of lost human potential, productivity, child and fam- priately languishing in U.S. jails and prisons. trouble. He has served as president of the tenant ily stability, and public safety, states and cities council and as a consumer advocate for a Thresh- JUriSdictionS leading the Way are spending billions as a result of failed policies. olds’ jail diversion program, working with judges and Nationwide, more and more cities, counties, and Among the 20,000 parolees with mental illness the district attorney. Of his new life, Lavelle says, “I states are investing in supportive housing for people exiting California prisons each year, about 3,500 have three children and six grandchildren. Before re-entering their communities from jails and pris- become homeless. Ninety-four percent of those who Thresholds, years and years passed before I could ons. Highlighted next are examples of real work on are homeless return to prison within 24 months. This see them — at one point I couldn’t even knock at my the ground that is proving successful in ending the alarming recidivism rate results in an equally shock- family’s door. Now that they’ve opened up their door cycle of homelessness and incarceration for people ing expense to the state — the average annual cost to me, I learned how to be a grandfather.” with serious behavioral and other health issues. of housing an inmate with mental illness in Califor- SUPPortive hoUSing WorKS Frequent Users Service Enhancement Initiative nia is $110,000. Keeping someone incarcerated in Supportive housing — permanent, affordable hous- — New York City a Chicago jail or at New York’s Rikers Island is simi- ing linked with services that meet the needs of The New York City Department of Correction, Home- larly expensive and averages more than $47,000 a individuals and families — has emerged as a real less Services, and CSH, with assistance from the year, without considering the added costs of mental solution that works. Services are tailored and coordi- Human Resources Administration, the Department health treatment. The nation’s jails and prisons are of Health and Mental Hygiene, Housing Preserva- 58 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 55. tion and Development, and the New York City Hous- ing Authority are implementing the FUSE Initiative. New York’s FUSE program, which places people with This groundbreaking initiative has placed more than a history of incarceration in permanent supportive 150 people with long histories of incarceration and homelessness into permanent supportive housing — housing, has resulted in 91 percent housing retention, breaking their institutional circuit among jail, shelter, 53 percent reduction of jail days used, and 92 percent emergency health, and other public systems. reduction of shelter days used. FUSE participants showed significantly increased As the program’s name implies, it is targeted to fre- resilience and extended time in the community, quent users of public services. Eligible participants are identified through an administrative data match yielding cost offsets of $2,953 per person per year. between the Department of Corrections and New York City Homeless Services, and recruitment and enroll- health, and other agencies to more effectively and amounts of public resources with little or no ben- ment often begin while people are still incarcerated. efficiently transition people back into the community efit. This cycle wastes money and lives, but solu- Participants are provided with an initial, intensive from prison. tions exist. Efforts like the ones in New York, Ohio, burst of services as outreach is done, housing is se- Priority placement within the program is given to and other communities across the country dem- cured, and they begin to stabilize in the community. people identified as being most likely to require hous- onstrate that we can more efficiently invest our FUSE is funded with a blend of federal, state, local, scarce public resources and more effectively serve ing linked to support services to maintain housing. and private philanthropic resources. Housing for the people with histories of homelessness and incar- Through this pilot, ODRC and CSH are working with program is funded using a combination of Section ceration. Some lessons learned and strategies that select nonprofit organizations to demonstrate how 8 rental subsidies from the NYCHA and funds from are working are captured in a systems change re- supportive housing can reduce an offender’s return to New York City departments, including the DOHMH port the Urban Institute recently completed for CSH the criminal justice system and prevent homelessness. and DHS. NYCHA granted a criminal justice waiver for (http://documents.csh.org/documents/policy/ Over the course of the pilot, ODRC is providing more sponsor-based vouchers that are linked with stabiliza- Reentry/UI-RHI-After3Yrs-Nov09.pdf). than $3.8 million, which will be used for rental sub- tion and support services that promote public safety sidies, tenant assistance, case management, program In short, communities need to and tenant success. Funds for service enhancements evaluation, and project management. Providers use a >> Identify the scale and scope of this problem in have been provided by the New York DOC and DHS, mix of scattered-site and single-site housing and also their own communities. CSH, and the Justice, Equality, Human Dignity, and coordinate with community-based organizations for Tolerance Foundation. >> Develop the interagency collaborations needed additional behavioral health and other services. The first round of FUSE has been extremely success- among criminal justice, housing, behavioral health, CSH, in collaboration with the Ohio Housing Finance and other agencies. ful in helping people maintain housing and avoid Agency, has also established a rental subsidy program returning to homelessness. An evaluation conducted >> Create in-reach and outreach programs that are to assist Returning Home tenants who may require by John Jay College, of the first year after placement, linked to a network of supportive housing providers. rental subsidy for an indeterminate amount of time demonstrates beyond the pilot period. >> Direct housing and support services resources to >> 91 percent housing retention. effectively serve this population, including rein- The first of 92 participants was accepted into housing >> 53 percent reduction of jail days used. in March 2007. As of March 2009, 51 people (55%) vestment of criminal justice funds. >> 92 percent reduction of shelter days used. were in housing, 20 (22%) had exited with posi- >> Support data-driven evaluation that documents the tive outcomes, 11 (12%) had been terminated with costs and impacts on individuals and the community. When results are viewed next to those of a matched negative outcomes, and 5 (5%) had exited for other comparison group, FUSE participants showed signifi- We can do better — and cities and states across the reasons (e.g., death, to participate in a treatment cantly increased resilience, extended time in the com- country are proving it. program, placement in a nursing home). munity, and a reduced rate of cycling between DOC and DHS, showing cost offsets to those systems of The Returning Home pilot includes an evaluation Andy McMahon leads Returning Home, the Corporation for $2,953 per person per year. component, which is being conducted by the Urban Supportive Housing’s national initiative focused on engaging cor- Institute’s Justice Policy Center in Washington, DC. rections and criminal justice systems to create supportive housing Returning Home — Ohio An interim report can be viewed at www.urban.org/ and end the cycle of homelessness and incarceration that so The Ohio Department of Rehabilitation and Correc- many people face. He also is responsible for providing strategic publications/411869.html. direction for Returning Home in its three primary sites — Los tions has invested in a supportive housing program Angeles, New York City, and Chicago — and leads CSH’s national targeted to parolees at risk of homelessness. The the Way ForWard efforts to increase investment in re-entry supportive housing and program links and integrates the efforts of the cor- Too many people like LaVelle languish in a cycle of change public policy to better integrate efforts among corrections, human service, and housing agencies at all levels of government. rections system with housing, mental and behavioral homelessness and incarceration, using immense NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 59
  • 56. Beyond Bars Mental Health First Aid USA Equips Police Officers to De-escalate Crises richard h. leclerc, President, Gateway Healthcare G ateway Healthcare in Pawtucket, Rhode Island was a pilot site for the rollout of Mental Health First Aid USA training. As Gateway staff were trained way who serves as training coordinator for the community mental health organization’s LifeWatch Employee Assistance Program. “I co-train with an of- this is key for them.” It has become clear to Bernardo from the first course she facilitated at the academy that officers and certified to offer the 12-hour Mental Health ficer, Lt. Joe Coffey of the Warwick police. I basically prefer a practical learning approach that empha- First Aid program to the public, local police depart- present the mental health information, and Joe puts sizes examples of options for defusing potentially ments in Rhode Island were seeking to broaden of- it in their world.” harmful situations involving people with mental ill- ficers’ response options during incidents involving “Carole covers the signs and symptoms of mental ness. Both Bernardo and Coffey emphasize that they citizens with serious mental illness. This fostered a illness, and I interject examples of scenarios and do not ask participating officers to change the way strong partnership that now has mental health pro- engagements that the officers might see,” says Cof- they do their jobs; officers are simply acquiring new fessionals and law enforcement officers speaking a fey. “Then I talk about the response side. We talk tools with which to respond to potential crises. common language. about giving the officer discretion in what to do, and Just as police departments have acquired new Police officers have become priority recipients of offering ideas that are outside the box.” methods for applying non-deadly force in danger- Mental Health First Aid training in Rhode Island, Bernardo recalls that she was observing another ous situations, the knowledge acquired in Mental with eight training courses having been offered at training at the Municipal Police Academy when she Health First Aid training gives officers strategies for the state’s Municipal Police Academy since spring informed the training coordinator, Captain David trying to prevent a situation on the street from es- 2008. Representatives from both Gateway and the Ricciarelli, that she was becoming certified as a calating, Coffey says. The training became available law enforcement community say the effort has suc- trainer for the innovative 12-hour Mental Health to municipal departments shortly after a number of ceeded largely because the course offers much First Aid course. They agreed to follow up later and highly publicized incidents in the state that ended practical information on mental illness and a police came up with plans for a jointly taught class that tragically with an officer’s use of deadly force on a lieutenant helps officers figure out how to apply this has become one of the academy’s most popular of- suspect with mental illness. new knowledge on their beat. ferings. “The officers have seen these behaviors, and now “Law enforcement is a pretty tight-knit group, and “Officers certainly need to know about the signs and they can understand people with mental illness, and bringing in an outsider to do this training alone symptoms and the definitions of what constitutes a they can respond without compromising safety,” he would be kind of tough,” says Carole Bernardo, a mental illness,” Coffey says. “As first line responders, certified Mental Health First Aid instructor at Gate- continued on page 60 60 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 57. about Mental health First aid USa Mental Health First Aid 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. Mental Health First Aid is delivered to members of Mental Health First Aid was created in 2001 by By the Numbers the public through an interactive 12-hour course, Professor Tony Jorm, a respected mental health which introduces participants to risk factors and literacy professor, and Betty Kitchener, a nurse > 6,000+ warning signs of mental health problems, builds specializing in health education, and is auspiced Mental Health First Aiders trained understanding of their impact, and overviews at the University of Melbourne. Five published common treatments. Participants learn a 5-step studies in Australia show that the program saves > 700 action plan encompassing the skills, resources lives, expands knowledge of mental illnesses and instructors certified and knowledge to help an individual in crisis their treatments, increases the services provided, connect with appropriate professional, peer, and reduces overall stigma by improving mental > 1,000,000+ social, and self-help care. The course also pro- health literacy. In the USA, Mental Health First media impressions vides participants with an understanding of the Aid is coordinated by three national authorities prevalence of various mental health disorders in — the National Council for Community Behavioral the U.S. and the need for reduced stigma in their Healthcare, the Maryland State Department of communities. Mental Hygiene, and the Missouri Department of The 12-hour Mental Health First Aid course has Mental Health. been offered to a variety of audiences and key The national authorities certify instructors to im- professions, including police/corrections staff/ plement Mental Health First Aid in communities first responders/security personnel; educators/ throughout the United Sates. Each Mental Health school administrators; human resources profes- First Aid site develops individualized plans to sionals; members of faith communities; homeless reach its community, but undergoes tight cre- shelters workers; nurses/physician assistants/ dentialing to guarantee fidelity to the original, primary care workers; social workers; consumers tested model. and family members; and caring citizens. 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 www.MentalhealthFirstaid.org or contact Susan Partain at 202.684.3732 or SusanP@thenationalcouncil.org NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 61
  • 58. Beyond Bars continued from page 58 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 Just as police departments have acquired new methods for will need to occur. applying non-deadly force in dangerous situations, the knowledge Mental Health First Aid training has also helped officers overcome challenges in negotiating the acquired in Mental Health First Aid training gives officers strategies mental health system. They realize that just as they for trying to prevent a situation on the street from escalating. experience frustration with the long waits they may encounter when they take an individual to a hos- The training became available to police officers in Rhode Island pital emergency room, mental health professionals shortly after a number of highly publicized incidents in the state also get frustrated in their efforts to get people the help they need. This realization has forged greater that ended tragically with an officer’s use of deadly force on a mutual respect between the mental health and law suspect with mental illness. enforcement communities. “We’re trying to get everyone talking the same lan- guage,” Bernardo says, adding that employees at all he was sent directly to a hospital for evaluation. lates the auditory hallucinations that plague many sites at which a person with serious mental illness In what was perhaps the most surprising devel- people with a psychotic illness. When asked to com- might appear should possess the same basic knowl- opment of all, Coffey says, the bail commissioner plete an exercise while listening to the simulator, edge of mental illness. agreed to conduct necessary paperwork at the hos- the officers experience obvious frustration — and pital so that the man could receive needed services begin to understand what a suspect with serious With 25 officers participating in each Mental Health with no delays. “That’s unheard of,” Coffey says. mental illness might face when trying to respond to First Aid course, the program has already reached an officer’s commands. most of the state’s police departments. Bernardo This anecdote is one example of how greater men- says officers’ evaluations of the training have tal health awareness and reduction of stigma can “That is the single most persuasive method we praised the team approach to instruction. change a community’s mindset. “We kind of open have,” Coffey says. Although Coffey says a formal evaluation of the pro- their hearts a little bit,” Coffey says of the participat- gram’s impact in terms of street response has not ing officers. Richard Leclerc is the President and CEO of Gateway Health- care, overseeing all operations of over 700 employees within yet taken place, he knows from anecdotal informa- Some participants are encouraged by their local the organization. He is on the Board of Directors of the National tion that officers are applying the skills creatively chief to enroll in the course, but many volunteer to Council for Community Behavioral Healthcare and the Rhode and effectively. He cites a recent example from his participate in what has become one of the acad- Island Council of Community Mental Health Organizations. own police jurisdiction to support this. He chairs the Rhode Island Governor’s Council on Behavioral emy’s most appreciated course offerings. “This is Health. Leclerc is a member of the Academy of Certified Social Police in the city of Warwick reported to an apart- absolutely working,” Coffey says. Workers and the Association of Mental Health Administrators and also a Licensed Independent Clinical Social Worker. ment building where a man with schizophrenia had Perhaps the biggest eye opener for all participating barricaded himself in his residence after having bro- officers is the course’s use of technology that simu- 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- Join the Gateway Healthcare team and the National Council for in-depth ness, combined with the fact that a responding of- workshops on Mental Health First Aid training and applications for law ficer had taken the Mental Health First Aid course, triggered an entirely different set of responses. enforcement and corrections communities at the National Council’s 40th Annual Mental Health and Addictions Conference & Expo (March 15-17, Coffey says the officers at the scene were able to contact the man’s family members, who communi- Disney World, FL), the National GAINS Center Conference (March 17-19, cated key information. Within an hour, police were 2010, Disney World, FL), and the International Crisis Intervention Team able to defuse the situation. Instead of transporting Conference 2010 (June 1-3, 2010, San Antonio, TX) the man to the police department cell block, where trouble in calming him would likely have occurred, 62 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 59. Your Voice Matters Join us in Washington, DC National Council 6th Annual HILL DAY JUNE 29 – 30, 2010 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 www.TheNationalCouncil.org/HillDay Bring a team—board Questions? members, medical directors, Email RebeccaF@thenationalcouncil.org or call 202.684.3735. local law enforcement allies, state legislators, county commissioners, consumers, and family members.
  • 60. Beyond Bars E-learning for Corrections: Viable Training Option in a Tough Economy diane geiman, Manager, Online Corrections Academy, American Correctional Association I n December 2008, the American Correctional As- sociation surveyed state departments of correc- tions and juvenile justice and asked them to identify 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 staff can be trained for fewer dollars. The Florida Department of Juvenile Justice offers nearly 200 department-specific courses online. Mike Mc- specific areas of operations designated for budget online training. “E-learning offers many advantages Caffrey, director of staff development and train- cuts. The top three areas for adult agencies were that are even more compelling in a tough economy,” ing, says that online training is “definitely a cost staffing, non–education-related offender programs, points out Stephen Flavin, executive director of Bab- benefit during these economic times,” and it has and training. Juvenile justice agencies designated son Executive Education. saved the department “a lot of money.” He pro- similar areas. There are many benefits to e-learning: vides a good example of the potential savings. If These results are not surprising. Nearly every day, 25 staff are brought to Tallahassee, the central of- >> Consistency: Even when trainers use the same fice location, for 1 week of training, the cost would the media announce more company layoffs, and lesson plans, delivery of the training varies from executives talk about cutting budgets to survive the be approximately $25,000. Teaching the same class to class simply because no two people are material online would cost considerably less. economic downturn. “Vulnerable sectors, notably alike. For instance, trainers have different deliv- retail and the government are cutting back on train- ery styles and may emphasize different sections >> Time effectiveness: Online training removes ing,” notes Susan Vardoe, president of Ninth House, of the content. Similarly, they have varying levels geographical barriers because staff can take an e-learning company. She says, “One government of experience that influence the training. Online the courses at various locations throughout an agency told me they are too busy buying gasoline training, in contrast, provides the same training area. It also solves the problem of trying to get and bullets. It’s all they can afford to do.” to all staff — there are no obvious or subtle dif- staff and trainers in one place at one time. As The financial struggle in most states and counties ferences. The state of Iowa launched an inter- Terri Schuster points out, online training allevi- means that correctional training departments are nally built online system in 2009. Terri Schuster, ates the problem of “having to find half a day confronted with the challenge of training staff at all Training Specialist II (or “e-trainer”), emphasizes or several days to relieve staff for training.” In levels with fewer dollars. Corporations faced with that online training ensures the agency is deliv- addition, learning time is often reduced. Online this same dilemma are able to scale back or drop ering “one clear, consistent message.” courses can be designed in shorter time blocks programs deemed a luxury or unprofitable. In cor- or staff can work on longer courses in 1-hour or >> Centralization: All documentation can be main- longer time blocks. rections, however, training is not a luxury — it’s a tained in one location. Staff progress can be necessity. Yet there is good news. Unlike their corpo- monitored on a daily basis, and reports are read- Yet, the quality of the training material does not rate counterparts who are often forced to deal with ily available to document completion of training. need to be sacrificed. Well-designed online courses the bottom line, correctional trainers have the op- can be as effective as classroom training and, at portunity not only to deliver training but also to de- >> Cost effectiveness: In many cases, online train- times, more effective. Some researchers believe velop staff even during the worst economic times. ing costs less than traditional learning, and more that learning retention is higher for online training 64 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 61. than for traditional classroom training. Sample e-learning corrections courses A well-designed course is one that is created according to strict standards. As Stephen Flavin reminds us, “Informa- Essential Learning has partnered with American Correctional Association and its On- tion is not instruction.” An interactive course must engage line Corrections Academy to provide a full range of e-learning solutions to meet the learners throughout and include proper testing or evalu- specific training needs of adult and juvenile correctional agencies. Courses are offered for ation. Flavin cautions wisely that “effective e-learning is pre-service and in-service training ; compliance with legislation, ACA accreditation, not taking existing course material from a classroom, put- professional licensing, and ACA re-certification; and agency-specific training. ting it on the web and rolling it out and calling it a day.” However, you can convert that valuable material to online the corrections library includes courses such as courses. H Corrections and Mental Illness: H Sexual Abuse and Assault Intervention ACA believes that online training is one part of an overall An Overview for Corrections Officers (PREA) correctional training program. The association relies on its H Supervising Mentally Ill Offenders H Intoxication and Withdrawal for many years of training and correctional experience when H Overview of Suicide Prevention for Corrections Officers assisting correctional agencies and facilities in navigating Corrections Professionals H Grief and Loss in the Corrections Setting the e-learning landscape. An agency’s needs, both learn- H Crisis Management for Corrections H Understanding Addiction: ing and monetary, are priorities throughout the process. Professionals An Overview for Corrections Professionals ACA has partnered with Essential Learning, the largest H Disciplining Offenders: Enforcing Rules H Legal Issues and Women Offenders e-learning provider in human services online training, and Regulations H Mental and Physical Health Issues for to offer a vast library of courses tailored to corrections H Working with Incarcerated Persons: Older Inmates professionals — including behavioral health courses ac- An Overview for Corrections Professionals H Overview of Substance Abuse for credited by national organizations — through the Online H Working with Incarcerated Persons: Corrections Officers Corrections Academy. As a result, the OCA now offers more Best Practices in Treatment H Supervising Mentally Ill Offenders than 70 corrections-specific courses to meet agency train- H Disciplining Offenders: Report Writing H Security and Offender Management: ing requirements and national standards. Topics include supervision, management, leadership, ethics, medical and H Professional Ethics in Corrections Supervising Offenders in Programs and H The Transition to Correctional Supervisor on Work Details mental health, security, and special management offend- ers (e.g., women and elderly people). New correctional H Ethical Behavior in Corrections: H Corrections and Mental Illness: courses will be added on a regular basis, through the joint Best Practices An Overview for Corrections Officers efforts of ACA and Essential Learning. H Fire Safety in Corrections H Security and Offender Management: Preventing and Responding to Emergencies Non-corrections-specific courses are also offered and H Security and Offender Management: focus on topics such as workplace issues (e.g., commu- Escorting and Transporting Offenders H Women Offenders and the Correctional Environment nication and problem solving), Occupational Safety and H Supervising Offenders in Segregation Units Health Administration compliance, and computer skills. All H Security and Offender Management: H Overview of Suicide Prevention for Preventing Escapes the academy’s courses may be used by certified correc- Corrections Professionals tions professionals for recertification. All ACA-developed H Understanding Mental Health Treatment courses are approved by the Commission on Accreditation H Nursing Health Assessment in Corrections in the Corrections Setting for Corrections for preservice and in-service training. H Security and Offender Management: Using H Maintaining Security Part 1 Force in the Correctional Environment Online training is a tool that your correctional agency can H Suicide Prevention in use regardless of its budget, and it can be implemented H Co-Occurring Disorders: An Overview for Juvenile Correctional Facilities Corrections Professionals painlessly. Classroom training is being supplemented, not H Co-Occurring Disorders: supplanted. H Introduction to Mental Health Issues An Overview for Corrections Professionals for Correctional Officers H Motivational Interviewing for Corrections Diane Geiman is the Online Corrections Academy Manager at the H Managing Offender Resistance Professionals American Correctional Association. She also serves as the Academy’s H Ethical Standards for Corrections H Disciplining Offenders: Report Writing instructional curriculum developer. Geiman has more than 20 years of Supervisors 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 the complete corrections course library is available at www.aca.org/onlinecorrections. juvenile justice, medical and mental health, supervision, management, and law. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 65
  • 62. Member Spotlight MArCH 2010 national Council member Spotlight A National Council publication featuring members in action 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 66 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 63. Member Spotlight 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 affiliate Members Turn-A-Frown-Around Foundation, Freehold, NJ Improving the lives of persons who have lost hope The National Council for Community Behavioral May Farr, Pacific Clinics, Arcadia, CA Healthcare thanks all our Improving the behavioral healthcare system affiliate members for outstanding service to the EXCELLENCE IN GRASSROOTS ADVOCACY (STATE) behavioral health industry. association for Behavioral healthcare, natick, Ma H Anasazi Software Campaign for Addiction Prevention, Treatment and Recovery H Askesis Development Group H Credible Behavioral EXCELLENCE IN GRASSROOTS ADVOCACY (LOCAL) Healthcare Software colorado West regional Mental health center, glenwood Springs, co H Defran Systems Grassroots advocacy program to retire debt H Echo Group H eHana UP & COMING LEADERSHIP H Essential Learning rosa M. West, Vice President for Specialty Programs and New Initiatives, Meridian Behavioral Healthcare, Inc., Gainesville, FL H Foothold Technology H Genoa Healthcare VISIONARY LEADERSHIP H Hazelden Publishing Mary anderson, Board Member, Newaygo County Mental Health Services, White Cloud, MI H Mental Health Risk howard Bracco, Phd, cBhe, President & CEO, Seven Counties, Inc., Louisville, KY Retention Group david guth, CEO, Centerstone of America, Nashville, TN H Negley Associates Jay reeve, President & CEO, Apalachee Center, Tallahassee FL H Netsmart richard van horn, President Emeritus, Mental Health America of Los Angeles, Los Angeles, CA H Peter and Elizabeth C. Tower Foundation EXCELLENCE IN PUBLIC SERVICE H Qualifacts Pamela greenberg, President and CEO, Association for Behavioral Health and Wellness, Washington, DC H UNI/CARE carol Mcdaid, Principal, Capitol Decisions, Inc., Washington, DC 68 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
  • 64. Become a Mental Health First Aid USA Instructor 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 Mental Health www.MentalHealthFirstAid.org for a 5-day Instructor Training in 2010 First Aid = Blue Bell, PA May 3-7 The initial help given to a person (outside of Philadelphia) showing symptoms of mental Denver, CO May 10 – 14 illness or in a mental health crisis Washington, DC Jun 28 – Jul 2 until appropriate professional or Houston, TX Jul 12 – 16 other help, including peer and Chicago, IL Aug 2 – 6 family support, can be engaged. San Francisco, CA Sept 13 – 17 Atlanta, GA Sept 27 – Oct 1 Contact Susan Partain at the National Council, SusanP@thenationalcouncil.org or 202.684.3732 to ask how we can bring training to a location near you. Don’t miss the Mental Health Mental Health First Aid USA is coordinated by the National Council for Community Behavioral Healthcare, First Aid USA Workshop at the the Maryland Department of Health and Mental Hygiene, and the Missouri Department of Mental Health. 40th National Council Conference, Tuesday March 16, 4:00 – 5:30 pm, Fiesta 7/8, Coronado Springs www.MentalHealthFirstAid.org Save Lives and Build Stronger Communities Convention Center.
  • 65. Better Business Processes… Better clinical outcomes… RESULTS STRATEGIES Community behavioral health organizations have achieved: The SPQM team has implemented winning $200,000 in annual savings per organization through change concepts in 500+ community access to care efficiencies. behavioral health organizations: 40% reduction in client wait times — with SPQM Dashboards greater engagement and reduced no-shows. Enhancing Revenue 37% reduction in access to care staff time costs. Streamlining Documentation 450 hours of additional services, without Improving Access and Retention additional staff. Leadership and Workforce Development Documentation time savings of up to 9 hours a week Clinical Assessment Tools 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 JeannieC@thenationalcouncil.org. The SPQM Services Suite is brought to you by the National Council for Community Behavioral Healthcare and MTM Services … a Better Bottom line
  • 66. thankyou! We w an t to th an k ou r cu st om er s— n ew an d ol d — fo ch o o si n g Q u al if r ac ts as yo u r p ro vi d er fo r Web -b electronic health re as ed cords and practice management system s. B ec au se of yo u, Q ua li fact s is ce le br at in g re co rd grow in 20 09 . D es p it e th a d if fi cu lt ec on om ic cl im at e, a re co n u m be r of provid rd ers across the coun tr y have selected successful ly impl and emented C areL og ™ ic ov er th e p as t ye ar. J If yo u’re n ot al re ad y a cu st om er, ca ll to d ay to le ar n yo u r ag en cy ca n h ow “G o- L iv e” w it h Q u al if ac ts in le ss th si x m on th s! an For more information, please call 866-386-6755 | or e-mail info@qualifacts.com | or visit www.qualifacts.com