National Council Magazine, 2010 Issue 1


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National Council Magazine, 2010 Issue 1

  1. 1. m a g a z i n e NationalCouncilSharing Best Practices in Mental Health & Addictions TREATMENT Published by the National Council for Community Behavioral Healthcare Improving Public Safety and Maximizing Taxpayer Dollars Neal Cash Ending an American Tragedy National Leadership Forum for Behavioral Health/Criminal Justice Services Human Rights at Home: Mental Illness in U.S. Prisons and Jails David Fuller Where Does the Buck Stop? Linda Rosenberg Decriminalizing Mental Illness: Miami Dade County Tackles a Crisis at the Roots Judge Steven Leifman, Tim Coffey Mental Health First Aid Equips Police Officers to De-escalate Crises Richard Leclerc Beyond Bars Mental Health-Addictions and Criminal Justice Collaborations 2 0 1 0 , Issu e 1
  2. 2. p.34 From the Field National Council Magazine is published quarterly by the National Council for Community Behavioral Healthcare, 1701 K Street, Suite 400, Washington, DC 20006. Editor-in-Chief: Meena Dayak Specialty Editor, Mental Health-Addictions and Criminal Justice Collaborations: Mohini Venkatesh Editorial Associate: Nathan Sprenger Editorial and advertising queries to or 202.684.7457, ext. 240. PDF available at NationalCouncilM A G A Z I N E 2 What Happened to Me, Not What Was Wrong With Me Tonier Cain 4 Editorial Improving Public Safety and Maximizing Taxpayer Dollars Neal Cash 6 Human Rights at Home: Mental Illness in U.S. Prisons and Jails David Fuller 8 Ending an American Tragedy: Addressing the Needs of Justice-Involved People with Mental Illnesses and Co-Occurring Disorders National Leadership Forum for Behavioral Health/Criminal Justice Services 14 Behavioral Health and Criminal Justice Collaboration: Where Does the Buck Stop? Interview with Linda Rosenberg 18 Decriminalizing Mental Illness: Miami Dade County Tackles a Crisis at the Roots Steven Leifman, Tim Coffey 24 Jails and Prisons, Our New Mental Asylums Interview with Pete Earley 26 Reducing Justice Involvement for People with Mental Illness: Strategies that Work Interview with Fred Osher 28 Funding for Behavioral Health and Criminal Justice Programs Henry J. Steadman, Samantha Califano 30 Back to Basics: Evaluating Opportunities to Serve the Justice-Involved Population in Community Behavioral Health John Petrila 32 Advocate to Give Youth a Second Chance: Juvenile Justice and Delinquency Prevention Reauthorization Act Mohini Venkatesh 34 FROM THE FIELD Center for Health Care Services, Centerstone, Citrus Health Network, Community Partnership of Southern Arizona, Community Psychiatric Clinic, Chrysalis, Hands Across Long Island, John Eachon Re-entry Program, The Kent Center, Mental Health Center of Denver, MHMR Tarrant County, River Edge Behavioral Health Center, River Oak Center for Children, Seacoast Mental Health Center, Spanish Peaks Mental Health Center, Wayne State University Project CARE 52 Double Tragedies: Speaking Out Against the Death Penalty for People with Mental Illness Ron Honberg 54 Reinstating Medicaid Benefits: Life in the Community after Incarceration Alex Blandford 56 Incarceration and Homelessness: Breaking the Tragic and Costly Cycle Andy McMahon 58 Mental Health First Aid Equips Police Officers to De-escalate Crises Richard Leclerc 62 E-learning in Corrections: Viable Training Option in a Tough Economy Diane Geiman 64 Member Spotlight National Council 2010 Awards of Excellence Honorees Beyond Bars Mental Health-Addictions and Criminal Justice Collaborations National Council Magazine, 2010, Issue 1
  3. 3. 4 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars Iam a 41-year-old African American woman who has been in and out of prison multiple times; I am a mental health consumer who’s been hospi- talized many times; and I have been in so many substance abuse programs, I can’t even name them all. Most important, I am a trauma survivor. During every incarceration, every institutionaliza- tion, every court-ordered drug treatment program, it was always the same: I was always treated like a hopeless case.All people could see was the way I looked or the way I smelled. It wasn’t until I finally entered a recovery-oriented, trauma-informed treatment program a little more than four years ago, where I felt safe and respected, that I could begin to heal. As a young child, I had a belief system that I was nothing and that I would never amount to anything. I thought that the men whom my mother enter- tained, who touched and hurt me, did it because something was wrong with me and I deserved it. I thought that my mother abused me and didn’t love me because I was a bad child.My eight broth- ers and sisters needed me to protect them. I had to keep the men from hurting them, like they hurt me; I only wished my mother loved me enough to protect me. I spent a long time living with no hope and finding no help in the different systems I entered. Every time I went into jail or prison, I asked for help, but I was told that it was a jail, not rehab.When I was leaving, they said,“See you when you come back, we’ll hold your cell for you.” No one ever said, “I hope you make it this time.” When I was admitted to mental health units, I was told that I had several diagnoses, and I always asked, “How do you know? I’ve been up smoking crack for 7 days.” They never allowed the street drugs to get out of my system before they evalu- ated me. I also went to many substance abuse programs — at one, I was raped by a counselor; others used a “tear you down and build you back up”model,but I was broken down enough already. Even in school, where I was teased because of the way I smelled, no one asked about what was hap- pening to me. I have also been secluded and restrained several times. I am a victim of neglect and abandonment, and one of the worst things that you can do to someone with this type of history is to put them into a seclusion room. When that door was shut, the flashbacks of my mother’s abuse and aban- donment began. When they’d come later with a tray of food, I had been triggered, and so I pushed the tray away from me, but then they restrained me.I was a rape victim,and this restraint triggered me even more. I was also always overmedicated. It’s hard not to lose hope under those circum- stances. Then, after 19 years of drug addiction, alcohol- ism, homelessness, going in and out of prison (83 arrests and 66 convictions), mental health insti- tutions, and substance abuse programs, I finally found the help that I needed to heal. Someone finally asked me“What happened to you?”instead of “What’s wrong with you?” I was in prison and pregnant, and I was terrified that I was about to lose another child: I had al- ready had four kids taken from me,and I could not survive losing another. I was told about a program that would help me heal from my trauma, recover from my addictions, treat my mental illness, and let me keep my baby with me. Well, I didn’t know how they were going to manage all that,but I knew I had to give it a try.What did I have to lose? The first thing my therapist said to me was “Everything that happened to you as a child, hap- pened to you; you didn’t do it to yourself,” and I believed her because her tone was gentle and not judgmental. Then we began the work, and I had to remember and talk about every time I was touched and assaulted as a child. I talked about my issues with my mother,how she never loved me What Happened to Me, Not What Was Wrong With Me Tonier Cain, Consumer Advocate Tonier Cain is a featured “In My Own Words” speaker at the 2010 National Council Conference, March 15-17, Disney World, Florida. “ Tonier Cain has spoken nationally on trauma,incarceration, and recovery. She has served as a member of the Protection and Advocacy for Individuals with a Mental Illness Council. She has also worked as a case manager and director of advocacy services for a private nonprofit in Annapolis, Maryland. She is the team leader for the National Center for Trauma Informed Care, which provides consultation, technical assistance, and training to revolutionize the way in which mental health and human services are organized, delivered, and managed while furthering the understanding of trauma-informed practices through education and outreach. Ms. Cain is the subject of “Healing Neen,” a documentary based on her life as she moved through multiple systems of care.
  4. 4. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 5 and never protected me. I began to heal because I started to understand that I am an adult now, and my mother’s lack of love for me, and men’s abuse of me, is a reflection of who they are; it’s not about who I am. Then my therapist told me that we had to start talking about my children, and I shut down. I asked her how I could talk about something that gives me so much pain and suffering every day of my life: How do you heal from having four kids walking the earth when you don’t know how they’re doing, what they look like, or who they are? She said, “You do; you just don’t do it by yourself,” and she was there with me, for weeks of crying and rocking, as I allowed myself to remember them and grieve them. In that program, I felt safe for the first time.The walls had pictures and positive quotes on them.We had our own rooms with nice colors. No one was screaming “medication time”at us or secluding or restraining us. I was asked every day, “How are you feeling today?” Everybody there was trained in trauma, which meant I could talk to any staff member at any time, and they would listen. For the first time in my life, I felt like a person, a human being, and not like the monster I had been treated as in the past. I felt hope. Oh, what a difference it makes when someone asks,“What hap- pened to you?” instead of “What’s wrong with you?” Once I was able to start healing from the trauma in my life, my belief system changed from “I am nothing” to “I am somebody, and I can be anything I want in this world.” All of the earlier treatment and informa- tion that people had tried to give me for years had only reached the surface; it didn’t get down to the foundation of my problems and needs. Since getting trauma treatment in a safe, trauma-informed setting, however, I have been able to heal. I make better deci- sions. I have a healthy, beautiful child whom I simply adore and who is securely attached to me. I do not have the desire to use drugs or alcohol.I am no longer on medication. I am now an advocate in the streets where I once lived, used drugs, and was raped and beaten.I am now a national spokesperson on trauma, I am a homeowner, and I sit on several boards. Five years ago, I was taking hits of crack, in a mental institution, and in and out of prison. Everyone then thought that I would spend the rest of my life going in and out of prisons and mental institutions or that I was going to die in the streets.They were wrong. Where there’s breath, there’s hope, and for me it be- gan with respectful, individualized trauma treatment.” Every time I went into jail or prison, I asked for help, but I was told that it was a jail, not rehab. When I was leaving, they said, “See you when you come back, we’ll hold your cell for you.” Suited for Performance! Contact us today to arrange a 60-minute demonstration on how InfoMC can help you. - performing at the speed of your business! Come Visit Us in Booths 707,709 and 711 at the 2010 National Council Conference. InfoMC, Inc. 101 West Elm Street Suite G10 Conshohocken, PA 19428 phone 484-530-0100 InfoMC - the leading Business Solutions Partner for Behavioral Healthcare Payors InfoMC’s Incedo™ solution allows Employee Assistance / Work-Life Programs (EAPs), Managed Behavioral Healthcare and Disease Management Organizations (MBHOs and DMOs) to enroll and track member eligibility, manage provider networks, do referrals, authorizations and care coordination, and process and pay claims. It also links Providers and Payors via the internet to streamline communications.
  5. 5. Editorial 6 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Community behavioral healthcare’s role in pre- venting crime and increasing public safety is one of our country’s best-kept secrets. And that’s a shame. A few months ago, news reports focused on a third straight year of decreased crime rates across the United States, surprising law enforcement officials and other experts who predicted just the opposite, given the high rate of unemployment and the eco- nomic recession. In previous periods of economic stress, crime rates increased.Yet preliminary statis- tics for 2009, released by the FBI in late December, showed that rates for all types of crime had again decreased from the year before. As analysts struggled to explain this anomaly,few to none mentioned the role of community behavioral health services.Yet many of us in the field know how important our efforts have been in this regard — and how much more we can accomplish. Community behavioral healthcare serves as an important partner for the criminal justice system, whether by providing treatment which prevents be- haviors that could bring people into contact with law enforcement; training officers in how to deal with people with mental illness who are in crisis; or preventing recidivism by ensuring continued and coordinated treatment for people involved with the justice system, leaving the justice system, or both. In these difficult financial times, it is especially important that our systems recognize and embrace their interrelatedness and work together to maxi- mize public resources. At the same time, we must educate the public about how effective behavioral health treatment reduces crime, avoids expensive incarceration,helps people remain in or re-enter the community as contributing citizens, and enhances the quality of life of everyone in the community. As reported in the National Leadership Forum on Behavioral Health/Criminal Justice Services Report featured in this issue, the interface between our systems often is frayed, if it exists at all. Yet there are pockets of excellence around the country that provide models for collaboration and cooperation, with promising results in both individual outcomes and taxpayer savings — examples are featured in the From the Field section of this issue.Representa- tives of the Center for Mental Health Services’ Na- tional GAINS Center visited some of these pockets of excellence in fall 2009, including those operated by the Community Partnership of Southern Arizona. Collaboration Is Key As a community-based nonprofit organization, CPSA has a large stake in the quality of life and public safety of the communities it serves — more than 1 million people across five counties. Our work helps prevent crime, reduce recidivism, and divert people with mental illness and substance use issues from incarceration into less expensive, and more effec- tive, community-based treatment. CPSA, the regional behavioral health authority over- seeing publicly funded care in southernArizona,has sought creative ways to collaborate with the crimi- nal justice system.We’ve learned that: >> Any cross-system program or strategy must be built on a firm foundation of mutual respect and understanding and on relationships that both grow out of and are nurtured by the collaboration. >> Planning needs to be deliberate and incremental, with both short- and long-term common goals. >> Processes, strategies, and results should be monitored and evaluated, and improvements should be made on the basis of findings. >> Communication, including sharing and celebrat- ing results, should be structured and ongoing. >> Collaborations must be cost effective and sus- tainable, even in tough times. This is supported by the mutual advocacy and identification of new opportunities that evolve out of collabora- tive relationships, further strengthening commit- ment, and magnifying the impact of strategies and programs. This is basic community development.It can be slow and at times frustrating, but CPSA’s experience has demonstrated that it is worth it — and that no sub- stantive and lasting change can happen without it. CPSA began this journey in the late 1990s by form- ing a work group of behavioral health and criminal justice stakeholders in Tucson/Pima County that sought to identify systemic strategies to decrease the time people with a mental illness were inap- propriately incarcerated.This group evolved into the current Forensic Task Force, which meets quarterly and includes representatives of the court system, law enforcement, jails and corrections, local behav- ioral health providers, crisis services, attorneys, the veterans’ hospital, and other community stakehold- Neal Cash, President and CEO, Community Partnership of Southern Arizona, and Member, Board of Directors, National Council for Commu- nity Behavioral Healthcare Improving Public Safety and Maximizing Taxpayer Dollars Community Behavioral Healthcare’s Best-kept Secret Neal Cash is president and CEO of the Community Part- nership of Southern Arizona, the regional behavioral health authority contracted by the state of Arizona for funding and oversight of the public behavioral health system in five counties. He has a bach- elor’s degree in psychology from Syracuse University and a master’s degree in rehabilitation counseling from the University of Arizona. He is a member of the National Leadership Forum on Behavioral Health/Criminal Justice Services of the National GAINS Center. Participants in the mental health court experienced a 50 percent overall reduction in subsequent criminal charges in the 2 years after being in the program.
  6. 6. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 7 ers. The task force, along with collocated behavioral health and criminal justice staff, provides the founda- tion and framework for all strategies and programs. Most of CPSA’s efforts in this collaboration have fallen into two areas: diversion programs and service coordi- nation via information sharing (see article, p. 37). CPSA also helped to establish Arizona’s first mental health court in 1999 in Tucson and has founded ad- ditional mental health courts in the Pima County Su- perior Court and Consolidated Justice Court. It also developed a formal mental health collaboration with every other limited-jurisdiction court in Pima County (six in total). CPSA has developed relationships and tools to allow swift identification of members who have been arrested and appropriate, real-time shar- ing of information while protecting confidentiality. These relationships and tools expedite communica- tion between the community behavioral health treat- ment provider and the jail’s treatment provider,ensur- ing that members receive support in navigating the criminal justice system while maintaining coordina- tion of care. Most recently,CPSA has established an InitialAppear- ance program, which involves community behavioral healthcare staff participation.This program has signif- icantly decreased the likelihood that a CPSA member will be detained in the jail system. CPSA has also be- gun training forensic peer mentors to provide support and advocate for members involved with the criminal justice system and is again offering crisis intervention training to law enforcement in southern Arizona. Participants in the mental health court experienced a 50 percent overall reduction in subsequent criminal charges in the 2 years after being in the program.The most recent annual figures for CPSA’s diversion pro- grams in Tucson City Court and Pima County Justice Court show graduation rates of 97 percent and 92 percent, respectively — a total of 627 CPSA members who avoided incarceration and had charges dropped. “Many people were skeptical about mental health court,”noted the Hon.NanetteWarner,Judge of Supe- rior Court, Division 20, in a recent letter,“but with the leadership and the commitment from CPSA,it became a reality and allayed all concerns...The result has been fewer people with mental illnesses falling through the cracks. They have escaped the revolving door of the criminal justice system and are now experiencing meaningful recovery and success for the first time in their lives. There are innumerable people who have graduated from mental health court, even people the professionals thought would not be successful.” Current Conditions Demand Creativity Collaborations are especially critical now.Federal and state governments face historic budget shortfalls, just as expenditures on corrections across the country are nearing a staggering $70 billion annually, according to the Bureau of Justice Statistics. Some states are releasing inmates early, and many are increasingly relying on community supervision as an alternative to expensive incarceration. At the same time, publicly funded behavioral health services — the very resources that can help ensure the success of these alternative justice approaches — are in grave danger of being cut. With states struggling to cut costs and few lawmak- ers willing to consider new revenue sources,the result could be a mad, self-defeating scramble for funding among different systems and stakeholders. Alter- natively, our industry’s proactive engagement with criminal justice could create collaboration instead of chaos and lead to thoughtful changes and strategies that result in real improvements at both the systems and individual levels — not only to make the best use of dwindling dollars but to create stronger, more efficient, more effective, and more humane systems in the long run. The status quo is being shattered by fiscal realities. We can seize this opportunity to create partnerships with criminal justice and to educate decision makers and the public about community behavioral health- care’s critical role in the safe diversion and release of people with substance use issues and mental illness. We can make real connections between community behavioral healthcare and criminal justice. And by promoting our accomplishments to the larger com- munity, we can emphasize our contribution to public safety. Expenditures on corrections across the country are nearing a staggering $70 billion annually. Some states are releasing inmates early, and many are increasingly relying on community supervision as an alternative to expensive incarceration.At the same time, publicly funded behavioral health services — the very resources that can help ensure the success of these alternative justice approaches — are in grave danger of being cut.
  7. 7. 8 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars “Mr. Chairman, Ranking Member Coburn, and dis- tinguished members of this Subcommittee, it is an honor to provide testimony before this body. My purpose in testifying is to bring to light some of the experiences people with mental illness encounter when they enter the criminal justice system and to expose the inhumane treatment they receive. I have also included information on how this travesty in human rights can start to be corrected. With the ability of hindsight, I can say I started to experience depression at an early age. The first twinge of it was in elementary school at the time of Martin Luther King, Jr.’s assassination. I can re- member thinking, “The people in this country will never change. If they could kill a man as good as him what chance do I have?”These thoughts were in the context of experiencing racism through my en- tire life, from times visiting family in the rural south as a young child to going to a majority white school in my native New York from elementary through high school. I think now, and feel seven years old is too young to feel hopelessness, especially in a country that has as much as this country. When I was seventeen I experienced my first arrest. New York City’s Rikers Island at that time was called the “gladiator school” by local youth. I was arrested for illegal gambling because I had betted a few dollars on some numbers and was caught near the “number spot.” Honestly, I used to bet to get a thrill because even at that age, it was hard for me to feel joy or happiness like other young men, so I used to fill that void with thrill seeking and other non goal- producing behaviors like drugs and alcohol use.This charge was considered a misdemeanor in New York City [and] State. In the few days it took for me to post bail I experi- enced suicidal thoughts and was actually stabbed by another inmate for the jacket I was wearing. I was afraid to go to the clinic because I knew they would put me in isolation on suicide watch and I felt punished enough. When I became eighteen years old, things were not getting better for me. I was abusing drugs like heroin and crack cocaine. My family did not know what to do. I was trying to outrun someone I could never outrun, myself. By the time I was twenty-one years old,I had been arrested several times for drug possession/sale and gambling. I was using a large amount of drugs and got caught in a drug den dur- ing a police raid. I was facing a lot of time and was scared to death. My family found me a good attor- ney who eventually got the charges dismissed and suggested that I seek drug treatment. I went to a long-term drug treatment facility in NewYork State.I did not like being there,but I thought maybe I could get help with the problems I had been experiencing. I told my counselor I thought I had more than just a drug problem — that I felt sad and lonely pretty much all the time no matter what I did. I also told him I thought about ending my life quite a bit.When he heard this, he warned me that if I mentioned that again I would be discharged from the program and sent to a mental hospital. I never mentioned it again. I graduated from the program after a year, went back home,picked up drugs again in less than two weeks, and was back in the street like nothing ever changed. Through the next twenty years, I went back and forth to jail. My ability to function was slowly, but steadily, declining. I was arrested at least twenty or thirty times in that time period. I served sentences from ten days to one year.The first six to ten times I would ask my lawyer or the staff in the jail for help with the issues I had, I got the same answer every time — that is if they bothered to answer; that either I went to drug treatment or the mental hospital. I knew one or the other by itself would not work, so I gave up asking for help from the system. Towards the last few years of my suffering, I ex- perienced my first hospitalization for psychiatric reasons; it was after my first suicide attempt. I was there for a couple of months. I went to therapy, and I was put on medication. It helped; I became stable and was discharged from the hospital. I did not have stable housing when I was discharged. I was referred to a“¾ house”to live and it was worse than living on the streets, so that is what I did. I ended up not taking my medication, not participating in therapy, and quickly re-offended. When I went to jail the next time I didn’t stand up for the count. I was written up and put into punitive segregation (“the box”). In segregation, I was put in a cold, dark, barren cell — no TV, no books — where the environment exaggerated my symptoms and I even experienced some new ones like audio hal- Testimony of David Fuller, Certified Psychiatric Rehabilitation Practitioner and Forensic Peer Specialist; a Person with a History of Incarcer- ation and Psychiatric Disability, before the United States Senate Committee on the Judiciary, Subcommittee on Human Rights and the Law, Hearing on “Human Rights at Home: Mental Illness in US Prisons and Jails,” September 15, 2009. Printed with permission of David Fuller Human Rights at Home: Mental Illness in U.S. Prisons and Jails This cycle would repeat itself many more times: get out, no place to live, stop taking my medication, use drugs, become suicidal, then go back to jail.
  8. 8. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 9 lucinations. The officers were verbally and physically abusive.There was no point in making an official com- plaint because the officers would just abuse you more and nothing would ever be done about it. This cycle would repeat itself many more times: get out, no place to live, stop taking my medication, use drugs, become suicidal, then go back to jail. I remem- ber I“caught a ticket”in jail one time and before they could send me to the box I tried to hang myself in my cell,my cellmate found me before the officers did and untied the sheet. He did not tell the officers because he knew what would happen.I wept in my cell the rest of the night; I was discharged after two days. There were fights with other inmates almost every time I went to jail. Because of my depression, I would appear to be an easy victim and some of the other inmates would try to steal my food. Most of the time I would win the fight, but lose the battle for my self- esteem and self-respect — fighting for food like a common animal. “There is no HIPAA in jail” because there is really no privacy in regards to your psychiatric care. Either you are on the “Mental Observation Unit” with all the stig- ma and dangers that implies, or you are living in gen- eral population where every time you go for medica- tion or need to see the doctor it is announced through the cell block. When you are getting your medication you are on a line with a hundred other inmates and inmates going back and forth on the other side of the hall. People are buying and selling medication and other illicit drugs. Everybody pretty much knows what the other person is getting.When you go to the“clinic” to see the doctor you have to wait for hours on end and once again, everybody knows what you are there for. You can hear staff talking about other patients when you are meeting someone about yourself, so you think about whether they talk about you when you leave, so you do not share much and do not get the help you need. For 28 years of my life, I struggled with depression and then later [posttraumatic stress disorder]. I used hard drugs most of this period and it seemed like I was always going in and out of jail. Violence was al- ways around me.Through my periods in jail and being homeless I have been stabbed and shot.I was abused by the very people and system that were supposed to be helping me, and keeping me safe. I did not have access to the services I needed; I was alienated from friends and family. I felt isolated and alone. I dwelled in hopelessness, shame, guilt, and fear of the future. I believed God had abandoned me and things would never change. I turned down treatment a few times in the past when I was in jail before because I was never offered a place [where] I could address my psychiatric disabil- ity and my drug addiction at the same time, in the same place.I had been through treatment many times for one or the other at different times and it seemed to never work for me. I am happy to say things did change. The last time I was incarcerated I was offered an opportunity to par- ticipate in a Mentally Ill/Chemically Addicted — resi- dential treatment rather than stay in jail. It turned my life around. I was able to be around people who had similar experiences and I did not feel so alone. I talk- ed to people like me who had recovered and [were] on their way to happy, productive lives. For the first time in a long time, I had real hope for the future. I learned I had to be honest,open-minded,and willing to do the footwork in order to recover. I had to take responsibility for my life. I gained a relationship with a higher power that I choose to call God. I confronted my fears and insecurities and made friends with other people, some like me and some that did not have the same experiences as me. I did not use my past as an excuse to fail; I used it as a source of strength and truth to move me forward.I learned to love again; first myself and then others. I learned to forgive. It set me free. I went back to work with the help of my peers at the Howie T. Harp Advocacy Center, a supportive employ- ment/training center for people with histories similar to my own, got a place to live, and found someone special to share my life with. I learned to be a father, a husband, a citizen — a man! Eight years ago I never thought I would be able to say this, but I am happy, joyous, and free.Today, all things are possible! Through my years of suffering, the government has probably spent about one million dollars (not includ- ing court and law enforcement costs) on incarceration and treatments that just made my life worse and were ineffective in diminishing or eliminating the problem. All my drug use was a desperate attempt to medicate symptoms that I did not understand and that society had made me ashamed and fearful to get help for. All of my arrests were due to my drug use. Why did I have to be punished so severely, for so long, for be- ing sick? Psychiatric disability and substance abuse are chronic illnesses similar to hypertension or diabetes.The last time I checked, people with those illnesses were not being put in jail and shunned by society. People can live with all of these disorders with proper treatment and support. In closing, I encourage everyone to read Ending an American Tragedy: Addressing the Needs of Justice-In- volved People with Mental Illnesses and Co-Occurring Disorders, which I have attached. I believe this document can point this committee in the right direction in changing the way services are given; in a cost-effective and humane way that ben- efits the community as a whole” Sincerely, David L. Fuller David Fuller, CPRP, a consumer in recovery from psychiatric disability, substance abuse, and the criminal justice system, is employed at Kings County Hospital Center in Brooklyn as a peer counselor who coordinates the Adult Outpatient Walk-In Clinic and a group facilitator with its Continuing Day Treatment Program. He is also an outreach and housing coordinator for the Manhattan Outreach Consortium.As an administrator, service provider, and independent consultant, Fuller draws on his personal experiences as a consumer — and his opportunity to overcome many chal- lenges — to fuel his mission to improve access to services for people who have been affected by psychiatric diagnoses and who use the public mental health system. Fuller is also a member of the National Leadership Forum on Behavioral Health/Criminal Justice with the National GAINS Center; an advisory board member of the Peer Integration Project through the Columbia School of Social Work’s Workplace Center; a guest lecturer at the Columbia,Adelphi, and New York Universities Schools of Social Work on trauma and mental health recovery models. Psychiatric disability and substance abuse are chronic illnesses similar to hypertension or diabetes. The last time I checked, people with those illnesses were not being put in jail and shunned by society.
  9. 9. 10 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars In 1841, Dorothea Dix was appalled by the conditions she observed in Massachusetts jails and crusaded for more humane responses to the needs of those inmates with mental illnesses. Within a decade her work was translated into therapeutic state run institutions that traded punishment for care. Over the next century, without sustained commitment to Dix’s vision for recovery, these facilities fell into disrepair to the point that today,hundreds of thousands of people with mental illnesses crowd our county jails and state prisons. In 1946, Life Magazine published an exposé detailing cruel and inhumane conditions in State psychi- atric hospitals across the United States.1The article described widespread abuse of patients resulting, in part, from “public neglect and legislative penny pinching;” and was punctuated by a series of haunting photographs depicting desolate and shameful conditions under which people with mental illnesses were being confined, often for years or even decades on end. The author referenced grand jury reports as well as State and Federal investigations documenting widespread abuses and hazard- ous living conditions in State institutions. Citing severely inadequate staffing, substandard treatment, inappropriate use of restraints, and provision of little more than custodial care, the institutions were described as, “…costly monuments to the States’ betrayal of the duty they have assumed to their most helpless wards” Although the population of State psychiatric hospitals continued to grow over the next decade, the publication of this article, along with similar accounts from other media sources, began to expose a crisis that had existed largely hidden from public view for far too long. As more light was shed on the horrific treatment people received in State psychiatric hospitals, along with the hope offered by the availability of new medications, a flurry of federal lawsuits resulted in court decisions leading to substantial reductions in the numbers of people housed in State psychiatric hospitals. Unfortunately, while State hospital beds were shut down by the thousands, the types of comprehensive community-based services and supports promised as a condition of their closing were never developed. Combined with changes in sentencing practices, evolution of quality of life ordinances, and restricted definitions of eligibility for public sector behavioral health services, this has resulted in many individu- A Report of the National Leadership Forum for Behavioral Health/Criminal Justice Services, Co-chaired by Linda Rosenberg, MSW, President and CEO, National Council for Community Behavioral Healthcare and Henry J. Steadman, PhD, President, Policy Research Associates; CMHS National GAINS Center Ending an American Tragedy: Addressing the Needs of Justice-Involved People with Mental Illnesses and Co-Occurring Disorders It is my privilege to co-chair the National Leadership Forum for Behavioral Health/Criminal Justice Services. Ending an American Tragedy: Addressing the Needs of Justice-Involved People With Mental Illnesses and Co-Occurring Disorders is a working document of the NLF.The report is designed as both a call to action, focusing on the crisis in our nation’s jails and prisons — men and women with mental illnesses and addictions incarcerated because they didn’t get the treat- ments they desperately need — and an inspiration — highlighting the possibilities of effective services.We are asking leaders in all communities to come together, pool resources, and work as one. I’m proud of member organizations that are already providing such leadership and you’ll find a small sample of member programs in the “From the Field” section of this issue. National Council members are endlessly creative in overcoming financial, bureaucratic, and cultural barriers and establishing collaborations that solve community problems.And we look forward to the growth and spread of programs and services that offer productive lives to people with mental illnesses and addictions as the alternative to incarceration.” — Linda Rosenberg
  10. 10. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 11 als with mental illnesses and co-occurring substance use disorders repeatedly coming into contact with the criminal justice system. Our Nation is once again in the midst of another shameful and costly mental health crisis that has been allowed to fester and grow, largely out of public sight. It is a secret of stunning proportions; in numbers and in harm. Everyday, in every community in the United States, our law enforcement officers, courts, and correctional institutions are witness to a parade of misery brought on by an inadequately funded, antiquated, and frag- mented community mental health system that is un- able to respond to the needs of people with serious mental illnesses. Each year, more than 1.1 million people diagnosed with mental illnesses are arrested and booked into jails in the United States. Roughly three-quarters of these individuals also experience co-occurring substance use disorders, which increase their likelihood of becoming involved in the justice system. On any given day, between 300,000 and 400,000 people with mental illnesses are incarcer- ated in jails and prisons across the United States,and more than 500,000 people with mental illnesses are under correctional control in the community. Overthepast50yearswehavegonefrominstitutional- izing people with mental illnesses, often in subhuman conditions, to incarcerating them at unprecedented and appalling rates — putting recovery out of reach for millions of Americans. These people are not all the same.They are a hetero- geneous group. >> A small subgroup does resemble the State hos- pital patients of yesteryear, and their presence in our jails/prisons is one of the most egregious and disturbing images related to our failed systems of care. The availability of intensive care models, in- cluding hospital care for some, is critical. >> Many other citizens with mental illnesses in our jails have less disabling conditions and with ac- cess to appropriate community treatment and support, will do quite well. >> A third subgroup includes people with mental ill- nesses who have traits that are associated with high arrest and recidivism rates.These individuals would be best served with good treatment and supports, which include interventions targeted to their dynamic risk factors for arrest. As we attempt to respond to the needs of these peo- ple and respect the legitimate public safety concerns of all community members, conditions in these cor- rectional settings, which are designed for detention and not therapeutic purposes, are often far worse than conditions described in the State hospitals of the 1940s. Moreover, when justice-involved persons with co-occurring disorders leave correctional institu- tions, they repeatedly are left adrift only to recycle through the criminal justice system. Furthermore, individuals who become involved in the justice sys- tem often must contend with the additional stigma of criminal records, which make access to basic needs in the community, such as housing, education, and employment, even more difficult to obtain. This national disgrace, kept hidden for too long, represents one area in civil rights where we have actually lost ground.This failed policy has resulted in a terrible misuse of law enforcement, court, and jail resources, reduced public safety, and compromised public health. These conditions have recently resulted in investiga- tionsintothetreatmentofpeoplewithmentalillnesses in institutional settings, only this time the institutions are correctional facilities that were never intended to serve as de facto psychiatric hospitals. Over the past decade alone, the U.S. Department of Justice has issued findings from investigations of mental health conditions in more than 20 jail and prison systems across the United States, with additional investiga- tions currently ongoing. Equally reminiscent of the past, among the more pervasive findings from these investigations are severely inadequate staffing, sub- standard treatment, inappropriate use of restraints, and provision of little more than custodial care. The following excerpts are taken from recent grand jury and Department of Justice reports: >> During our tour, we observed inmate JM hitting her head on the window of her cell and talking with slurred speech. She was housed in a hospital cell under suicide watch. She spoke of seeing angels and said that she was afraid of her cellmate (who was in the advanced stages of pregnancy) was trying to harm her. She had been at [the jail] for approximately one month prior to our visit. JM stated on her intake form that she had previously been treated at a mental hospital in Little Rock and that she had been seen at a local hospital in January 2005 for seeing ‘spiritual things.’ Shortly after her admission to [the jail], she was placed on suicide watch for making statements about going to sleep and not getting up and ‘not caring if she was alive or not.’ Her medical record notes numerous instances of ‘talking wildly’ and ‘talking to herself.’ She told us that she had a history of hypothyroidism and told us the names of various psychiatric medications that she had been taking before being admitted to [the jail].Throughout our tour, we could hear JM moaning and crying and at times screaming. In spite of all this, this inmate was never evaluated by a mental health care pro- vider.We were told that she was not started on any psychiatric medications or sent to the local hos- pital because she did not have the ability to pay. >> Inmate M.K. hung herself on January 5, 2003 af- ter having been admitted on December 4, 2002. Her record contained the following inmate request form dated two days before her death on January 3, 2003.The note indicated the following. ‘I need to see the doctor to get my medicine straightened out. I am not getting my meds that my doctor faxed prior orders for me, and I brought in the medication myself and paid for it. I cannot afford to be treated this way! Please help me! I need my medicine.’ There is no indication that M.K.received her medi- cation before her death. There are no comparable Department of Justice inves- tigations into a lack of community services, because there is no constitutional right to community-based services as there is for persons who are incarcerated. However, by contrast, there are success stories in the community.A recent report by the Health Foundation of Greater Cincinnati offers a number of compelling personal stories from four Forensic Assertive Commu- nity Treatment (FACT) Teams they fund. Clearly, jails and prisons were never intended as a community’s primary setting to provide acute care services to individuals experiencing serious mental illnesses. In most cases they are ill equipped to do so.
  11. 11. 12 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars >> “My housing is a lot better. My Social Security just got approved today, so I start receiving that again. They cut it off while I was in prison. I did 18 months in prison. I got [Social Security] back with the help of [the FACT team]. And they’ve been helping me with my housing. And that’s a lot better ‘cause now I can get adjusted to a cer- tain environment.And I don’t have to worry about where I’m going to live, one week to the next for whatever reason.” >> “Well, I was really in bad shape. I didn’t know how to go about getting help.The only thing that I really knew that I had to do was try to care for myself and my habit. And that’s what leads to criminal behavior, which limited me on jobs. I felt like I couldn’t work because of my record. So,I had to keep being a criminal to support my- self and my habit. I didn’t know where to go for help. I didn’t know who to talk to. I was suicidal all the time.And I really hated myself for all the feelings and things that I was doing. I had an apartment but I was evicted because I couldn’t pay the rent.And then,I was just,like,going from place to place and sometimes in homeless shel- ters and sometimes with friends or just wherever. I was in jail all the time. I just spent two years in the penitentiary. I’ve been in the penitentiary 3 times and I’ve been in jail probably 30 to 40 times.” The same consumer, when asked about life after receiving FACT services,reported:“Yeah, I haven’t had any problems.I work at McDonalds full-time.” Clearly, jails and prisons were never intended as a community’s primary setting to provide acute care services to individuals experiencing serious mental illnesses.Inmostcasestheyareillequippedtodoso. When we look at community-based services,we find current policies governing the funding and organiza- tion of community mental health care have resulted in people with more intensive and chronic treat- ment needs being underserved or unserved in typi- cal community-based settings. This is due in large part to rules and regulations that limit flexibility in designing service and reimbursement strategies targeting the specific needs of people with serious mental illnesses. For example, the Substance Abuse and Mental Health Services Administration (SAMH- SA) and the Centers for Medicare and Medicaid Ser- vices (CMS) are two agencies housed within the U.S. Department of Health and Human Services (DHHS). SAMHSA has identified intensive case management, psychosocial rehabilitation,supported employment, and supported housing as evidence-based inter- ventions, consistently yielding positive outcomes for persons with serious mental illnesses. However there are several obstacles to using Medic- aid to pay for these effective services.These include categorical restrictions on eligibility, which exclude many people with serious mental illnesses and co- occurring substance use disorders who have been involved in the criminal justice system, as well as fragmentation in coverage for treatment of medical, mental health,and substance abuse problems.Nar- row criteria for “medical necessity” and definitions of covered services that are often not aligned with what we know about evidence-based practices cre- ate barriers to more effective service delivery and recovery outcomes.As a result,there is an increased demand for services provided in hospitals, emer- gency settings, and the justice system, contributing to extraordinarily high costs for local communities, states, and the Federal government. Furthermore, new practices have been slow to be made available to justice-involved persons with co-occurring disorders. For example, it has now be- come widely accepted that all services for people with serious mental illnesses,particularly those with criminal justice involvement, be trauma-informed. Among both women and men with criminal justice involvement, histories of trauma are nearly univer- sal. Ninety-three percent of 2,000 women and men in federally funded jail diversion programs between 2002 and 2008 reported at least one incident of physical or sexual abuse in their lifetime. Sixty- one percent reported physical or sexual abuse in the last 12 months. Yet few programs, institutional or community-based, offer environments that are trauma informed or trauma specific. Moreover, a recent study found 31 percent of women being booked into local jails with current symptoms of serious mental illness.2This compares with 14 percent of men.These rates exacerbate the issues of providing adequate services for women in predominantly male facilities whose physical plants and staffing are geared to men.Gender-specific ser- vices that reflect a trauma-informed culture must be developed in all institutional and community settings to respond to the frighteningly high rates of mental illness among women in contact with the criminal justice system. In addition, we know that individuals using mental health services — often referred to as“consumers”— have a significant impact on creating recovery-ori- ented mental health and substance abuse services. For people involved in the criminal justice system, forensic peer specialists — those with histories of mental illness and criminal justice system involve- ment — can help pave the way for a successful re- turn to the community. The ability to effectively design, implement, and reimburse treatment providers for delivering high quality services targeting specialized treatment needs is critical to establishing an effective com- munity-based system of care for people who expe- rience serious mental illnesses. In the absence of what are now seen as essential services for peo- ple with mental illnesses living in the community, people will continue to be forced into more costly, deep-end services in hospitals, crisis centers, emer- gency rooms, and the justice system. The result is a recycling of individuals between jails, prisons, shelters, short-term hospitalizations, and homelessness — with public health, public safety, and public administration implications that are staggering. Now more than ever, as we strive to provide health care to our most vulnerable citizens, we must address this serious public health and public safety crisis. It is high time to be open and honest about the deplorable conditions that ex- ist and take steps to address them. We offer four recommendations for immediate action. In the absence of what are now seen as essential services for people with mental illnesses living in the community, people will continue to be forced into more costly, deep-end services in hospitals, crisis centers, emergency rooms, and the justice system.
  12. 12. 14 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars u The President should appoint a Special Advisor for Mental Health/Criminal Justice Collaboration. Currently, there is no fixed responsibility within the Federal government to promote effective mental health/criminal justice activities and ensure ac- countability for the use of public dollars.The Special Advisor will serve as an advocate and ombudsman across the wide array of Federal agencies that serve the multiple needs of justice-involved people with mental and substance use disorders. One of his or her tasks will be to implement an immediate re- view of all CMS and SAMHSA regulations to identify conflicts and inconsistencies for people with mental illnesses and co-occurring substance use disorders — particularly those involved in the justice system. u Federal Medicaid policies that limit or discourage access to more effective and cost-efficient health care services for indi- viduals with serious mental illnesses and co-occurring substance use disorders should be reviewed and action taken to create more efficient programs. Congress is encouraged to review Medicaid policies and take action that will enable states to create more effective and appropriate programs target- ing eligible beneficiaries most likely to experience avoidable admissions to acute care settings. Such programs should allow states flexibility in designing and implementing targeted outreach and engage- ment services, coordinated care management, and community support services that are likely to reduce expenditures on deep-end services, and en- gage people in prevention, early intervention, and wellness care in the community. Services provided should reflect evidence-based and promising prac- tices and should be designed around principles of recovery, person-centered planning, and consumer choice. Because of the high rates of co-morbid health care needs among people with serious men- tal illnesses and co-occurring substance use disor- ders, programs should seek to establish more ef- fective integration of primary and behavioral health care service delivery system as well. u All States should create cross-system agencies, commissions, or positions charged with removing barriers and creating incen- tives for cross-agency activity at the State and local level. No one system can solve this problem alone.These cross-system groups or individuals will play a key role in spanning the different administrative struc- tures, funding mechanisms, and treatment philoso- phies of the mental health, substance abuse, and criminal justice systems. States must make clear that collaboration is not only possible but expected. In Montana, for example, the State Department of Corrections and Department of Public Health and Human Services jointly fund a boundary spanner position that facilitates shared planning, communi- cation, resources, and treatment methods between the mental health and criminal justice systems. u Localities must develop and implement core services that comprise an Essential Sys- tem of Care: Recognizing the limited resources often available and the complexities of the cross-system collabora- tions required,the eight components of an Essential System of Care are best approached in two phases. Phase 1 includes less expensive, easier to mount services. Phase 2 includes essential evidence- based practices that are more expensive and more challenging to implement, but are critical to actu- ally increasing positive public safety and public health outcomes. Phase 1 >> Forensic Intensive Case Management >> Supportive Housing >> Peer Support >> Accessible and Appropriate Medication These four services are the ones we believe are minimally necessary to break the cycle of illness, arrest and incarceration, and recidivism.We believe these services — described in brief below — can be implemented quickly, cost-effectively, and with positive results. However, these services can only be effective if the programs that provide them are structured and staffed by people who understand and are prepared to address trauma as a risk fac- tor for both mental health problems and criminal justice involvement.A trauma-informed system that features trauma-specific interventions can help en- sure public health and public safety and transform individuals’ lives. Forensic Intensive Case Management (FICM) is designed for justice-involved people with multiple and complex needs and features services provided when and where they are needed. FICM focuses on brokering rather than providing services directly, making it less expensive than ACT. For a brokered service model to be effective, communities must have adequate and accessible services to which in- dividuals can be linked.What makes these services “forensic” is “criminal justice savvy,”3 that is, pro- viders understand the criminal justice system and the predicaments of their clients involvement in it. Supportive Housing is permanent, affordable hous- ing linked to a broad range of supportive services, including treatment for mental and substance use disorders. Supportive housing can significantly de- crease the chance of recidivism to jails and prisons and is less costly on a daily basis than jail or prison. Unfortunately, affordable housing is in short supply in many communities,and ex-offenders with drugre- lated offenses often have trouble securing public housing assistance. Housing for ex-offenders must balance the needs for supervision and the provision of social services. Peer Support services can expand the continuum of services available to people with mental and substance use disorders and may help them engage in treatment. Forensic peer specialists bring real- world experience with multiple service systems and an ability to relate one-on-one to people struggling to reclaim their lives. The practice of consumer- driven care — as exemplified by the involvement of mental health consumers in service design,delivery, and evaluation — is at the heart of a transformed mental health system. Accessible and Appropriate Medication supports continuity of care for individuals with mental ill- nesses whose treatment often is disrupted when they become involved in the criminal justice system. They may not receive appropriate medication in Recommendations for Immediate Action
  13. 13. NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 15 jail or prison or adequate follow-up when they return to the community. It is imperative that people with mental illnesses and co-occurring substance use disorders have access to the right medication at the right dosage for their condition, as determined by the individual together with his or her clinician. Phase 2 Clearly, the Phase 1 services are necessary, but not sufficient. Services that support the Essential System of Care include several evidence-based practices for people with serious mental illnesses. These services may be more expensive or difficult to implement than the four listed above, but we encourage States and communities to move toward development of these services by codifying them in policy, supporting them in practice, and rewarding their implementation. Phase 2 services include: >> Integrated Dual Diagnosis Treatment, which provides treatment for mental and substance use dis- orders simultaneously and in the same setting >> Supported Employment, which is an evidence- based practice that helps individuals with mental ill- nesses find, get, and keep competitive work >> Assertive Community Treatment (ACT)/ Foren- sic Assertive Community Treatment (FACT), which is a service delivery model in which treatment is pro- vided by a team of professionals, with services deter- mined by an individual’s needs for as long as required, and >> Cognitive Behavioral Interventions Targeted to Risk Factors specific to offending, are a set of in- terventions, well researched within both institutional settings and community settings, that have a utility when extended to community treatment programs. This list of evidence-based and promising practices is illustrative but not exhaustive. Clearly, however, there is much that can be done to help people with mental and substance use disorders avoid arrest and incar- ceration and return successfully to their communities after jail or prison. We acknowledge that in difficult financial times, new dollars may not be available. However,though new money is not always required for systems change, new ways of thinking are. To meet the public health and public safety needs of our communities demands a fully collaborative campaign involving both the behavioral health and criminal justice systems. Neither system can continue business as usual. The criminal justice system needs to do an adequate job of screening, assessing, and individualizing responses to detainees and inmates identified with mental illness. The behavioral health system needs to refine and deliver evidence-based practices with an awareness of its responsibility to not only improve the quality of life of its clients,but to ad- dress interventions to factors associated with criminal recidivism in these clients and to more directly involve clients as partners in a recovery process that recog- nizes the community’s public safety concerns. Prime examples of this Essential System of Care have been developed within the CMHS TCE Jail Diversion program since 2002. San Antonio, TX, has become a national model with a highly integrated system of care that reflects strong behavioral health and criminal justice partnerships that have resulted in a central- ized police drop-off that directly links persons to case management, medications, housing, and peer sup- port. A medium-size city that has built a comprehen- sive, integrated system around an existing community mental health center is Lincoln, NB.These are but two examples of successfully moving entire communities forward via a jail diversion program to achieve Phase 1 services and move towards Phase 2 implementa- tion. These goals are achievable even in today’s eco- nomic tough times. We must move toward a day when people with men- tal and substance use disorders receive the effec- tive community-based interventions they need and deserve, and jails and prisons no longer are forced to serve as primary, de facto treatment facilities. We know what works to address successfully the needs of people with mental and substance use disorders who come in contact with the criminal justice system; now we have to DO what works. The time for action is now! National Leadership Forum Members Thomas Berger Vietnam Veterans of America Sandra Cannon Ohio Department of Mental Health Neal Cash Community Partnership of Southern Arizona David Fuller Manhattan Outreach Consortium Robert Glover National Association of State Mental Health Program Directors Gilbert Gonzales Bexar County Mental Health Authority Center for Health Care Services Richard Gowdy Missouri Department of Mental Health Jennifer Johnson San Francisco Office of the Public Defender Hon. Steve Leifman Special Advisor on Criminal Justice and Mental Health to Florida Supreme Court Stephanie LeMelle New York State Psychiatric Institute, Columbia University Department of Psychiatry Ginger Martin Oregon Department of Corrections Transitional Services Division John Morris The Technical Assistance Collaborative Fred Osher Council of State Governments Justice Center Linda Rosenberg* National Council for Community Behavioral Healthcare David Shern Mental Health America Henry J. Steadman* Policy Research Associates, CMHS National GAINS Center Carol Wilkins Corporation for Supportive Housing B. Diane Williams Safer Foundation Dee Wilson Texas Department of Criminal Justice Sharon Wise The Gregory Project of Washington D.C. *Co-chair of National Leadership Forum To meet the public health and public safety needs of our communities demands a fully collaborative campaign involving both the behavioral health and criminal justice systems. Neither system can continue business as usual.
  14. 14. 16 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Interview Linda Rosenberg, MSW, President & CEO, National Council for Community Behavioral Healthcare, shares her thoughts about the current status of treatment for justice-involved individuals with mental illness and ad- diction. Committed to supporting the efforts of member organizations to address the problems of their communi- ties, Rosenberg has positioned the National Council to promote the expansion of community based alternatives to incarceration. Prior to her position at the National Council, she served as the Senior Deputy Commissioner for the New York State Office of Mental Health, during which time she oversaw the state’s services for justice-in- volved individuals,implementing a network of jail diversion programs including New York’s first mental health court. National Council: What challenges exist in serving justice-involved people with mental illness and addic- tions? Linda: There are many challenges in connecting jus- tice involved consumers with services. We’re talking primarily about people with little money or power and they may have little or no interest in mental health or addictions treatment services. They’ve not found ser- vices useful or relevant and often dislike programs that are highly structured. Our job at the National Council is to identify member organizations that have devel- oped successful services for this population and then to facilitate the member to member spread of these programs. National Council: New York has an assisted outpa- tient treatment law — what is the controversy behind such laws? Linda: Some view these laws as victimizing — blaming — people with mental illness. In a perfect world, court ordered treatment would be unnecessary but in our world the combined power of the court and treatment can mean successful community living for consumers that would otherwise be in and out of hospital or jail. Assisted Outpatient Treatment must be carefully used but when all else fails it can connect people to vital services. But AOT alone isn’t enough — a full array of community services including housing, effective treat- ments, work supports, and general medical care must be available and accessible. Unfortunately passage of AOT is often a political reaction to an unfortunate inci- dent — a law is passed with no financing of the services that are critical if we’re going to keep both individuals with mental illnesses and our communities safe. National Council: As a state official in New York, you were a strong supporter of the state’s first mental health court. What benefits do such courts bring to providers and the individuals they serve? Linda: I’ve seen mental health courts and to an even greater extent, drug courts, emerge as a powerful means through which people access care. In many places the court begins with a judge who has personal and/or professional interest in behavioral health is- sues. Mental health and drug courts aren’t meant to be applied broadly — these courts are alternatives for people with serious mental illnesses and addictions that are on the way to jail or prison.And like AOT, there must be seamless connections to the full continuum of treatment and support services.These problem-solving courts give individuals with serious behavioral health disorders a unique opportunity to engage with a judge around their needs.The courts provide alternatives to people with mental illnesses and addiction — offering services instead of time behind bars. National Council: How can states move forward in creating programs for justice-involved persons in this era of budget cuts? What role do community providers play? Linda:Change is often incremental in our very complex world but it looks like we’ve reached a tipping point in regard to diversion and re-entry. Policy change is often driven by a convergence of ideas and money. States are in tremendous economic distress and can’t con- tinue to build new jails and prisons or support grow- ing numbers of incarcerated individuals. At the same time it’s becoming clear that treatment and services works and are less expensive alternatives. Look at the President’s budget proposal – growth in financing of alternatives to criminal justice involvement. This is an area where there is both new money and potential for re-investment of dollars currently directed to incarcer- ation.And as always leadership is essential — excited by the possibilities, local leaders emerge, enlist others in their vision, and the money follows. National Council: How does the justice-involved population “fall through the cracks?” Linda: The falling through the cracks problem is not unique to justice-involved individuals. Every time we create a new program or service to keep people from falling through the cracks, we are creating another crack for someone to fall through.The system has got- ten so rich and so complicated — multiple programs and services, most under different corporate auspices and each with its unique rules and operating practices — that it’s difficult to navigate it.A person’s treatment is run by one organization, their housing by another, their employment supports by another — and getting all these organizations on the same page and at the same table becomes nearly impossible. It is very, very difficult to coordinate services. National Council:What can be done to support co- ordinated treatment? Linda: I think in the end we need a system where one organization/person is responsible. If everyone is re- sponsible, then no one is responsible. The buck has to stop somewhere and I think it needs to stop with an organization that gets an adequate pot of money and ensures that the consumer gets the services they need and want.With adequate financing, clarity as to what treatments and services are effective and the de- livery of those interventions, use of health information technology, and the ongoing measurement of simple outcomes — hospitalization, incarceration and home- lessness — we can coordinate care and go a long way toward supporting successful community tenure. That doesn’t mean that all justice-involved people will have a straight trajectory to recovery. Some people will be hospitalized and some might be incarcerated or be- come homeless. We can do better but challenges will remain.Our jobs are to address the challenges,always exploring new approaches and refining our efforts to improve lives. Mohini Venkatesh serves as the staff policy liaison to the National Council for Community Behavioral Healthcare’s network of associations throughout the states, conducts federal legislative and policy analysis on an array of issues, and man- ages political engagement activities including an annual Hill Day in Washington, DC. She received a masters in public health from Yale University and a BA in psychology from the University of Massachusetts-Amherst. Nathan Sprenger supports the National Council’s public rela- tions and marketing efforts, leads the social media activities, maintains the website, and serves as editorial assistant for National Council Magazine. He has a masters degree in public communication from American University in Washington DC. Linda Rosenberg, MSW, President & CEO, National Council for Community Behavioral Healthcare, Interviewed by Mohini Venkatesh, Director, Federal and State Policy and Nathan Sprenger, Marketing and Communications Associate — National Council for Community Behavioral Healthcare Behavioral Health and Criminal Justice Collaboration: Where Does the Buck Stop? There must be a single point of accountability. If everyone is respon- sible, then no one is responsible.”
  15. 15. VIVITROL... there when they need it. For the treatment of alcohol dependence VIVITROL is a registered trademark of Alkermes, Inc. ©2010 Alkermes, Inc. All rights reserved VIV 981 B January 2010 Printed in U.S.A. Please see brief summary ofViViTrol Prescribing informaTion, including boxedwarning,onThe nexT Page. Naltrexonehasthecapacitytocausehepatocellularinjurywhengiveninexcessivedoses. Naltrexoneiscontraindicatedinacutehepatitisorliverfailure,anditsuseinpatientswithactiveliver diseasemustbecarefullyconsideredinlightofitshepatotoxiceffects. Themarginofseparationbetweentheapparentlysafedoseofnaltrexoneandthedosecausing hepaticinjuryappearstobeonlyfive-foldorless.VIVITROLdoesnotappeartobeahepatotoxinatthe recommendeddoses. Patientsshouldbewarnedoftheriskofhepaticinjuryandadvisedtoseekmedicalattentionifthey experiencesymptomsofacutehepatitis.UseofVIVITROLshouldbediscontinuedintheeventofsymptoms and/orsignsofacutehepatitis. VIVITROLisadministeredasaglutealintramuscularinjection.Inadvertentsubcutaneousinjectionof VIVITROLmayincreasethelikelihoodofsevereinjectionsitereactions.VIVITROLmustbeinjectedusing thecustomizedneedleprovidedinthecarton.Becauseneedlelengthmaynotbeadequateduetobody habitus,eachpatientshouldbeassessedpriortoeachinjectiontoassurethatneedlelengthisadequate forintramuscularadministration.VIVITROLinjectionsitereactionsmaybefollowedbypain,tenderness, induration,swelling,erythema,bruisingorpruritus;however,insomecasesinjectionsitereactionsmaybe verysevere.Injectionsitereactionsnotimprovingmayrequirepromptmedicalattention,includinginsome casessurgicalintervention. Considerthediagnosisofeosinophilicpneumoniaifpatientsdevelopprogressivedyspneaandhypoxemia. InanemergencysituationinpatientsreceivingVIVITROL,suggestionsforpainmanagementincluderegional analgesiaoruseofnon-opioidanalgesics.Alcoholdependentpatients,includingthosetakingVIVITROL, shouldbemonitoredforthedevelopmentofdepressionorsuicidalthoughts.Cautionisrecommendedin administeringVIVITROLtopatientswithmoderatetosevererenalimpairment. ThemostcommonadverseeventsassociatedwithVIVITROLinclinicaltrialswerenausea,vomiting, headache,dizziness,asthenicconditionsandinjectionsitereactions. 1. VIVITROL [full prescribing information]. Waltham, MA: Alkermes, Inc; May 2009. *Eligibility for co-pay assistance: Offer not valid for prescriptions purchased under Medicaid, Medicare, or any federal or state healthcare programs, including any state medical or pharmaceutical assistance program. Offer not valid in Massachusetts. Void where prohibited by law, taxed or restricted. Alkermes, Inc. reserves the right to rescind, revoke or amend these offers without notice. indicaTion1 VIVITROL® isindicatedforthetreatmentofalcoholdependenceinpatientswhoareabletoabstain fromalcoholinanoutpatientsettingpriortoinitiationoftreatmentwithVIVITROL. PatientsshouldnotbeactivelydrinkingatthetimeofinitialVIVITROLadministration. TreatmentwithVIVITROLshouldbepartofacomprehensivemanagementprogramthatincludes psychosocialsupport. imPorTanT safeTy informaTion for ViViTrol1 VIVITROLiscontraindicatedinpatientsreceivingopioidanalgesicsorwithcurrentphysiologic opioiddependence,patientsinacuteopiatewithdrawal,anyindividualwhohasfailedthenaloxone challengetestorhasapositiveurinescreenforopioids,orinpatientswhohavepreviouslyexhibited hypersensitivitytonaltrexone,PLG,carboxymethylcelluloseoranyothercomponentsofthediluent. VIVITROLpatientsmustbeopioidfreeforaminimumof7-10daysbeforetreatment.Attemptstoovercome opioidblockadeduetoVIVITROLmayresultinafataloverdose.Inprioropioidusers,useofopioidsafter discontinuingVIVITROLmayresultinafataloverdosebecausepatientsmaybemoresensitivetolower dosesofopioids.PatientsrequiringreversaloftheVIVITROLblockadeforpainmanagementshouldbe monitoredbyappropriatelytrainedpersonnelinasettingequippedforcardiopulmonaryresuscitation. For more information, call toll-free 1-800-VIVITROL (1-800-848-4876, ext. 2). Tell Your Patients About Our Co-Pay Assistance Program Upto6monthsofmedicationwith potentiallynoout-of-pocketcosts*
  16. 16. BRIEF SUMMARY See package insert for full Prescribing Information. INDICATIONS AND USAGE: VIVITROL is indicated for the treatment of alcohol dependence in patients who are able to abstain from alcohol in an outpatient setting prior to initiation of treatment with VIVITROL. Patients should not be actively drinking at the time of initial VIVITROL administration. Treatment with VIVITROL should be part of a comprehensive management program that includes psychosocial support. CONTRAINDICATIONS: VIVITROL is contraindicated in: • Patients receiving opioid analgesics (see PRECAUTIONS). • Patients with current physiologic opioid dependence (see WARNINGS). • Patients in acute opiate withdrawal (see WARNINGS). • Any individual who has failed the naloxone challenge test or has a positive urine screen for opioids. • Patients who have previously exhibited hypersensitivity to naltrexone, PLG, carboxymethylcellulose, or any other components of the diluent. WARNINGS: Hepatotoxicity Eosinophilic pneumonia In clinical trials with VIVITROL, there was one diagnosed case and one suspected case of eosinophilic pneumonia. Both cases required hospitalization, and resolved after treatment with antibiotics and corticosteroids. Should a person receiving VIVITROL develop progressive dyspnea and hypoxemia, the diagnosis of eosinophilic pneumonia should be considered (see ADVERSE REACTIONS). Patients should be warned of the risk of eosinophilic pneumonia, and advised to seek medical attention should they develop symptoms of pneumonia. Clinicians should consider the possibility of eosinophilic pneumonia in patients who do not respond to antibiotics. Unintended Precipitation of Opioid Withdrawal—To prevent occurrence of an acute abstinence syndrome (withdrawal) in patients dependent on opioids, or exacerbation of a pre-existing subclinical abstinence syndrome, patients must be opioid-free for a minimum of 7-10 days before starting VIVITROL treatment. Since the absence of an opioid drug in the urine is often not sufficient proof that a patient is opioid-free, a naloxone challenge test should be employed if the prescribing physician feels there is a risk of precipitating a withdrawal reaction following administration of VIVITROL. Opioid Overdose Following an Attempt to Overcome Opiate Blockade VIVITROL is not indicated for the purpose of opioid blockade or the treatment of opiate dependence. Although VIVITROL is a potent antagonist with a prolonged pharmacological effect, the blockade produced by VIVITROL is surmountable. This poses a potential risk to individuals who attempt, on their own, to overcome the blockade by administering large amounts of exogenous opioids. Indeed, any attempt by a patient to overcome the antagonism by taking opioids is very dangerous and may lead to fatal overdose. Injury may arise because the plasma concentration of exogenous opioids attained immediately following their acute administration may be sufficient to overcome the competitive receptor blockade. As a consequence, the patient may be in immediate danger of suffering life-endangering opioid intoxication (e.g., respiratory arrest, circulatory collapse). Patients should be told of the serious consequences of trying to overcome the opioid blockade (see INFORMATION FOR PATIENTS).There is also the possibility that a patient who had been treated with VIVITROL will respond to lower doses of opioids than previously used. This could result in potentially life-threatening opioid intoxication (respiratory compromise or arrest, circulatory collapse, etc.). Patients should be aware that they may be more sensitive to lower doses of opioids after VIVITROL treatment is discontinued (see INFORMATION FOR PATIENTS). PRECAUTIONS: General—When Reversal of VIVITROL Blockade is Required for Pain Management In an emergency situation in patients receiving VIVITROL, suggestions for pain management include regional analgesia or use of non-opioid analgesics. If opioid therapy is required as part of anesthesia or analgesia, patients should be continuously monitored in an anesthesia care setting, by a person not involved in the conduct of the surgical or diagnostic procedure. The opioid therapy must be provided by an individual specifically trained in the use of anesthetic drugs and the management of the respiratory effects of potent opioids, specifically the establishment and maintenance of a patent airway and assisted ventilator. Depression and Suicidality In controlled clinical trials of VIVITROL, adverse events of a suicidal nature (suicidal ideation, suicide attempts, completed suicides) were infrequent overall, but were more common in patients treated with VIVITROL than in patients treated with placebo (1% vs. 0). In some cases, the suicidal thoughts or behavior occurred after study discontinuation, but were in the context of an episode of depression which began while the patient was on study drug. Two completed suicides occurred, both involving patients treated with VIVITROL. Depression-related events associated with premature discontinuation of study drug were also more common in patients treated with VIVITROL (~1%) than in placebo-treated patients (0). In the 24-week, placebo-controlled pivotal trial, adverse events involving depressed mood were reported by 10% of patients treated with VIVITROL 380 mg, as compared to 5% of patients treated with placebo injections. Alcohol dependent patients, including those taking VIVITROL, should be monitored for the development of depression or suicidal thinking. Families and caregivers of patients being treated with VIVITROL should be alerted to the need to monitor patients for the emergence of symptoms of depression or suicidality, and to report such symptoms to the patient’s healthcare provider. Injection Site Reactions VIVITROL injections may be followed by pain, tenderness, induration, swelling, erythema, bruising or pruritus; however in some cases injection site reactions may be very severe. In the clinical trials, one patient developed an area of induration that continued to enlarge after 4 weeks with subsequent development of necrotic tissue that required surgical excision. In the postmarketing period, additional cases of injection site reaction with features including induration, cellulitis, hematoma, abscess, sterile abscess and necrosis have been reported. Some cases required surgical intervention. VIVITROL is administered as a gluteal intramuscular injection. An inadvertent subcutaneous injection of VIVITROL may increase likelihood of severe injection site reactions. VIVITROL must be injected by the customized needle provided in the carton. Alternate treatment should be considered for those patients whose body habitus precludes a gluteal intramuscular injection with the provided needle. Patients should be informed that any injection site reactions should be brought to the attention of the healthcare provider (see INFORMATION FOR PATIENTS). Patients exhibiting signs of abscess, cellulitis, necrosis or extensive swelling should be evaluated by a physician. Renal Impairment VIVITROL pharmacokinetics have not been evaluated in subjects with moderate and severe renal insufficiency. Because naltrexone and its primary metabolite are excreted primarily in the urine, caution is recommended in administering VIVITROL to patients with moderate to severe renal impairment. Alcohol Withdrawal Use of VIVITROL does not eliminate nor diminish alcohol withdrawal symptoms. Intramuscular injections As with any intramuscular injection, VIVITROL should be administered with caution to patients with thrombocytopenia or any coagulation disorder (e.g., hemophilia and severe hepatic failure). Information for Patients Physicians are advised to consult Full Prescribing Information for information to be discussed with patients for whom they have prescribed VIVITROL. Drug Interactions Patients taking VIVITROL may not benefit from opioid-containing medicines (see PRECAUTIONS, Pain Management). Because naltrexone is not a substrate for CYP drug metabolizing enzymes, inducers or inhibitors of these enzymes are unlikely to change the clearance of VIVITROL. No clinical drug interaction studies have been performed with VIVITROL to evaluate drug interactions, therefore prescribers should weigh the risks and benefits of concomitant drug use. The safety profile of patients treated with VIVITROL concomitantly with antidepressants was similar to that of patients taking VIVITROL without antidepressants. Carcinogenesis, Mutagenesis, Impairment of Fertility Carcinogenicity studies have not been conducted with VIVITROL. Carcinogenicity studies of oral naltrexone hydrochloride (administered via the diet) have been conducted in rats and mice. In rats, there were small increases in the numbers of testicular mesotheliomas in males and tumors of vascular origin in males and females. The clinical significance of these findings is not known. Naltrexone was negative in the following in vitro genotoxicity studies: bacterial reverse mutation assay (Ames test), the heritable translocation assay, CHO cell sister chromatid exchange assay, and the mouse lymphoma gene mutation assay. Naltrexone was also negative in an in vivo mouse micronucleus assay. In contrast, naltrexone tested positive in the following assays: Drosophila recessive lethal frequency assay, non-specific DNA damage in repair tests with E. coli and WI-38 cells, and urinalysis for methylated histidine residues. Naltrexone given orally caused a significant increase in pseudopregnancy and a decrease in pregnancy rates in rats at 100 mg/kg/day (600 mg/m2 /day). There was no effect on male fertility at this dose level. The relevance of these observations to human fertility is not known. Pregnancy Category C Reproduction and developmental studies have not been conducted for VIVITROL. Studies with naltrexone administered via the oral route have been conducted in pregnant rats and rabbits. Teratogenic Effects Oral naltrexone has been shown to increase the incidence of early fetal loss in rats administered ≥30 mg/kg/day (180 mg/m2 /day) and rabbits administered ≥60 mg/kg/day (720 mg/m2 /day). There are no adequate and well-controlled studies of either naltrexone or VIVITROL in pregnant women. VIVITROL should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Labor and Delivery The potential effect of VIVITROL on duration of labor and delivery in humans is unknown. Nursing Mothers Transfer of naltrexone and 6β-naltrexol into human milk has been reported with oral naltrexone. Because of the potential for tumorigenicity shown for naltrexone in animal studies, and because of the potential for serious adverse reactions in nursing infants from VIVITROL, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. Pediatric Use The safety and efficacy of VIVITROL have not been established in the pediatric population. Geriatric Use In trials of alcohol dependent subjects, 2.6% (n=26) of subjects were >65 years of age, and one patient was >75 years of age. Clinical studies of VIVITROL did not include sufficient numbers of subjects age 65 and over to determine whether they respond differently from younger subjects. ADVERSE REACTIONS: In all controlled and uncontrolled trials during the premarketing development of VIVITROL, more than 900 patients with alcohol and/or opioid dependence have been treated with VIVITROL. Approximately 400 patients have been treated for 6 months or more, and 230 for 1 year or longer. Adverse Events Leading to Discontinuation of Treatment In controlled trials of 6 months or less, 9% of patients treated with VIVITROL discontinued treatment due to an adverse event, as compared to 7% of the patients treated with placebo. Adverse events in the VIVITROL 380-mg group that led to more dropouts were injection site reactions (3%), nausea (2%), pregnancy (1%), headache (1%), and suicide-related events (0.3%). In the placebo group, 1% of patients withdrew due to injection site reactions, and 0% of patients withdrew due to the other adverse events. Common Adverse Events The most common adverse events associated with VIVITROL in clinical trials were nausea, vomiting, headache, dizziness, fatigue, and injection site reactions. For a complete list of adverse events, please refer to the VIVITROL package insert for full Prescribing Information. A majority of patients treated with VIVITROL in clinical studies had adverse events with a maximum intensity of “mild” or “moderate.” Post-marketing Reports—Reports From Other Intramuscular Drug Products Containing Polylactide-co-glycolide (PLG) Microspheres – Not With VIVITROL. Retinal Artery Occlusion Retinal artery occlusion after injection with another drug product containing polylactide- co-glycolide (PLG) microspheres has been reported very rarely during post-marketing surveillance. This event has been reported in the presence of abnormal arteriovenous anastomosis. No cases of retinal artery occlusion have been reported during VIVITROL clinical trials or post-marketing surveillance. VIVITROL should be administered by intramuscular (IM) injection into the gluteal muscle, and care must be taken to avoid inadvertent injection into a blood vessel (see DOSAGE AND ADMINISTRATION). OVERDOSAGE: There is limited experience with overdose of VIVITROL. Single doses up to 784 mg were administered to 5 healthy subjects. There were no serious or severe adverse events. The most common effects were injection site reactions, nausea, abdominal pain, somnolence, and dizziness. There were no significant increases in hepatic enzymes. In the event of an overdose, appropriate supportive treatment should be initiated. This brief summary is based on VIVITROL Prescribing Information (VIV 566C May 2009). Naltrexone has the capacity to cause hepatocellular injury when given in excessive doses. Naltrexone is contraindicated in acute hepatitis or liver failure, and its use in patients with active liver disease must be carefully considered in light of its hepatotoxic effects. The margin of separation between the apparently safe dose of naltrexone and the dose causing hepatic injury appears to be only five-fold or less. VIVITROL does not appear to be a hepatotoxin at the recommended doses. Patients should be warned of the risk of hepatic injury and advised to seek medical attention if they experience symptoms of acute hepatitis. Use of VIVITROL should be discontinued in the event of symptoms and/or signs of acute hepatitis. Alkermes® and VIVITROL® are registered trademarks of Alkermes, Inc. Manufactured and marketed by Alkermes, Inc. ©2009 Alkermes, Inc. VIV 107C July 2009 Printed in U.S.A. All rights reserved.
  17. 17. 20 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 Beyond Bars Judge Leifman Encounters the Challenge “When I first became a judge,I discovered a situation familiar to many of my colleagues but seldom discussed outside the courtroom — a situation that my legal and judicial training had not prepared me for. Day after day, defendants stood be- fore me, disheveled and distraught. Most were charged with relatively minor offenses such as loitering or panhandling. Some exhibited impulsive behaviors, speaking in pressured, incoherent sentences. Others were guarded and withdrawn, appearing to have little understanding of the circumstances in which they found themselves. Homelessness, substance abuse, and trauma were symptoms of a larger set of personal and social factors contributing to their unfortunate and often repeated involvement in the criminal justice system. These people of many backgrounds shared one thing in common — serious and persistent mental illness. When I first came across defendants experiencing acute men- tal illness, I followed the lead of my fellow judges by appoint- ing experts and ordering psychiatric evaluations to determine their competence to proceed with their court cases.Although these evaluations tended to be very costly and meant that defendants would remain in jail for weeks or possibly even months, the idea of releasing a person in acute psychiatric distress to the streets with nowhere to live and no supports seemed a far more cruel response to the situation. I assumed that once evaluations by mental health experts were complet- ed and the need for treatment was documented, the mental health treatment system would step in, if not voluntarily, then by court order. Before long, I realized my assumptions were wrong. Even though I had expert opinions indicating that people were indeed experiencing severe psychiatric symptoms — and in many cases requiring immediate hospitalization — state law prohibited judges presiding over misdemeanor cases from ordering treatment in the forensic mental health system. In- stead, the law required people to be released to the commu- nity on the condition that they participate in treatment, but there was no mechanism to ensure that treatment,housing,or any other type of support was actually provided. Judge Steven Leifman, Special Advisor on Criminal Justice and Mental Health, Supreme Court of Florida, and Associate Administrative Judge, County Court, Criminal Division, 11th Judicial Circuit of Florida; Tim Coffey, Coordinator, 11th Judicial Circuit, Criminal Mental Health Project Decriminalizing Mental Illness: Miami Dade County Tackles a Crisis at the Roots Miami-Dade County, Florida houses the largest percentage of people with serious mental illness (e.g., schizophrenia, bipolar disorder, major depression) of any urban community in the United States. Roughly 9.1 percent of the population (170,000 adults) experiences serious mental illness, yet only 1 percent (24,000 adults) receives treatment in the public mental health system. By contrast, the number of people accessing mental health services through the Miami-Dade County jail is staggering. Of the roughly 114,000 bookings into the jail this past year, it is estimated that as many as 20,000 people with mental illness required psychiatric treatment during incarceration. On any given day, the county jail houses approximately 1,200 people with mental illness receiving psychotherapeutic medications. This number represents 17 percent of the total inmate population and costs taxpayers more than $50 million annually.The Miami-Dade County jail serves as the largest psychiatric institution in the state of Florida, housing more beds serving people with mental illness than any inpatient hospital in the state and nearly half as many beds as there are in all state civil and forensic mental health hospitals combined. Sadly, these statistics are not unique to south Florida. Findings from a recent study suggest that people with serious mental illness are arrested and booked into jails in the United States more than two million times annually. Roughly three-quarters of these people also have co-occurring substance use disorders that increase their likelihood of becoming involved in the justice system. On the basis of the most recent population data reported by the Department of Justice, it is estimated that currently 400,000 people with mental illnesses are incarcerated in jails and prisons across the country, and nearly 900,000 are on probation or parole in the community.