Download Sequential Intercept Mapping Lewis and Clark County, Montana

Sequential Intercept Mapping
Lewis and Clark County,
Montana
June 28- 29, 2016
Prepared by: Policy Research Associates, Inc.
Dan Abreu, MS CRC LMHC, Senior Project Associate, Policy Research Associates
Patricia Griffin, PhD, Expert Consultant, Policy Research Associates
Sequential Intercept Mapping Report – Lewis and Clark County Montana
Introduction:
Lewis and Clark County, with the support of the Montana Healthcare Foundation, contracted with Policy
Research Associates (PRA) to develop behavioral health and criminal justice system maps focusing on
the existing connections between behavioral health and criminal justice programs to identify resources,
gaps and priorities in Lewis and Clark County.
Background:
The Sequential Intercept Model, developed by Mark R. Munetz, M.D. and Patricia A. Griffin, Ph.D. in
conjunction with SAMHSA’s GAINS Center,1 has been used as a focal point for states and communities to
assess available resources, determine gaps in services, and plan for community change. These activities
are best accomplished by a team of stakeholders that cross multiple systems, including mental health,
substance abuse, law enforcement, pretrial services, courts, jails, community corrections, housing,
health, social services, peers, family members, and many others.
A Sequential Intercept Mapping is a one-day and a half workshop to develop a map that illustrates how
people with behavioral health needs come in contact with and flow through the local criminal justice
system. Through the workshop, facilitators and participants identify opportunities for linkage to services
and for prevention of further penetration into the criminal justice system.
The Sequential Intercept Mapping workshop has five primary objectives:
1. Development of a comprehensive picture of how people with mental illness and co-occurring
disorders flow through the criminal justice system along five distinct intercept points: Law
Enforcement and Emergency Services, Initial Detention and Initial Court Hearings, Jails and
Courts, Re-entry, and Community Corrections/Community Support.
2. Identification of gaps, resources, and opportunities at each intercept for individuals in the target
population.
3. Development of priorities for activities designed to improve system and service level responses
for individuals in the target population
4. Develop of an action plan to implement the priorities
5. Nurture cross system collaboration
The participants in the workshops represented multiple stakeholder systems including mental health,
substance abuse treatment, health care, human services, corrections, advocates, individuals, law
enforcement, health care (emergency department and inpatient acute psychiatric care), and the courts.
1
Munetz, M., and Griffin, P. (2006). A systemic approach to the de-criminalization of people with serious mental
illness: The Sequential Intercept Model. Psychiatric Services, 57, 544-549.
1
Sequential Intercept Mapping Report – Lewis and Clark County Montana
Patricia Griffin, PhD, Senior Consultant, and Dan Abreu, MS CRC LMHC, Senior Project Associate, for
Policy Research Associates facilitated the workshop session.
Thirty-four (34) people attended the Lewis and Clark Sequential Intercept Mapping workshop.
Dr. Gary Mihelish, President of the Montana Alliance for Mental Illness (NAMI) welcomed participants
to the workshop and introduced Lewis and Clark County Commissioner, Andy Hunthausen to
introduce Lieutenant Governor Mike Cooney. Commissioner Hunthausen said that Lieutenant
Governor Cooney represents “all that is good and right about government.” The Commissioner
thanked participants for coming together to revamp the system to insure good care and that only
people who need jail end up there. He noted that he is grateful for Lieutenant Governor Cooney’s
advocacy and support in the Governor’s Office as well as in prior government positions in which he
strategized to make things work and to promote good care with the tax payer in mind.
Mr. Cooney acknowledged Mr. Hunthausen expertise and years of advocacy and thanked Andy for the
invitation. He also thanked participants for their service to persons with behavioral health issues who
are most vulnerable when involved in the criminal justice system. He told the group that Montana is
looking for ways to be smarter with criminal justice policy and is utilizing Justice Reinvestment
strategies and using data to find out what works. Montana is working to expand services and is now
implementing the Affordable Care Act (ACA) and Montana Department of Corrections is enrolling
eligible individuals in Medicaid prior to release. Beyond enrollment, he noted that the DOC Clinical
Services Director met with local Community Service Directors to ensure collaboration and develop
reach-in engagement strategies. He concluded his remarks saying planning should focus on safety,
protecting the vulnerable and respect for all involved parties.
On Day 2, Mike Batista, Director of the Montana Department of Corrections, addressed the group and
noted that the Sequential Intercept Model made perfect sense with its emphasis on design, on
program and on investment in partnerships. He noted the Montana Sentencing Commission provides
the greatest opportunity in a long time to improve partnerships, investment and service design. Two
Sentencing Commission recommendations are to focus on: 1) early intervention and front end services
and 2) deferring prosecution and designing appropriate services to address offender needs.
Director Batista, highlighted system change principles which include: using evidence-based practices,
focusing on high risk and high need individuals, using data to inform program design and response,
focusing on people with service needs and developing or enhancing front end investment in
community services.
Deb Matteucci, Executive Director of the Montana Board of Crime Control (MBCC), informed the
group of an MBCC funded project to enhance jail offender management systems by making the DOC
Offender Management Information System (OMIS) available to county jails at nominal cost. In addition
an interface between OMIS and local Computer Assisted Dispatch (CAD) is being explored so that
transition from arrest to detention will be seamless and will not require additional or redundant data
entry. There are plans to develop 2-3 pilot sites by the end of 2016.
2
Sequential Intercept Mapping Report – Lewis and Clark County Montana
This report contains:
 Background regarding the workshop
 Agendas for each day
 Lewis and Clark Sequential Intercept Map developed by the participants
 Resources and Opportunities along with Gaps and Challenges identified by the participants for
each Intercept
 Lewis and Clark County Priorities
 Action Plans developed during the workshop
 Recommendations
 Resources
 Appendices
3
Sequential Intercept Mapping Report – Lewis and Clark County Montana
Sequential Intercept Mapping
AGENDA
Lewis and Clark County
June 28, 2016
8:00
Registration and Networking
8:30
Openings
 Welcome and Introductions
Lt. Governor Cooney
Overview
of the Workshop

 Workshop Focus, Goals, and Tasks
 Collaboration: What’s Happening Locally

What Works!
 Keys to Success
The Sequential Intercept Model
 The Basis of Cross-Systems Mapping
 Five Key Points for Interception
Cross-Systems Mapping
 Creating a Local Map
 Examining the Gaps and Opportunities
Establishing Priorities
 Identify Potential, Promising Areas for Modification Within the Existing
System
 Top Five List
 Collaborating for Progress
Wrap-Up
 Review
4:30
Adjourn
4
Sequential Intercept Mapping Report – Lewis and Clark County Montana
Sequential Intercept Mapping
AGENDA
Lewis and Clark County
June 29, 2016
9:00
Opening
 Remarks --- Mike Batista, Director of the Montana Department of
Corrections
 Preview of the Day
Review
 Day 1 Accomplishments
 Local County Priorities
 Keys to Success in Community
Action Planning
Finalizing the Action Plan
Next Steps
Summary and Closing
12:30
Adjourn
5
Lewis and Clark County Sequential Intercept Map
6
Intercept 1
Law Enforcement/Emergency
Services



Law Enforcement Agencies in Lewis and Clark County include:
o Helena Police Department
o Lewis and Clark Sheriff’s Office
o East Helena Police Department
911 Dispatch Center
The Lewis and Clark County Sheriff's Office is the chief law enforcement agency in Lewis and Clark County,
Montana. It is comprised of sixty employees including sworn officers, detention officers and professional
support staff. The Sheriff's Office provides general law enforcement, detention functions, rural fire
support and search and rescue operations for the citizens of Lewis and Clark County in a service area of
over two million acres. Additionally, this agency provides specialized regional services to the entire county
and contract law enforcement to specific areas. The Sheriff, who is elected by the residents of Lewis and
Clark County, is the chief executive officer of the agency. He and his command staff manage the day to day
investigations, evidence management, civil process and a number of support operations necessary to
provide full law enforcement coverage and services for Lewis and Clark County. Currently, the Sheriff's
Office provides regional/resident law enforcement services in Lincoln and Augusta as well as contract law
enforcement services at Canyon Ferry Lake during the summer. These services include general patrol
services and the D.A.R.E. program, as well as any necessary investigative services. The patrol division
currently consists of 27 sworn positions in two detachments. Three Deputies are assigned to our Substations as resident deputies to serve the residents of Lincoln, Augusta and Wolf Creek. Two of these live
in or around Lincoln and Augusta. The remaining 24 are assigned to the greater Helena Valley area and
primarily serve the communities and neighborhoods around Helena, East Helena, Canyon Creek,
Marysville, Birdseye, Baxendale, Lakeside, York, East and West Valley, and Canyon Ferry. Of these, Helena
and East Helena have their own local police departments that the Sheriff’s Office works closely with. The
Sheriff’s Office operates lake patrols around Canyon Ferry Lake. Patrol deputies also handle prisoner
transports along with fielding calls for service and performing general patrol duties and traffic
enforcement.
7
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

Western Montana Mental Health is responsible for crisis services. In addition, The Center for Mental
Health has been partnering to improve lives for over 40 years. Originally, the North Central Community
Mental Health Center was established in 1974 to serve the nine county region from Great Falls to the HiLine. This wheat farming region is often referred to as "The Golden Triangle," so the Center became
Golden Triangle Community Mental Health Center. In 1997 the Center began providing services to the TriCounty Area: Lewis and Clark, Broadwater, and Jefferson counties. Meagher County was added in
2005.This addition expanded the total service area to 10 counties, and the Center now serves over 4,000
clients in Central Montana. In Helena and the Tri-County area, the Center serves more than 1,700. The
Behavioral Health Unit (BHU) at St. Peter’s also provides related crisis services.
Crisis Stabilization --- A non-secure (unlocked) short-term voluntary program designed to assist adults who
are experiencing increased symptoms of mental illness and do not meet the criteria for inpatient
psychiatric care. The program is also designed to meet the needs of adults who have co-occurring
(chemical use and mental health) treatment needs. Individual and group services based upon a psychosocial rehabilitation model are provided in order to allow individuals to return home as soon as possible.
Crisis Intervention Team: Helena is operated through the Helena Police Department and Lewis and Clark
County Sheriff's Office).
Resources and Opportunities


Teleconference with Crisis Response Teams (CRT) (therapists with Western Montana Mental Health
(WMMH)
13 full-time 911 staff, some with Crisis Intervention Team (CIT) training
o
Initiate calls to CRT

CIT training exists for the Lewis and Clark Sheriff’s Department (70%) and Helena Police Department and is
a presence on most shifts

CRT is 24/7

o
3 people (on 4 days, off 3 days)
o
Divert, evaluation, phone consultation with the Sheriff’s Department or Police Department
o
CRT goes to the hospital
Journey Home looking at substance use clearance protocol/resources
o

6 voluntary beds and 2 emergency detention beds
Triage:
o
Physical health and behavioral health: BHU hospital
o
Substance use and behavioral health: Journey Home
8

Role of EMTs
Gaps and Challenges

911 receives “sporadic” mental health training

CIT has limited on-scene response

There is no co-response with CIT

Journey Home lacks medical clearance capacity; most individuals go through the emergency room first

The pre-booking diversion process is not clear due to lack of data

There are not yet CIT officers available for all shifts

Officers wait up to four hours at St. Peter’s

Substance use clearance = medical clearance?

Police referral/diversion options are few

The “biggest frustration” for law enforcement is how to connect people with resources

There is a disconnect for individuals with suicidal ideation who are intoxicated

Lack of detoxification strategies- no payment source
9
Intercepts 2 and 3
Court-Based Diversion/Jail
Diversion




Helena Municipal Court (formerly Helena City Court) is part of the state judicial system and enforces
laws for the City of Helena and the Honorable Bob Wood presides. Helena Municipal Court processes
all misdemeanor traffic, criminal and animal control offenses, city ordinances, orders of protection,
and civil cases that occur within Helena City limits.
Justice Court is the judicial branch of the County and handles initial appearances for felony cases.
Justice Court processes citations issued by:
o Montana Highway Patrol
o Lewis and Clark County Sheriff's Office;
o Montana Fish, Wildlife and Parks Department
o Motor Carrier Services of the Department of Transportation
o Lewis and Clark County Animal Control Officer
o State Department of Livestock
o State Gambling Control Division
o and in some cases the Helena Police Department.
The County Attorney's Office is responsible for the prosecution of criminal offenses committed within
Lewis and Clark County. It represents the State of Montana in child abuse and child neglect cases, as
well as juvenile court proceedings. The County Attorney serves as the attorney for County
government, including all agencies and boards.
The Criminal Division prosecutes felony offenses committed within Lewis and Clark County, and
misdemeanor offenses committed within the county, but outside the City Of Helena. The Criminal
Division also handles involuntary commitments for those who are "seriously mentally ill" and assists
the state with involuntary commitment for those who are "seriously developmentally disabled" who
are residents of the county. Generally, the office does not investigate criminal offenses and only
prosecutes cases referred to it by law enforcement agencies such as the Lewis and Clark County
Sheriff, the Helena City Police Department, the East Helena Police Department and the Montana
Highway Patrol. In addition, the office accepts referrals of criminal matters from a variety of state and
10
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



federal law enforcement agencies.
On July 1, 2006 the Office of the State Public Defender assumed responsibility for statewide Public
Defender Services, previously provided by cities and counties. These services are now provided
statewide through Regional Offices of the State Public Defender. The mission of the Office of the State
Public Defender is to ensure equal access to justice for the State's indigent and to provide appellate
representation to indigent clients.
The First Judicial District Treatment Court is a court-supervised, comprehensive treatment program for
non-violent offenders. The court is a voluntary program that includes regular court appearances
before the treatment court judge. The mission of the First Judicial District Treatment Court is to
improve the overall quality of life in our community by providing a court supervised program for
substance dependent offenders that will enhance public safety, reduce crime, foster healthy families,
hold offenders accountable, reduce costs to our community and ultimately transform these offenders
into positive, contributing members of our community. Treatment includes individual and group
counseling and regular attendance at self-help meetings, provided through community based
treatment providers. The treatment staff will also assist with obtaining education and skills
assessments and will provide referrals for vocational training, education and/or job placement
services. The program length, determined by each participant’s progress, will be no less than one year.
The Lewis and Clark County Sheriff's Office was established in 1865. The first Lewis and Clark County
Jail was built in 1891 and was located at 15 North Ewing Street, which is now "The Myrna Loy Center"
for the performing and media arts. This jail was in use until 1985 when the current Law Enforcement
Center was built and located at 221 Breckenridge Street. The Law Enforcement Center has the Lewis
and Clark County Detention Center on the second floor and offices on the main floor are shared with
the Lewis and Clark County Sheriff's Office and Helena Police Department. The Law Enforcement
Center is located next to the Lewis and Clark County Courthouse. The Lewis and Clark County
Detention Center is designed to house fifty-eight (58) beds, but runs at an average daily population of
eighty-two (82), responsible cost for 100+. There were 3,075 inmates booked into the detention
center during the year of 2010. The detention center is supervised by a Deputy Sheriff Captain and
staffed with twenty-five (25) Detention Officers, one (1) part-time Registered Nurse, (1) part-time
Physician Assistant and two (2) Transport Officers.
The Lewis and Clark County Detention Center is also responsible for testing for the 24/7 Sobriety
Program.
The Detention Center provides essential medical, dental, and mental health (psychiatric) services by
professional staff in a manner consistent with accepted community standards for a correctional
environment. The Detention Center uses a licensed and credentialed health care provider in its
ambulatory care. For inmates with chronic or acute medical conditions, the Detention Center
coordinates with medical referral centers providing advanced care. Health promotion is emphasized
through counseling provided during examinations, education about the effects of medications,
infectious disease prevention and education, and chronic care clinics for conditions such as
cardiovascular disease, diabetes, and hypertension. The detention center contracts with SPECTRUM
Medical Inc. affiliated with Benefits Health Systems out of Great Falls, Montana for all inmates’
medical care. The county received grant funding to support a full time mental health professional and
case worker at the detention center.
11

The jail reports the following information about persons with mental illness served in the jail January
through March 2016:
January
194 inmates in jail
65 males reported mental illness
39 females reported mental illness
February
154 inmates in jail
28 males reported mental illness
13 females reported mental illness
March
163 inmates in jail
41 males reported mental illness
18 females reported mental illness

Mental Illness that was reported
January
BiPolar
Depression
PTSD
Schizophrena
Anxiety
ADHD
19
26
14
4
17
6
February
BiPolar
Depression
PTSD
Schizophrena
Anxiety
ADHD
12
23
13
3
13
7
March
BiPolar
Depression
PTSD
Schizophrena
Anxiety
ADHD
24
34
16
6
17
4
Jail Diversion staff work with inmates within the Lewis and Clark County Detention Center to meet their
mental health needs while incarcerated and work with community agencies to reduce recidivism due to
mental health issues. The jail diversion program has been demonstrated to decrease recidivism rates of
individuals with mental health issues.
Resources and Opportunities

Citizens Advisory Council (CAC) to make recommendations for justice court regarding bond
o
Can refer to pre-trial services
12

New service: assessment now, will do monitoring later, works with Probation, can work with community
behavioral health

Need data regarding the number of people pending disposition not in jail

Match the warrant list against the CMH database?
o
Give a number to project out possibilities for diversion
o
Could match against veterans’ re-entry search service?

Pre-trial services (new program under construction)

CAC wants to reevaluate it being under Detention Center

o
Would like to see it independent
o
Look at Gallatin County model
o
Want to grow it as much as possible
The Treatment Court three-year grant is for 30; the Judge prefers 25
o
The State is committed to sustain the program

Monthly operational meetings to review cases

Public defender’s Social Workers get referrals from attorneys and Probation

Self-report study indicates that 40% report mental health problems

ACLU report has some jail data

Applied for a Family Treatment Court federal grant, and hope to hear by the end of September
o

Recovery Management Group for Treatment Court graduates
Treatment Court has evaluation funding
Gaps

Jail overcrowding has resulted in increases in “tickets” (notice to appear)
o
Affects all potential arrestees, including those with mental health problems
o
Felony cases going to jail

Average bail: $7,000

Unsupervised releases
o

Perception that County has a high failure to appear- warrant list
Could have three initial appearance hearings for the same felony case
13

Limits in mental health funded treatment for individuals in Treatment Court

A number of people in jail are there because they can’t pay bail (the County pays)

Most people in jail are pre-trial; very few are sentenced

People can wait a long time to go to trial

People entering jail may not report a mental health problem but report taking mental health medication

The Jail Therapist position has been open since April 2016; also trying to fill a Jail Case Manager positionthis individual will be doing the continuity of care into and out of jail

o
Interviewing now
o
Need to find ways to sustain these positions; both positions are funded by a state grant on an
annual basis
Continuity of medication from community
o
CRT can do evaluations after hours, but do not prescribe medication

Jail is limited by the Department of Corrections formulary

Some concerns that jail treatment staff are reluctant to prescribe for some individuals
o
Spectrum will not share information with public defenders

Need for an evaluator/evaluation for Treatment Court; need to make an evaluation public

The VA Medical Center has a suicide prevention coordinator
14
Intercepts 4 and 5
Reentry Community Supervision




Lewis and Clark County Probation Office --- Montana Department of Corrections
NAMI of Lewis and Clark County
PureView – Outreach Coordinator
Services Available in Lewis and Clark County
 Children’s Case Management
 Day Treatment
 Adult Therapeutic Aide
 Adult Case Management
 PACT- Program for Assertive Community Treatment
 Outpatient Therapy
 Outpatient Medical Services
 Veteran’s Affairs
 Case Management Veteran’s Affairs
 Adult Foster Care
 Group Homes
 Psychiatry Services
 Medication management
 Drop-in Center
Resources and Opportunities

The jail Case Manager position is available to do some re-entry work

Within the Treatment Court, CMH can provide medication for two weeks
o
DOC has funding to pay for medication for people in supervision (Probation can arrange)

Jail provides five days of medication and a prescription upon release

The VA of Montana provides Vivitrol
15

Journey Home is beginning Medication Assisted Treatment (MAT)

State Re-entry Group

There are two CIT-trained individuals within Probation, and they are interested in receiving more CIT
training

CMH has several Mental Health First Aid instructors

There is interest in developing cross-Intercept data

There is one Mental Health Probation Officer with a caseload of 75

The ORASS assessment is used by DOC and Probation and Parole

There are 12 Probation and Parole staff in Helena

Specialized caseloads:
o
Mental Health, Treatment Court, Treatment Accountability Program (sanction for substance use
disorders)

Cognitive principles and restructuring- may adopt Thinking for Change curriculum

Probation funding is available for treatment
Gaps and Challenges

It can take six months to get medication in the community- Treatment Court experience

Significant increase in revocations in last year- new criminal charges (meth, opioids)

Medicaid expansion began in Montana in the last month

Individuals are released without a driver’s license or Social Security card, so they cannot get into Federal
buildings and cannot get community mental health services or employment

Some providers do not take Medicaid

Lack of timely access to care

Lack of residential treatment

Lack of substance abuse services

The public safety community is not familiar with Mental Health First Aid, but is interested

The group homes are full

Lack of Housing First
16
Quick Fixes

Mental Health First Aid will distribute contact information for trainers listed

VA referrals by police treatment- Bob McCabe

Address gaps in aftercare medication for people leaving the jail
o Get specifics of what is actually happening
o

Develop a list of people in detention center with Severe Mental Illness and/or receiving
psychotropic medication in last two months

Capt. Grimmis will ask SPRECTRUM
Put in place a working committee to address issue

Capt. Grimmis will call for a meeting by the end of July
Planning Groups

Criminal Justice Coordinating Council

Citizens Advisory Board

Local Advisory Committee

Monthly operations meeting
Housing


YWCA Transitional Housing
o
Women and children- 26 beds
o
Less than two years; average is six months to one year
Public Housing Authority
o
Allows appeals; often approved

Continuity of Care meeting on Housing First

Florence Crittenton has a HUD Housing First grant

DOC has stipends for transition rent
o
Several sober houses
17
o
Boyd Andrews: 7 beds

Private landlords

Religious organizations with housing
o
20 private landlords- Charlie Carson
o
Salvation Army- male, female, family, God’s love shelter

VA grant per diem

HUD VASH

Volunteer of America
18
Priorities for Change (as determined by mapping participants)
Rank
Priority
1
Develop a county information system that criminal justice agencies
feed into.
 Hire 1 FTE to coordinate data integration
 Develop system performance indicators
Expand Affordable and safe housing options
 Explore the Quixote Village Model
New Detention Center
 Space for all this good work
Implement jail case manager and therapist positions and Detention
Facility Coordinator
 Determine why using CM’s and address
Expand detox options
Develop public education/awareness.
Increase awareness of CJ System and BH
 Engage and inform the public to get their support
 City and County government need formal education
 Link to Montana Justice Reinvestment
 Focus on cost savings, recidivism reduction and public
health outcomes
Implement evidence-base pre-trial services
-develop data driven performance measures
Strengthen links between crisis and detention and Law Enforcement
 CRT response with LE
 CRT Expansion
Mental Health 1st Aid Training
Identify who should be trained
Strategy to track who has been trained
Develop a Resource Directory
 Build on work of the MSU-Cody
 One stop shop
 Maintain an update directory
Expand treatment capacity
Providers and prescribers
Providers who take Medicaid and Medicare
Expand evidence based risk assessment for jail detainees
Implement for misdemeanors and early felonies in Municipal and
Justice Court
CJ Coordinating Council needs staff adjustments
 Support CJCC efforts and move them forward
Enhance CIT
 Explore adding CIT training to POST
Develop a liaison to /from Native American community to focus on
the CJ/BH intersections
2
3
3
4
5
6
6
7
8
8
9
9
9
9
19
Priority
Vote
15
General
Vote
4
Total
0
11
11
4
5
9
3
6
9
1
0
5
5
6
5
1
2
3
1
2
3
0
3
3
0
2
2
0
2
2
0
1
1
0
0
1
0
1
1
19
Rank
Priority
Priority
Vote
Continue to improve communication and shared responsibility
between county and state
Address gaps in aftercare medications
Strengthen early identification for children and youth
Formalize ways for case managers and liaisons to strengthen “warm
hand offs”
 Look at Bozeman’s systems navigators
20
General
Vote
Total
0
0
0
0
Lewis and Clark County Action Plan
Priority: Moving Forward
Objective
Report summarizing results
of mapping workshop
Follow up meeting
Encourage leadership and
action by the Criminal Justice
Coordinating Council
Action Step
 First draft of Action Plan
Who
PRA to Laura Erikson
who will share with
other participants

Participant List
Laura to participants

First draft of the report
PRA to Laura

Smaller subcommittee of LAC to
review our report
LAC

LAC subcommittee and other
workshop participants will provide
feedback to county who will compile
and provide to PRA


PRA to finalize report
Commissioner Andy Hunthausen to
call next meeting

Support buy-in of these efforts by
judiciary
o Consider bringing in
judges who have been
leaders in other localities:
Judge Steve Leifman of
Miami-Dade County,
21
Commissioner
Hunthausen
When
7/7/16
By 7/29/16


Encourage and support
citizen input
Develop staff position(s) to
support the work of the CJCC
Build on Stepping Up
Partnership

Integrate this work with the
work of the LAC

Laura Erikson
mid-August





Connect with other key
players in broader system
who are interested in same
priorities
Judge Goss, other
possibilities?
Develop staff support for CJCC
Submit grant application to Montana
Healthcare Foundation
Build on work of Citizens Advisory
Council (CAC)


Resolution has been passed
At County Commissioners, LAC (MH
Advisory Council) to take the lead
LAC’s current priorities:
o Protocol for community
commitments
o Suicide
 Incorporate MHFA
training
o Housing
o Crisis from point of view of
law enforcement
 Incorporate work of
priority from this
workshop
Develop smaller subcommittee of LAC
to review the report from this
workshop
Include the work from the mapping
workshop as part of the regular
agenda of the LAC going forward
Early Identification
Housing Continuum of Care
22
LAC
LAC
New committee
LAC
LAC
Begins in September
As city and county look at
System Redesign of larger
criminal justice system, build
on the work of this mapping
workshop focusing
specifically on the justiceinvolved behavioral health
population




Develop Performance
Indicators for the behavioral
health and criminal justice
systems to determine if
progress is being made with
this work going forward




Are there Intercept 0
changes/interventions that can be
made?
Can we shorten the time in jail for the
behavioral health population?
Specifically for those with severe
mental illness? Those with substance
use disorders?
Explore deferred prosecution options
Build on successes of what is already
working
Develop a committee
First meeting to lay issues on the table
and develop open dialogue with
SPECTRUM
Second meeting to follow up with
SPECTRUM to see what they can do
Explore Outcome Measures
developed in Salt Lake County as part
of their Stepping Up Initiative:
o
o
o
o
Decrease the number of
people with mental illness
being admitted to jail
Decrease time people with
mental illness spend in jail
Increase linkage to community
services for people with
mental illness as they leave
jail
Decrease returns to jail for
people with mental illness
23
Capt. Jason Grimmis,
Molly, SPECTRUM,
Jaden
 Priority Area 1: Develop a County Information System that incorporates information from criminal justice agencies
Group Action Planning
Objective
DOC Offender
1.1
Management
Information
System ---“Platform”
Action Step
County next steps:
Who

Determine costs for mapping to patrol
and dispatch

Startup grant
Jail Based Module

With a bridge to
MA eligibility;
including
suspension
Develop an understanding of costs to
start

Develop a plan to sustain:
In development:
application for MA
o
Primary cost is hosting data
o
Deb has funds now
o
Need estimates for future
Validated risk
assessment for BH
(MH and SA) and
suicide
Piloting in 2
counties (counties
already chosen)
-
24
When
1.3
Hire 1 FTE staff
person to
coordinate data
integration


1.4
Develop system
performance
indicators

1.5
Use the data to
“tell our story”


Priority Area 2: Implement jail case manager and therapist positions along with Detention Facility Coordinator
Objective
2.1 Implement case
manager position
Action Step

Group Action Planning
Who
Determine why lost case managers in
the past and address those issues

2.2
Implement jail
therapist position
2.3
Implement

Detention Facility
Coordinator position
2.4
Examine Bozeman’s
Systems Navigators


25
When
Priority Area 3: Develop a new Detention Center
Group Action Planning
Objective
3.1 Incorporate space
for “all this good
work”
Action Step


3.2

Develop strategies
to more effectively
get the message out
Who
When
Priority Area 4: Develop public education/awareness efforts to increase understanding of criminal justice and behavioral health
systems
Objective
Action Step
4.1
Engage and inform
public to get their
support

4.2
Provide
education/training for
City and County
government

4.3
Link to Montana Justice
Reinvestment initiative

Group Action Planning
Who
26
When
4.4
Meet with newspaper
staff

4.5
Focus on cost savings,
reduction of criminal
recidivism, and public
health outcomes

Gary Mihelish, Eric Bryson,
Commissioner Good Geise,
Molly , Sheriff, Commissioner
Hunthausen, Mignon
Waterman
Share information about this
initiative
By end of July
Priority Area 5a: Implement evidence-based Pretrial Services and Pretrial Release
Committee: Capt. Jason Grimmis, Pretrial Services staff of Detention Center, Jenny Kaleczyc, John Wilkinson, and Annette Carter
Group Action Planning
Objective
Action Step
Who
When
5.1
5.2
First meeting to review the
issue
Examine what other
Montana Counties are
doing for pretrial

Capt. Grimmis will meet with
Pretrial Services staff and John

Get updated on current status

Take a look at risk assessment tool
being used

Consider what it will take to get
the pretrial services initiative
progressing further

27
Capt. Grimmis

5.3
Include Initial Appearance
judges in discussion
5.4
Build on the work Annette

Carter currently does
reviewing the jail census for
those on
probation/warrant/”pretrial 
status”
5.5
Develop data driven
performance measures

5.6
For the long term, consider
where pretrial services will
be housed

Tuesday at 10 a.m. in
Annette Carter’s office
Now looking to screen and
develop a viable release plan that
helps maintain sobriety
Invite others to join: Social
worker in Public Defenders Office,
others
Priority Area 5b: Strengthen links between Crisis Services and Law Enforcement along with EMTs
Group Action Planning
Who
Objective
Action Step
5.7

Email others to be involved
Natalie to:

Duplicate Bozeman protocols

Operations Manager

HB33 Funds

Prescriber

crisis/jail diversion state funds

Sheriff

look at this process

Helena Police Department

consider applying
Put protocols in place
as soon as possible
28
When
5.8
Expand Crisis Response
Team capacity

Priority Area 6: Provide Mental Health First Aid Training to Public Safety staff and others
Committee: Jill, Melanie, Michele, Annette
Objective
Action Step
6.1
Identify who should be
trained

6.2
Track who has been
trained

Group Action Planning
Who
When
Priority Area 7a: Develop a Resource Directory of Community Resources
Objective
Action Step
7.1
Build on work of MSUCody staff

7.2
Make this a “one stop
shop”

7.3
Develop a strategy to
keep this directory
updated

Group Action Planning
Who
29
When
Priority Area 7b: Expand treatment capacity in the county
Group Action Planning
Objective
Action Step
Who
7.4
Focus on providers and
prescribers

7.5
Focus on providers who
take Medicaid and
Medicare

Priority Area (unranked): Strengthen early identification and intervention for children and youth
Group Action Planning
Objective
Action Step
Who
Develop better
understanding of youth
in detention center

Build on the work
County Commissioners
currently fund for
community supports
and early intervention

Engage Childhood
Council

Develop a position to sustain their
efforts
Build on work of ACES
and Trauma Informed
Care Initiative

Take advantage of available
training

Engage Elevate Helena Affiliate
Get age data from the detention
center: Who comes to jail, why,
and how long they stay
Trina is a trainer
Rebecca Harvest
@Youthhome
30
When
When
Recommendations
1. Formalize Behavioral Health and Criminal Justice planning efforts.
Current planning for Behavioral Health and Criminal Justice initiatives is divided among the
Criminal Justice Coordinating Council (CJCC), the Local Advisory Board (LAC) and the Citizens
Advisory Board (CAB). In addition, there is a monthly operations meeting attended by department
heads or representatives. While there is ample discussion among the various groups, there does
not appear to be a cohesive planning structure which promotes prioritizing issues and developing
Action Planning to address the issues. The roles of the various committees must be clearly
delineated and responsibility assigned to address priorities and develop Action Steps.
Creating a Behavioral Health Criminal Justice Coordinator position, may also help focus efforts on
more formal planning and program development.
2. Improve coordination between the Police CIT Teams, hospitals, Journey Home and the Crisis
Response Team.
While there are many elements of a Crisis Continuum of Care
(http://store.samhsa.gov/shin/content/SMA14-4848/SMA14-4848.pdf ) : CIT Officers, a Crisis
Response Team, Crisis Stabilization Center (Journey Home) their remains fragmentation in
functioning, partly due to design and partly to funding. Since medical clearance is required before
someone can be brought to Journey Home, law enforcement must first transport to local hospitals
resulting in hours spent in emergency rooms waiting for medical clearance.
Solutions depend partially on funding, partially on policy or possibly legislative change and
availability and deployment of medical personnel.
Suggestion to address the issues are:






Add capacity for medical clearance at Journey Home
Allow EMT’s who respond to provide medical clearance
Add Psychiatric Emergency component at local hospitals to accelerate medical clearance
and provide short term (24 hour) assessment and stabilization and triage.
Expand capacity of the CRT Team to develop co-response capacity with law enforcement
and provide additional capacity to provide post ER room engagement with services
Consider developing telehealth capacity to guide and assist law enforcement response in
remote locations. Remington, A. (2016). Skyping During a Crisis? Telehealth is a 24/7
Crisis Connection (Appendix 1)
Consider development of Peer Respite component to provide for both respite placement to
avoid crisis or to provide additional time to transition from emergency or crisis services
(https://www.power2u.org/downloads/Peer-Respite-Toolkit.pdf )
3. Develop more formal and coordinated screening and diversion strategies for Arraignment
Diversion (Intercept 2) and pre plea diversion (Intercept 3)
31
There is a lack of formal screening and diversion strategies at arraignment and at the jail.
Discussion suggested screening for mental health issues and veteran’s issues was not consistent
and formal screening tools were not being utilized. Formalizing screening protocols at arraignment
and at the jail is the first step in expanding and implementing diversion strategies.
Many screens, such as the Brief Jail Mental Health Screen, are in the public domain
(http://gainscenter.samhsa.gov/pdfs/disorders/bjmhsform.pdf).
Additional brief mental health screens include the
i.
Correctional Mental Health Screen:
http://www.asca.net/system/assets/attachments/2639/MHScreenMen082806.pdf?1300974667
ii.
Mental Health Screening Form III: http://www.ncbi.nlm.nih.gov/books/NBK64187/
Brief alcohol and drug screens include the
iii.
Texas Christian University Drug Screen V: http://ibr.tcu.edu/wpcontent/uploads/2014/11/TCUDS-V-sg-v.Sept14.pdf
iv.
Simple Screening Instrument for Substance Abuse:
http://www.ncbi.nlm.nih.gov/books/NBK64187/
v.
Alcohol, Smoking and Substance Involvement Screening Test:
http://www.who.int/substance_abuse/activities/assist/en/
Guidelines for Screening for Veteran status can be found in Appendix 2.
Essential elements of Intercept 2 diversion can be found in the SAMHSA Monograph, “Municipal
Courts: An Effective Tool for Diverting People with Mental and Substance Use Disorders in the
Criminal Justice System”, http://store.samhsa.gov/product/Municipal-Courts-An-Effective-Tool-forDiverting-People-with-Mental-and-Substance-Use-Disorders-from-the-Criminal-JusticeSystem/All-New-Products/SMA15-4929 . The monograph identifies 4 essential elements of
arraignment diversion programs. Improving screening, clinical assessment and engagement at
diversion may also help address the failure to appear cases with behavioral health disorders who
are released without referral or follow-up. Two program briefs, CASES brief, MAP brief which
describe arraignment diversion programs can be found in Appendix 3 and 4.
The planned probation pre-trial unit of the Lewis and Clark County Sheriff’s Office can be an
important partner in screening and identifying potential diversion both at arraignment and at the
jail for later diversion candidates to minimize jail time and expedite entry into diversion programs.
Examine the role of the social worker in the Public Defender’s Office to be more central in
screening and initiating referrals for diversion programs. Shelby Co. TN, Travis Co. Texas and
Legal Aid in NYC, have Public Defender run diversion programs.
32
4. In planning for the new jail, address specific program needs of persons with behavioral health
disorder.
Lewis and Clark County has a great opportunity to develop a jail that addresses both custody and
program needs of persons with health behavioral health disorders.






Consider a behavioral health planning subcommittee to make recommendations to the jail
planning committee.
Insure screening for behavioral health disorders using formal screening tools. (See
Recommendation #3) for a list of screening tools.
Insure screening for veterans’ status at booking. The proper question, “Have you ever
served in the military?” should be included in booking protocols. (Appendix 2).
Consider utilizing the Department of Veterans Affairs Veterans Reentry Search Service
(VRSS) (Appendix 5). This service allows jails to match their data base to the Department
of Defense data base to identify individuals with military experience. For jails/prisons that
participate, identification of veterans has increased by 30%.
Include Screening for Native Americans. The CSG Montana Justice Reinvestment Report
indicate the Native Americans are overrepresented in the Criminal Justice system. Though
participants did not perceive an over representation in Lewis and Clark County, there were
no formal screening procedures established and no data available to make a definitive
finding.
In selecting health care providers insure the following:
o Jail health/behavioral health services can participate in community health
information exchanges and policy and procedure insure adequate exchange of
health information between the community and the jail health provider.
(Technology and Continuity of Care: Connecting Justice and Health: Nine Case
Studies http://www.cochs.org/files/HIT-paper/technology-continuity-care-nine-casestudies.pdf)
(Jails and Health Information Technology: A Framework for Creating Connectivity
http://www.cochs.org/files/HIT-paper/cochs_health_it_case_study.pdf)
o Insure jail formulary includes medication commonly provided by community
behavioral health agencies and that policy and procedures be developed to
address off formulary medication needs.
o Insure staffing capacity (this can also be done by in-reach DSS staff or community
staff dedicated to transition planning) to enroll individuals in Medicaid to insure
prompt access to medication and services upon release. Insure local Medicaid is
involved in planning for prompt processing of Medicaid applications
5. Explore strategies to address housing and improve collaboration with the Housing Authority and
to develop and expand housing options.
Housing was the # 2 ranked priority. Housing First strategies were not generally used to target
high need individuals for housing. While there is a Continuum of Care Committee, there has not
been focus on the justice involved population. Communities around the country have begun to
33
develop more formal approaches to housing development, including use of the Housing First
model. The 100,000 Home Initiative identifies key steps for communities to take to expand
housing options for persons with mental illness (see http://100khomes.org/resources/housing-firstself-assessment ). The following resources are suggested to guide strategy development:

Moving Toward Evidence-based Housing Program for Person with Mental Illness in
Contact with the Justice System
http://gainscenter.samhsa.gov/pdfs/ebp/MovingTowardEvidence-BasedHousing.pdf

Stefancic, A., Hul, L., Gillespie, C., Jost, J., Tsemberis, S., and Jones, H. (2012).
Reconciling Alternative to Incarceration and Treatment Mandates with a Consumer Choice
Housing First model: A Qualitative study of Individuals with Psychiatric Disabilities. Journal
of Forensic Psychology Practice, 12, 382–408.

Tsemberis, S. (2010). Housing First: The Pathways Model to End Homelessness for
People with Mental Illness and Addiction. Center City, MN: Hazelden Press.

Stefancic, A., Henwood, B. F., Melton, H., Shin, S. M., Lawrence-Gomez, R., and
Tsemberis, S. (2013). Implementing Housing First in Rural Areas: Pathways Vermont,
American Journal of Public Health, 103, 206–209.

An Alliance for Health Reform Toolkit:
http://www.allhealth.org/publications/Disparities_in_health_care/Health-and-HousingToolkit_168.pdf

Housing First Self-Assessment:
http://100khomes.org/sites/default/files/Housing%20First%20Self%20Assessment%20Tool
%20FINAL%2010.31.13.pdf

Shifting the Focus from Criminalization to Housing:
http://homelessnesslaw.org/2016/07/shifting-the-focus-from-criminalization-to-housing/

Lehman, M.H., Brown, C.A., Frost, L.E., Hickey, J.S., and Buck, D.S. (2012). Integrated
Primary and Behavioral Health Care in Patient-Centered Medical Homes for Jail
Releasees with Mental Illness. Criminal Justice and Behavior, published online.
6. Expand use of the SOAR initiative to the justice involved populations.
Expanding the SOAR initiative to the justice involved population is likely to improve access to
treatment, improve access to housing and lower recidivism as has been documented in MiamiDade County and Oklahoma. See Resources section for a list of SOAR resources.
34
Resources
Crisis Response and Law Enforcement

International Association of Chiefs of Police. Building Safer Communities: Improving Police Responses to
Persons with Mental Illness.
http://www.theiacp.org/portals/0/pdfs/ImprovingPoliceResponsetoPersonsWithMentalIllnessSummit.pdf

International Association of Chiefs of Police. Improving Officer Response to Persons with Mental Illness and
Other Disabilities. http://www.theiacp.org/Portals/0/pdfs/IACP_Responding_to_MI.pdf

CIT International, Inc. - http://www.citinternational.org

Saskatchewan Building Partnerships to Reduce Crime. The Hub and COR Model.
http://saskbprc.com/index.php/2014-08-25-20-54-50/the-hub-cor-model

Suicide Prevention Resource Center. The Role of Law Enforcement Officers in Preventing Suicide.
http://www.sprc.org/sites/sprc.org/files/LawEnforcement.pdf

Bureau of Justice Assistance. Engaging Law Enforcement in Opioid Overdose Response: Frequently Asked
Questions. https://www.bjatraining.org/sites/default/files/naloxone/Police%20OOD%20FAQ_0.pdf

National Association of Counties. Crisis Care Services for Counties: Preventing Individuals with Mental
Illnesses from Entering Local Corrections Systems.
http://www.naco.org/newsroom/pubs/Documents/Health,%20Human%20Services%20and%20Justice/Cri
sisCarePublication.pdf

SAMHSA. Crisis Services: Effectiveness, Cost-Effectiveness, and Funding Strategies.
http://store.samhsa.gov/product/Crisis-Services-Effectiveness-Cost-Effectiveness-and-FundingStrategies/SMA14-4848
Data Analysis/Matching/Frequent Users

Stepping Up Initiative. https://stepuptogether.org/updates/county-teams-work-to-make-stepping-upinitiative-a-movement-not-a-moment-at-national-summit

The Council of State Governments Justice Center. Ten-Step Guide to Transforming Probation Departments to
Reduce Recidivism. http://csgjusticecenter.org/corrections/publications/ten-step-guide-to-transformingprobation-departments-to-reduce-recidivism/

New Orleans Health Department. New Orleans Mental Health Dashboard.
http://www.nola.gov/getattachment/Health/Data-and-Publications/NO-Behavioral-Health-Dashboard-4-0515.pdf/

Center for Supportive Housing FUSE Resource Center. Supportive housing initiatives for super utilizers
(frequent users) of jails, hospitals, healthcare, emergency shelters and other public systems.
http://www.csh.org/fuse
35

National Governors Association. Using Data to Better Serve the Most Complex Patients.
http://www.nga.org/files/live/sites/NGA/files/pdf/2015/1509UsingDataBetterServeComplexPatients.pdf
Diversion

GAINS Center. Practical Advice on Jail Diversion: Ten Years of Learnings. http://www.prainc.com/wpcontent/uploads/2015/10/practical-advice-jail-diversion-ten-years-learnings-cmhs-national-gainscenter.pdfStepping Up Initiative

SAMHSA’s GAINS Center. Municipal Courts: An Effective Tool for Diverting People with Mental Illness and
Substance Use Disorder from the Criminal Justice System. http://store.samhsa.gov/product/Municipal-CourtsAn-Effective-Tool-for-Diverting-People-with-Mental-and-Substance-Use-Disorders-from-the-Criminal-JusticeSystem/All-New-Products/SMA15-4929S
Mental Health First Aid

Illinois General Assembly. Public Act 098-0195: “Illinois Mental Health First Aid Training Act.”
http://www.ilga.gov/legislation/publicacts/fulltext.asp?Name=098-0195

Mental Health First Aid http://www.mentalhealthfirstaid.org/cs/. See modules for Public Safety and Military,
Veterans, and Family Members.

Pennsylvania Mental Health and Justice Center of Excellence. City of Philadelphia Mental Health First Aid
Initiative.
http://www.pacenterofexcellence.pitt.edu/documents/Session10_Piloting_the_Public_Safety_Version_of_MH
FA.ppt
Reentry

SAMHSA’s GAINS Center. Guidelines for the Successful Transition of People with Behavioral Health Disorders
from Jail and Prison. http://gainscenter.samhsa.gov/cms-assets/documents/147845-318300.guidelinesdocument.pdf

Community Oriented Correctional Health Services. Technology and Continuity of Care: Connecting Justice and
Health: Nine Case Studies http://www.cochs.org/files/HIT-paper/technology-continuity-care-nine-casestudies.pdf

SAMHSA’s Reentry Resources for Individuals, Providers, Communities, and States.
http://www.samhsa.gov/sites/default/files/topics/criminal_juvenile_justice/reentry-resources-for-consumersproviders-communities-states.pdf

U.S. Department of Justice Reentry work
o
Inaugural National Reentry Week
http://ojp.gov/ojpblog/reentry-bridging-gaps.htm
36

o
Corrections and Reentry Practice Outcomes at CrimeSolutions.gov
http://www.crimesolutions.gov/TopicDetails.aspx?ID=2
o
Center for Faith-Based and Neighborhood Partnerships
http://ojp.gov/fbnp/reentry.htm
Council of State Government Justice Center Reentry Resource Center:
https://csgjusticecenter.org/nrrc/publications/about-the-national-reentry-resource-center/
Screening and Assessment

SAMHSA’s GAINS Center. Screening and Assessment of Co-Occurring Disorders in the Justice System.
http://store.samhsa.gov/product/Screening-and-Assessment-of-Co-occurring-Disorders-in-the-JusticeSystem/SMA15-4930

Brief Jail Mental Health Screen. http://www.prainc.com/resources/criminal-justice/
o
Steadman, H.J., Scott, J.E., Osher, F., Agnese, T.K., and Robbins, P.C. (2005). Validation of the Brief Jail
Mental Health Screen. Psychiatric Services, 56, 816-822.
Recovery and Peers - Forensic

SAMHSA’s GAINS Center. Involving Peers in Criminal Justice and Problem-Solving Collaboratives.
http://gainscenter.samhsa.gov/cms-assets/documents/62304-42605.peersupportfactsweb.pdf

SAMHSA’s GAINS Center. Overcoming Legal Impediments to Hiring Forensic Peer Specialists.
http://www.prainc.com/wp-content/uploads/2015/10/overcoming-legal-impdiments-hiring-forensic-peerspecialists.pdf

SAMHSA’s GAINS Center (2008). Peer Support Within Criminal Justice Settings: The Role of Forensic Peers
Specialists. http://www.prainc.com/wp-content/uploads/2015/10/peer-support-criminal-justice-settingsrole-forensic-peer-specialists.pdf

Policy Research Associates (2015). Championing Peer Integration. http://www.prainc.com/championingpeer-integration-success

NAMI California. Inmate Medication Information Forms: LA NAMI Medication Form - English | LA NAMI
Medication Form - Spanish

Lincoln Police Department Crisis Referral Program.
http://www.scattergoodfoundation.org/innovideas/mental-health-association-nebraska#.V1GW5Fc4nsF
o

Keya House. http://www.mha-ne.org/keya/?gclid=CPTLpZGErsYCFRc8gQodW00IeA
Bringing Recovery Supports to Scale TA Center Strategy (BRSS TACS). http://www.samhsa.gov/brss-tacs
o http://www.samhsa.gov/brss-tacs/webinars
37
Sequential Intercept Model

Munetz, M.R., and Griffin, P.A. (2006). Use of the Sequential Intercept Model as an Approach to
Decriminalization of People with Serious Mental Illness. Psychiatric Services, 57, 544-549.
http://ps.psychiatryonline.org/doi/10.1176/ps.2006.57.4.544

Griffin, P.A., Heilbrun, K., Mulvey, E.P., DeMatteo, D., and Schubert, C.A. (2015). The Sequential Intercept
Model and Criminal Justice. New York: Oxford University Press.
https://global.oup.com/academic/product/the-sequential-intercept-model-and-criminal-justice9780199826759?cc=usandlang=enand

SAMHSA’s GAINS Center. Developing a Comprehensive Plan for Behavioral Health and Criminal Justice
Collaboration: The Sequential Intercept Model. http://gainscenter.samhsa.gov/cmsassets/documents/145789-100379.bh-sim-brochure.pdf
SOAR --- SSI/SSDI Outreach, Access and Recovery
Increasing efforts to enroll justice-involved persons with behavioral disorders in the Supplement Security Income
and the Social Security Disability Insurance programs can be accomplished through utilization of SSI/SSDI
Outreach, Access, and Recovery (SOAR) trained staff. Enrollment in SSI/SSDI not only provides automatic Medicaid
or Medicare in many states, but also provides monthly income sufficient to access housing programs.

Information regarding SOAR for justice-involved persons can be found here:
https://soarworks.prainc.com/topics/criminal-justice

The online SOAR training portal can be found here: http://soarworks.prainc.com/course/ssissdi-outreachaccess-and-recovery-soar-online-training

The SOAR Works contact for https://soarworks.prainc.com/states/montana
Trauma-Informed Care

SAMHSA, SAMHSA’s National Center on Trauma-Informed Care, and SAMHSA’s GAINS Center. Essential
Components of Trauma Informed Judicial Practice.
http://www.nasmhpd.org/docs/NCTIC/JudgesEssential_5%201%202013finaldraft.pdf

SAMHSA’s GAINS Center. Trauma Specific Interventions for Justice Involved Individuals.
http://gainscenter.samhsa.gov/pdfs/ebp/TraumaSpecificInterventions.pdf

SAMHSA. SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach.
http://gainscenter.samhsa.gov/cms-assets/documents/200917-603321.sma14-4884.pdf
Tribal

Bureau of Justice Assistance. Risk Need Responsivity: Turning Principles into Practice for Tribal Probation
Personnel. https://www.appa-net.org/eweb/docs/APPA/pubs/RNRTPPTPP.pdf
38

Center for Court Innovation. State and Tribal Courts: Strategies for Bridging the Divide.
http://www.courtinnovation.org/sites/default/files/documents/StateAndTribalCourts.pdf

State Health Reform Assistance Network. Implications of Health Reform for American Indian and Alaska Native
Populations. http://www.rwjf.org/en/library/research/2012/02/implications-of-health-reform-for-americanindian-and-alaska-nat.html

National Tribal Judicial Center. Walking on Common Ground: Tribal-State-Federal Justice System Relationships.
https://www.walkingoncommonground.org/files/Background%207%20WOCG%202010.pdf

Bureau of Justice Assistance. Improving the Administration of Justice in Tribal Communities through
Information Sharing and Resource Sharing.
https://www.bja.gov/Publications/APPA_TribalInfoResourceSharing.pdf

Bureau of Justice Assistance. Tribal Probation: An Overview for Tribal Court Judges. https://www.appanet.org/eweb/docs/appa/pubs/TPOTCJ.pdf

Office of Justice Programs. Healing to Wellness Courts: A Preliminary Overview of Tribal Drug Courts.
http://www.tribal-institute.org/download/heal.pdf
Veterans

SAMHSA’s GAINS Center. Responding to the Needs of Justice-Involved Combat Veterans with Service-Related
Trauma and Mental Health Conditions. http://gainscenter.samhsa.gov/pdfs/veterans/CVTJS_Report.pdf

Justice for Vets. Ten Key Components of Veterans Treatment Courts.
http://justiceforvets.org/sites/default/files/files/Ten%20Key%20Components%20of%20Veterans%20Treatme
nt%20Courts%20.pdf

Department of Veterans Affairs Veterans Re-entry Search Service (VRSS)
At the request of the former Secretary of Veterans Affairs (VA), Eric Shinseki, the Homeless Program Office
developed an automated system called Veteran Re-entry Search Service (VRSS) to locate Veterans who are
currently incarcerated in federal, state, city and county correctional facilities, or who are represented as
defendants on court dockets. There are approximately 1,295 federal and state, 3,000 city/county correctional
facilities, and 3,000 to 4,000 courts in the United States (US), but no automated method to identify charged,
convicted, or incarcerated Veterans. Through comparison of records from Correctional Facilities and Court
Systems and the Veterans Affairs/Department of Defense Identity Repository (VADIR), VRSS will be used to
identify Veterans incarcerated or under supervision in the courts. User Guide can be found at:
https://vrss.va.gov/vrss_userguide.pdf
39
APPENDIX INDEX
Appendix 1
Sequential Intercept Mapping Workshop Participant List
Appendix 2
Remington, A.A. (2016). Skyping During a Crisis? Telehealth is a 24/7 Crisis Connection.
Appendix 3
SAMHSA’s GAINS Center. (2008). Responding to the Needs of Justice-Involved Combat
Veterans with Service-Related Trauma and Mental Health Conditions.
Appendix 4
CASES. (2011). Transitional Care Management Program: New York County Misdemeanor
Diversion Program for People with Mental Illness.
Appendix 5
Policy Research Associates. (2013). Creating an Indigent Defense Diversion Team: The
Manhattan Arraignment Diversion Project.
Appendix 6
Department of Veterans Affairs. (2014). VA’s Veterans Justice Outreach Program: Services for
Veterans Involved in the Justice System.
40
Appendix 1:
Participant List
Contact Information SIM Workshop Attendees
Andy Hunthausen
Co Commissioner
Annette Carter
Adult Probation Officer
Ben Horn
Helena Indian Alliance
Brian Garrity
Consumer
Capt. Curt Stinson
City Police Captain
Curt Chisholm
CAC
Deb Matteucci
ED MBCC
Eric Bryson LCC CAO
Evonne Hawe
Boyd Andrew
Gary Mihelish
Family Member Jackie Merrit
VA Outreach
Jason Grimmis
Detention Center
Jenny Kaleczyc
Regional Dep. Public Defender
Jill Steeley
PureView
Jocelyn Olsen
YWCA Helena
John Wilkinson
Family Member Jonathan Jackson
Helena Public Schools
Laura Erikson
Lewis and Clark County
Layla Coffman
Treatment Court
Leo Dutton
County Sheriff
Luke Berger
Deputy County Attorney
Mary Protheroe (Molly)
Consumer
Meghan Gallagher
BHU
Melanie Reynolds
County Health Dept
Michelle Cuddy
Provider of Adult MH Svcs
Mignon Waterman
MHCF
Mike Murray
Co Commissioner
Natalie McGillen
Western Mental Health
Robert "Bob" McCabe
VA Local Recovery Coor. Scott Malloy
MHCF
Sharon Tregidga
Youth Probation Officer
Susan Good Geise
Co Commissioner
Tammara Rosenleaf
Mental Health PO
email addresses
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Phone Number
447.8304
444.0929
449.5796
459.2106
447.8284
459.7562
444.3604
447.8311
447.3280
447.8246
444.0104
457.8956
438.2029
447.8383
457.8810
447.8204
447.8251
495.6578
457.8910
443.7151
442.8648
447.8304
533.5637
447.8228
447.8304
Trina Filan
United Way
[email protected]
442.4360
Appendix 2:
Skyping During a Crisis?
SKYPING
DURING
A CRISIS?
Telehealth is a 24/7
Crisis Connection
Arnold A. Remington
Program Director, Targeted Adult Service
Coordination Program
W
hen Nebraska law
enforcement officials
encounter people
exhibiting signs of
mental illness, a state
statue allows them to place individuals
into emergency protective custody. While
emergency protective custody may be
necessary if the person appears to be
dangerous to themselves or to others,
involuntary custody is not always the best
option if the crisis stems from something
like a routine medication issue.
Officers may request that counselors
evaluate at-risk individuals to help them
determine the most appropriate course
of action. While in-person evaluations are
ideal when counselors are readily available,
officers often face crises in the middle of
the night and in remote areas where mental
health professionals are not easily accessible.
The Targeted Adult Service Coordination
program began in 2005 to provide crisis
response assistance to law enforcement
and local hospitals dealing with people
struggling with behavioral health problems.
The employees respond to law enforcement
calls to provide consultation, assistance in
recognizing a client’s needs and help with
identifying resources to meet those needs.
The no-charge service program
offers crisis services to 31 law
enforcement agencies in 15 rural
counties in the southeast section of
the Cornhusker state.
Six months ago, the program offered select law
enforcement officials a new crisis service tool:
telehealth. The Skype-like technology makes
counselors available 24/7, even in remote
rural parts of the state. Officers can connect
with on-call counselors for face-to-face
consultations through secure telehealth via
laptops, iPads or Toughbooks in their vehicles.
The technology, which is in use in select jails
and police and sheriff departments, is proving
to be a win-win for both law enforcement
officers and clients. Officers no longer have to
wait for counselors to arrive for consultations.
In rural communities, it is too common
for officers to wait for up to two hours for
counselors traveling from long distances.
Telehealth also supports the Targeted Adult
Service Coordination program’s primary goal of
preventing individuals from being placed under
emergency protective custody. The program
maintains an 82 percent success rate of keeping
clients in a home environment with proper
supports. The technology promotes faster
response times that mean more expedient
and more appropriate interventions for at-risk
individuals, particularly those in rural counties.
their routines and adopt the technology.
Some officers still want in-person
consultations, a method that is preferable
when counselors are available and nearby.
But when reaching a counselor is not
expedient and sometimes not even possible,
telehealth can play an invaluable role.
Police officers’ feedback on telehealth has
been mainly positive. Officers often begin
using the new tool after hearing about
positive experiences from colleagues. As
more officers learn that they can contact
counselors with a few keystrokes from their
cruisers, telehealth will continue to grow.
The Targeted Adult Service Coordination
program plans to expand the technology
next year by making it available to additional
police and sheriff departments.
Telehealth has furthered the Targeted Adult
Service Coordination program’s goal of
diverting people from emergency protective
custody and helping them become
successful, contributing members of the
community. This creative approach to crisis
response provides clients with better
care and supports reintegration and
individual autonomy.
So far, the biggest hurdle has been getting
law enforcement officers to break out of
NATIONAL COUNCIL MAGAZINE • 2016, ISSUE 1 / 45
Appendix 3:
Justice-Involved
Veterans
Responding to the Needs of Justice-Involved Combat Veterans with
Service-Related Trauma and Mental Health Conditions
A Consensus Report of the CMHS National GAINS Center’s Forum on Combat Veterans, Trauma, and the Justice System
August 2008
… The 33-year-old veteran’s readjustment to civilian life is tormented by sudden blackouts, nightmares and severe
depression caused by his time in Iraq. Since moving to Albany last June … [he] accidentally smashed the family minivan,
attempted suicide, separated from and reunited with his wife and lost his civilian driving job.
In June … [he] erupted in a surprisingly loud verbal outbreak, drawing police and EMTs to his home.
War’s Pain Comes Home
Albany Times Union – November 12, 2006
… His internal terror got so bad that, in 2005, he shot up his El Paso, Texas, apartment and held police at bay for three
hours with a 9-mm handgun, believing Iraqis were trying to get in …
The El Paso shooting was only one of several incidents there, according to interviews. He had a number of driving
accidents when, he later told his family, he swerved to avoid imagined roadside bombs; he once crashed over a curb
after imagining that a stopped car contained Iraqi assassins. After a July 2007 motorcycle accident, his parents tried,
unsuccessfully, to have him committed to a mental institution.
The Sad Saga of a Soldier from Long Island
Long Island Newsday – July 5, 2008
On any given day, veterans account for nine of
every hundred individuals in U.S. jails and prisons
(Noonan & Mumola, 2007; Greenberg & Rosenheck,
2008). Although veterans are not overrepresented in
the justice system as compared to their proportion
in the United States general adult population,
the unmet mental health service needs of justiceinvolved veterans are of growing concern as more
veterans of Operation Iraqi Freedom (OIF) and
Operation Enduring Freedom (OEF) return home
with combat stress exposure resulting in high
rates of posttraumatic stress disorder (PTSD) and
depression.
OEF/OIF veterans constitute a small proportion of
all justice-involved veterans. The exact numbers are
not known — the most recent data on incarcerated
veterans is from 2004 for state and Federal prisoners
(Noon & Mumola, 2007) and 2002 for local jail
inmates (Greenberg & Rosenheck, 2008) before OEF/
OIF veterans began returning in large numbers.
Some states have passed legislation expressing
a preference for treatment over incarceration
(California and Minnesota) and communities such
as Buffalo (NY) and King County (WA) have
implemented strategies for intercepting veterans
with trauma and mental conditions as they
encounter law enforcement or are processed through
the courts. However, most communities do not know
where to begin even if they recognize the problem.
This report is intended to bring these issues into
clear focus and to provide local behavioral health
and criminal justice systems with strategies for
working with justice-involved combat veterans,
especially those who served in OEF/OIF.
Combat Veterans, Trauma, and the Criminal
Justice System Forum
The CMHS National GAINS Center convened
a forum in May 2008 in Bethesda, MD, with
the purpose of developing a community-based
approach to meeting the mental health needs of
combat veterans who come in contact with the
criminal justice system. Approximately 30 people
participated in the forum, representing community
providers, law enforcement, corrections, the courts,
community-based veterans health initiatives, peer
support organizations, Federal agencies, and veteran
advocacy organizations. See Appendix.
www.gainscenter.samhsa.gov
We begin with the recommendations that emerged
from this meeting and then provide the data that
support them.
Did you ever serve in the U.S. Armed Forces?
Yes
No
In what branch(es) of the Armed Forces did you
serve?
Army (including Army National Guard or
Reserve)
Navy (including Reserve)
Marine Corps (including Reserve)
Air Force (including Air National Guard and
Reserve)
Coast Guard (including Reserve)
Other – Specify
When did you first enter the Armed Forces?
Month
Year
During this time did you see combat in a combat line
unit?
Yes
No
When were you last discharged?
Month
Year
Altogether, how much time did you serve in the
Armed Forces?
# of Years
# of Months
# of Days
What type of discharge did you receive?
Honorable
General (Honorable Conditions)
General (Without Honorable Conditions)
Other Than Honorable
Bad Conduct
Dishonorable
Other – Specify
Don’t Know
Recommendations for Screening and Service
Engagement Strategies
The following recommendations are intended to
provide community-based mental health and
criminal justice agencies with guidance for engaging
justice-involved combat veterans in services, whether
the services be community-based or through the
U.S. Department of Veterans Affairs’s healthcare
system — the Veterans Health Administration
(VHA).
hhRecommendation 1: Screen for military service
and traumatic experiences.
The first step in connecting people to services
is identification. In addition to screening for
symptoms of mental illness and substance use, it is
important to ask questions about military service
and traumatic experiences. This information is
important for identifying and linking people to
appropriate services.
The Bureau of Justice Statistics of the U.S.
Department of Justice, Office of Justice Programs,
has developed a set of essential questions for
determining prior military service (Bureau of
Justice Statistics, 2006). These questions relate to
branch of service, combat experience, and length
of service. See Figure 1 for the questions as they
were asked in the 2002 Survey of Inmates in Local
Jails. One question not asked in the BJS survey, but
worth asking, is:
Did you ever serve in the National Guard or
Reserves?
Yes
No
Figure 1. Military Service Questions from the Bureau
of Justice Statistics 2002 Survey of Inmates in Local
Jails (Bureau of Justice Statistics, 2006)
A number of screens are available for mental illness
and co-occurring substance use. Refer to the CMHS
National GAINS Center’s website (www.gainscenter.
samhsa.gov) for the 2008 update of its monograph
on behavioral health screening and assessment
instruments. The National Center for PTSD of
the U.S. Department of Veterans Affairs provides
the most comprehensive information on screening
instruments available for traumatic experiences,
including combat exposure and PTSD. Many of the
screens are available for download or by request from
the Center’s website (http://www.ncptsd.va.gov).
Comparison charts of similar instruments are
provided, rating the measures based on the number
of items, time to administer, and more. Measures
available from the Center include:
2
•• PTSD Checklist (PCL): A self-report measure
that contains 17 items and is available in three
formats: civilian (PCL-C), specific (PCL-S),
and military (PCL-M). The PCL requires up
to 10 minutes to administer and follows DSMIV criteria. The instrument may be scored in
several ways.
hh
Recommendation 3: Help connect veterans
to VHA healthcare services for which they are
eligible, either through a community-based benefits
specialist or transition planner, the VA’s OEF/OIF
Coordinators, or through a local Vet Center.
Navigating the regulations around eligibility for
VHA services is difficult, especially for those in
need of services. To provide greater flexibility for
combat veterans in need of health care services,
enrollment eligibility has been extended to five
years past the date of discharge (U.S. Department
of Veterans Affairs, 2008) by the National Defense
Authorization Act (Public Law 110-181). Linking
a person to VHA health care services is dependent
upon service eligibility and enrollment. Community
providers can help navigate these regulations
through a benefits specialist or by connecting
combat veterans to a VA OEF/OIF Coordinator or
local Vet Center.
•• Deployment Risk and Resilience Inventory
(DRRI): A set of 14 scales, the DRRI can be
administered whole or in part. The scales assess
risk and resilience factors at pre-deployment,
deployment, and post-deployment.
•• Clinician Administered PTSD Scale (CAPS):
A 30-item interview that can assess PTSD
symptoms over the past week, past month,
or over a lifetime (National Center for PTSD,
2007).
hh
Recommendation 2: Law enforcement, probation
and parole, and corrections officers should receive
training on identifying signs of combat-related
trauma and the role of adaptive behaviors in justice
system involvement.
Vet Centers, part of the U.S. Department of Veterans
Affairs, provide no-cost readjustment counseling
and outreach services for combat veterans and their
families. Readjustment counseling services range
from individual counseling to benefits assistance to
substance use assessment. Counseling for military
sexual trauma is also available. There are over
200 Vet Centers around the country. The national
directory of Vet Centers is available through the
national Vet Center website (http://www.vetcenter.
va.gov/).
Knowing the signs of combat stress injury and
adaptive behaviors will help inform law enforcement
officers and other frontline criminal justice staff
as they encounter veterans with combat-related
trauma. Such information should be incorporated
into Crisis Intervention Team (CIT) trainings. The
Veterans Affairs Medical Center in Memphis (TN)
has been involved in the development of the CIT
model, training officers in veterans crisis issues,
facilitating dialogue in non-crisis circumstances,
and facilitating access to VA mental health services
for veterans in crisis.
OEF/OIF Coordinators, or Points of Contact, are
available through many facilities and at the network
level (Veterans Integrated Service Network, or
VISN). The coordinator’s role is to provide OEF/
OIF veterans in need of services with information
regarding services and to connect them to facilities
of their choice — even going so far as to arrange
appointments.
The Veterans Health Administration has committed
to outreach, training, and boundary spanning
with local law enforcement and other criminal
justice agencies through the position of a Veterans’
Justice Outreach Coordinator (Veterans Health
Administration, 2008a). Each medical center
is recommended to develop such a position. In
addition to training, a coordinator’s duties include
facilitating mental health assessments for eligible
veterans and participating in the development of
plans for community care in lieu of incarceration
where possible.
In terms of access to VA services among justiceinvolved veterans, data are available on one criterion
for determining eligibility: discharge status. Among
jail inmates who are veterans, 80 percent received
a discharge of honorable or general with honorable
conditions (Bureau of Justice Statistics, 2006).
Inmates in state (78.5%) or Federal (81.2%) prisons
have similar rates (Noonan & Mumola, 2007). Apart
3
from discharge status, access to VA health care
services is dependent upon service needs that are a
direct result of combat deployment and enrollment
within in a fixed time period after discharge. So
despite this 80 percent figure, a significant proportion
of justice-involved veterans who are ineligible for
VA health care services based on eligibility criteria
or who do not wish to receive services through the
VA will depend on community-based services.
Background
Since the transition to an All Volunteer Force
following withdrawal from Vietnam, the population
serving in the U.S. Armed Forces has undergone
dramatic demographic shifts. Compared with Vietnam
theater veterans, a greater proportion of those
who served in OEF/OIF are female, older, and
constituted from the National Guard or Reserves.
Fifteen percent of the individuals who have served
in OEF/OIF are females, almost half are at least 30
years of age, and approximately 30 percent served
in the National Guard or Reserves.
hhRecommendation 4: Expand communitybased veteran-specific peer support services.
Peer support in mental health is expanding as a
service, and many mental health–criminal justice
initiatives use forensic peer specialists as part of
their service array. What matters most with peer
support is the mutual experience — of combat, of
mental illness, or of substance abuse (Davidson &
Rowe, 2008). National peer support programs such
as Vets4Vets and the US Department of Veteran
Affairs’s Vet to Vet programs have formed to meet
the needs of OEF/OIF veterans. It is important
that programs such as these continue to expand in
communities around the country.
From the start of combat operations through
November 2007, 1.6 million service members have
been deployed to Iraq and Afghanistan, with nearly
500,000 from the National Guard and Reserves
(Congressional Research Service, 2008). One-third
have been deployed more than once. For OEF/
OIF, the National Guard and Reserves have served
an expanded role. Nearly 40 percent more reserve
personnel were mobilized in the six years following
September 11, 2001 than had been mobilized in the
decade beginning with the Gulf War (Commission
on the National Guard and Reserves, 2008). The
National Guard, unlike the active branches of the
U.S. Armed Forces and the Reserves, serves both
state and Federal roles, and is often mobilized in
response to emergencies and natural disasters.
hhRecommendation 5: In addition to mental health
needs, service providers should be ready to meet
substance use, physical health, employment, and
housing needs.
Combat stress is a normal experience for those serving
in theater. Many stress reactions are adaptive and
do not persist. The development of combat-related
mental health conditions is often a result of combat
stress exposure that is too intense or too long (Nash,
n.d.), such as multiple firefights (Hoge et al., 2004)
or multiple deployments (Mental Health Advisory
Team Five, 2008).
Alcohol use among returning combat veterans is a
growing issue, with between 12 and 15 percent of
returning service members screening positive for
alcohol misuse (Milliken et al, 2007). Based on a
study of veterans in the Los Angeles County Jail
in the late 1990s, nearly half were assessed with
alcohol abuse or dependence and approximately
60 percent with other drug (McGuire et al, 2003).
Moreover, the same study found that of incarcerated
veterans assessed by counselors, approximately
one-quarter had co-occurring disorders. One-third
reported serious medical problems. Employment
and housing were concerns for all the incarcerated
veterans in the study.
A recent series of reports and published research has
raised concerns over the mental health of OEF/OIF
veterans and service members currently in theater.
The Army’s Fifth Mental Health Advisory Team
report (2008) found long deployments, multiple
deployments, and little time between deployments
contributed to mental health conditions among
those currently deployed for OEF/OIF. The survey
found mental health problems peaked during the
middle months of deployment and reports of
Available information suggests that comprehensive
services must be available to support justiceinvolved veterans in the community.
4
12% to 17%) and 92 percent
for Army National Guard
and Army Reserve members
(from 13% to 25%) (Milliken,
Auchterlonie, & Hoge, 2007).
Depression screens increased
as well, with Army National
Guard and Army Reserve
members reporting higher
rates than those who were
active duty.
In addition to the increase in
mental health conditions, the
post-deployment transition
is often complicated by
barriers to care and the
adaptive behaviors developed
during combat to promote
survival.
Behaviors that promote
survival within the combat
zone may cause difficulties
during the transition back to
civilian life. Hypervigilance,
Figure 2. Most Reported Barriers to Care from Two Surveys of Individuals Who
aggressive driving, carrying
Served in OEF/OIF & Who Met Criteria for a Mental Health Condition
weapons at all times, and
command
and
control
interactions, all of which may be beneficial in theater,
problems increased with successive deployments. In
can result in negative and potentially criminal
terms of returning service members, a random digit
behavior back home. Battlemind, a set of training
dial survey of 1,965 individuals who had served in
modules developed by the Walter Reed Army
OEF/OIF found approximately 18.5 percent had a
Institute of Research, has been designed to ease the
current mental health condition and 19.5 percent
transition for returning service members. Discussing
had experienced a traumatic brain injury (TBI)
aggressive driving, the Battlemind literature states,
during deployment. The prevalence of current
“In combat: Driving unpredictably, fast, using rapid
PTSD was 14.0 percent, as was depression (Tanelian
lane changes and keeping other vehicles at a distance
& Jaycox, 2008).
is designed to avoid improvised explosive devices
Reports of mental health conditions have increased
and vehicle-born improvised explosive devices,”
as individuals have separated from service. By
but “At home: Aggressive driving and straddling
Department of Defense mandate, the Postthe middle line leads to speeding tickets, accidents
Deployment Health Assessment is administered to
and fatalities.” (Walter Reed Army Institute of
all service members at the end of deployment. Three
Research, 2005).
to six months later, the Post-Deployment Health
Many veterans of OEF/OIF in need of health care
Reassessment is re-administered. From the time
services receive services through their local VHA
of the initial administration to the reassessment,
facilities, whether the facilities be medical centers or
positive screens for PTSD jumped 42 percent for
outpatient clinics. Forty percent of separated active
those who served in the Army’s active duty (from
5
duty service members who served in OEF/OIF use
the health care services available from the VHA. For
National Guard and Reserve members, the number
is 38 percent (Veterans Health Administration,
2008b).
on Bureau of Justice Statistics data (Noonan &
Mumola, 2007; Greenberg & Rosenheck, 2008),
on any given day approximately 9.4 percent, or
223,000, of the inmates in the country’s prisons and
jails are veterans. Comparable data for community
corrections populations are not available.
A number of barriers, however, reduce the likelihood
that individuals will seek out or receive services.
According to Tanelian and Jaycox (2008), of those
veterans of OEF/OIF who screened positive for
PTSD or depression, only half sought treatment in
the past 12 months. To compound this treatment
gap, the authors determined that of those who
received treatment, half had received only minimally
adequate services. In an earlier study of Army and
Marine veterans of OEF/OIF with mental health
conditions, Hoge and colleagues (2004) found only
30 percent had received professional help in the
past 12 months despite approximately 80 percent
acknowledging a problem. Even among OEF/OIF
veterans who were receiving health care services
from a U.S. Department of Veterans Affairs Medical
Center (VAMC), only one-third of those who were
referred to a VA mental health clinic following a
post-deployment health screen actually attended
an appointment (Seal et al., 2008). Based on surveys
(Hoge, Auchterlonie, & Milliken, 2004; Tanelian &
Jaycox, 2008) of perceived barriers to care among
veterans of OEF/OIF who have mental health
conditions, the most common reasons for not seeking
treatment were related to beliefs about treatment
and concerns about negative career outcomes.1 See
Figure 2 for a review of the two surveys’ findings.
The best predictor of justice system involvement
comes from the National Vietnam Veterans
Readjustment Study (NVVRS). Based on interviews
conducted between 1986 and 1988, the NVVRS
found that among male combat veterans of Vietnam
with current PTSD (approximately 15 percent of all
male combat veterans of Vietnam), nearly half had
been arrested one or more times (National Center
for PTSD, n.d.). At the time of the study, this
represented approximately 223,000 people.
Veterans coming into contact with the criminal
justice system have a number of unmet service
needs. A study by McGuire and colleagues (2003)
of veterans in the Los Angeles County Jail assessed
for service needs by outreach workers found 39
percent reported current psychiatric symptoms.
Based on counselor assessments, approximately
one-quarter had co-occurring disorders. Housing
and employment were also significant issues: onefifth had experienced long term homelessness,
while only 15 percent had maintained some form of
employment in the three years prior to their current
jail stay. Similar levels of homelessness have been
reported in studies by Greenberg and Rosenheck
(2008) and Saxon and colleagues (2001).
Justice System Involvement Among Veterans
Conclusion
At midyear 2007, approximately 1.6 million
inmates were confined in state and Federal prisons,
with another 780,000 inmates in local jails (Sabol
& Couture, 2008; Sabol & Minton, 2008). Based
This report provides a series of recommendations
and background to inform community-based
responses to justice-involved combat veterans with
mental health conditions. Many combat veterans of
OEF/OIF are returning with PTSD and depression.
Both for public health and public safety reasons,
mental health and criminal justice agencies must
take steps to identify such veterans and connect
them to comprehensive and appropriate services
when they come in contact with the criminal justice
system.
1 In May 2008, Department of Defense Secretary Robert
Gates, citing the Army’s Fifth Mental Health Advisory Team
report (2008) findings on barriers to care, announced that
the question regarding mental health services on the security
clearance form (Standard Form 88) would be adapted (Miles,
2008). The adapted question will instruct respondents to answer
in the negative to the question if the delivered services were for
a combat-related mental health condition. Those whose mental
health condition is not combat related will continue to be
required to provide information on services received, including
providers’ contact information and dates of service contact.
6
References
Bureau of Justice Statistics. (2006). Survey of inmates
in local jails, 2002. ICPSR04359-v2. Ann Arbor, MI:
Inter-University Consortium for Political and Social
Research.
Noonan, M. & Mumola, C. (2007). Veterans in state and
federal prison, 2004. Washington, DC: U.S. Department
of Justice, Office of Justice Programs, Bureau of
Justice Statistics.
Congressional Research Service. (2008). CRS report for
Congress: National Guard personnel and deployments:
Fact sheet. Washington, DC: Library of Congress,
Congressional Research Service.
Saxon, A.J., Davis, T.M., Sloan, K.L., McKinight, K.M.,
McFall, M.E., & Kivlahan, D.R. (2001). Trauma,
symptoms of posttraumatic stress disorder, and
associated problems among incarcerated veterans.
Psychiatric Services, 52, 959-964.
Davidson, L. & Rowe, M. (2008). Peer support within criminal
justice settings: The role of forensic peer specialists.
Delmar, NY: CMHS National GAINS Center.
Seal, K.H., Bertenthal, D., Maguen, S., Gima, K., Chu, A., &
Marmar, C.R. (2008). Getting beyond “don’t ask; don’t
tell”: An evaluation of U.S. Veterans Administration
postdeployment mental health screening of veterans
returning from Iraq and Afghanistan. American Journal
of Public Health, 98, 714-720.
Greenberg, G. & Rosenheck, R. (2008). Jail incarceration,
homelessness, and mental health: A national study.
Psychiatric Services, 59, 170-177.
Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting,
D.I., & Koffman, R.L. (2004). Combat duty in Iraq and
Afghanistan, mental health problems, and barriers to
care. New England Journal of Medicine, 351, 13-22.
Tanelian, T. & Jaycox, L.A., Eds. (2008). Invisible wounds
of war: Psychological and cognitive injuries, their
consequences, and services to assist recovery. Santa
Monica, CA: RAND Center for Military Health Policy
Research.
Mcguire, J., Rosenheck, R.A., & Kasprow, W.J. (2003).
Health status, service use, and costs among veterans
receiving outreach services in jail or community
settings. Psychiatric Services, 42, 201-207.
U.S. Department of Veterans Affairs. VA healthcare eligibility
and enrollment. Accessed July 8, 2008. Available from:
http://www.va.gov/healtheligibility/
Mental Health Advisory Team Five. (2008). Operation Iraqi
Freedom 06-08: Iraq and Operation Enduring Freedom
08: Afghanistan. Washington, DC: U.S. Army Medical
Command, Office of the Surgeon General. Available
from: http://www.armymedicine.army.mil/news/mhat/
mhat_v/mhat-v.cfm
Veterans Health Administration. (2008a). Uniform mental
health services in VA medical centers and clinicals. VHA
Handbook 1160.1. Washington, DC: US Department
of Veterans Affairs, Veterans Health Administration.
Veterans Health Administration. (2008b). Analysis of VA
health care utilization among US Global War on Terrorism
(GWOT) veterans: Operation Enduring Freedom
Operation Iraqi Freedom (OEF/OEF). Washington,
DC: US Department of Veterans Affairs, Veterans
Health Administion, Office of Public Health and
Epidemiology.
Miles, D. (2008, May 1). Gates works to reduce mental
health stigma. American Forces Press Service. Available
from:
http://www.defenselink.mil/news/newsarticle.
aspx?id=49738
Milliken, C.S., Auchterlonie, J.L., & Hoge, C.W. (2007).
Longitudinal assessment of mental health problems
among Active and Reserve Component soldiers
returning from the Iraq war. Journal of the American
Medical Association, 298, 2141-2148.
Yusko, D. (2006, November 12). War’s pain comes home:
Veterans back from war zones sometimes carry an
invisible wound — post-traumatic stress disorder.
Albany Times Union.
Nash, W.P. (n.d.). PTSD 101: Medical issues: Combat stress
injuries. White River Junction, VT: National Center
for PTSD. Available from: http://www.ncptsd.va.gov/
ptsd101/modules/nash_combat_stress.html
Walter Reed Army Institute of Research. (2005). Battlemind
training I: Transitioning from combat to home. Rockville,
MD: Author.
National Center for PTSD. (n.d.) Epidemiogical facts about
PTSD. White River Junction, VT: Author. Available
from: http://www.ncptsd.va.gov/ncmain/ncdocs/fact_
shts/fs_epidemiological.html
Recommended citation: CMHS National GAINS Center.
(2008). Responding to the needs of justice-involved combat
veterans with service-related trauma and mental health
conditions: A consensus report of the CMHS National GAINS
Center’s Forum on Combat Veterans, Trauma, and the Justice
System. Delmar, NY: Author.
National Center for PTSD. (2007). PTSD Information
Center. White River Junction, VT: Author. Available
from: http://www.ncptsd.va.gov/ncmain/information/
National Commission on the National Guard and Reserves.
(2007). Second report to Congress. Arlington, VA:
Author.
7
Appendix
Participants of the CMHS National GAINS Center
Forum on Combat Veterans, Trauma, and the Criminal Justice System
May 8, 2008, Bethesda, MD
A. Kathryn Power, MEd, Director of the Center for Mental Health Services at the Substance Abuse and Mental
Health Services Administration, provided the opening comments at the forum.
Richard Bebout, PhD
Community Connections
Washington, DC
David Morrissette, DSW
Center for Mental Health Services
Rockville, MD
Thomas Berger
Vietnam Veterans of America
Columbia, MO
Lt. Jeffry Murphy
Chicago Police Department
Chicago, IL
Mary Blake
Center for Mental Health Services
Rockville, MD
Fred Osher, MD
Council of State Governments Justice Center
Bethesda, MD
Judith Broder, MD
Soldiers Project
Los Angeles, CA
Matthew Randle
Vets4Vets
Tucson, AZ
Neal Brown
Center for Mental Health Services
Rockville, MD
Frances Randolph, DPH
Center for Mental Health Services
Rockville, MD
Sean Clark
U.S. Department of Veterans Affairs
Washington, DC
Maj. Cynthia Rasmussen
US Army Reserve
Ft. Snelling, MN
Karla Conway
Community Alternatives
St. Louis, MO
Cheryl Reese
Educare Systems
Washington, DC
Jim Dennis
Corrections Center of Northwest Ohio
Stryker, OH
Hon. Robert Russell, Jr.
Drug Treatment Court Judge
Buffalo, NY
Jim Driscoll
Vets4Vets
Tucson, AZ
Susan Salasin
Center for Mental Health Services
Rockville, MD
Alexa Eggleston
National Council for Community Behavioral Health
Rockville, MD
Lt. Col. Andrew Savicky
New Jersey Department of Corrections
Glassboro, NJ
Guy Gambill
Minneapolis, MN
William Schlenger, PhD
Abt Associates
Bethesda, MD
Justin Harding
National Association of State Mental Health Program
Directors
Alexandria, VA
Paula Schnurr, PhD
National Center for PTSD
White River Junction, VT
Thomas Kirchberg, PhD
Veterans Affairs Medical Center – Memphis
Memphis, TN
Elizabeth Sweet
Center for Mental Health Services
Rockville, MD
Larry Lehman, MD
US Department of Veterans Affairs
Washington, DC
Charlie Sullivan
National CURE
Washington, DC
James McGuire, PhD
US Department of Veterans Affairs
Los Angeles, CA
8
Appendix 4:
Transitional Case
Management Program
Transitional Case Management Program:
New York County
Misdemeanor Diversion Program for
People with Mental Illness
Transitional Case Management
Program Evaluation
Background
The New York County (Manhattan) Criminal Court is one of the nation’s busiest. In 2007,
there were 104,333 cases arraigned in Manhattan, 75,882 of which were misdemeanor
arraignments. More than half of all cases are disposed of in arraignment. This is more than at
any other stage in the life of a criminal court case. Even given the high prevalence of
individuals with serious mental illness found in the justice system (14.5% for men and 31.0%
for women)1, the high volume of cases in the Manhattan court system presents challenges in
identifying individuals appropriate for diversion. Furthermore, the average time from arrest to
arraignment is only 21.7 hours. The short time between arrest and arraignment and the large
numbers of cases in the court system mean it is difficult to identify and screen defendants
with serious mental illness during the arrest to arraignment stage of adjudication.
Individuals arrested for misdemeanors account for more admissions to the NYC Department
of Correction (DOC) than individuals arrested for felonies. During the three-year TCM pilot
operations, the number of misdemeanor jail admissions in Manhattan ranged from 14,989 in
2007 to 13,622 in 2009, a nine percent decline. During the same period, the proportion of
Brad H2 designated inmates has increased from 25.1 percent to 29.6 percent of all inmates3.
The average length of stay in the DOC for individuals arrested in Manhattan for
misdemeanors was 16.8 days. Citywide, the average length of detention for misdemeanor
offenders was 19.4 days.4 After admission to DOC custody, there is little time for people with
serious mental illness arrested for misdemeanor offenses to receive a mental health diagnosis,
much less treatment services and discharge planning referrals to community treatment
resources. For individuals with mental illness, the costs of detention are higher, they are prone
to repeated justice contact, and they experience longer periods of incarceration during each
episode.5
In February 2008, the Center for Alternative Sentencing and Employment Services (CASES)
and the DOC convened a set of stakeholders from the criminal justice and mental health
communities for regular meetings to improve local awareness and develop effective responses
for defendants with serious mental illness charged with misdemeanor crimes. The focus of the
stakeholders group was to:
ƒ Monitor the implementation of the pilot Transitional Case Management (TCM)
diversion program;
1
Steadman, H et al (2009) Prevalence of Serious Mental Illness Among Jail Inmates. Psychiatric Serv. 60:761-765
Brad H. v. City of New York is a class action lawsuit filed in 1999 challenging the City’s failure to provide discharge
planning for people with mental illness in the jail system. In 2003, the parties settled the case with an agreement that the City
would provide people who have received mental health treatment or have taken medication for a mental health condition
while in jail with discharge planning. Discharge planning services include continued mental health care, case management,
and assistance in accessing public benefits and housing.
3
New York City Department of Correction Research Department direct communication July 2010
4
ibid
5
Ditton, P., Mental Health and Treatment of Inmates and Probationer, Bureau of Justice Statistics Special Report (1999)
2
2
ƒ
ƒ
ƒ
ƒ
ƒ
Increase cross-system collaborations among government and nonprofit jail diversion
and associated service providers;
Establish routine mechanisms for screening individuals with mental illness and cooccurring substance use disorders in New York County Criminal Court;
Expand the sentencing options available to the justice system;
Improve stakeholder agencies’ ability to respond to the needs of individuals who are
identified with mental illness and co-occurring disorders and accepted for diversion;
Make training in mental health, co-occurring and diversion issues available to
correction officers, defense lawyers, prosecutors, judges and others who are involved
in the justice system.
The evaluation of the policy work of the stakeholder’s group will be addressed in a separate
report. This report describes how the program evolved during its three years of pilot
operations (from July 1, 2007 to June 30, 2010), participant characteristics and outcomes, and
findings and lessons learned. The report contains process and outcome components. The TCM
program experienced significant changes in its structure and overall operations during the first
eighteen months of operations in order to increase program enrollment and improve the
provision of community case management services to participants. The program model that
TCM implements today has been in operation since January 2009. This evaluation draws
conclusions and makes recommendations on the need for diversion services for people with
serious mental illness convicted of misdemeanor crimes and how those services should be
delivered.
New York City Mental Health and Criminal Justice Recommendations
The lessons learned from the pilot TCM program and the associated policy work of the
stakeholder group are informed by the New York State/New York City Mental HealthCriminal Justice Panel’s June 2008 report and recommendations6. The panel explored how
New York City’s mental health and justice systems respond to adults and adolescents with
serious mental illness. The panel’s recommendations include the expansion of mental health
courts and alternatives to incarceration programs providing court-monitored mental health
treatment and the piloting of mental health screening in the Bronx Criminal Court for
individuals sentenced to a community sanction. The TCM stakeholders group includes
representatives from the City Department of Health and Mental Hygiene, Mayor’s Office of
the Criminal Justice Coordinator, and the New York State Office of Mental Health. These
stakeholders were members of the Panel and continue to oversee the implementation of the
panel’s recommendations. The New York County stakeholders have concentrated their efforts
on the arrest to arraignment process, working to raise the visibility of systems and policy
change. Alternative to incarceration responses during the arrest to arraignment process were
not addressed in the report. Using the TCM program process and outcome data, CASES is
cultivating awareness among these key City and State officials about the interventions needed
for defendants with serious mental illness during the arrest to arraignment timeframe.
6
http://www.omh.state.ny.us/omhweb/justice_panel_report/
3
The Program
CASES launched the TCM program in July 2007. The program has received funding from the
DOC under a 30-month Bureau of Justice Assistance (BJA) Justice and Mental Health
Collaboration Program Planning and Implementation grant, the Mayor’s Office of the
Criminal Justice Coordinator, and the van Ameringen Foundation. TCM consists of a
screening component to identify eligible participants and a community case management
component to assess and coordinate access to treatment and support services. This model aims
to:
ƒ Divert misdemeanor defendants with mental illness from short jail stays;
ƒ Provide them with access and linkage to mental health and substance abuse
treatment, housing and other needed supports and resources;
ƒ Support and monitor their engagement in those and other needed services;
ƒ Help them to develop skills necessary for community living;
ƒ Prevent their further involvement with the criminal justice system and promote public
safety; and
ƒ Reduce public expenditures.
Section I
SCREENING
In the absence of the ideal screening system used in some jurisdictions to match defendants
against state and local mental health records, diversion programs need to establish a local
screening structure that can successfully be integrated into the criminal justice procedures,
without slowing down the flow of cases and timely adjudication of the legal case. This
section describes the screening protocols implemented to generate program intakes from three
distinct sources: CASES’ Day Custody Program, criminal court arraignments, and postarraignment criminal court parts.
Eligibility
Criminal Justice Eligibility Criteria
Since TCM was initially an extension of the Day Custody Program, the legal admission
criteria for TCM were defined by DCP: defendants with 3 or more misdemeanor convictions,
no history of violent crime, and not designated as Operation Spotlight7. These defendants are
at risk of receiving short-jail sentences of ten days8. CASES’ Day Custody Program (DCP) is
a three-day alternative sentence for repeat misdemeanants. DCP participants report to a secure
DOC facility each day, where they perform community service and receive substance abuse
education, counseling, and referrals to treatment providers. As the TCM program evolved to
accept individuals under a court mandate directly from arraignments and other criminal court
parts, it has expanded the legal criteria to include defendants with less than three prior
misdemeanor convictions or histories of violent crime, as well as those designated as
Operation Spotlight or at risk of receiving longer jail sentences of up to one year.
7
Launched under Mayor Bloomberg in July 2002, Operation Spotlight authorizes judges to sentence repeat misdemeanor
offenders with three or more prior convictions in a 12-month period to a jail sentence.
8
Solomon, F (2008) The Day Custody Program: First Year Report, Criminal Justice Agency
4
The program has retained its commitment to only accept those defendants at risk of jail
sentences. For individuals who enter the program under a court mandate, CASES has worked
to ensure that the period of judicial supervision is not longer than the jail sentence the
individual would have received under regular case processing. Given that misdemeanor
offenders in New York City spend very little time in jail, the mandates for arraignment cases
have ranged from three to five case management sessions. Post-arraignment cases also
included defendants arrested for felony crimes that were eventually reduced to misdemeanors.
Typically, this occurred for individuals found incompetent, sent to forensic hospitals, and
restored to competency before being re-admitted to jail. The criminal court mandates in postarraignment cases have ranged from one case management session to eleven months of
judicial monitoring through quarterly progress hearings. The upper limit was used in a few
cases where individuals were at risk of receiving a one-year jail sentence.
Mental Health Eligibility Criteria
TCM is for adults with serious mental illnesses or those with serious mental illnesses and cooccurring substance use disorders. Serious mental illness refers to participants currently or at
any time during the past year having a diagnosable mental disorder of sufficient duration to
meet criteria specified within DSM-IV with the exception of substance use disorders, and
developmental disorders, unless they co-occur with another diagnosable serious mental
illness. Participants need to experience impaired functioning due to the mental disorder9.
In its earliest iteration, TCM was developed as the mental health screening and case
management expansion to DCP. The DCP court representatives deliver the Brief Jail Mental
Health Screen (BJMHS)10 in arraignments before participants are sentenced to DCP by the
arraignment judge. TCM selected the validated BJMHS flagging instrument because on
average it takes only 2.5 minutes to administer and can be used by non-mental health
professionals. TCM staff then screen DCP participants flagged by the BJMHS. It was
anticipated that following the comprehensive mental health screening, an annual pool of 48
participants would elect to receive the TCM program’s voluntary community case
management services for 2-3 months after completion of the mandated three-day DCP
alternative sentence11.
9
Impairment in functioning is defined as exhibiting any of the following: Homelessness; Difficulty completing self-care
(personal hygiene, diet, clothing, etc.); Difficulty securing healthcare or in complying with medical advice; Restriction in the
ability to complete activities of daily living (such as maintaining a residence, using transportation, or accessing community
services) independently; Difficulty in maintaining social functioning and interpersonal interactions, in complying with social
norms, and; Frequent deficiencies of concentration resulting in failure to complete tasks in a timely manner at home, work,
etc.
10
The Brief Jail Mental Health Screen (BJMHS) is a validated mental health screening instrument. It was developed by
Policy Research Associates. It is a quick, simple and effective 8 yes or no question mental health screen that aids in the early
identification of severe mental illnesses in criminal justice settings. The screen takes about 2.5 minutes to administer and can
be used by non-mental health staff. It identifies the individuals that need to be assessed by the mental health clinician. The
effectiveness of the BJMHS was validated in a study that found 73.5 percent of male jail detainees and well as 61.6 percent
of women were correctly identified by the BJMHS. The tool has not been widely used in court settings but within jails it was
validated and found to be practical and reliable. Steadman, et al (2005) Validation of the Brief Jail Mental Health Screen
Psychiatric Services July 2005 pp 816-822 & Steadman et al (2007). Revalidating the Brief Jail Mental Health Screen to
increase accuracy for women. Psychiatric Services 58 (12): pp 1598-1601.
11
The estimate of 48 participants was derived from the pilot of the BJMHS by DCP for one year before TCM started its
operations. The estimate was based on the number of service referrals for participants flagged positive by the BJMHS.
5
Development of the Screening Protocol
(Legal and Clinical Components)
Overview
The TCM screening protocol was initially developed to respond to the needs of defendants
with serious mental illness sentenced to DCP. Within five months of start-up, the program
expanded its screening activities to criminal court arraignment and post-arraignment criminal
court parts because of the low enrollment of voluntary DCP participants and defense attorney
referrals of defendants ineligible for DCP. In the second year of operations, the program also
amended the screening protocol to include standardized and validated mental health and
substance abuse instruments used in criminal justice settings. The revised screening protocol
responded to challenges the program experienced with its integration into the arraignment
court operations and the general complexity of screening individuals with co-occurring mental
health and substance use disorders within a short timeframe. The sections below describe how
TCM’s screening protocol evolved over time.
Initial Screening Protocol and Expansion to Arraignments and Criminal Court
At the start of its operations, TCM assigned the project coordinator and program social
worker to screen the DCP participants flagged by the BJMHS during their participation in the
three-day alternative to incarceration program. DCP court representatives administered the
BJMHS to approximately 109 defendants each month prior to their arraignment, and on
average, twelve percent of those flagged by the screening instrument were admitted to DCP.
The clinical screening conducted by the TCM staff then consisted of a one-hour semistructured interview. The professional clinician gathered information about the individual’s
psychiatric, substance abuse, and housing history, as well as motivation to participate in case
management services to access community treatment. The staff would also talk to the
participant about life goals, identify immediate needs, and explore how the program could
best work to support their recovery. Admission to TCM from the DCP track was based on the
participant’s decision to voluntarily enter the case management services after completing the
DCP court mandate.
In November 2007, TCM expanded the location of its one-hour semi-structured screening
interview to include arraignments and criminal court parts in response to low program
enrollment of voluntary DCP participants. The program assigned the social worker to
establish a daily presence in the arraignments parts, communicating with DCP court
representatives to screen defendants flagged by the BJMHS and identified by defense
attorneys and judges. The arraignment track gave judges the option to mandate defendants to
three case management sessions in lieu of the jail sentence. The program offered the
mandated case management sessions followed by 2-3 months of voluntary services to the
defendants who agreed to participate. Defendants enrolled from post-arraignment criminal
court parts were mandated by the judge to a specified number of case management sessions or
a period of court monitoring. Judges monitored arraignment cases through a compliance
hearing generally scheduled 60-days after program admission. The criminal court cases were
monitored by progress hearings. At the compliance date or progress hearing, TCM would
submit a report about the participant’s compliance with the court mandate.
6
The program experienced several screening challenges when it began to conduct the clinical
screening interview in arraignments. Defendants were often referred only 15-30 minutes
before the arraignment hearing. This did not give the social worker adequate time to
complete the one-hour screening interview, make the eligibility decision, and explain the
mandate and program expectations to the defendant. Although the time challenge was a
major impediment, there were also other factors that hindered the program’s progress
conducting the screening interview in arraignment.
The two main obstacles were the experience level of the first year social worker and the
inadequacy of the one-hour semi-structured screening interview to support the eligibility
determinations. The program social worker often needed to consult with the project
coordinator before she could confirm the clinical eligibility standard was met. The social
worker was challenged by the high prevalence and complexity of defendants with mental
health and substance abuse problems, the spectrum of diagnoses, and the range of
impairments and functioning levels encountered among the arraignment defendants. The
social worker found it difficult to provide the immediate intake decision needed in the
arraignment setting.
There was only one direct arraignment admission in the first six months of the program’s
daily presence in arraignments. The majority of defendants with screenings interviews started
in arraignments during the first six months were sentenced to DCP. Only after entering DCP
was TCM able to confirm whether or not the participant met eligibility for the program. In the
few instances in which participants were identified as eligible during the court-based
screening, they were targeted for additional contact during their DCP participation to increase
the likelihood that they would agree to participate in the voluntary case management services.
Fine-Tuning the Screening Protocol
In April 2008, CASES requested technical assistance on its screening protocol from Dr. Fred
Osher M.D., Justice Center, Council of State Governments, during the site visit for the
oversight of the BJA JMHCP grant. The technical assistance was requested because the
program had experienced low enrollment throughout the first nine months of operations. The
program was utilizing the resources of the project coordinator and the program social worker
to identify eligible program participants but only 21 participants were admitted during the first
nine months when it was expected that 48 participants would be enrolled by the end of the
first year.
Dr. Osher is a leading national expert and has published extensively in the areas of
homelessness, community psychiatry, co-occurring mental and addictive disorders, and
effective approaches to persons with behavioral disorders within justice settings. Dr. Osher
observed the program social worker screening a defendant in arraignments and met with the
project coordinator and social worker to review the components of the screening interview
and discuss the processes used by the staff to determine whether a defendant was accepted or
rejected by the program.
7
Dr. Osher’s Observations
ƒ The program administers the Brief Jail Mental Health Screen (BJMHS) to a biased
sample; only defendants with three prior misdemeanor convictions and not designated
as Operation Spotlight. This sampling may undermine the external validity of the test
because the BJMHS was developed to be administered to all arrestees being admitted
into a jail or justice setting regardless of prior legal history;
ƒ Screening protocol used by the TCM program showed bias towards rejecting
individuals with co-occurring mental health and substance use disorders. Dr. Osher
noted that even in the most rigorous research protocols that use the ‘gold star’ of
mental health interviewing, the Structured Clinical Interview for DSM Disorder
(SCID), on average fifteen percent of subjects were found to be incorrectly diagnosed.
Given the time constraints in arraignments and the unstructured format of the
screening interview he stated the TCM program was rejecting defendants with cooccurring disorders;
ƒ The program social worker would benefit from a structured screening form to conduct
the screening interview, and
ƒ Eligible Day Custody Program participants could benefit from brief motivational
interventions during the three-day mandate to support enrollment in the voluntary
aftercare case management services offered by the TCM program.
Dr. Osher’s Recommendations
ƒ The Brief Jail Mental Health Screen completed in arraignments should be readministered in the Day Custody Program to reduce the likelihood of missing eligible
participants;
ƒ Program staff should modify their screening findings to account for the likelihood of a
participant having a co-occurring mental health and substance use disorder rather than
just a substance disorder and admit dually diagnosed individuals into the program;
ƒ TCM should use standardized instruments applicable to the justice setting such as the
Texas Christian University Drug Screen II (TCUDS II) and the Mental Health
Screening Form III (MHSF III) during the screening interview to screen for cooccurring disorders;
ƒ Day Custody Program should use brief motivational interventions to increase
opportunities to voluntarily engage eligible participants in TCM services; and
ƒ TCM should explore with the Mayor’s Office of the Criminal Justice Coordinator the
admission of Operation Spotlight defendants with serious mental illness.
The April 10, 2008, site visit led to modifications to the screening protocol. CASES decided
to primarily use the project coordinator, a clinical psychologist with over ten years of
experience, to conduct the screening interviews, build the program’s court presence and
educate criminal court stakeholders about how to successfully fit the program’s screening
protocol into arraignment court operations. Because of her extensive clinical and diagnostic
experience, the project coordinator was able to ensure the program developed a best practice
screening protocol informed by Dr. Osher’s recommendations. The screening interview was
structured to take 75 minutes to complete and to be applied consistently to all individuals
screened for admission to TCM. The screening protocol revisions also included the
8
administration of the two standardized instruments recommended by Dr. Osher (TCUDS II12
and the MHSF III,13) and the review of psychosocial domains, risk factors, court mandate
conditions, and program expectations and goals.
Operation Spotlight Defendants
In late 2008, the program expanded and finalized the screening procedures and protocol when
it began to screen, with the approval of the Mayor’s Office of the Criminal Justice
Coordinator, the Operation Spotlight defendants classified at higher risk for criminal
recidivism. This responded to requests from defense attorneys to offer the program services to
individuals the attorneys believed were more likely to be mentally ill as well as Dr. Osher’s
site visit recommendations. Operation Spotlight is a multi-agency initiative implemented by
the Mayor’s Office in 2002. Defendants identified under Operation Spotlight have three or
more prior convictions in a twelve-month period and face a more severe jail sanction than
they would otherwise, in an attempt to increase the Court’s ability to deter repeat
misdemeanor offenders. The agreement with the Criminal Justice Coordinator’s Office
required Operation Spotlight participants to complete five mandated case management
sessions and face a jail alternative of at least 30 jail days. 45 percent of participants admitted
to TCM during the pilot were designated Operation Spotlight.
Screening and Program Admissions
Day Custody Program Admission Process
The BJMHS appears to have performed as expected, with approximately 12 percent of the
individuals identified by the instrument prior to their arraignment being sentenced to DCP.
During the three-year pilot, only 59.37 of the males and 58.82 percent of females screened
positive by the BJMHS were found to have a serious mental illness by the TCM program. The
revisions to the screening protocol finalized during 2008 appear to have improved the
accuracy of the BJMHS. In the final year of the pilot, 76 percent of the men and 82 percent of
the women flagged by the BJMHS and screened by the TCM program were found clinically
eligible. In contrast, the BJMHS is expected to correctly find 73.5 percent of the males that
have a serious mental illness and 61.6 percent of the women that have a serious mental illness.
In June 2008, DCP program staff started to administer the BJMHS a second time to all DCP
participants, following Dr. Osher’s recommendation. However, the second administration of
the BJMHS has yielded very few additional flagged participants to be screened during DCP
program participation or actual TCM program admissions.
12
The TCUDS-II is a 15-item instrument derived from a substance abuse diagnostic instrument developed by the Texas
Christian University. The instrument provides a self-report measure of substance use problems within the past 12 months,
and is based on Diagnostic and Statistical Manual (DSM) criteria. The TCUDS-II provides a brief screen for frequency of
substance use, history of treatment, substance dependence, and motivation for treatment. A score of three or higher on the
TCUDS-II indicates significant substance abuse problems. The TCUDS had the highest sensitivity (.85) and overall accuracy
(.82) among several substance abuse screening instruments examined in a corrections-based study.
13
The MHSF-III is an 18-item interview instrument designed to screen for mental health disorders. The items assess mental
health treatment history, perceived need for treatment, hallucinations, depressive disorders, suicidal behavior, nightmares and
flashbacks, phobias, aggressive actions, paranoid delusions, sexual problems, eating disorders, mania, panic attacks,
obsessive compulsive disorder, gambling problems, and learning problems. The MHSF-III has been used with offenders
and has exhibited good temporal stability (i.e., test-retest reliability, r >.80) and convergent validity.
9
Figure 1: Screening Outcomes for DCP Participants
Screening Outcomes for DCP participants
400
350
300
Number
250
200
150
100
50
0
Flagged by
BJMHS
Screened by TCM
and Eligible
Agreed to enroll
Enrolled
DCP Screening Process
As shown in Figure 1, during the three-year pilot, 44 participants, representing 13 percent of
the 342 individuals flagged by the BJMHS, actually enrolled and utilized the voluntary TCM
case management services. The main reason identified by the TCM staff as to why over 50
percent of the DCP participants that agreed to enroll in the case management do not turn up
for the services, is lack of interest in treatment to address problem areas such as substance
abuse. The program did not have a structured protocol to track the reasons why eligible DCP
participants rejected the voluntary case management services. The lack of a structured
procedure for the collection of rejection reasons has led to an incomplete understanding of the
reasons why the DCP participants rejected the voluntary services.
Arraignment Admission Process
In the arraignment court setting, TCM staff responded to a combination of referrals from the
DCP court representatives of defendants flagged by the BJMHS, defense attorneys and
judges. The Legal Aid Society is the second largest source of referrals in arraignments,
accounting for 89 percent of all defense attorney referrals. Six judges also made arraignment
referrals to the program.
For three years of program operations, defendants referred in arraignments by attorneys and
judges were found in 83 percent of the cases to be clinically appropriate for admission to the
TCM program. This was significantly higher than the TCM program’s predecessor in
arraignments, the EXIT program14, which found 47 percent of all defendants screened to be
eligible for the program. Defense attorneys referred the overwhelming majority of defendants
referred to the EXIT program. The TCM program appears to have benefited from the
experience the attorneys developed during the operation of the EXIT program in arraignments
14
http://www.gainscenter.samhsa.gov/pdfs/jail_diversion/TheEXITProgram.pdf
10
from 2002 to 2005. The core group of the Legal Aid Society permanent arraignment staff
attorney and supervisors that referred defendants to EXIT has continued to work in
arraignments and is very skilled in the identification of defendants with mental illness. They
accounted for 78 percent of the Legal Aid Society referrals to the program. These attorneys
deal with criminal issues related to people with mental illness on a daily basis.
During the three-year pilot, 66 individuals were released to the TCM program from
arraignments. Of these, 58 participants actually enrolled and utilized the case management
services, representing 88 percent of those released.
Criminal Court Admission Process
Although the TCM program was conceived as an arraignment program, defense attorneys and
judges started to utilize the program in post-arraignment cases because there were no other
viable diversion resources in the County for individuals with mental illness at this stage of the
judicial process. The Legal Aid Society was the main source of referrals followed by six
criminal court judges that also made post-arraignment referrals to the program. Forty-two
Legal Aid Society attorneys made post-arraignment criminal court referrals to the program.
The TCM program has had adequate time to screen these defendants (using the same protocol
described earlier) either before the next court appearance or on the day of the court
appearance.
Figure 2: Criminal Court Screening Outcomes
Screening Outcomes for Criminal Court participants
120
100
Number
80
60
40
20
0
Screened by TCM
Screened by TCM
and found eligible
Released by Court
Enrolled in TCM
Criminal Court Screening Process
As shown in Figure 2, of the 110 criminal court defendants screened, 55 individuals were
released to the TCM program from criminal court. Of these, fifty-one participants actually
enrolled and utilized the case management services, representing 93 percent of those released
from criminal court.
11
Screening Outcomes
A summary of screenings and admissions by year is presented below in Figures 3 & 4.
Figure 3: Screenings
Transitional Case Management Screening Activities
Attempted and/or Completed Screening Interviews
Day Custody
Arraignments
Criminal Court
Program
Year
Total
Number
Percent Number
Percent Number
Percent
Screened Screened
Screened
Screened
191
150
79%
20
10%
21
11%
FY 08
261
148
57%
79
30%
34
13%
FY 09
129
44
34%
30
23%
55
43%
FY 10
581
342
59%
129
22%
110
19%
Total
Note: The screening numbers include the 581 screening contacts the program had with defendants. 534 were designated as complete
screening interviews by the program. The program admission totals exclude self-referrals. The self-referred participants returned for
services after being discharged or requested services after receiving a jail sentence.
Figure 4: Admissions
Year
FY 08
FY 09
FY 10
Total
Transitional Case Management
Program Admissions
Day Custody
Arraignments
Program
Total
Number
Percent Number
Percent
Admissions Admitted
Admitted
28
17
61%
1
4%
76
21
28%
34
45%
49
6
12%
23
47%
153
44
29%
58
38%
Criminal Court
Number
Admitted
10
21
20
51
Percent
36%
28%
41%
33%
During its three years of pilot operations, the TCM program completed full screening
interviews for 534 of the 581 individuals the program approached for screening and there
were 153 program admissions. The data show that the program increased its annual
admissions in the second and third years compared to the first year of operations. This was the
result of developing a standardized screening protocol that includes the administration of
standardized mental health and substance abuse screening tools, adjusting the screening
decision-making processes to account for defendants with co-occurring mental health and
substance use disorders, and deploying the experienced project coordinator in arraignments to
screen and recruit program participants. Overall, 29 percent of the completed screening
interviews resulted in participant enrollment into the community case management services.
Data for only the third year of program operations indicate that 126 individuals completed the
full screening interview and 49 were admitted, representing 39 percent of screened
participants. These percentages are very high when compared with other jail diversion
programs for people with serious mental illness. A national study of the decision-making
processes related to enrollment in jail diversion programs for people with serious mental
12
illness found that only 3.5% of the cases screened in the 20 jail diversion sites were accepted
by the court for diversion. The study established that jail diversion programs screen an
extremely large number of cases to divert a small number of individuals into program
services.15 On this basis, we believe the TCM program has established a relatively reliable
screening protocol to identify the target population.
There was significant disparity in the screening resources TCM needed to devote to yield
program admissions from each of the three sources: DCP, arraignments and criminal court.
For every DCP admission, the TCM program needed to complete over seven screenings,
whereas approximately only two screenings were needed to generate a TCM admission from
the arraignment and post-arraignment parts. For arraignments, this was likely due to the fact
that the Legal Aid Society’s permanent arraignment staff were very skilled at identifying
individuals with mental illness, as previously noted. For criminal court, the defense attorney
or judge making the referral likely had more information about the mental health history of
the defendant compared to arraignments. For instance, the defense attorney may have had
time to speak to collateral sources and review records. Some of these defendants were also
found incompetent after their arrest and sent to a forensic hospital for treatment. The nature
of the arrest charges may also have been an indicator of mental illness—twenty-five percent
of the post-arraignment admissions were for “harm against a person” arrests.
The admissions of voluntary participants from DCP have significantly declined during the
three years of the TCM program. The main reason for the decline was the program staff
awareness that DCP eligible participants were less likely to enroll in the program than
participants admitted directly from court. Staff therefore prioritized the court-based referrals
because they saw these cases as a means of guaranteeing the flow of regular program
admissions needed to meet the program’s annual admission goal.
The goals of the TCM program include the diversion of the target population from jail and the
reduction of the public expenditures associated with jail utilization. 84 percent of the postarraignment criminal court admissions were detained in jail before their admission to TCM.
The average length of detention was 8.16 days in custody for TCM participants arrested for
misdemeanors. In 2009, the average length of stay in the DOC for individuals arrested for
misdemeanors in Manhattan was 16.8 days and citywide the average length of detention for
misdemeanor offenders was 19.4 days. This suggests the TCM screening was able to reduce
by 50 percent the average time the participants arrested for misdemeanors would spend in jail.
The TCM program seems to have successfully ensured the participants did not accumulate
numerous jail days while detained before their enrollment in the program.
The TCM program experienced increased levels of use by arraignment judges in the second
and third years of its operations. In total, twelve judges made referrals to the program. As the
judges became familiar with the project coordinator and the program model, they made
referrals to the program and were more willing to release defendants to TCM. In its second
year of operations, the judges had established confidence in the project coordinator and were
15
Naples, M, et al, Factors in Disproportionate Representation Among Persons Recommended by Programs and Accepted by
Courts for Jail Diversion (2007) Psychiatric Services 58:1095-1101
13
likely to release the defendant when the program recommended diversion at arraignment or in
criminal court.
The defense attorneys were very successful in the identification of suitable defendants for
participation in TCM. 74 percent of the defense attorney referrals were found clinically
eligible for participation in the program. The attorneys also effectively identified at the
beginning of the TCM pilot that Operation Spotlight defendants were likely to have serious
mental illness, are at risk of jail sentences and therefore could benefit from participation in the
diversion services. 45 percent of the participants admitted to TCM were designated Operation
Spotlight.
Conclusion and Recommendations
ƒ The screening of defendants with serious mental illness is challenging within a firstappearance court setting because of the time constraints and the high prevalence of cooccurring substance use disorders among defendants with serious mental illness involved
in the justice system. The overlapping symptoms of these disorders together with the time
constraints induced by the court setting point to the need for professional clinical staff
with at least 3-5 years of experience to manage the complex demands of the screening
activities.
ƒ The TCM program had an average of only 75 minutes to screen and make the intake
decision. This type of screening protocol will inevitably capture a few individuals who
have only substance use disorders because of the complexity of mental health screening
and the need to make an intake decision without the benefit of medical records or
information from collateral sources. The program needs to make accommodations for this
likelihood and ensure these types of participants are referred to appropriate treatment
services. In an effort to reduce this likelihood, the TCM program initially rejected eligible
participants with co-occurring mental health and substance use disorders. After the
program received technical assistance and revised its screening protocol and clinical
findings, individuals with co-occurring disorders were appropriately screened and
enrolled.
ƒ In the absence of a system to match identified defendants against local mental health
databases, the Brief Jail Mental Health Screen (BJMHS) is an efficient and powerful tool
to identify from a large pool of defendants, within a first-appearance court setting, the
ones that should be screened by the mental health professional.
ƒ The program’s limited screening services were more efficiently deployed in arraignments
and post-arraignment criminal court. The admission of participants from arraignments
and post-arraignment criminal court increases the number of individuals CASES diverts
annually from short jail sentences and is therefore a more effective use of limited
resources.
ƒ The TCM program was originally conceived to target individuals at risk of short jail
sentences of about ten days. The program also screened participants at risk of longer jail
sentences ranging up to one year and those enrolled received judicial monitoring for
periods up to eleven months. CASES may want to consider whether the issue of postarraignment diversion for individuals at risk of longer jail sentences should be presented
to the stakeholders group for strategic planning to standardize the legal admission criteria,
14
judicial oversight and court mandate standards for these cases, rather than relying on the
individualized approach to these cases used during the pilot.
Section II
PROGRAM PARTICIPANTS
General Demographics
The mean age of TCM participants was 39.67±9.26 years (within one standard deviation of
the mean), and 78 percent were male. 53 percent were African American, 26 percent were
Hispanic/Latino, 12 percent were Caucasian, 7 percent were Multi-Ethnic, and 3 percent were
Asian.
Criminal Case Characteristics and Legal History
Among the participants admitted to TCM, July 1, 2007 - June 30, 2010 (n=156), 90 percent
(141 participants) had prior misdemeanor convictions, 45 percent (70 participants) were
designated Operation Spotlight, and 53 percent (82 participants) had prior felony convictions.
The participant population also had an average of 19.4 lifetime arrests.
As shown in Figure 5, the most prevalent intake conviction for TCM participants was for
property-related crimes such as petit larceny, followed by drug crimes and harm against a
person (such as assault, harassment and menacing). 55 percent of participants (86
participants) enter the program due to a conviction for property crimes; 24 percent (38
participants) were convicted of possession of a controlled substance or marijuana; 15 percent
(24 participants) were convicted of crimes against a person; and 5 percent (8 participants)
were convicted of other misdemeanor offenses. A recent study examining the relationship
between homelessness, mental illness, and violent and non-violent criminal activity found that
both street and sheltered homelessness is associated with the higher likelihood of committing
non-violent crimes related to subsistence although this relationship is weaker for sheltered
homelessness16. This relationship was also observed with the TCM homeless participants,
who were mainly arrested for misdemeanor property crimes.
16
Fischer S. N., et. al. (2008) Homelessness, Mental Illness, and Criminal Activity: Examining Patterns Over Time,
American Journal of Community Psychology Vol. 42 No.3-4
15
Figure 5: Misdemeanor Intake Conviction
Misdemeanor Intake Category
100
Percentage
90
80
70
60
Property
50
40
Drugs
Harm Against Person
30
20
10
0
DCP
Arraignments
Criminal Courts
All TCM
Participants
Point of Diversion
Figure 6 shows that overall, 71 percent of participants released from arraignments and
criminal court completed the court mandate. The groups with the highest court mandate
completion rates were homeless participants and those charged with harm against a person
offenses, at about 82 percent. Operation Spotlight participants were least likely to complete
the court mandate, at 58 percent. This confirms that this sub-group is at greater risk of poor
criminal justice outcomes.
Figure 6: Compliance with Court Mandate
Completed Mandate
100
90
80
Percentage
70
60
50
40
30
20
10
0
Harm Against Arraignments
Persons
Criminal
Courts
Homeless
Operation
Spotlight
All TCM
Participants
Category
Although Operation Spotlight participants as a whole were the group least likely to complete
the court mandate, Figure 7 shows that the court mandate compliance rates varied
16
considerably by point of diversion. The Operation Spotlight participants released from
arraignments were significantly more successful in completing the court-ordered mandate
than Spotlight defendants released from post-arraignment criminal court parts after being
detained in jail for an average of one week (72% vs. 27% for post arraignment criminal court
releases). There were 25 Operation Spotlight defendants diverted into TCM from
arraignments and eleven from post-arraignment criminal court parts. Given the small sample
size, it is not clear if the distinction in court mandate completion rates is meaningful. While
differences in baseline arrest rates or severity of substance abuse problems could help explain
the difference in court mandate completion, we found that Operation Spotlight participants
diverted from arraignments and criminal court were similar with respect to these
characteristics. Further investigation is needed to determine how to treat this population in the
future.
Figure 7: Operation Spotlight Compliance with Mandate
Percentage of Operation Spotlight participants w ho w ere mandated to TCM and
completed their mandate
100%
90%
80%
Percentage
70%
60%
50%
40%
30%
20%
10%
0%
Arraignment s
Criminal Court s
All Operation Spot light Participants
Point of Diversion
Figure 8 establishes that in general the TCM program enrolled a participant population with
an average of 3.83 arrests in the twelve months before TCM program enrollment. Thus, the
program did not select lower-risk first-time offenders with a good likelihood of success. The
prior offense baseline and the prevalence of those designated Operation Spotlight (45 percent
of the TCM participants, with an average of 5.1 arrests in the prior twelve months) quantifies
in this target population the pattern of repeat low-level offending commonly associated with
mental illness17. TCM served a high-risk group of offenders with mental illness, multiple prior
offenses and criminal risk attributes, such as co-occurring substance use disorder, indicating
high risk for recidivism.
17
National Association of Mental Health Planning and Advisory Councils (2005). Jail Diversion Strategies for Persons with
Serious Mental Illness. DHHS
17
Figure 8: Mean Number of Prior Arrests One Year Pre-Admission to TCM
Number of Arrests One Year Pre-Admission to TCM
6
5.10
5
4.62
Mean Number of Arrests
4.40
4
3.83
3.53
3.39
3.21
3
2
1
0
DCP
Arraignments
Criminal
Courts
Operation
Spotlight
Homeless
Harm Against
TCM
a Person
Participants
Category
Mental Health
There were no clear differences in the mental health diagnosis of the TCM participants when
the admission routes—DCP, arraignments, and criminal court—were compared. Figure 9,
below shows the most prevalent diagnosis was Bipolar Disorder, at 38 percent. Only 19
percent of TCM participants were diagnosed with schizophrenia. The TCM program
distinguishes itself from community case management services delivered by other mental
health providers by providing case management to a larger proportion of participants
diagnosed with bipolar disorder who appear at high rates in the referrals to the program.
New York City case management programs and Assertive Community Treatment (ACT)
teams overwhelmingly serve the most disabled recipients of public mental health services.
These recipients meet the State criteria for a severe and persistent mental illness (SPMI)18 and
are more likely to be diagnosed with schizophrenia. Case management and ACT are designed
to assist people with serious and persistent mental illness to achieve the goals of illness
management, increase self-sufficiency, and increase the appropriate utilization of communitybased services. Case management is therefore an important feature of services for individuals
with a severe and persistent mental illness to support and monitor engagement and
participation in treatment services. Approximately 79 percent of recipients enrolled in these
18
Criteria for SPMI: DSM IV psychiatric diagnosis other than alcohol or drug disorders, organic brain syndrome,
developmental disabilities, social conditions and SSI/SSDI for designated mental illness or Marked impairment of self -care,
ADLs, social functioning, concentration or 50 or less on GAF scale or Reliance on psychiatric treatment
18
care coordination services are diagnosed with schizophrenia19. Approximately 67 percent of
TCM participants met criteria for SPMI. Only 3 percent were enrolled in case management or
ACT. TCM participants are generally not eligible for the care coordination case management
or Assertive Community Treatment services available to people with severe mental illness.
This is because they do not have the required number of psychiatric emergency room visits or
inpatient psychiatric admissions in the preceding twelve months, are not subject to Assisted
Outpatient Treatment (AOT) orders, and in 33 percent of cases, do not meet the standard for
severe and persistent mental illness. TCM is therefore filling an important service gap for
these individuals whose needs are not being met through existing mental health services.
TCM participants also had very limited recent mental health treatment history. On admission
to TCM, only 16 percent of participants were receiving mental health treatment through
linkage to a psychiatrist, clinic or ACT. Ten percent of participants were residents in mental
health supportive housing programs. The program was therefore working with participants
with limited pre-arrest treatment participation and no demonstrated ability to respond
positively to linkage to long-term treatment services, given their low pre-arrest treatment
rates. This was reflected in the program’s ability to link only 38 percent of the program
participants to long-term treatment services during the pilot operations. In addition to not
receiving treatment for their mental health disorders, 55 percent of participants had a medical
condition such as asthma, hepatitis C, HIV or diabetes, and the majority of these individuals
were not connected to a primary care physician.
Figure 9: Mental Health Diagnosis
Mental Health Diagnosis FY2008 - FY2010
50%
45%
40%
Percentage
35%
30%
Schizophrenia
25%
Depressive Disorder
20%
Bipolar Disorder
15%
10%
5%
0%
DCP
Arraignments Criminal Courts
Total
Unduplicated
Admissions
Screen Location
19
http://bi.omh.state.ny.us/act/statistics?p=team-summary retrieved July 10, 2010 and direct communication from Mitchell
Dorfman, NYS Office of Mental Health, Community Based Care Coordination & Treatment Services, July 2010
19
Co-occurring Substance Use Disorders
86 percent of TCM participants had co-occurring substance use disorders, higher than the 72
percent rate found in the population of people with mental illness in jails20. The most
prevalent co-occurring diagnoses among participants were Cocaine Abuse or Dependence, at
37 percent; Opioid Abuse or Dependence, at 16 percent; and Cannabis Abuse or Dependence,
at 14 percent.
As shown in Figure 10, approximately 60 percent of program participants scored three or
more on the Texas Christian University Drug Screen II, confirming the high rate of those with
severe substance abuse problems. Additionally, Figure 11 shows that 61 percent of
participants reported they had abused illegal drugs in the 30 days before their arrest for the
instant offense that resulted in the diversion. This finding is important because substance
abuse is one of the central eight dynamic risk/need factors, which are directly linked to
criminal behavior21.
Figure 10: Substance Use and Severity at Intake
Substance Use and Severity at Intake
100%
90%
80%
Percentage
70%
60%
Scored 3 or less on the TCU
50%
Scored 3 or higher on the TCU
40%
30%
20%
10%
0%
DCP
Arraignments Criminal Courts
Total
Unduplicated
Admissions
Point of Diversion
As indicated previously in Figure 5, 24 percent of TCM participants were convicted of
misdemeanor drugs crimes and 55 percent were arrested for misdemeanor property crimes.
Program staff reported that the majority of participants convicted of property related crimes
also appeared to have committed these crimes to support their drug habits in addition to
subsistence needs (see Appendix A. Case Study).
20
21
National GAINS Center (2004) The Prevalence of Co-Occurring Mental Illness and Substance Use Disorders in Jail
Andrews, D. A., & Bonta, J. (2006). The psychology of criminal conduct (4th ed.). Newark, NJ: LexisNexis.
20
Figure 11: Abused Drugs 30 Days Prior to Intake
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
No drug use 30 days prior to
intake
Total
Unduplicated
Admissions
Criminal
Courts
Arraignments
Admitted to drug use 30 days
prior to intake
DCP
Percentage
Abused Drugs 30 Days Prior to TCM Program Intake
Point of Diversion
Homelessness
Homelessness makes people with mental illness highly visible to the police and is one of the
reasons they are disproportionately involved in the justice system22. There was a very high
rate of homelessness among the program participants—51 percent were homeless upon intake
to the program (living on the streets, in shelters, or temporarily doubled up in substandard
housing). Homeless participants completed the court mandate at the rate of 82 percent. This
rate was exactly the same as the participants that had stable housing. While housing status
does not appear to have had an impact on court mandate completion, the lack of stable
housing was a major challenge when the program tried to facilitate participant engagement in
long-term treatment services. In addition, finding adequate housing for participants was
difficult. The few participants that secured supportive housing with the support of the TCM
program were only able to do so by remaining engaged in program services beyond the
standard 2-3 month program model. On average, it took the TCM program eleven months to
help five participants secure supportive housing.
TCM participants had a low incidence of chronic homelessness (defined as living in a
homeless shelter continuously for one year or living on the streets and being continuously
connected to homeless services for a least one year). Consequently, TCM participants were
not a “priority” homeless population and therefore could not access the mental health
supportive housing that has available slots but is designated solely for the chronically
homeless. The participants were repeatedly cycling through crisis and institutional settings
such as emergency rooms, detox facilities, courts and jails, shelters, and living on the streets.
They made frequent transitions and had very brief contacts with the public systems they
22
New Freedom Commission on Mental health (2004) Subcommittee on Housing and Homelessness
21
encountered. The TCM program experience suggests that homeless participants need an
integrated service approach that includes housing. Housing is a priority need for homeless
participants, and they generally are not interested in making the transition to another case
management program or provider to have this need addressed.
Figure 12: Homeless Profiles
Percentage
Homelessness Profiles Comparing Rates of Street, Shelter, and Doubled Up living
situations
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Street Homeless
Shelter
Doubled up
DCP
Arraignments
Criminal Courts
All TCM
participants
combined
Point of Diversion
Conclusion and Recommendations
ƒ The TCM program serves a high-risk target population, characterized by high rates of
lifetime arrests and frequent arrests within the twelve months before program enrollment.
ƒ 71 percent of all participants released from arraignments and post-arraignment criminal
court parts fulfilled their obligation to the Court by completing the mandate whether it
was three or five mandated case management sessions, or up to eleven months of court
monitoring. We have demonstrated the efficacy of the TCM model by successfully
diverting a population with extremely low rates of mental health treatment participation
(16 percent) and a high prevalence of other risk factors, such as substance abuse and
homelessness.
ƒ The TCM program fills an important service gap by intervening to serve participants not
eligible for traditional mental health case management services because they do not utilize
emergency rooms and psychiatric hospitals at the rate required to establish their eligibility
for these services or do not meet the standard for severe and persistent mental illness, in a
third of cases. These individuals are rapidly and repeatedly cycling through the criminal
justice system. The opportunity to intervene with these participants occurs when they
encounter the justice system.
ƒ The TCM program should evaluate the appropriateness of diverting Operation Spotlight
defendants from post-arraignment criminal court parts given their very low court mandate
completion rate.
22
SECTION III
Community Case Management Services
Overview
Case management includes a set of core functions such as outreach, assessment, service
planning, linkage, monitoring, and client advocacy. Case management models generally
contain a set of operational features such as low client staff ratios, in vivo services, and
frequent and intense contact. Within the context of jail diversion, case management helps
consumers navigate the criminal justice system, access benefits, treatment and services, and
make the transition to mainstream services.23 Hence, an effective case management program
is one of the most important components of successful diversion24.
The TCM case management services have evolved during the pilot. The initial main focus
was on care coordination to link participants to mental health and integrated treatment
services as the main pathway to reductions in criminal recidivism. Over time, the program
recognized the case managements services had to include additional components such as
counseling and problem-solving around criminal behavior. Two main participant trends
guided the revisions to the case management services. First, some participants utilized the
case management services on a voluntary basis beyond their court mandate and the standard
2-3 model, but refused to be linked to long-term treatment services. Second, even with 38
percent of participants linked to treatment and/or support services upon their enrollment to
TCM, participants continued to get re-arrested suggesting that treatment enrollment alone was
not sufficient to minimize and stop re-arrest.
In 2009, the program started to examine how its case management services could also include
criminogenic risk and need assessment and service planning services, and cognitive
behavioral skills group components to respond more directly to participant criminal
recidivism. The sections below describe how the case management staffing and services
evolved to respond more effectively to the criminogenic risk and needs of the program
participants.
Community-Based Case Management Staff
In January 2009, the program restructured the staffing model and hired a Social Work
Supervisor to supervise a Substance Abuse Case Manager and the Forensic Peer Specialist.
The purpose of the restructuring was to strengthen the functioning of the community case
management services so that the program would meet its goals and objectives. The program
identified participant co-occurring substance use disorders as the main risk factor for
recidivism and wanted to ensure the case management interventions explicitly addressed this
risk factor by promoting rapid engagement in outpatient substance abuse, detox, or integrated
mental health and substance abuse treatment services. The social worker supervisor had
previously worked in a residential drug treatment program and had extensive experience
working with dually diagnosed participants with limited motivation to participate in
treatment. Under the current model, the team delivers the community case management
services, and the social work supervisor and substance abuse case manager are each assigned
23
CMHS National GAINS Center. (2007). Practical advice on jail diversion: Ten years of learnings on jail diversion from
the CMHS National GAINS Center. Delmar, NY: Author.
24
Ibid.
23
a caseload. The forensic peer specialist provides peer support and case management as
directed by the supervisor.
Figure 13: TCM Staffing
Court-Based Screening Staff
Project Coordinator
Full-time
(Psychologist)
Community
Case Management Team
Social Work Supervisor
Full-time
Licensed Social Worker
Substance Abuse Case
Full-time
Manager (BA)
Forensic Peer Specialist
Part-time
Orientation
In January 2009, the TCM program also implemented a structured orientation protocol to
consistently collect baseline data across clinical, legal, and psychosocial domains to better
describe the participants at enrollment. The program started to use the baseline jail diversion
interview, created by the TAPA center to evaluate multi-site jail diversion programs across
the country using pre-post repeated measures. During the orientation session, the staff
administers the standardized tool that includes the Government Performance Results Act
(GPRA) client outcomes measures, psychosocial and criminal justice questions and measures
of mental health e.g., D.C Trauma Collaboration Study Violence and Trauma Screening,
Posttraumatic Stress Disorder Checklist (PCL-C), Colorado Symptom Index and the
Perceived Coercion Scale (from MacArthur Mandated Community Treatment Survey).
Once a participant is enrolled in TCM they are assigned to the caseload of the social work
supervisor or the substance abuse case manager. The orientation generally takes places
immediately after release from court for direct admissions or on the day following completion
of the DCP program. Program orientation takes place at the program office, where the
participant is introduced to the community staff by the project coordinator who completed the
screening interview. The project coordinator also gives the staff an overview of the
participant, highlighting pressing immediate needs, risk factors and details about the court
mandate.
Case Management Engagement Protocol
The TCM program developed a case management protocol to ensure new participants were
adequately oriented into the program using standardized procedures. The protocol was
implemented to increase the probability that the newly enrolled participant would engage and
be retained in the case management services. The distinct features of the initial case
management session and the mandated sessions are described below.
Session 1: Orientation and Engagement: The orientation and engagement session, which is
at least 2 hours in duration, includes: 1) administration of the TAPA Center Jail Diversion
24
Program Baseline Assessment; 2) immediate needs assessment and documentation of the plan
to address these needs such as detox, shelter and emergency psychiatric evaluation; 3) review
of legal requirements for mandated participants; 4) review of offending behavior; 5) outline of
treatment linkage options and scheduling of intake appointments; and 6) establishment of
frequency, schedule and location for case management contacts. The amount and frequency
of case management services varies according to the participant’s needs, the court mandate,
and the plan agreed-upon for treatment linkage.
Session 2: The focus of the second case management session is to engage the participant in
the TCM case management services by escorting him or her to the intake appointment
scheduled during the first session or an appointment to apply for Medicaid and entitlements.
Program staff use motivational interviewing techniques and peer counseling to explain the
benefits of treatment participation to reduce offending behavior and dynamic risk factors,
particularly, substance abuse. Sessions are also conducted in the program office for
participants to receive supportive counseling around relapse triggers, education around mental
health symptoms, medications, and the interaction between substance abuse relapse and
psychiatric decompensation and to identify preferred long-term treatment resources.
Session 3-5: These sessions provide the platform for completing the court mandate and
promoting continued participation in the voluntary program services. For those mandated into
TCM, the option to continue voluntarily is discussed within the context of the support the
program will continue to provide to ensure sufficient community supports and the reduction
of re-arrest. These case management sessions are conducted at participants’ homes, the
program office, and long-term treatment provider sites to facilitate intake into services.
Participants and Case Management Services
Over the course of the three-year pilot, 156 unduplicated participants received case
management services25. Participants were informed the program would provide services for
approximately 2-3 months until they were linked to long-term treatment services. The
exception was the small number of participants mandated by criminal court judges to remain
in the program for periods beyond the standard 2-3 month program model. Over the course of
the pilot, 63 percent of all the participants admitted from arraignments and criminal court
parts continued to participate voluntarily in case management services after they had
completed the court mandate. We also found that the Operation Spotlight participants engaged
in voluntary case management services at the same rate (63 percent). The rate of voluntary
participation for TCM compares favorably to its predecessor, the EXIT Program. The court
mandate for EXIT participants was only one three-hour assessment session, and 71 percent of
those participants had subsequent voluntary case management contact.
The relatively high incidence of voluntary program participation for mandated participants
indicates that the TCM program was able to successfully engage them. On average,
participants remained engaged in case management services for 118 days and received 12
case management sessions.
25
This total includes individuals who entered the program as self-referrals. Self-referrals were participants that returned
voluntarily for services and were re-admitted to the program without a court mandate.
25
Linkage to Long-Term Treatment Services
The central goal of the TCM program was to link participants to appropriate services, thereby
ensuring that aftercare from the Day Custody Program and direct court diversion increased
positive outcomes, including increased treatment of mental illness and co-occurring substance
use disorders. The TCM program’s contracted goal with the DOC was to link at least 50
percent of the enrolled participants to long-term treatment and support services. During the
three-year pilot, 38 percent of participants were linked to long-term treatment by the TCM
program while 38 percent of participants were already linked to either treatment or support
services upon enrollment in TCM. These services included methadone maintenance treatment
programs, clinics, supported housing, case management and ACT, and mentally ill chemically
addicted (MICA) treatment.
As shown in Figure14, during the three year pilot, the percentage of participants linked to
long-term treatment services has increased. The program attributes the increase in the overall
number of participants linked to treatment to its extensive outreach to find one primary
treatment provider, the Realization Center, which was very responsive to the needs of the
participants. The work between TCM and the Realization Center is discussed below.
Figure 14: Treatment Linkage
Percent
Percentage of Participants Linked to
Long Term Treatment
45
40
35
30
25
20
15
10
5
0
FY 2008 (N=28)
FY 2009 (N=80)
FY 2010 (N=62)
Total Participants Served Each Year
The TCM program did not achieve its contract goal to link at least 50 percent of its enrolled
participants to long-term treatment services. As previously mentioned, some of the
participants refused to be linked to long-term treatment services although they accepted the
case management services and short term treatment interventions, such as detox and rehab
treatment, and others dropped out because of re-arrest before the treatment linkage was
completed. TCM staff routinely provided case management services to help program
participants access detox and rehab services, entitlements, psychiatric evaluations and
medications, physical healthcare, half-way houses, homeless services, and other supports to
address concrete immediate needs. One unique feature of the TCM program included the
project coordinator and social work supervisor providing individual weekly supportive
counseling when necessary to fill the gap while participants were awaiting enrollment in
26
mental health clinics. Figure 15 below shows that overall, it took an average of 52 days to link
participants to long-term treatment services.
Figure 15: Average Time to Treatment Linkage
Average Number of Days for
Llinkage to Long Term Services
Average number of days
60
50
40
30
20
10
0
FY 2008 (N=28)
FY 2009 (N=80)
FY 2010 (N=62)
FY 08-10 (N=170)
Fiscal Year and Total Number of
Participants Served
Note: The total number of participants served includes self-referrals and participants with multiple admissions
In 2009, TCM also received time-limited funding that allowed the program to pilot weekly
psychiatric hours in the model. The temporary psychiatric enhancement helped address the
resistance the program experienced with participants who did not want to go to psychiatric
emergency rooms or walk-in clinics, where they had to wait for many hours to be seen. It
also addressed the long wait times between the enrollment of participants into the TCM
program and the first available mental health clinic appointment. The rapid contact between
the participants and the program psychiatrist during the pilot ensured decompensated
participants received a full psychiatric evaluation and access to medications as quickly as
possible after program enrollment.
The psychiatrist did not have the workload pressures experienced within emergency rooms
and walk-in clinics and was therefore able to spend a lot of time (at minimum one hour) with
the participants. The participants reported they felt she really listened to them, especially
around medication issues. The psychiatrist was able to get some very medication-resistant
participants to start a trial of medications. She also provided the case management staff with
comprehensive psychiatric evaluations. This increased the efficiency of the program in
making referrals to case management and ACT, supportive housing, and vocational training
and psychosocial clubs. The program had experienced many barriers getting copies of
psychiatric evaluations from external psychiatrists in a timely fashion.
The TCM program utilizes 26 different service providers to access long-term community
treatment and support services for its participants. The main treatment partner is the
27
Realization Center. The Realization Center offers a comprehensive, full-service outpatient
addictions treatment program for men and women with substance abuse issues, as well as a
range of mental health issues. 45 percent of the participants linked to long-term services by
the TCM program received services at the Realization Center. The TCM program identified
the Realization Center as the preferred treatment provider in the second year of the pilot
because of its willingness to accept participants with pending Medicaid and its ability to offer
an intake appointment within 1-3 days of the referral. In contrast, outpatient mental health
clinics had an average wait time of one month before a participant was offered an intake
appointment and only accepted individuals with active Medicaid for intake appointments.
The TCM program was not able to retain homeless participants in the case management
services until they secured housing. Homeless Operation Spotlight participants were least
likely to remain engaged in the case management services after completing the court mandate.
One of the challenges the program experienced was confirming participants’ eligibility for
supportive housing and developing housing referral packages because participants would drop
out of the case management services before these activities were completed. Without a
targeted housing intervention, the homeless participants that enroll in TCM are unlikely to
break the repeated cycle of arrest, incarceration, and homelessness.
When Behavioral Health Is Not Enough
The TCM case management services were developed to provide participants with access and
linkage to mental health and substance abuse treatment, housing and other needed supports
and resources. The program initially employed the typical case management approach found
in programs for people with severe mental illness throughout New York City. Mental health
and substance abuse treatment and housing were identified as central to supporting reductions
in recidivism and public safety outcomes. Researchers suggest this is not a valid model of
what reduces recidivism for the cross-section of people with mental illness that are involved
in the criminal justice system26. A predominant approach to understanding and preventing
arrest and incarceration includes the principles of risk, needs, and responsivity27. This
framework states criminal behavior can be predicted in a reliable manner when there is a
focus on criminogenic needs referred to as the “central eight” dynamic risk factors28.
Criminogenic needs predict recidivism more strongly than the risk factors that are unique to
mental illness such as diagnosis, symptom severity, and treatment compliance29. This
suggests diversion models such as the TCM program need to deal with the behavioral health
treatment and social needs of their participants, but the case management can be more
effective if it is enhanced with interventions that pay attention to and target criminogenic
needs.
The “what works” research recommends the assessment of recidivism risk using risk
assessment instruments to distinguish between individuals at high and low risk of re-
26
. Skeem, J. L., Manchak, S., Peterson, J, K., (2010) Correctional Policy for Offenders with Mental Illness: Creating a New
Paradigm for Recidivism Reduction. Law and Human Behavior
27
Taxman F, Marlowe D: Risk, needs, responsivity: in action or inaction? Crime and Delinquency 52:3–6,2006
28
Andrews, D. A., & Bonta, J. (2006). The psychology of criminal conduct (4th ed.). Newark, NJ:LexisNexis.
29
Skeem, J., Nicholson, E., & Kregg, C. (2008). Understanding barriers to re-entry for parolees with mental disorder. In D.
Kroner (Chair), Mentally disordered offenders: A special population requiring special attention.
28
offending30. Secondly, the level of treatment services provided should be proportional to the
individual’s risk to re-offend. Providing treatment to low risk offenders is associated with a
very mild effect of about 3 percent reduction in recidivism31. Intensive services should be
reserved for the higher risk offender. Finally, the interventions responsive to recidivism are
cognitive behavioral techniques and standardized cognitive behavioral therapy programs that
support individuals to replace criminal behavior and cognitions with prosocial behaviors and
cognitions. Researchers have also observed that many persons with serious mental illness
offend not because they are mentally ill but because they are poor and share with other
similarly situated persons exposure to various criminogenic risk factors32. Their poverty
places them at risk of engaging in many of the same behaviors as people without mental
illness. The TCM program targets a population that lives in poverty, experiences problems
with employment and has an absence of prosocial attachments in the community.
The TCM case management staff recognized they were serving a group of participants at high
risk for recidivism as they assessed the baseline criminal justice history of the participants and
participants dropped out of the case management services because of re-arrest. In January
2009, the TCM program implemented a standardized orientation session and strategies to
spend more time during the case management sessions discussing and addressing the
criminogenic needs of the participants. The program also sought advice from the stakeholders
group convened to monitor the implementation of the pilot. The program shared with
stakeholders the challenges it had experienced connecting the target population to treatment
services. Stakeholders recommended the program try to intervene using an incentive such as
employment as a stabilizing factor and pathway to enhance and enable the program to
increase its effectiveness improving the public health and public safety outcomes of its
participants. In response to this recommendation, the TCM program developed a proposal to
enhance the model by partnering with the Center for Employment Opportunities (CEO)33 to
offer participants access to transitional paid employment, job placement services and postplacement job supports. To increase the responsiveness of the core services to address
criminogenic needs the program also plans to pilot the Level of Service/Case Management
Inventory (LS/CMI), an assessment that measures the risk and need factors of late adolescent
and adult offenders, and implement a cognitive behavioral skills group using the problemsolving module of Reasoning and Rehabilitation.34 The program also continues to train the
case management staff to ensure all aspects of the case management are infused with the
cognitive interventions that target criminal recidivism.
30
Andrews, D. A., & Bonta, J., 21
ibid
32
Draine, J., Salzer, M., Cuhane, D., et al., Poverty, social problems, and serious mental illness. Psychiatric Services 53:899,
2002
33
For more than 30 years, CEO has offered immediate, effective and comprehensive employment services exclusively to
men and women with criminal records. A unique feature of the CEO model is participant access to paid transitional work
opportunities.
34
Porporino, F. J., & Fabiano, E. (2000). Program overview of cognitive skills reasoning and rehabilitation revised: Theory
and application. Ottawa: T3 Associates.
31
29
Conclusion and Recommendations
ƒ TCM case management should include a rapid treatment component such as access to a
psychiatric nurse practitioner or psychiatrist. This additional service component will
provide rapid access to psychiatry and help increase the effectiveness and efficiency of the
case management services. This strategy will reduce the program’s reliance on
emergency psychiatric services and will respond to the long-wait times some participants
experience when being linked to outpatient mental health clinics. Such a rapid approach
to psychiatric evaluation and medication management can offer a more responsive,
individualized and structured plan of action for the alienated, dysfunctional and troubled
participants that are served by the program and typically refuse linkage to mainstream
treatment.
ƒ Overall, 63 percent of participants that successfully completed the court mandate (ranging
from a minimum of 3 case management sessions to eleven months of judicial monitoring
in a few cases) engaged in voluntary case management services. Operation Spotlight
participants participated in the voluntary case management services at the same rate. This
suggests that higher-risk Operation Spotlight participants are just as likely to utilize case
management services once they are successfully engaged, as evidenced by completing the
court mandate. Therefore, they also have the potential to obtain the gains that are derived
from participation in case management.
ƒ The average length of stay in the case management services was 118 days and the average
number of case management sessions received was 12 sessions. This provides a good
platform for an effective intervention.
ƒ A program such as TCM that provides case management to participants who are heavy
users of the criminal justice system, needs to respond to the criminal recidivism risks and
needs of the participants they serve. The case management services menu is likely to be
more effective when it includes the approaches, such as cognitive behavioral
interventions, that are proven to be effective in reducing criminal behavior for higher risk
offenders.
ƒ When the program finalizes the incorporation of the assessment of criminogenic risk and
need factors and the cognitive skills focused case management approaches, further
research will be needed to establish the structure, function, and effectiveness of this case
management model of service delivery for people with serious mental illness who
repeatedly commit misdemeanor crimes.
30
Section IV RECIDIVISM
The goal of the TCM program was to demonstrate that through linkage to mental health and
substance abuse treatment, participants would have reductions in criminal justice
involvement, arrests and convictions. Recidivism analysis was conducted for all participants
admitted through DCP, arraignments and criminal court, July 1, 2007 – June 30, 2009,
(n=104) that received at least one community case management session. The analysis
compares participant recidivism across time for successful and unsuccessful program
participants. This is the most objective measurement approach because it reflects outcomes
for everyone intended to benefit from the program and not just the participants that achieved
positive results. We compare criminal justice involvement for each participant 12 months
pre-program to 12 months post-program admission. We break out this data by distinct
characteristics relevant to recidivism, including Operation Spotlight, homelessness, program
admission on “harm against a person” offenses, and participant baseline criminal justice
history.
Rationale for Measurement Periods
The 12-month pre- and post-measurement periods are intended to reflect the short-term
duration of the TCM program. The average length of program enrollment for the participants
in the recidivism analysis was 134.75 days and the average number of face to face case
management contacts was 12.42 sessions.
Changes in Arrests and Convictions
Participants admitted July 1, 2007 through June 30, 2009
n = 104
Any arrests
Arrests (Mean)
Any Convictions
Convictions
(Mean)
Pre-Admission
(1 year)
N
%
104
100%
3.83
103*
100%
3.72
Post-Admission
(1 year)
N
%
76
73%
2.60
73
71%
2.38
Percent
Decrease
27%
32%
29%
36%
*One program participant received a CPL 730 dismissal
Of the cohort of 104 participants, there was a 27 percent reduction in arrests and a 36 percent
reduction in the aggregate number of convictions
To determine whether this finding is statistically significant, the researcher conducted a paired
samples t-test evaluating the difference between the mean number of arrests 1 year prior to
admission into the TCM program and the mean number of arrests 1 years post admission in to
the TCM program. The results indicated that the mean number of arrests one year prior to the
admission date (M= 3.83, SD= 2.58), was significantly greater than the mean number of
arrests one year post admission in to the TCM program (M= 2.60, SD= 3.03), t(103) = 4.26,
p= .00, a= .05; and we must therefore reject the null hypothesis that there is no significant
31
difference between the two populations. The 95 percent confidence interval for the mean
difference between the two periods was .66 to 1.80.
Operation Spotlight Participants
Operation Spotlight Participants admitted July 1, 2007 through June 30, 2009
n = 48
Any arrests
Arrests (Mean)
Any Convictions
Convictions
(Mean)
Pre-Admission
(1 year)
N
%
48
100%
5.10
48
100%
5.02
Post-Admission
(1 year)
N
%
41
85%
3.46
39
81.00%
3.21
Percent
Decrease
15%
32%
19%
36%
The aggregate number of arrests for Operation Spotlight participants declined from 245 (5.10
per participant) in this group for the one year pre-program admission to 166 (3.46 per
participant) in the post-program admission year, a 32 percent reduction. Similarly, the
aggregate number of convictions declined from 241 (5.02 per participant) to 154 (3.21 per
participant), a 36 percent reduction. A further breakdown of conviction rates indicates that 19
percent of this group (9 participants) had zero convictions in the year following program
admission. The average arrest-free period after program intake for Operation Spotlight
participants was 75.9 days.
To determine whether this finding is statistically significant, the researcher conducted a paired
samples t-test evaluating the difference between the mean number of arrests 1 year prior to
admission into the TCM program and the mean number of arrests 1 year post admission in to
the TCM program for the Operation Spotlight Participants. The results indicated that the mean
number of arrests one year prior to the admission date (M= 5.10, SD= 2.50), was significantly
greater than the mean number of arrests one year post admission in to the TCM program (M=
3.46, SD= 3.55), t(47) = 3.22, p= .00, a= .05; and we must therefore reject the null hypothesis
that there is no significant difference between the two populations. The 95 percent confidence
interval for the mean difference between the two periods was .62 to 2.67.
Homeless Participants
Homeless Participants admitted July 1, 2007 through June 30, 2009
n = 53
Any arrests
Arrests (Mean)
Any Convictions
Convictions
(Mean)
Pre-Admission
(1 year)
N
%
53
100%
4.40
53
100%
4.25
Post-Admission
(1 year)
N
%
42
79.00%
3.34
41
69.00%
3.11
Percent
Decrease
21%
24%
23%
27%
32
The aggregate number of arrests for homeless participants declined from 233 (4.40 per
participant) in this group for the one year pre-program admission to 177 (3.34 per participant)
in the post program admission year, a 24 percent reduction. A further breakdown of arrest
rates indicates that 21 percent of this group (11 participants) had zero arrests in the year
following program admission. Similarly, the aggregate number of convictions declined from
225 (4.25 per participant) to 165 (3.11 per participant), a 27 percent reduction. A further
breakdown of conviction rates indicates that 31 percent of this group (12 participants) had
zero convictions in the year following program admission.
To determine whether this finding is statistically significant, the researcher conducted a paired
samples t-test evaluating the difference between the mean number of arrests 1 year prior to
admission into the TCM program and the mean number of arrests 1 year post admission in to
the TCM program for Homeless Participants. The results indicated that the mean number of
arrests one year prior to the admission date (M= 4.40, SD= 2.94), was significantly greater
than the mean number of arrests one year post admission in to the TCM program (M= 3.34,
SD= 3.63, t(52) = 2.24, p= .03, a= .05; and we must therefore reject the null hypothesis that
there is no significant difference between the two populations. The 95 percent confidence
interval for the mean difference between the two periods was .11 to 2.00.
Participants Arrested and Convicted of Harm Against a Person Offense
N = 19
Any arrests
Arrests (Mean)
Any Convictions
Convictions
(Mean)
Pre-Admission
(1 year)
N
%
19
100%
3.21
18
100%
2.89
Post-Admission
(1 year)
N
%
12
63%
1.74
10
56%
1.63
Percent
Decrease
37%
46%
44%
44%
The aggregate number of arrests for participants convicted of harm against a person offenses
declined from 61 (3.21 per participant) in this group for the one year pre-program admission
to 33 (1.74 per participant) in the post-program admission year, a 46 percent reduction. A
further breakdown of arrest rates indicates that 37 percent of this group (7 participants) had
zero arrests in the year following program admission. Similarly, the aggregate number of
convictions declined from 55 (2.89 per participant) to 31 (1.63 per participant), a 44 percent
reduction. A further breakdown of conviction rates indicates that 44 percent of this group (8
participants) had zero convictions in the year following program admission.
To determine whether this finding is statistically significant, the researcher conducted a paired
samples t-test evaluating the difference between the mean number of arrests 1 years prior to
admission into the TCM program and the mean number of arrests 1 year post admission in to
the TCM program for participants categorized as having committed a crime considered to be
“harm against person.” The results indicated that the mean number of arrests one year prior to
the admission date (M= 3.21, SD= 2.82), was not significantly greater than the mean number
of arrests one year post admission in to the TCM program (M= 1.74, SD= 2.40, t(18) = 1.77,
33
p= .09, a= .05; and we must therefore accept the null hypothesis that there is no significant
difference between the two populations. The 95 percent confidence interval for the mean
difference between the two periods was -0.27 to 3.22.
Participant Life Time History of Arrest and Conviction
ARREST RATE
AMONG
RECIPIENTS
(N=104) PRE vs.
POST
ADMISSION:
7/1/2007 6/30/2009
Baseline Rate for
Lifetime Arrests
(including
Misdemeanor
and Felony)
0-3
4-10
11-20
21-40
41 or more
n
9
20
18
32
25
Baseline Rate for
Lifetime Arrests
(including
Misdemeanor
and Felony)
0-3
4-10
11-20
21-40
41 or more
1 Year PreAdmission
Arrests
1.44
2.10
3.94
4.53
5.08
1 Year PostAdmission
Arrests
0.33
0.60
2.72
3.50
3.76
1 Year Pre- 1 Year PostAdmission Admission
Convictions Convictions
n
9
20
18
32
25
1.33
2.05
3.72
4.44
5.00
0.22
0.45
2.39
3.16
3.68
Difference in
Mean Values
1.11
1.50
1.22
1.03
1.32
Percent
Decrease
77.08%
71.43%
30.98%
22.76%
25.98%
Difference in
Mean Values
Percent
Decrease
1.11
1.60
1.33
1.28
1.32
83.46%
78.05%
35.82%
28.87%
26.40%
These tables show past criminal history correlates strongly with reductions in recidivism postadmission to the TCM program. Those individuals with lower lifetime arrests or convictions
are less likely to be re-arrested or re-convicted a year after admission to the program while
individuals with higher lifetime arrests or convictions are more likely to be re-arrested or reconvicted a year after admission to TCM.
34
Discussion
The preliminary recidivism analysis of re-arrest and convictions for TCM participants show
moderate and consistent reductions. Overall, participants experience a 32 percent reduction in
re-arrest. The reductions in re-arrest were also consistent for the higher-risk Operation
Spotlight participants.
The TCM program is more effective at reducing recidivism than its predecessor in
arraignments, the EXIT Program. The TCM program produced a 25 percent decrease in one
year post-admission convictions for all the participants admitted from arraignments. This
compares to the EXIT program, which produced an 18 percent reduction in convictions for all
participants in its study and a 24 percent decrease in convictions for participants that received
10 or more case management contacts35.
The TCM program recidivism results are promising but they do not appear to support the
hypothesis that linkage and engagement in long-term services facilitates the reduction in
recidivism. There was no clear difference in the recidivism reductions of the participants
linked to long-term treatment after TCM program enrollment to those not linked, as shown in
the table below.
Reduction in arrests for those linked to long-term treatment and those not
linked to long term treatment post-program admission
Average number Average number
Percent
of arrests one
of arrests one
Decrease
year preyear postArrest Status
N
admission
admission
Linked to longterm treatment
post-admission
60
3.43
2.40
30%
Not linked to long
term treatment
post-admission
44
4.36
2.86
34%
One of the main differences between the participants that experienced re-arrests compared to
the participants that were not re-arrested 12-months post-TCM program enrollment was the
baseline number of average lifetime arrests. The participants re-arrested had an average of
33.25 lifetime arrests compared to 16.54 for the group that was not re-arrested. This result is
consistent with findings that suggest the predominant factors for recidivism are baseline
criminal history combined with the central eight criminogenic risk factors displayed by
offenders without mental illness.36
35
Foley, G., & Ruppel, E, 11
Fisher, W H, et al (2006) Patterns and prevalence of arrest in a statewide cohort of mental health care consumer.
Psychiatric Services, 57 (11):1623-1628
36
35
Arrest status one year post admission to TCM and the average number of
lifetime arrests
Arrest Status
N
Average number of lifetime arrests
Rearrested one year post
admission to TCM
76
33.25
Not rearrested one year post
admission to TCM
28
16.54
Although we did not examine the correlation between case management dosage and
recidivism, the EXIT program evaluation found participants that received a higher “dose” of
the case management services delivered by the program, ten or more case management
sessions, were more likely to have a greater decrease in the number of convictions they
accumulated one year after they entered the EXIT program. The evidence that service
engagement in the case management services was an important factor to reduce repeat
offending is supported by the experience of the TCM program, which has a higher
requirement of mandated case management sessions than the EXIT program and continues to
fine-tune explicit criminogenic risk and needs assessment and cognitive behavioral skills
interventions within its case management services to address criminal recidivism.
Conclusion
ƒ TCM achieved statistically significant reductions in arrests for its participants, (i.e., all
those that enrolled in the program, regardless of whether they successfully completed the
program). These statistically significant results were maintained for distinct sub-groups of
participants; Operation Spotlight and homeless participants. These are two distinct groups
of participants we may have assumed would have experienced poorer recidivism
outcomes. The results provide evidence of the potential for TCM to achieve the goal of
reducing recidivism among people with serious mental illness who are in the justice
system for frequent and repeat arrests for misdemeanor crimes.
SECTION V
SUMMARY
When criminal and therapeutic objectives are pursued jointly in diversion services, benefits
can accrue to the defendant, victims, the court, jail, police, and the other stakeholders
responsible for criminal case management, as well as to the greater principles of justice. The
TCM program provides promising evidence that people with serious mental illness who
rapidly and repeatedly cycle through criminal court can be diverted from arraignments and
post-arraignment criminal court parts and engaged in case management services. 71 percent of
participants completed the court mandate and 63 percent continued to receive voluntary case
management services. The program also achieved a 32 percent, statistically significant,
reduction in arrest for participants (i.e., all those that enrolled in the program, regardless of
whether they successfully completed the program). The statistically significant reductions in
arrests were also achieved for higher-risk Operation Spotlight and homeless participants.
36
The program’s screening services were successfully embedded into mainstream court
operations. The TCM program’s screening resources were more efficiently deployed in the
screening and admission of arraignment and post-arraignment criminal court cases than DCP
cases. Because of the significant difference in resources needed to enroll DCP participants
into the program, TCM should seek to enroll eligible DCP participants with mental illness
directly from arraignments to increase the likelihood that these defendants will access and
benefit from the case management services. This will also ensure the program’s limited
screening resources are available in arraignments and post-arraignment criminal court, where
they are most effective.
TCM successfully identified an underserved population of people with serious mental illness
who are repeatedly arrested for misdemeanor crimes and at risk of jail sentences. The TCM
program results provide evidence that the program is a promising arraignment and postarraignment criminal court diversion model to reduce the involvement of high-risk persons
with serious mental illness in the criminal justice system.
The TCM program findings support the rationale of providing diversion services to people
with serious mental illness who have repeatedly committed misdemeanor crimes in
arraignments and post-arraignment criminal court parts. The model of short-term case
management sessions or a period of judicial monitoring mandated by the judge combined with
voluntary services for individuals at risk of repeated arrest and jail sentences shows promising
outcomes.
37
APPENDIX A
CASE STUDY
Mr. A is a 45-year-old African American male. Prior to his arrest, Mr. A had been living in
the New York City shelter system for three years. Mr. A has a long history of crack cocaine
and alcohol abuse; he has been admitted for inpatient drug treatment in the past, but received
no recent substance use treatment. Mr. A is diagnosed with bipolar disorder, but he was not
linked to a psychiatrist and tended to get his medications through the emergency room at a
city hospital. Mr. A entered the court system on a charge of petit larceny, after being arrested
on the street for selling goods stolen from a drugstore. The Day Custody Program court
representatives administered the Brief Jail Mental Health Screen (BJMHS) in arraignments,
and flagged Mr. A as needing a full mental health screening. Mr. A. met with a CASES TCM
project coordinator, Dr. Allison Upton, who conducted a full screening assessment for 75
minutes including the administration of the Texas Christian University Drug Screen II and the
Mental Health Screening Form III and confirmed Mr. A’s reported diagnosis of bipolar
disorder. Mr. A did not display obvious signs of mental illness and without the intervention of
flagging procedures implemented by CASES, he might have slipped through the system
unnoticed.
Mr. A has one prior felony conviction and 25 prior misdemeanor convictions. Two of these
misdemeanor convictions were in the year leading up to his current arrest; this meant that Mr.
A’s case was designated ‘Operation Spotlight’, and he faced an automatic jail sentence of up
to a year. Following a recommendation from the TCM Stakeholders Group, NYC sentencing
policy was changed in November 2008 to make Operation Spotlight offenders with mental
illness eligible for jail diversion. Participants are mandated to five case management sessions
with a minimum 30-day jail alternative. The TCM project coordinator successfully advocated
for Mr. A’s release to the TCM program, and he received a conditional discharge, requiring
him to complete five community-based case management sessions by a specified compliance
date, or spend 30 days in jail.
TCM staff conducted a comprehensive assessment and worked with Mr. A. to develop and
implement a needs-based service plan. They were able to get Mr. A’s benefits reinstated,
including Medicaid and food stamps, and they helped him to apply for State identification.
They focused on supporting Mr. A. to tackle the root causes of his offending behavior by
motivating him to engage in services and by linking him to a clinic providing integrated dual
disorder treatment for mental illness and substance abuse.
38
Appendix 5:
MAD Project
POLICY RESEARCH ASSOCIATES
Creating an Indigent Defense Diversion Team:
The Manhattan Arraignment Diversion Project
Jacob & Valeria Langeloth Foundation | The Legal Aid Society | Policy Research Associates
few of the diversion programs
Relatively
developed in response to the overrepresentation
of people with mental illness in the United
States criminal justice system have targeted
initial arraignment or first appearance courts.
In 2010, the Legal Aid Society piloted the
Misdemeanor Arraignment Project (MAP)
in New York City Criminal Court through
funding from the Langeloth Foundation.
The Project aims to better identify, assess,
and represent individuals with mental illness
facing criminal charges at the earliest possible
stages after arrest.
MAP is an early intervention model that
seeks to decrease the frequency of arrest
and short jail sentences for individuals with
mental illness. MAP enhances the ability of
a community to serve people with mental
illness and provides them with continuous
community-based mental health treatment,
appropriate housing, and supports.
The interdisciplinary team includes the
attorney and paralegal assigned to the case
and a MAP licensed clinical social worker.
The attorney is responsible for providing
legal representation in arraignments. He/
she works together with the other team
members to distinguish how and when
screening and assessment information
should be used in legal advocacy to assist
in the successful resolution of the case. The
licensed clinical social worker is responsible
for identifying and assessing detained
January 2013
clients awaiting arraignment, treatment
planning, and court advocacy. The social
worker is also responsible for organizing
collateral contacts with family, significant
others, and community providers. He/she
also offers referrals to community treatment
and accompanies clients in emergency/crisis
situations when necessary.
Individuals who qualify for the target
population for MAP:
ƒƒ are 18 years of age or more
ƒƒ have a mental illness and/or a substance
use disorder
ƒƒ are at risk of
xx being arraigned and released without
supportive services
xx a jail sentence
xx being held in jail pending a court
appearance
ƒƒ consent to accept assessment, referral,
and connection to treatment
Many MAP clients face challenges such as
intellectual or developmental disabilities
and homelessness or the risk of becoming
homeless, in addition to behavioral health
issues. MAP clients may be dealing with
current crises (e.g., suicidal ideation) that
require immediate attention in a psychiatric
emergency room or may have a history of
repeated use of inpatient treatment beds,
crisis services, and/or correctional healthcare.
Current engagement in treatment does not
preclude a potential client from use of MAP
services.
Table 1. 149 MAP Jail-Divertible Case Assessments
in Arraignments
Status
Participants
MAP served 250 clients between July 2010
and April 2012. These clients varied in age:
20 years old and below (10%), 21-29 years
old (20%), 30-39 years old (24%), 40-49
years old (25%), 50-59 years old (16%), and
60 years old and above (5%). A majority of
the clients were male (72%). About half of
the clients were African American (49%),
followed by Hispanic (28%), Caucasian
(15%), and other varied ethnicities.
N
%
Diverted
88
59.1
Judge Denied – DOC
32
21.5
Client Refused
17
11.4
MAP Unable to Place
4
2.7
LAS Relieved
2
1.3
Parole Hold
2
1.3
Transfer (MMTC)
2
1
Open Warrants – DOC
1
0.7
Attorney Denied – DOC
1
0.7
149
100
Total
Mood disorders (38%) and schizophrenia
and other psychotic disorders (34%) were
the most frequently seen diagnoses in clients.
Overall, 57% of clients had co-occurring
mental illness and substance abuse issues;
22% dealt only with mental illness; 7%
dealt only with substance abuse issues; and
14% were missing diagnoses.
Table 2. Legal Outcomes of MAP-Diverted
Pre-Arraignment Defendants
The crime that preceded enrollment in
MAP was most frequently larceny (29.6%),
followed by controlled substance offenses
(12.4%), assault and related offenses (11.6%),
other offenses relating to theft (10%), and
burglary and related offences (9.2%).
Status
N
%
ROR: Released on own Recognizance
44
50.0
PGSI: Conditional Discharge
24
27.3
PGSI – CASES
7
8.0
PGSI: Time Served
6
6.8
PGSI: Adj. Contemplation of Dismissal
5
5.7
9.43 – Dismissed
2
2.3
Total
88
100
Eighty-eight individuals (59%) were diverted
at arraignment. Table 2 shows the breakdown
of legal outcomes for these 88 persons.
Outcomes
Of the 27 people assessed post-arraignment,
16 (59%) were diverted, for a total of 104
persons diverted. Of the 104 clients diverted
between July 2010 and April 2012, 52% had
no arrests within one year, 16% had one
arrest, 13% had two arrests, 12% had three
arrests, and 7% had four or more arrests.
Between July 2010 and April 2012, MAP
completed 223 pre-arraignment assessments
and 27 post-arraignment assessments. Of the
223 individuals assessed pre-arraignment,
149 were determined to be jail-divertible
at arraignment. Table 1 shows the final
determinations of all 149 cases.
2
The above data was compared to the number
of arrests for 61 non-MAP-diverted clients.
Twenty-three clients either refused MAP
services, were unable to be placed, or their
Legal Aid Society attorney was relieved,
and 38 clients were either denied diversion
by the judge, were on parole hold, were
transferred, had an open warrant, or were
remanded into custody for adjudicating or
sentencing. Of these non-MAP diverted
clients, 25% had no arrests within one year,
32% had one arrest, 11% had two arrests,
10% had three arrests, and 21% had four or
more arrests. Figure 1 shows the difference
in percentage of individuals arrested at 1
year between MAP-diverted clients and
non-MAP-diverted clients.
perception of the success and usefulness
of MAP are key to evaluating potential
and ongoing success of the program.
Judicial feedback may indicate potential
modifications to procedures in the courtroom.
In addition, judicial endorsement of MAP
is an incentive for prosecutorial cooperation
and overall success.
Attorney Engagement and Endorsement
Attorneys have not generally referred matters
to social workers during arraignments but
have waited until subsequent appearances
to have social workers assist. Continuous
education of attorneys, both new and
experienced, through presentations by the
social worker will help foster understanding
of the overall arraignment part defense
strategies that can utilize social workers.
Figure 1. Proportion Arrested 1 Year Post-MAP
Assertive Assessment and Engagement of
Clients Throughout Each Arraignment Shift
80%
70%
The social worker in this role must have a skill
set suited to working with many different
personalities (clients, attorneys, judges) in a
fast-paced environment, which can often be
highly charged for the client. Social workers
must screen files prior to the attorneys and
take the initiative to suggest to the attorneys
that a client could be diverted to treatment
or back to treatment. The social worker in
the MAP project has to be on the lookout for
appropriate clients in all ways – reviewing
files, discussing with the attorneys, and
assessing clients visually and through initial
interaction. Some clients don’t want to
speak to anyone other than their attorney or
speak to anyone without their attorney. The
skill of the social worker in making clients
feel at ease in a difficult and potentially
traumatizing situation is essential.
60%
50%
40%
30%
20%
10%
0%
MAP Diverted
Non-MAP Diverted
Four Keys to Program Success
Education and Engagement of the Judiciary
Judicial buy-in and appreciation of the goals
of MAP are essential to its success. Focus
groups prior to the initiation of MAP and
subsequent follow-up with judges as to their
3
Ability to Establish Data Collection Systems
Prior to Program Initiation and Conduct Accurate
Follow Up
This is a labor-intensive part of the project.
If it is possible to secure outside help to
conduct extensive data analysis and program
evaluation, either through partnership with
a university or other outside source, this
might be ideal.
References
Ditton, P. M. (1999). Mental health and treatment
of inmates and probationers. Bureau of Justice
Statistics: Special Report. Retrieved October
10, 2012 from http://bjs.ojp.usdoj.gov/index.
cfm?ty=pbdetail&iid=787.
Substance Abuse and Mental Health Services
Administration. (1995). Double jeopardy: Persons
with mental illnesses in the criminal justice system.
Report to Congress. Retrieved October 16, 2012
from http://gainscenter.samhsa.gov/pdfs/disorders/
Double_Jeopardy.pdf.
Steadman, H. J., Osher, F. C., Robbins, P. C., Case,
B., & Samuels, S. (2009). Prevalence of serious
mental illness among jail inmates. Psychiatric
Services, 60(6), 761-765.
Teplin, L. A. (1984). Criminalizing mental disorder.
The comparative arrest rate of the mentally ill.
American Psychologist, 39(7), 794-803.
www.langeloth.org
www.prainc.com
4
Appendix 6:
Services for JusticeInvolved Veterans
Veterans Health Administration
Fact Sheet
January 2014
VA’s Veterans Justice Outreach Program:
Services for Veterans Involved in the Justice System
The Department of Veterans Affairs (VA) Veterans Justice Outreach (VJO) Program
provides outreach to Veterans involved with the local criminal justice system (i.e.,
police, jails, and courts). The goal of the program is to provide timely access to VA
services for eligible Veterans, preventing homelessness and avoiding unnecessary
criminalization, while providing routes to mental health and other clinical treatment
aimed toward a lasting rehabilitation and independence for the involved Veterans.
Approximately 50 percent of homeless Veterans have histories of encounters with the
legal system. The most recent data from the U.S. Department of Justice Bureau of
Justice Statistics (BJS) Survey of Inmates in Local Jails (2002) indicate that 9.3 percent
of people incarcerated in jails are Veterans.1 On average, these Veterans had five prior
arrests, and 45 percent had served two or more state prison sentences. Three out of five
had substance dependency problems, almost one in three had serious mental illness,
and one in five was homeless, while 60 percent had a serious medical problem. From
the beginning of the VJO program in fiscal year (FY) 2010 through the end of FY 2013,
VJO Specialists served over 66,000 Veterans, gave over 4,800 presentations to 53,000
VA and community audience members, and participated in 289 trainings for over 6,000
police officers.
Each VA medical center has a VJO Specialist who serves as a liaison between VA and the
local criminal justice system. Contact information for each Specialist is available at:
http://www.va.gov/HOMELESS/VJO.asp. Structural and procedural differences
among local justice systems dictate that not all VJO Specialists’ roles are identical. VJO
Specialists provide direct outreach, assessment, and, often, case management for
justice-involved Veterans in local courts and jails. They may also provide or coordinate
training for law enforcement personnel on Veteran-specific issues such as Posttraumatic
Stress Disorder. Specialists may assist in eligibility determination and enrollment,
function as members of court treatment teams, use evidence-based interventions
appropriate for the justice-involved Veteran population2 (e.g., Motivational
Interviewing) and refer and link Veterans to appropriate VA and community services.
Each Specialist’s time may be spent differently in achieving this mission. One may work
1
U.S. Department of Justice, Bureau of Justice Statistics. Survey of Inmates in Local Jails, 2002. Conducted by U.S.
Department of Commerce, Bureau of the Census. Ann Arbor, MI: Inter-university Consortium for Political and
Social Research, 2006.
2
See Blodgett, J., Fuh, I., Maisel, N., & Midboe, A. (2013). A structured evidence review to identify treatment
needs of justice-involved veterans and associated psychological interventions. Available at:
http://csgjusticecenter.org/nrrc/publications/a-structured-evidence-review-to-identify-treatment-needs-of-justiceinvolved-veterans-and-associated-psychological-interventions/.
1
primarily with Veterans in court, while another conducts outreach mostly in jails.3 Both
can be equally valid models for achieving VJO’s goal of linking justice-involved Veterans
with VA services, because each will reflect a locally-informed decision, made in
consultation with community partners, as to the most effective way to reach Veterans.4
VJO Specialists work with Veterans in a variety of justice system settings, but their work
in the courts is the most visible. Increasingly, this work is done in Veterans Treatment
Courts (VTC), a new but rapidly growing5 model designed to connect justice-involved
Veterans with needed treatment. VA was instrumental in creating the first VTC in
Buffalo, New York, and efficient linkage to VA health care and benefits remains a
defining aspect of the VTC model.6
VJO Specialists often contact Veterans in jail settings. The Specialists work closely with
jail administrators and staff to identify Veterans as quickly as possible, conduct an
initial clinical assessment, and facilitate linkage to needed treatment and other
resources upon release.
Because a Veteran’s contact with the justice system will often begin with a law
enforcement encounter, VJO Specialists often provide training and consultation on
Veteran-specific issues to community law enforcement agencies. As part of a joint
national initiative to promote positive resolutions of crisis encounters with law
enforcement, VJO Specialists and other VA mental health providers at each medical
center serve on local training teams with VA Police officers. By the end of 2015, all VA
Police officers will have received this two day skill-enhancement training.
VJO’s newest initiative is the Veterans Reentry Search Service (VRSS), which launched
in FY 2013. VRSS allows justice system users to identify all Veterans among their
inmates or defendants via a comparison with VA’s list of all Veterans who have served in
the United States military. Since justice-involved Veterans tend to under-report their
military service, many systems see more Veterans than they know of. For more
information about VRSS, please go to: https://vrss.va.gov/ or call the contact number
on this Fact Sheet.
Point of contact: Sean Clark, National Coordinator, Veterans Justice Outreach;
[email protected], (859) 233-4511 ext. 3188.
3
See Clark, S., McGuire, J., & Blue-Howells, J. (2010). Development of veterans treatment courts: Local and
legislative initiatives. Drug Court Review, 7, 171-208.
4
See Blue-Howells, J.H., Clark, S.C., van den Berk-Clark, C., & McGuire, J.F. (2013). The US Department of
Veterans Affairs Veterans Justice Programs and the sequential intercept model: Case examples in national
dissemination of intervention for justice-involved veterans. Psychological Services, 10, 48-53.
5
An informal VA survey identified 257 operational VTCs in November 2013.
6
Justice for Vets, “The Ten Key Components of Veterans Treatment Courts.” Available at:
http://justiceforvets.org/sites/default/files/files/Ten%20Key%20Components%20of%20Veterans%20Treatment%20
Courts%20.pdf.
2