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Best Practices Model for Intervention with the Mentally Ill in the Broward County Criminal Justice System Quality of Life Grant 2007 2008 2007-2008 James Pann, Pann Ph Ph.D., D Lenore Walker Walker, Ed Ed.D. D (Co (CoPrincipal Investigators), David Shapiro, Ph.D., & Vincent Van Hasselt, Ph.D. Introduction y Rising trend for mentally ill to be in and out of jails nationally y 20% diagnosable mental illness with over 50% history y Broward jail no exception with 18% of 5,500 in 2005 y Special mental health unit with full range of services y Evaluations 2001 – 464 p month to 2005 – 614 p month +32% y MH Unit 2001 – 194 p month to 2005 - 375 p month +104% y Speciall units in men’s ’ andd women’s ’ jails l ffor ddomestic violence l & substance abuse y Design g of a jjail not supportive pp of mental health treatment y Revolving door with mentally ill having high recidivism rate y No continuity of care and treatment with community agencies O Overview i off P Project j t y Grant was funded by the Broward Sheriff Sheriff’ss Office (BSO) and NSU y NSU research group reviewed the literature and consulted national eexperts perts to determine the best practices in the identification and intervention with the mentally ill in the criminal justice system y Researchers attempted to objectively examine the relevant issues and related controversies while conductingg this studyy Overview of Project (cont.) (cont ) y Conceptualized process a mentally ill person would go through once y y y y y y y y y y encounteredd by b police l officer ff Reviewed the literature on best practices of each step Interviewed consultants on best practices p Presentation at APA in August 2007 for feedback Discussed available services at BSO Attended Judge Speiser’s Speiser s Task Force meeting Telephone survey of community agencies Attended misdemeanor and felony mental health courts Hired lead interviewer, Julie Bruno, Psy.D. to assist with coordinating and interviewing selected community agency personnel Completed qualitative (interviews) and quantitative (surveys) data analysis l Prepared report and submitted to BSO for feedback Students & Residents Involved in Study At all stages we worked together with graduate students at CPS and Post Doctoral Residents at CJI. y Ryan R M Montes, M M.A. A y Justin Rigsbee, Ph.D. y Amy Angleman, M.S. y Alison Nemes, Psy.D. y Lauren Katchen, Psy.D. y Maria Karilshtadt,, Ph.D. y Kelley Gill, M.S. y Gretchen Lamendola,MS y Gillespie Stedding, Stedding M.S. MS y Markesha Bennett, M.S. y Eduardo Vargas, M.S. y Crystal C lC Carrio, i M M.S. S WHAT IS THE BEST PRACTICE MODEL? KEEP MENTALLY ILL PEOPLE OUT OF JAIL WHERE EVER POSSIBLE BALANCE PUBLIC SAFETY If need treatment, follow BPM B Best P Practice i M Model d l 1. 2. 3. 4. 5. 6. 7. Pre-arrest diversion by law enforcement into community treatment facilities Diversion out of the criminal justice system after arrest into treatment or problem-solving problem solving courts Problem-solving court diversion with monitoring in the communityy Mental health treatment while in jail Competency p y restoration simultaneous with treatment programs in hospitals and in the community Mental health probation if on community release Long-term mental health treatment in the community - Seamless continuity with treatment in jail BPM for Treatment y Good Case Management y Housing Needs y Job Training y Crisis Services y Coordinate with jail & probation y Competent Medical Care y Appropriate Medication Available y Psychological & Neuropsychological Evals y Psychotherapy y Trauma Therapy y Cognitive Rehabilitation y Substance Abuse Treatment y Competency Restoration Intervention y Integration with families y Continuity of Care & Integration with other community agencies and services Crisis Intervention Team (CIT) y Mission: “CIT is a community partnership working with mental health consumers and professionals, and family members. The goal is to set a standard of excellence for officers with respect p to the treatment of individuals with mental illness. This is accomplished by establishing individual responsibility for each event and overall accountability for the results. Officers will be pprovided with the best qqualityy trainingg available,, theyy will be part of a specialized team which can respond to a crisis at any time, and they will work with the community to resolve each situation in a manner that shows concern for the citizen’s well being.” g Major Sam Cochran Memphis Police Department Historical Overview y Initiated in 1988 b by Memphis PP.D. D in partnership with ith NAMI NAMI, mental health providers, and two Universities (Memphis and Tennessee) y Developed to provide a more intelligent and safe approach to crisis events y Composed of volunteer officers y Training by mental health providers, family advocates, and mental health consumer groups CIT Training Topics y Suicide Awareness and Intervention y Alcohol and Drug Assessment y Co-Occurring Disorders y Homeless Mentally Ill y Psychotropic Medications & Side Effects y Personality Disorders y Developmental Disorders y Posttraumatic P SStress D Disorder d y Crisis Intervention CIT Training Topics (cont.) (cont ) y Clinical Issues - Children’s Mental Health y Baker Act/Marchman Act y Special Needs of Older Adults y Family & Consumer Perspective y Role Plays y Legal Aspects y Community Resources y CIT Policy P l & Philosophy Ph l h y Mental Illness from the Inside CIT Program Benefits y Immediate Crisis Response y Decrease in Arrests and Use of Force y Decrease in Patient Violence and Use of Restraints y Decline in Officer and Consumer Injuries y Consumers are Identified by Officers and Provided with Care CIT in Broward County y Initiated in 2002, with Fort Lauderdale Police Department as First Participating Agency y CIT C Coordinated d d andd FFacilitated l d bby N Norma W Wagner off the h Broward Regional Health Planning Council y Program Has Expanded to Six Additional Law Enforcement Agencies g y From 2002-2008, 12 CIT Trainingg Events With 286 Participating Officers Participating Agencies y National Alliance on Mental Illness (NAMI) of Broward y Henderson Mental Health Center y Broward Regional Health Planning Council y North Broward Hospital District y Department of Children and Families y Broward Coalition for the Homeless y Nova Southeastern University Future Plans y Encourage a Greater Number of Police Agencies to Participate y Implement I l t a Research R h Program P tto D Determine t i th the Impact I t off CIT in Broward County Problem Solving Courts y y y y Deferral at earliest point in system Vl Voluntary consent Cooperation between prosecution and defense Community agency collaboration and funding y Adequate Programs y Out Patient y Residential y Adequate Space y Adequate case management y Frequent status conferences y Adequate housing Misdemeanor Mental Health y y y y y y y y Broward is the model and leader in US Early identification Non-punitive Voluntary Mental health staff in courtroom Frequent status conferences (monthly) Strong case management P supportt group Peer y Collaboration with NAMI y Will be staffing Freedom House y N Needd more community it agencies i andd services i y Goal is to take responsibility for maintaining own mental health Felony Mental Health y Person may be deferred into felony MHC if history of or current y y y y y y serious mental illness and arrested for non-violent felonyy Referral after arrest or while in jail by attorney, judge or jail staff Not voluntary Mental health staff in courtroom Court Projects refers for competency or psychological evaluation Referrals to MH agencies after reports to judge C management andd speciall probation Case b y Follow up with VOPs to avoid revocation & jail y Psychological evaluation is done prior to being deferred into y y y y MHC by court-appointed psychologist MHC judge keeps case and continues to follow up legally Some ggo to MH pprobation and communityy treatment pprogram g Judge holds monthly meeting for all stakeholders Over 1400 cases in first three years Drug Court y Early identification of addiction y Immediate I di t deferral d f l upon arrestt y Voluntary and must meet state criteria y Users not drug pushers or sellers y 12 to 18 months treatment for addiction y Residential or out-patient treatment y Develop substance abuse therapeutic community y BPM includes SA +2 co-occurring co occurring disorders – M.I. M I & Trauma y Need psychotherapy, DV & trauma tx with S.A. treatment as part of probation y Treatment may be in jail or in community settings settings, or in other locked y y y y residential facility Treatment for abuse issues is also major importance. Frequent follow-up by court Need more mental health and trauma treatment Need more programs for ‘co-occurring’ disorders or ‘dual diagnosis’ Domestic Violence Court y Early identification y Well trained BSO DV Officers y Not voluntary y Misdemeanor and felony criminal y Restraining R i i orders d ffor protection i off victims i i y Need better understanding of protective mothers re: child access y More coordination with familyy court re: p protect children y More coordination with DCF & dependency court re: children y Referral to approved treatment providers y Offender Specific p Treatment + MH therapy py is BPM y BPM for Treatment includes MHP contact with victims & DV probation y Need special treatment for women DV perpetrators y Need better follow up p and timelyy contempt p hearings g y Need better collaboration with BSO DV officers and units Mental Health Programs in Jails y y y y Jail vs. Prison Sh t t Short-term Focused on acclimating to jail Psychiatric y unit y Individual therapy y Psychotropic medication y Domestic violence units y Women y Men y Substance S b abuse b units i y AA, NA, ALANON groups y Educational programs p g Important Issues for Treatment in Jail y Groups in jails different from prisons or other agencies y Open groups rather than closed groups y Best if on special contained unit y Can not control numbers attending so need more therapists y Less like therapy if new members in & out but still therapeutic y Time commitment is great for outside therapists Helpful to have manualized treatment but may not cover same issues in one session in jail as in community due to factors beyond control y Each session must stand on its own as cannot count on women returning to group next week. week Each unit requires own materials & evaluation measures. y Expect group members to be on different levels y Staff S ff ffollow-up ll iff emotionall issues occur& coordinate d MH tream y Continuation in community when discharged STEP in Detention Center Setting C bi d BAI M Combined Means ffor S Sessions i 1 1-10 10 Literature Review on Tx in Jails y Need to train correctional officers in M.I. y Need N d trained i d MH caseworkers k as part off staff ff y Need to do Admission Screening y Mental M l ill illness y Suicide risk y Need special mental health housing y Types of tx available y CBT, CBT DBT, DBT therapeutic communities communities, behavioral techniques (token economies, skills training), medication, groups y Not useful y Regressive interventions, interpersonal trust, development of insight Competency Restoration y Problem area y What constitutes competency? What does it mean to be restored? y Adjudicated Adj di t d ITP y the person must be mentally ill y unable to understand the charges or court proceedings or assist counsel in his or her own defense y Treatment of mental illness should occur simultaneously in BPM y When should competency restoration begin? y Cannot force medication in jail unless dangerous y Need more collaboration with defense attorneys y Frequent q movement in and out for hearings g y Where should treatment occur? y Out-patient y In-patient y How longg should it last? y What to do about those deemed non-restorable? y Up to 3 years misdemeanor & 5 years felony and then discharged or civilly committed y Need more communityy based services integrated g with BMP y Address psychological issues and not only competency in competency restoration programs Community Based Programs Community-Based y Forensic clients be seamlessly integrated into community programs y Similar treatment programs in the community communit as when hen the they lea leavee a facility, ensuring continuity of care y It is the availability of intervention programs with intensive case management access to psychotropic medication when needed management, needed, psychotherapy, competency restoration, drug treatment, domestic violence trauma therapy, and residential services for short periods (or longer g pperiods for severelyy and ppersistentlyy mentallyy ill)) that is needed in the community y Appropriate housing including Assisted Living Facilities (ALF) with transportation p to treatment facilities are needed y Family members need support services to assist them in their care of the mentally ill. Needs Assessment in Community y Needs of mentally ill y Needs of community agencies y Program practices y Community service listing y Staff challenges y Pre-arrest Pre arrest diversion y Competency restoration y Special mental health jail Stakeholder Interviews y The research group conducted semi-structured interviews with 24 key community stakeholders representing the criminal justice and mental health systems in Broward County Department of Children & Families (DCF) Nova Southeastern University Broward Sheriff's Office (BSO) Judges and public defenders office DCF have privatized some of its services in Broward County, so agencies within the community that have been awarded such contracts t t are also l included. i l d d y Independent mental health agencies and independent mental health providers who also are available to deliver services to the mentally ill y y y y y Data Analysis y Notes from the interviews were compiled and analyzed by the y y y y researchh team Conventional content analytic approach was utilized Two members from the research team independently read and attempted to obtain an understanding of the interview notes The researchers coded the notes and identified response patterns Codes were sorted into categories and then themes were identified Data Analysis (cont.) (cont ) y Patterns were identified as relevant themes if they occurred with sufficient ffi i frequency f y Research group members conducted a review of the themes with the interviewers in order to ensure the reliabilityy and validityy of the findings y Descriptions for each theme were developed and the themes were organizedd bbasedd on respondent d type (e.g., community provider, d court, etc.) to facilitate the reporting of the results y For example y For pre-arrest diversion most respondents indicated that it was effective but that it should be more widely used. y Need N d more iincentives/encouragement i / ffor officers ffi to participate. ii y Need more efficient system for Baker acting indiv.; Freedom house Survey y Developed instrument to administer along with interviews y Assessed 14 priority areas y Specialized treatment y Dual D l di diagnosis i y Women- trauma and DV y Structured approach pp to complement p interviews y Descriptive analysis by item y Findings were consistent with the interviews Findings y Increase available services y Case management y Co-occurring Co occurring disorders y Residential treatment facilities y Better integration between mental health programs in jail and in community y Medication issue y Treatment planning y Dynamic referral system using current IT y Training for staff y Need d better b forensic f related l d training for f sociall service staff ff y Partner with NSU for training future staff needs y CE & certificate programs for current staff needs y Mental health p probation officer program p g y Special needs jail y Therapeutic design y Not to become a “dumping ground” NSU Recommendations y y y y y y y y y y Community Agencies & BSO adopt BPM BSO continue training in CIT model Increase residential beds in community for M.I. Develop coordination for forensic & non-forensic C Community it llearn about b t jjailil treatment t t t & BSO llearn about b t community it treatment Integrate continuity of care whether in jail or community All attend monthly monthl MHTF meetings coordinated by b Judge Speiser Increase budget and MH staff for problem solving courts & integrate with community & jail Special programs for women in community including trauma treatment Develop problem solving courts for mentally ill, domestic violence, and substance abusing juveniles and integrate especially for those who are about to “age-out” g of the DCF system y