1. Essential Elements of the Kalamazoo Community Mental Health Recovery Court Program
Presented By:
Aki Nearchou, LBSW
&
Brian Fuller, PH.D.
KCMHSAS
418 W. Kalamazoo, MI 49007

3. Overview The extent and nature of the concern
Ten Essential Elements of Mental Health Courts (MHC)
Goals of Mental Health Courts
Kalamazoo Mental Health Recovery Court (MHRC)
What are peer support specialists and why they are an integral part of the MHRC team?

4. Extent and Nature of the Concern
13 million adults booked into U.S. jails each year.
More than 1.3 million people are currently incarcerated in the U.S.
631,000 people in jail on any given day
4.6 million under correctional supervision
Over 7% of those inmates suffer from a severe mental illness (SMI).
About 75% of the incarcerated SMI population has co-occurring addictive disorders.
Source: Steadman, Osher, Robbins, Case &Samuels, (2009)
Source Title: Prevalence of Serious Mental Illness Among Jail Inmates. (2009)

5. World Incarceration Rate
individuals incarcerated per 100,000 in the U.S.

6. Why are Persons with Mental Illness Over-Represented in the Criminal Justice System?
Higher arrest rates
“War on Drugs”
2/3 of inmates in local jails is due to drug law violations
Increased drug related offenses results in increased arrest for those that suffer from a SMI.
-Mentally ill persons are arrested at disproportionately higher rates than persons without such disorders.
-persons with mental illness use drugs at high rates.

7. SMI Over-Representation Cont.
housing of last resort
Affordable housing crisis results in a very visible homeless population that leads to crimes of survival:
Urinating in public
Panhandling
Theft
Etc.
Jails and prisons are often utilized to house individuals that have no other place to go.
Insufficient community treatment/residential options leads “mercy Bookings”

8. SMI Over-Representation Cont.
Longer jail and prison terms
Higher recidivism rate on re-entry as a result of the following:
Inadequate discharge planning
Inadequate resources
No connection to the community
Very little family and social supports
Etc.
-Mentally ill and co-occurring offenders will spend more time in jail and prison for the same offense of others that don’t struggle with SMI.

9. Many communities have adapted the Crisis Intervention Team (CIT) model
Specialty Programs that Addresses Over-Representation of persons with SMI involved in the Criminal Justice System
Many communities have adapted the Crisis Intervention Team (CIT) model
Growing number of Mental Health Courts
10 Mental Health Courts in Michigan (as of 2009)
- (Police officers are trained to be more effective in diverting the mentally ill from jails to treatment settings).

10. Ten Essential Elements of Mental Health Courts (MHC)
1. Planning and Administration
2. Co-Occurring Target Population
3. Timely Participant Identification & Linkage to Integrated Services
4.Terms of Participation
5. Informed Choice
6. Integrated Treatment Supports and Services
7. Confidentiality
8. Court Team
9. Monitoring Adherence to Court Requirements
10. Sustainability
Source: Council of State governments, Essential Elements of a MHC, (Third Edition.

11. MHC Planning & Administration
A multidisciplinary planning committee should be charged with designing the MHC.
The planning committee should identify agency leaders and policy makers to serve on an “advisory group”.
Keep the committee informed
Planning Committee: Mental health & substance abuse Treatment providers, judges, prosecutors, defense counsel, local police, sheriffs’ officials, corrections officials, mental health advocates, consumers and family, community members.
- High level policy makers, including those on the advisory group should be informed of the court’s successes and failures in promoting positive change and long term sustainability

12. Co-occurring Target Population
MI related to criminal offense
MHC’s offer options other than arrest and detention
Well defined clinical and criminal eligibility criteria
MHC screening tools
MHC’s should focus on individual defendants whose mental health and co-occurring disorders is related to their current offenses.
-MHC should offer options other than arrest and detention to the judicial and corrections systems when responding to individuals with mental and co-occurring disorders.
-Well defined clinical and criminal eligibility criteria should be developed with an understanding of treatment capacity and service accessibility in the community.
-Development of a process/mechanism (screening tools) to enable MHRC staff identification of potential candidate

13. Candidate Identification and Linkage to Integrated services.
Identified Participants
MHC Referral sources
Referral Source Training
Expedited referrals
Once identified they are referred and linked to community based service providers prior to their acceptance into MHC
-Referral Sources: MHC Judge, Prosecuting , Defense Attorney, Law enforcement, Probation and Parole office.
-MHC staff provide on going education to referral sources on eligibility criteria .
-Expedited referrals: and linkage to integrated services are especially important to individuals charged with misdemeanor offences

14. Terms of Participation
Minimize the impact of the charges
Individualized for each participant
Successful completion
Dismissal of charge
Reduced fines and cost
Well connected to community resources
MHC is a voluntary program
Option to withdraw
Minimizes impact of charges on the participants’ criminal record (diversion or reduced charge)
-Individualized: length of program, treatment expectations, restrictions (curfew etc.)
-Least restrictive supervision especially for misdemeanors to help prevent minor violations.
-Successful completion of the MHC: Reduction in fines and cost, dismissal of charges, etc.

15. Informed Choice
Participants fully understand the requirements of the MHC
Arising competency issue concerns are processed through well established and pre-determined procedures.
-In coordination with the defense attorney and Integrated treatment provider, candidates fully understand the legal and treatment program requirements.
-1 year commitment
- May need to report every other week to court
- work with community supports, ETC.

16. Integrated Treatment supports & Services.
Mental health court participants require an array of services
MHC participants typically have co-occurring substance abuse disorders
Treatment providers, Mental Health Court Team and the Participants should communicate on a regular basis
-Mental health court participants require an array of services (medication, substance abuse treatment, benefits, housing, crisis services, peer supports, and case management)

17. Confidentiality
Health and legal information is only shared in a way that protects the participants’ confidentiality rights as consumers and their constitutional rights as defendants.
Release forms that adhere to federal and state laws
Participants review releases with their defense counsel and treatment providers
Should not sign release of information forms until competency issues have been resolved
Potential participant meets with their attorney prior to entering the MHC.

18. The Court Team
Mental health court team works collaboratively to help participants achieve treatment goals by bringing together many of the following staff:
Judicial officer
Integrated Recovery Specialist (case manager)
Prosecutor
Defense attorney
Court liaison
Peer Supports
The role of each team member should be well defined and the team must be able to communicate with one another regarding the best interest of the participant.
-Discuss rewards and sanction (community service, increased AA/NA increased reporting, termination from the program, etc.)
-Each team player must be comfortable to express their unbiased opinions within the team meeting.
-The judicial players (judge, defense attorney, and prosecutor) must do their best to protect the community while keeping the best interest of the participant in mind.

19. Monitoring Adherence to Court Requirements
stay up-to-date on their progress
The mental health team and case managers regularly discuss the participants’ behavior rather positive or negative
MHC team meets on a regular basis with the judicial team
Regularly scheduled status hearings
-Criminal justice and mental health staff collaboratively monitor the participants’ adherence to court conditions by:
Stay in contact with integrated recovery specialists and other service providers
meet and openly discuss progress and/or lack of progress during status meetings
Stay connected with the community (jail, police, hospitals, etc.)
Keep an open dialogue with the participants and respond to concerns as soon as possible
- Regularly scheduled status hearings allows the MHC to publicly reward adherence to conditions of participation or to sanction non-adherence.
Graduated incentive (decreased court appearances, etc.)
Sanctions (increased meetings, reporting, community service, etc.)

20. Sustainability Performance measures and outcome data is essential.
Data describing the court’s impact on individuals and systems should be collected and analyzed.
MHC team should communicate with key county officers and state legislators.
Attempt to cultivate long-term funding sources early on.
Accurately keep track of the participant’s successes and failures.
Keep track of sanctions, jail days, criminal charges, hospital stays, crisis, ER visits, etc.
-Long term funding- (grants, local community agencies, courts, etc.)

21. The primary goal of MHC courts is to
The Goals of MHC are:
The primary goal of MHC courts is to
reduce recidivism and enhance access to & engagement in community treatment
To preserve public safety
To divert offenders with mental illness & co-occurring disorders
To maintain treatment, housing, insurance benefits and community support services for participants with mental illness
To reduce repeated criminal activity
To decrease the utilization of high cost system services
-divert offenders from incarceration to integrated community treatment services.
1. At times this population does not do well while in jail or on probation
-To help reduce repeated criminal activity by the MI/co-occurring population.
1. help move them towards recovery
2. help participants connect to community resources and solid support system.
3. Help with stable housing and medical care
4. help them gain insight into possible triggers and ways to deal with those situations (WRAP)

22. Inside a Mental Health Court
Video is Courtesy of PBS and Frontline

23. Kalamazoo Mental Health Recovery Court (MHRC)
Founded in fall of 2008
State and Federal Grants
MHRC Team:
8th District Court Judge
Kalamazoo Community Mental Health &Substance Abuse Services staff.
Defense Counsel
Prosecuting Attorney
8th district court discovered that some of the Kalamazoo SMI population repeatedly committed ordinance violations and were not suited for jail or probation.
-judges along with KCMHSAS Director discussed and concluded that Kalamazoo would benefit from the specialty court.

24. Nature and Scope of Concern in Kalamazoo County
Undersized jail
Large number of bookings and jail housing cost
High utilization of services for SMI population
Strain on budgets
Undersized jail (Kalamazoo County Jail houses 287 inmates in a community of approximately 250,000)
-Large number of bookings and jail housing cost (In 2010, Kalamazoo County jail had over 15,000 bookings and spent $750,000 in housing sentenced inmates)
-Local, state, and federal budgets are drained by increased costs associated with ineffectively serving these individuals.
Persons with severe mental illness and co-occurring disorders cycle through jails, local homeless shelters, emergency rooms, substance abuse and mental health programs.

25. Program Description Misdemeanors Recovery focused
Participants must have staff who will come to court
2 clinical staff and 2 Forensic Peer Support Specialists
Year long program
Two phases
Will take persons who have MI/DD, co-occurring and Personality Disorders
Provide Crisis Intervention Team Training (CIT) for Law Enforcement
Concept and focus on recovery is key to Kalamazoo MHRC. Recovery is a concept that covers the journey that individuals take from diagnosis to wellness
- Recovery Homework
- WRAP program
- Supports
- May include medication, AA/NA groups, therapy etc.

26. Who is eligible to Participate in the Kalamazoo Mental Health Recovery Court?
Must be charged with a misdemeanor
At least 17-years-old
Has a diagnosis of mental illness or is dually diagnosed with a developmental illness and substance abuse disorder and is in need of or assigned to case management services.
Is a Kalamazoo County Resident
No pattern of violent behavior
No more than one prior assault/battery
No more than two prior felony conviction of any kind
No violence at the time of arrest
Case by case

27. MHRC accepts referrals from:
The Referral Process
MHRC accepts referrals from:
Police Officers, District Judges, Defense Attorneys, Prosecuting Attorneys, Probation Officers, Kalamazoo County Jail staff, Family Members, KCMHSAS staff, Provider Agencies and Members of the public.

28. What Happens to an Accepted Case?
Agree to comply
Determine and assign team
Attend scheduled court hearings
Graduated incentives and sanctions
Accepted cases (A case may be in MHRC via Post –plea diversion, or a condition of probationary sentence)
-The defendant must agree to comply with a comprehensive integrated service plan as a condition of MHRC participation
-The participants work with there CM to develop plan
- May address medication, therapy, medical appointments, etc. )
-MHRC assigns a MHRC staff member and participant agency case manager to closely supervise the defendant and report progress to the judge
-The participant attends hearings before the MHRC judge at 14 and 30 day intervals depending on progress
-Individualized and graduated incentives and sanctions are used to reward positive behavior and promptly address negative behavior

29. Incentives and Sanctions
Praise from the Judge
Positive report by case mgr/PO
Clapping
See judge less often
Less judicial supervision requirements
Reduced or waived court cost /fees
Lecture from Judge
Report to MD, PhD, PO more often
Jail
Move back to phase I
Daily report to CMH
community service
Increase AA/NA, etc.
Incentives and Sanctions are discussed prior to each court session during the team meeting.
-diploma phase II and graduation

30. Performance Measure Criteria
Decrease in jail admissions, jail days, and psychiatric admissions among successful participants
Number served in MHRC
Outside researcher evaluation results
CIT training
41 participants either graduated/completed the requirements of the MHRC
39 terminated
3 administratively discharged
40 current MHRC participants

31. Outcomes for MHRC Participants* (N=37)
Jail Days
Hospital Days
37 graduates
16.7 Jail days each prior to entering MHRC
3.4 average jail days during MHRC and
Averaged 1.5 one year after
8.8 Hospital day prior
1.1 during
.5 hospital days after
Based on 37 graduates
Very early information
(N=37)
(N=37)
(N=20)
*Only those completing MHRC
*Those completing MHRC or still participating in MHRC

32. Before MHRC* % with Criminal Justice Involvement (N=62)
11.3%
Jail only
12.9%
New offense only
72.6%
BOTH new offense & jail
3.2% Neither
Speaks to the participants involved in the MHRC.
Shows active criminal justice Involvement
Kalamazoo pays other jails to house inmates, this means money
96.8% of the participants were involved in the criminal justice program 12 months prior to their involvement in the MHRC
96.8%
Criminal Justice-Involved
*In 12 months prior to enrollment

33. Before MHRC* % with Mental Health Crisis (N=62)
46.8%
Crisis contact only
35.5%
BOTH crisis contact & hospitalization
11.3%
Neither
6.5%
Hosp only
88.7 % of the 62 participants utilized either crisis residential, hospitals or both prior to MHRC involvement
88.7%
Mental Health Crisis
*In 12 months prior to enrollment

34. Felony-level Offenses (N=62)*
Higher percentage of felonies prior to MHRC involvement
Terminated group continued to commit felonies while there was a reduction in the number of felonies during and after their participation in MHRC.
Very important to the prosecutor
*statistically significant difference

35. Limitations of the MHRC
The impact of the program is limited to those charged with misdemeanors.
Integrated recovery specialist (case managers) are required to attend court with individuals they serve, but have no specific criminal justice training.
Number of participants and length of the program.
-judicial system struggles with additional sentencing for misdemeanor offenses (offense may carry a one day sentence)
Creative sentencing and sanctions
Disruption of life style (sanctions)
Limited numbers (50 max)
12 to 18 months for recovery

36. Role of Forensic Peer Specialist within Criminal Justice System
Peers play a pivotal role in the recovery process for the participants.

37. What is a Peer Support Specialist?
Individuals willing to provide history of disability and recovery with people in earlier stages of recovery
The stages of change are:
1.Precontemplation
2.Contemplation
3.Preparation/Determination
4.Action/Willpower
5.Maintenance
6.Relapse
Forensic peer support involves trained peer specialist with histories of mental illness and criminal justice involvement helping those with similar histories
-1.Precontemplation(Not yet acknowledging that there is a problem behavior
that needs to be changed)
2.Contemplation (Acknowledging that there is a problem but not yet ready or sure of  wanting to make a change)
3.Preparation/Determination (Getting ready to change)
4.Action/Willpower (Changing behavior)
5.Maintenance (Maintaining the behavior change) and
6.Relapse (Returning to older behaviors and abandoning the new change

38. Role of Peer Support Specialists within the MHRC Program
Participate in all status meetings, court sessions, etc.
Meet one on one with potential participates to determine recovery eligibility
Facilitate a 16 hour Wellness Recovery Action Plan (WRAP) training.
Meet with participants prior, during and after court sessions as needed.
79 WRAP graduates to date (new support system)

39. MHRC Participant Outcomes
MHRC successful and unsuccessful participant outcomes
48 graduation/completions
41 terminations
3 admin. Discharges
Successful: E.B. and T.L.
E.B: OWI 2008, hospitalized psychotic symptoms, no follow though with private insurance, , hospitalized in 2009 and referred to DCA, DX alcohol abuse and bipolar, married, 2 kids, treatment resistant (success: graduated program, WMU student, Treatment compliant, employed, secured housing, no new legal difficulties)
T.L.- DUI and domestic,dysfunctional home environment, alcohol dependent, police contacts per month, repeated jail stays, petitioned and hospitalized on treatment order. (success: graduated, 12 months sober, secured housing, improved family structure, zero police contact, probation officer thanked the court for the intervention, no hospitalizations, no new legal issues)
Unsuccessful: N.T. and S.M.
N.T.: DV, hospitalization and crisis stays, Borderline and MJ, homeless, poor follow through with services, (unsuccessful: terminated due to lack of recovery, recent new charges, came to court with two-three girlfriends, no WRAP,)
S.M.: borderline and alcohol/MJ, DV and DWLS, medical hospitalizations, treatment resistant, emotional dysregularity, (unsuccessful: continued legal issues, fighting, dishonest with court, new charges during, discharged due to recovery focused)
All co-occurring
Unsuccessful: personality disorders

40. Questions?

41. Kalamazoo Community Mental Health & Substance Abuse Services
Thank You
Kalamazoo Community Mental Health & Substance Abuse Services
Brian Fuller
&
Aki Nearchou