1. Mental Health Collaboration & Holistic Public Defense Desiree Fox Meghan Gill, MA Confederated Salish & Kootenai Tribes Holistic Defense Program

2. CSKT Public Defenders Criminal Defense & Civil Legal Aid 5 Criminal Attorney/Advocates Average caseloads of 90-200 cases each – 2011-2012 Defenders represented 721 adults, 231 juveniles Development of specialized diversions – Bad checks, Minor theft, Driver’s licenses Focus on Holistic Defense – Case Management, Psychological Services, Cultural Mediations, Collateral Consequences

3. What is Holistic Defense? 4 Pillars defined by Center of Holistic Defense in Bronx, NY: 1.Accessible services meet clients’ legal/social needs 2.Interdisciplinary communication and collaboration 3.Advocates with interdisciplinary skill sets 4.Understanding and connection to the community Help address core issues that bring individuals into the criminal justice system rather than just taking a punitive approach.

4. Current Funding 2009 awarded U.S. Department of Justice Justice & Mental Health Collaboration Project – Individuals who have come in contact with the criminal justice system with co-occurring mental health & chemical dependency – Grant expired in 2012, no opportunity offered for expansion that year 2013 Kevin Howlett from CSKT THHS allowed our program access to funding for the continuation of the essential elements of the program – P/T Case Manager and Clinical Psychology Trainee

5. Goals of our Program Address needs of individuals in the community – Client-identified needs Streamline access to mental health services Develop and foster partnerships between departments and fields to collaborate for optimal client outcomes – Tribal Health, Tribal Police, Tribal Court Engage the community Propose that this will reduce recidivism

6. Individuals Served Approximately 130 individuals received some level of services Members of federally-recognized tribes that have been accused of crimes through the tribal criminal justice system on the Flathead Reservation Co-occurring mental health & chemical dependency issues Age range of those served is 18-65 years of age – Average age 31 years old – Standard Deviation of 11 years

7. Services Offered Housing – Information, Applications, Application follow-up, Problem-solving Transportation – DHRD bus system, Bus Passes, Rides, Home-Visits Financial – Financial management training, Referrals to OPA, Application assistance Employment – Information, Referrals to Voc-Rehab

8. Services Offered Educational – Information, GED, Higher Education Donations Program – Community donations of clothing, shoes, toiletries Incentive Program – Rewards for reaching milestone goals Court-ordered conditions – Fine tracking, Community Service Fine- Replacement, Assessments, Probation

9. Services Offered Cultural Mediation and Mentoring – Community volunteers, Elders Psychoeducational Groups – Educational Presentations Educational Presentations Mental Health/Chemical Dependency – Assessments, Treatment, Referrals for Treatment – Crisis Intervention, Attorney/Advocate Consults

10. Case Management Services Provided 2009-2012 79 total individuals served – 42 males, 37 females 67 formal case management clients: – 45% Housing services – 27% Transportation services – 25% Financial services

11. Recidivism Outcomes 2009-2012 Of the 67 case management clients: – 48% had zero recidivism (no subsequent offenses) Of those, 37.5% had 10+ tribal criminal offenses prior to coming into case management (not including juvenile offenses) – 80.5% had 3 or fewer subsequent offenses – Only 13% had 0 or 1 offenses prior to referral to case management

12. Psychology Services Provided 2010-2012 50 individuals received psychological services through the Clinical Psychology Trainee – 6 chemical dependency related – 4 mental health related – 20 both chemical dependency and mental health – 20 other (acute crisis intervention, consultation)

13. Case Management Data 2013 25 total individuals served – 13 males, 12 females 13 full case management clients – 61.5% Housing services – 61.5% Transportation Services – 54% Financial Services 38% of the 13 had zero recidivism

14. Psychology Services Data 2013 March through June 2013 17 individuals received psychological services through the Clinical Psychology Trainee – 4 chemical dependency related – 2 mental health related – 4 both chemical dependency and mental health – 7 other (acute crisis intervention, consultation)

15. The importance of proactively providing services to those facing multi-generational stress and current hardship. How the Holistic Defense Mental Health Program addresses barriers to treatment. Future directions to develop. Overview

16. Historical Trauma and ACE’s One possible mechanism of how historical trauma may get transmitted is via Adverse Childhood Experiences (ACE’s). The higher the number of ACE’s the more risk for illness, addiction, instability and chronic stress in adulthood. ACE Score Adult Hardship

17. Historical Trauma and ACE’s Examples of ACE’s include early exposure to: substance abuse divorce socio-economic disadvantage loss witnessing domestic violencefamily in prison caretaker mental illness neglect physical/sexual abuse The adult hardships associated with ACE’s (mental/physical illness, addictions, instability and chronic stress) then become the ACE’s for the next generation.

18. Why “well-being” services for individuals facing legal hardship? Incarceration and legal challenges correlate highly with ethnic minority and low socio- economic status. Legal challenges can lead to a sense of entrapment, humiliation or loss of social rank: all powerful risk factors for suicidal behavior and depression. Legal challenges create a cascade of stressful events, and rather than serve as a deterrent, they can severely impair a person’s functioning and mental health.

19. Why “well-being” services for individuals facing legal hardship? Psychological, emotional and social support offered in adulthood demonstrates a moderating effect on the impact of ACE’s. American Indian health disparities call for a range of responses that are creative and community-based.

20. Primary among the barriers to getting effective health care is the impact of stress on individuals facing hardship. Stress can disproportionately affect those with ACE’s and/or chronic trauma. Stress can limit motivation, energy and ability to explore. The holistic defense program makes it easier to get necessary care. Why in a defender’s office setting?

21. Barriers to Treatment Economic & transportation challenges Going to new, unfamiliar place when feeling stigma, anxiety, shame and/or depression. Meeting with an unfamiliar person (mistrust) Disrupted continuity of care (the referrals trail) Cultural fit issues with the provider and interventions Initiating care feels overwhelming Hopelessness about outcome Access: Waitlists, shortage of services & procedural delays.

22. How Holistic Defense Manages Barriers Free, sometimes closer, resulting in less transportation hurdles. Proactive outreach efforts and marketing of services. Referral is usually followed by an immediate introduction. Referral association is supportive, client centered and nonjudgmental. In the same office where clients receive legal support.

23. Flexible approach with complementary services that bridge the gap in continuity of care: travel vouchers, case management, therapy, assessments and advocacy. Options for jail visits and assessments to be done in the jail. All treatment recommendations coming from assessments are client centered. How Holistic Defense Manages Barriers

24. Case Example Relapse and Inpatient Placement. Use until incarcerated. Detox in jail and renew motivation for sobriety and/or treatment Leave the jail and try to initiate treatment. Face barriers. Relapse due to instability in living situation and inaccessibility of services.

25. How Holistic Defense Could Respond Post detox, assessment can be conducted in jail. Part of jail term can be served in in-patient treatment setting. Better prepared to manage re-entry into community Assessment contact allows for an additional source of social support after returning from treatment. Case management services can be initiated right after jail term.

26. Future Development Integration of traditional well being practices – Elder led mediation program – Mentoring Program – Culturally based interventions Support services for families and loved ones – The stress and hardship of a family member facing legal challenges radiates out to the entire social network.

27. Funding Future Development Expansion Plans 2013 JMHCP Expansion Grant Application – Juvenile services – Cultural mentoring – Increased services to those incarcerated – Full-time case manager – Data consultant

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