3Overview The extent and nature of the concern Ten Essential Elements of Mental Health Courts (MHC)Goals of Mental Health CourtsKalamazoo Mental Health Recovery Court (MHRC)What are peer support specialists and why they are an integral part of the MHRC team?
4Extent 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 day4.6 million under correctional supervisionOver 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)
5World Incarceration Rate individuals incarcerated per 100,000 in the U.S.
6Why 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 violationsIncreased 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.
7SMI Over-Representation Cont. housing of last resortAffordable housing crisis results in a very visible homeless population that leads to crimes of survival:Urinating in publicPanhandlingTheftEtc.Jails and prisons are often utilized to house individuals that have no other place to go.Insufficient community treatment/residential options leads “mercy Bookings”
8SMI Over-Representation Cont. Longer jail and prison termsHigher recidivism rate on re-entry as a result of the following:Inadequate discharge planningInadequate resourcesNo connection to the communityVery little family and social supportsEtc.-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.
9Many communities have adapted the Crisis Intervention Team (CIT) model Specialty Programs that Addresses Over-Representation of persons with SMI involved in the Criminal Justice SystemMany communities have adapted the Crisis Intervention Team (CIT) modelGrowing number of Mental Health Courts10 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).
10Ten Essential Elements of Mental Health Courts (MHC) 1. Planning and Administration2. Co-Occurring Target Population3. Timely Participant Identification & Linkage to Integrated Services4.Terms of Participation5. Informed Choice6. Integrated Treatment Supports and Services7. Confidentiality8. Court Team9. Monitoring Adherence to Court Requirements10. SustainabilitySource: Council of State governments, Essential Elements of a MHC, (Third Edition.
11MHC 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 informedPlanning 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
12Co-occurring Target Population MI related to criminal offenseMHC’s offer options other than arrest and detentionWell defined clinical and criminal eligibility criteriaMHC screening toolsMHC’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
13Candidate Identification and Linkage to Integrated services. Identified ParticipantsMHC Referral sourcesReferral Source TrainingExpedited referralsOnce 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
14Terms of Participation Minimize the impact of the chargesIndividualized for each participantSuccessful completionDismissal of chargeReduced fines and costWell connected to community resourcesMHC is a voluntary programOption to withdrawMinimizes 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.
15Informed ChoiceParticipants fully understand the requirements of the MHCArising 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.
16Integrated Treatment supports & Services. Mental health court participants require an array of servicesMHC participants typically have co-occurring substance abuse disordersTreatment 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)
17ConfidentialityHealth 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 lawsParticipants review releases with their defense counsel and treatment providersShould not sign release of information forms until competency issues have been resolvedPotential participant meets with their attorney prior to entering the MHC.
18The Court TeamMental health court team works collaboratively to help participants achieve treatment goals by bringing together many of the following staff:Judicial officerIntegrated Recovery Specialist (case manager)ProsecutorDefense attorneyCourt liaisonPeer SupportsThe 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.
19Monitoring Adherence to Court Requirements stay up-to-date on their progressThe mental health team and case managers regularly discuss the participants’ behavior rather positive or negativeMHC team meets on a regular basis with the judicial teamRegularly 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 providersmeet and openly discuss progress and/or lack of progress during status meetingsStay 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.)
20Sustainability 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.)
21The primary goal of MHC courts is to The Goals of MHC are:The primary goal of MHC courts is toreduce recidivism and enhance access to & engagement in community treatmentTo preserve public safetyTo divert offenders with mental illness & co-occurring disordersTo maintain treatment, housing, insurance benefits and community support services for participants with mental illnessTo reduce repeated criminal activityTo 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 recovery2. help participants connect to community resources and solid support system.3. Help with stable housing and medical care4. help them gain insight into possible triggers and ways to deal with those situations (WRAP)
22Inside a Mental Health Court Video is Courtesy of PBS and Frontline
23Kalamazoo Mental Health Recovery Court (MHRC) Founded in fall of 2008State and Federal GrantsMHRC Team:8th District Court JudgeKalamazoo Community Mental Health &Substance Abuse Services staff.Defense CounselProsecuting Attorney8th 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.
24Nature and Scope of Concern in Kalamazoo County Undersized jailLarge number of bookings and jail housing costHigh utilization of services for SMI populationStrain on budgetsUndersized 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.
25Program Description Misdemeanors Recovery focused Participants must have staff who will come to court2 clinical staff and 2 Forensic Peer Support SpecialistsYear long programTwo phasesWill take persons who have MI/DD, co-occurring and Personality DisordersProvide Crisis Intervention Team Training (CIT) for Law EnforcementConcept 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.
26Who is eligible to Participate in the Kalamazoo Mental Health Recovery Court? Must be charged with a misdemeanorAt least 17-years-oldHas 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 ResidentNo pattern of violent behaviorNo more than one prior assault/batteryNo more than two prior felony conviction of any kindNo violence at the time of arrestCase by case
27MHRC accepts referrals from: The Referral ProcessMHRC 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.
28What Happens to an Accepted Case? Agree to complyDetermine and assign teamAttend scheduled court hearingsGraduated incentives and sanctionsAccepted 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
29Incentives and Sanctions Praise from the JudgePositive report by case mgr/POClappingSee judge less oftenLess judicial supervision requirementsReduced or waived court cost /feesLecture from JudgeReport to MD, PhD, PO more oftenJailMove back to phase IDaily report to CMHcommunity serviceIncrease AA/NA, etc.Incentives and Sanctions are discussed prior to each court session during the team meeting.-diploma phase II and graduation
30Performance Measure Criteria Decrease in jail admissions, jail days, and psychiatric admissions among successful participantsNumber served in MHRCOutside researcher evaluation resultsCIT training41 participants either graduated/completed the requirements of the MHRC39 terminated3 administratively discharged40 current MHRC participants
31Outcomes for MHRC Participants* (N=37) Jail DaysHospital Days37 graduates16.7 Jail days each prior to entering MHRC3.4 average jail days during MHRC andAveraged 1.5 one year after8.8 Hospital day prior1.1 during.5 hospital days afterBased on 37 graduatesVery early information(N=37)(N=37)(N=20)*Only those completing MHRC*Those completing MHRC or still participating in MHRC
32Before MHRC* % with Criminal Justice Involvement (N=62) 11.3%Jail only12.9%New offense only72.6%BOTH new offense & jail3.2% NeitherSpeaks to the participants involved in the MHRC.Shows active criminal justice InvolvementKalamazoo pays other jails to house inmates, this means money96.8% of the participants were involved in the criminal justice program 12 months prior to their involvement in the MHRC96.8%Criminal Justice-Involved*In 12 months prior to enrollment
33Before MHRC* % with Mental Health Crisis (N=62) 46.8%Crisis contact only35.5%BOTH crisis contact & hospitalization11.3%Neither6.5%Hosp only88.7 % of the 62 participants utilized either crisis residential, hospitals or both prior to MHRC involvement88.7%Mental Health Crisis*In 12 months prior to enrollment
34Felony-level Offenses (N=62) *Higher percentage of felonies prior to MHRC involvementTerminated 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
35Limitations 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 sanctionsDisruption of life style (sanctions)Limited numbers (50 max)12 to 18 months for recovery
36Role of Forensic Peer Specialist within Criminal Justice System Peers play a pivotal role in the recovery process for the participants.
37What is a Peer Support Specialist? Individuals willing to provide history of disability and recovery with people in earlier stages of recoveryThe stages of change are:1.Precontemplation2.Contemplation3.Preparation/Determination4.Action/Willpower5.Maintenance6.RelapseForensic 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 behaviorthat 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) and6.Relapse (Returning to older behaviors and abandoning the new change
38Role 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 eligibilityFacilitate 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)
39MHRC Participant Outcomes MHRC successful and unsuccessful participant outcomes48 graduation/completions41 terminations3 admin. DischargesSuccessful: 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-occurringUnsuccessful: personality disorders