improving employment outcomes for individuals with psychiatric disabilities adults with smi,...

Improving Employment Outcomes for Individuals with

Psychiatric Disabilities Adults with SMI, Substance Use/Abuse &

Corrections History

Charles Bernacchio, Ed.D., CRCEileen J. Burker, Ph.D., CRC

University of North Carolina at Chapel Hill Consultants:

Obie Johnson, BA/QMHPLaurie Coker, Director of NC Consumer

Advocacy Network and Support Organization

December 1, 2011

TACE Center: Region IV, a project of the Burton Blatt Institute.Funded by RSA Grant # H264A080021. © 2011

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Overview

• Reasons for & prevalence of SMI in corrections

• Co-occurrence of substance use/abuse

• National effort for alternatives (MIOTCRA)

• Mental health treatment within corrections

• Re-rentry challenges and models

• Integrated treatment of CODx


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Adults with SMI, Substance Use/Abuse & Corrections History • High numbers of people w/ SMI cycle through the

criminal justice system, often resulting in tragic outcomes for them, their families, and their communities .

• Law enforcement, courts, and corrections funding has been ineffective in resolving the problem.

• People w/ SMI are being incarcerated, oftentimes for minor offenses, and would be better served in the community, e.g., using jail diversion or community courts.


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Adults with SMI, Substance Use/Abuse & Corrections History • Mandated treatment of inmates w/ SMI within

corrections, reveals the system inadequacies for addressing the needs of this population.

• State/local governments face budget deficits, grapple with growing jail populations and reduce community services including mental health.

• Report findings are most reliable estimates of rates of adults w/ SMI entering jails in the last 20 years.

(Justice Center-CSG, 2009)


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Prevalence of SMI in Corrections

• Research on SMI included- bipolar, schizophrenia spectrum, and major depression disorders.

• Study of more than 20,000 adults in five local jails, researchers documented clinical presence of SMI in 14.5 % of men and 31 % of women, which taken together, comprises 16.9 % of study sample.

• Study highlights population w/ most significant disabilities and greatest need for comprehensive and continuous treatment, both inside the jail and after release.

• Estimates for women w/ SMI are double rates for men. Gender difference is particularly important given a rising number of women in U.S. jails.


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Prevalence of SMI in Corrections

• Estimates applied to the 13 million jail admissions reported in 2007, the study findings suggest that more than 2 million bookings of a person with a serious mental illness occur annually. Why?

• People w/ SMI confront public misperception of being violent (when in fact it is less than 1%); convictions are more often due to drug-related behaviors

• High rates of co-occurring SUDs help explain more arrests/convictions for drug-related crimes.


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Regier et al, JAMA 1990

Prevalence of substance use disorders in mental illness

This graph shows the percentage of people surveyed who had a substance use disorder. The bar on the left shows that about 15% of people in the general population had a substance use (alcohol or drug) disorder at some time in their life. The next bar show that almost 50% of people with schizophrenia had a substance use disorder and the next bar shows that people with bipolar disorder had even higher rates. The final three bars show that a quarter to a third of people with milder mood and anxiety disorders also have a substance use disorder at some time in their life.

0

10

20

30

40

50

60

% of respondents

with substance use disorder

Gen pop Schiz Bipolar Maj dep OCD Panic


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SMI & Co-morbid Substance Use/Abuse (CODx) • Relevance to address acute substance use/abuse

symptoms present closely linked w/ criminal behavior • Argument that behavioral health interventions are more

appropriate for them than arrest/jail.• Most engaged early with corrections system present as

being more actively symptomatic (high presence of psychotic features); often associated w/ crises (seen as untreated SMI; may encounter CIT).

• Population w/CODx have higher rate of acute SA symptoms when encountering law enforcement and often violent (self-medicating untreated SMI results in exacerbating agitation and aggression).


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Other Factors Related to Incarceration• People w/ SMI are often unable to access affordable

housing, and homelessness; frequently associated with arrest.

• Many people w/ SMI also have no health insurance or cannot access community care; some who are actively symptomatic do not seek care.

• Certain personality disorders (APD) are associated with more serious criminal behavior.

• A combination of these and other factors help account for the high rates of people with mental illnesses in jail.


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Institutional Trauma from Corrections Experiences

• Most prison officials agree with community-based treatment providers- a jail environment is not the best treatment setting for people w/ mental illnesses—in fact, this environment can exacerbate mental illnesses in a manner that poses risks to the individuals, the general jail population, and jail staff.

• Abuses while in jail can have lasting effects on persons w/ SMI; escalates use of substances.


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Implications for a National Initiative

Mentally Ill Offender Treatment Crime Reduction Act (MIOTCRA)

Supports comprehensive strategies to reduce recidivism and the prevalence of mental illnesses in jail, including:

• specialized police-based responses (CIT); • jail diversion and mental health courts (treatment

alternative); and • jail interventions, that all provide continuity of care,

training for community correction officers, and provision of evidence-based services and supports.


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Mental Health Treatment in Prison • The Criminal Justice/ Mental Health Census Project

(Council of State Government’s Justice Center) developed recommendations to improve the criminal justice system’s supports of individuals with mental illness: screen all detainees for mental illness, use

standardized tools and a trained screener, screening protocols should include suicide

assessment positive screens should result in a referral to a mental

health professional for a full mental health assessment facilitate release of information between jail and

provider


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Mental Health Treatment in Prison • The Criminal Justice/ Mental Health Census Project

recommendations continue: have in-house crisis response and short-term mental

health treatment facilitate individual’s continued use of prescribed

psychotropic medication begin discharge planning at the time of booking

(Scheyett, Vaughn & Taylor, 2009).


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Mental Health Treatment in PrisonThe following are six basic principles that should be

addressed in a gender responsive program for incarcerated women:

• Acknowledge that gender makes a difference. • Create an environment based on safety, respect, and dignity.• Develop approaches that are relational and promote healthy

connections to children, family, significant others, and the community.

• Address substance abuse, trauma, and mental health issues through comprehensive, integrated, and culturally relevant services and appropriate supervision.

• Provide women with opportunities to improve their socioeconomic conditions.

• Establish comprehensive and collaborative services for women reentering the community.

(Covington & Bloom, 2006)


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Mental Health Treatment in PrisonColorado Department of Corrections:• Evaluated the effectiveness of a modified Therapeutic

Community (TC) treatment program vs. a Mental Health (MH) treatment program for inmates with co-occurring SMI and substance abuse.


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Mental Health Treatment in PrisonThe TC program involved:• CBT and TC principles to change attitudes & lifestyles in 3 areas:

substance abuse, mental illness, criminal thinking and behavior• Psychoeducational classes to help inmates recognize their addiction

and drug use patterns, understand their diagnosis, develop emotional and behavioral coping skills for the substance abuse and mental health problems

• CBT protocols to help inmates examine how they interpret events to justify criminal behavior, teach ways to recognize and modify distorted perceptions and inappropriate responses

• Mental health status evaluation daily & medication use monitoring • Therapeutic interventions including groups to discuss personal

issues & address malaptive behaviors and foster personal responsibility with peer support & feedback

• Inmates attend the program 5 days/week 4 to 5 hrs/day


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Mental Health Treatment in PrisonColorado Department of Corrections:• The MH program involved:

• Weekly individual therapy, counseling & groups• Mandated CBT curriculum (thought process,

assertiveness training, problem solving, distorted thinking, stress mgt, personal responsibility)

• Anger management• Domestic violence and parenting• Weekly drug/alcohol therapyThe main difference between the 2 treatments was TC’s

use of the community as the healing agent & reliance on mutual peer self help.


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Mental Health Treatment in PrisonColorado Department of Corrections:• Inmates who completed the TC program in prison could

participate in the TC aftercare program after release.• Independence House, the TC-focused after-care

program, helps released inmates continue to work on their criminal thinking & behavior, master community living, integrate back into society, gain employment, connect with the larger recovery community.

• Activities focus on basic skills (cooking, banking, libraries), relapse prevention, symptom self-mgt, & coping.

• Mental health counseling, medications, and psychiatric services are provided by a local mental health center.


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Mental Health Treatment in PrisonColorado Department of Corrections Study Findings:• Duration of treatment:

TC + aftercare gp = 22 months TC only = 15 months MH = 11 months

• TC groups vs. MH group:• TC groups had lower rates of reincarceration

• TC + aftercare group (TCA) vs. MH group:• TCA group had lower rates of reincarceration & criminal

activityFindings suggest a need for long treatment duration and

continuous in prison and post-prison components. (Sacks, Sacks, McKendrick, Banks, & Stommel, 2004).


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Moving from Prison to Release

The Jail Inreach Project• For homeless individuals in prison with mental illness,

substance use disorders or both in a county jail in Texas• Provides services to treat mental health and substance

use issues improve health, and support social integration• Project continues to provide continuity of care and

access to care after jail release• Outcome:

More than 1/2 of persons in project remained connected with services after jail release

Less than 1/3 who weren’t in the program remained connected with services they had received while incarcerated.

(Buck, Brown, Hickey, 2011)


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Moving from Prison to Release

Oklahoma’s Discharge Planning program• Implemented in 3 Oklahoma state prisons for inmates with

SMI

• 3 discharge managers who were employees of the mental health center, but who had offices in the prison worked with members of the prison mental health treatment team

• Discharge managers identified inmates with SMI likely to be eligible for Medicaid and helped them apply for benefits prior to their release

• The program increased Medicaid enrollment at prison release by 15% and increased post-release Medicaid mental health service use by 16% (Wenzlow, Ireys, Mann, Irvin, & Teich, 2011)


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Work Release in Corrections

• At least within final 6 to 24 mos. of term

• Provides actual work experience in community before re-entry; provides opportunity to teach local employers of benefit/risk to hiring those w/ criminal record

• Promotes understanding between facility and the private sector


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Work Release in Corrections

• Prior to release, helps develop ‘soft skills’ for retaining jobs; helps to learn appropriate social skills for community/workplace settings

• Get exposed to work ethic needed to retain a job and avoid re-incarceration

• Temporary work placement can become a foundation for permanent job upon release


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Effective Work Release Models

• Adult Transition Centers, Safer Foundation, IL35 hrs./wk. in work, education, life skills or service

• Pioneer Human Services & WA DOCWork release units offer treatment, job training/support

• Jail Transition Program, VA DOCWork experience, intensive workshops, job search, or public service

• Pre-release Program, The Kintock Group, NJJob readiness, education, transition to work or community service


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Challenge of Re-entry

• Screening & follow-up in jails to ensure people w/ SMI receive safe/effective placement & care during custody and the transition back to the community (stress and trauma can actually worsen condition).

• Due to high system costs & scarcity of resources, people w/ SMI are better & safely served in the community, at less cost to taxpayers if resources are made available.

• Need for alternatives to incarceration when appropriate that can hold offenders responsible and uphold public safety, while providing adequate interventions.


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Jail Diversion Response to People w/ CODx• Greater need for this group to be accurately diagnosed

and to get behavioral health tx. not being provided to this group (Dx. assessment).

• Complexity of system involvement (including probation/supervision) requires integrated treatment (IDDT) to address CODx which uses assertive engagement techniques (motivational interviewing- MI) recognized as effective across service systems.

• Two types of models – pre-booking and more common post-booking


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Pre-booking Jail Diversion

Essential elements of pre-booking model:• High visibility (often in conjunction w/ CIT)

• Single point of entry

• No-refusal policy

• Streamlined intake procedure

• Legal foundation for police referrals

• Cross training of staff


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Post-booking Jail Diversion

Key features of effective post-book Jail Diversion:

• Integration of community-level services (MH, SS, & judiciary)

• Regular meeting among key players

• Designated liaison/boundary spanner- manages interactions between corrections, mental health & judiciary staff

• Early ID of detainees meeting diversion criteria and needing MH treatment


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Post-booking Jail Diversion

• Strong leader w/ good communication skills who understands all components of all systems, as well as informal networks

• Diversion case managers who have experience in both MH and criminal justice systems


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Mental Health Courts

True cross-system collaboration is necessary to realize the key elements and, for that matter, to successfully operate a mental health court; and the elements make clear, both explicitly and implicitly, that mental health courts are not a panacea.


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Mental Health Courts

Purpose is to divert MH consumers away from the criminal justice system to treatment programs.

• Handles all ID for community MH referral for initial booking for a specialized court docket

• Use court team approach to create Tx. plans & supervision protocol w/ designated court liaison

• Establishes designated appropriate Tx. slots prior to judicial rulings including ongoing monitoring with possible sanctions (charges) that can be reinstituted if necessary.


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MH Courts- 10 Essential Elements

1. Cross-system planning & administration

2. Clearly targeted group3. Timely ID and linkage

to services4. Terms of participation

w/ consequences (sanctions) if needed

5. Consumer informed-choice

6. Comp. treatment services & supports

7. Confidentiality safeguard

8. Court team/cross-system

9. Monitoring adherence to court requirements

10. Evaluation of court processes to ensure sustainability


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Why integrated treatment of CODx?

Treat each disorder separately was traditional. Either parallel or sequential

• Separate treatment is NOT effective

• Integrated treatment is more effective.

• 10 studies show integrated treatment is more effective than traditional separate treatment

(Drake et al, Schiz Bull 1998 and Drake et al, Psych Services 2001 for summaries).


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Principles of Integrated Dual Disorder Treatment

Integration of mental health and substance abuse treatment

• Same team of dually trained people• Same location of services• Both disorders treated at the same time• High level of intensity of service with team: psychiatrist,

nurse, substance abuse counselor, mental health clinician, vocational specialist and peer specialist


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Principles of Integrated Dual Disorder Treatment

• Staged Interventions• Assertive Outreach• Motivational interventions• Counseling• Social Support interventions• Long-term perspective• Comprehensiveness• Cultural sensitivity and competence


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Address Barriers to Re-entry

• Reduce recidivism risk to probation/parole: stress a law abiding attitude, avoid anti-social peers, maximize leisure/rec. time, abstain from substance use, minimize neglect/abuse or any home instability, and foster increasing work and education experiences.

• Supervision should be ‘firm but fair’; compliance that favors use of problem solving; probation boundary spanning links to services.


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Proactive Re-entry

To engage all jail detainees in need of mental health services, service planners need to be flexible and develop strategies for immediate engagement and promise of support after release, on the chance that the provider is meeting the client on the day of release.

(Draine et al,. 2010)


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Suggestions & Recommendations for Rehabilitation Counselors

• Recognize complexity of working collaboratively in the rehabilitation of people w/ SMI and corrections hx.

• Be aware of re-entry efforts and their role in facilitating community re-integration of people with SMI

• Partner with mental health-corrections models of re-entry to develop comprehensive rehabilitation services

• Promote use of IDDT services, as appropriate for mental health consumers with co-occurring disorders, especially those coming w/ a corrections history


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References

• Buck, D.S., Brown, C. A., & Hickey, J.S. (2011). The Jail Inreach Project: Linking Homeless Inmates who have Mental health illness with community health services. Psychiatric Services, 62(2), 120-122.

• Covington, S. & Bloom, B. (2006). Gender-responsive treatment and services in correctional settings. In: E. Leeder (Ed.) Inside and out: Women, prison, and therapy. Binghamton, NY: Haworth Press.

• Draine, J., Wilson, A.B., Metraux, S., Hadley, T. & Evans, A.C. (2010). The impact of mental illness status on the length of jail detention and the legal mechanism of jail release. Psychiatric Services, 61 (5), 458-462.


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References

• Draine, J., Blank, A., Kottsiepper, P. & Solomon, P. (2005). Contrasting jail diversion and in-jail services for mental illness and substance abuse: Do they serve the same clients? Behavioral Sciences and the Law, 23, 171-181.

• Drake, R.E., Merrens, M.R., & Lynde, D.W. (2005) Evidence-based mental health practice, New York, NY: W.W. Norton and Company.

• Drake et al. (2001). Implementing dual diagnosis services for clients with severe mental illness. Psychiatric Services, 52, 469-476.

• Drake et al. (1998). Review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin, 24, 589-608.


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References

• Justice Center (2009). Council of State Governments Justice Center Releases Estimates on Prevalence of Adults with Severe Mental Illnesses in Jails, New York, NY: Council of State Governments.

• Kessler, R. C., Nelson, C. B., McKinagle, K. A., Edlund, M. J., Frank, R. G., & Leaf, P. J. (1996). The epidemiology of co-occurring addictive and mental disorders: Implications for prevention and service utilization. American Journal of Orthopsychiatry 66: 17–31.

• Mueser, K., Noordsky, D., Drake, R.,& Fox, L. (2003). Integrated treatment for dual disorders. Guilford Press: New York, NY.


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References

• Mueser, K., Drake, R.,& Noordsky, D. (1998). Integrated mental health and substance abuse treatment for severe psychiatric disorders. Journal for the Practice of Psychiatry and Behavioral Health, May, 129-139.

• Sabol, W. J., & Minton, T. D. (2008). Jail Inmates at Midyear 2007. Washington D.C.: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.


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References

• Sacks, S., Sacks, J. Y., McKendrick, K., Banks, S., & Stommel, J. (2004). Modified TC for MICA Ofenders: Crime Outcomes. Behavioral Sciences and the Law, 22, 477-501.

• Scheyett, A., Vaughn, J., Taylor, M.F. (2009). Screening and access to services for individuals with serious mental illnesses in jails. Community Mental Health Joural, 45, 439-446.

• Wenzlow, A.T., Ireys, H.T., Mann, B., Irvin, C., & Teich, J.L. (2011). Effects of a discharge planning program on medicaid coverage of state prisoners with serious mental illness. Psychiatric Services, 62(1), 73-78.


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Comments & Questions


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Contact InformationCharlie Bernacchio

Assistant Professor, Coordinator Rehabilitation Counseling - University of Southern MaineEmail: [email protected]

Eileen BurkerAssociate Professor/Director, Rehabilitation Counseling & Psychology- University of North Carolina at Chapel HillEmail: [email protected]


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Upcoming Webinars

Improving Employment Outcomes for Individuals with Mental Health Disabilities

• January 12 – Adults with SMI, Substance Use/Abuse & Corrections History Part 2

• February 2 – Career Exploration, Development and Planning for Consumers w/ SMI

• March 9 – Job Development, Placement & Support Strategies for Consumers w/ SMI


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Education Credits

CRCC Credit - (1.0)Approved by Commission on Rehabilitation Counselor

Certification (CRCC) • By Friday, December 9, 2011, participants must score

80% or better on a online Post Test and submit an online CRCC Request Form via the MyTACE Portal.

CEU Credit - (0.1)Approved by the University College at Syracuse University• Participants must download an online CEU Request

Form and submit via fax or email. My TACE Portal: TACEsoutheast.org/myportal


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THANK YOU!

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Southeast TACE (Region IV)

Toll-free: (866) 518-7750 [voice/tty]

Fax: (404) 541-9002

Web: TACEsoutheast.org

My TACE Portal: TACEsoutheast.org/myportal

Email: [email protected]


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DisclaimerThis presentation was developed by the

TACE Center: Region IV ©2011 with funds from the U.S. Department of Education, Rehabilitation Services Administration (RSA) under the priority of Technical Assistance and Continuing Education Projects (TACE) – Grant #H264A080021. However, the contents of this presentation do not necessarily represent the policy of the RSA and you should not assume endorsement by the Federal Government [34 CFR 75.620 (b)].

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