Forensic Mental Health: Framing Integrated Solutions [2 ed.] 9780367636692, 9780367635541, 9781003120186

In this book author Michele P. Bratina demonstrates how the Sequential Intercept Model (SIM) supports integration of the

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Forensic Mental Health: Framing Integrated Solutions [2 ed.]
 9780367636692, 9780367635541, 9781003120186

Table of contents :
Half Title
Title Page
Copyright Page
Table of Contents
CHAPTER 1 An Overview of the Mental Health–Criminal Justice Nexus
Mental Health: Definitions, Prevalence, and Common Terminology
Intersections of Criminal Justice and Mental Health: Justice-Involved PwMI
Service Utilization/Treatment Engagement
Challenges in Managing Justice-Involved PwMI
Take-Home Message
CHAPTER 2 Historical Responses to Mental Illness
Advancements in Psychosurgery
Societal Responses to Mental Illness: Thematic Eras
Take-Home Message
CHAPTER 3 The Sequential Intercept Model
Why Diversion?
Mental Illness and the Criminal Justice System: An Integrative Framework
Key Diversion Points
Research on the SIM
Take-Home Message
CHAPTER 4 Intercept Zero: Community Services
Components of Intercept 0: Prevention, Response, and Ultimate Diversion
Response: The Crisis Care Continuum
Take-Home Message
CHAPTER 5 Intercept One: Law Enforcement
Police as First Responders to Citizens in Crisis
Specialized Police Responses to Crisis Events
Additional Complexities of LEO–Citizen Encounters: Responding to Special Populations
The Mental Health and Well-Being of Police
Take-Home Message
CHAPTER 6 Intercept Two: Initial Detention/Initial Court Hearings
Post-Booking Diversion: An Overview
Diversion Strategies
Determining Diversion Program Effectiveness
Processing and Disposition
Take-Home Message
CHAPTER 7 Intercept Three: Jails/Courts
Part One: Beyond Initial Detention—PwMI Incarcerated
Part Two: Diversion Strategies at Intercept Three
Take-Home Message
CHAPTER 8 Intercept Four: Reentry
Section One: Reentry for People with Mental Illness (PwMI)
Section Two: Effective Reintegration and the Role of Professional Service Providers
Section Three: Best Practices in Reentry Programming for PwMI
Take-Home Message
CHAPTER 9 Intercept Five: Community Corrections
Mental Health and Community Corrections
Interagency Cooperation, Intra-Agency Collaboration, and Systems Integration
Resistance to Treatment
Take-Home Message
CHAPTER 10 Trauma and Approaches to Trauma-Informed Care
What Is Trauma?
Trauma-Informed Care
The Juvenile Justice System’s Response to Trauma
Take-Home Message
CHAPTER 11 Conclusions and Future Directions
Review of the Issues and Suggestions for Change
Take-Home Message

Citation preview

“A fascinating look at the understudied linkage between mental health and the criminal justice system. A book that needs to be incorporated into criminal justice degree programs to better inform students and practitioners of what’s been missing in our efforts to achieve crime prevention and justice more systematically.” Jay Albanese, PhD, Virginia Commonwealth University “Bratina combines her academic and practitioner experience to produce an important text. Using the Sequential Intercept Model (SIM) framework, she carefully addresses the challenges faced by the individual consumers and personnel in every phase of the criminal justice system, from the streets through prison reentry. This should be mandatory reading for current and future criminal justice, social work, and human service practitioners.” Christine Tartaro, PhD, Distinguished Professor of Criminal Justice, Stockton University “As the nation moves to reform both the mental health and criminal legal systems, practitioners and policy makers need a solid understanding of the key issues and needs of the people these systems serve. Bratina’s text provides an excellent foundation that highlights systems issues, interventions, and the experiences of professionals and people with mental illnesses. This is an essential text for students and practitioners in fields including social work, criminal justice, and community psychology.” Amy C. Watson, PhD, Professor, Helen Bader School of Social Welfare, University of Wisconsin Milwaukee

Forensic Mental Health In this book author Michele P. Bratina demonstrates how the Sequential Intercept Model (SIM) supports the integration of the U.S. healthcare and justice systems to offer more positive outcomes for offenders with mental illness. The book describes a criminal justice–mental health nexus that touches every population—juvenile and adult male and female offenders, probationers and parolees, the aging adult prison population, and victims of crime. In the United States today, the criminal justice system functions as a mental health provider, but at great cost to society. The author summarizes the historical roots of this crisis and provides an overview of mental illness and symptoms, using graphics, case studies, and spotlight features to illustrate the most pressing issues encountered by justice and behavioral health professionals and the populations they serve. Forensic Mental Health takes a multidisciplinary approach, addressing social work, psychology, counseling, and special education, and covers developments such as case law related to the right to treatment and trauma-informed care. Designed for advanced undergraduates, this text also serves as a training resource for practitioners working with the many affected justice-involved individuals with mental illness and co-occurring substance use disorders, including juveniles and veterans. Michele P. Bratina is an Associate Professor in the Criminal Justice Department at West Chester University in West Chester, Pennsylvania. Previously, she was the Forensic and Children’s Mental Health Coordinator for the Florida Department of Children and Families in the 19th Judicial Circuit—a role that inspired this book. She is Past President of the Northeastern Association of Criminal Justice Sciences (NEACJS) and holds the position of Region 1 Trustee (Northeast) with the Academy of Criminal Justice Sciences (ACJS). Her research has focused on specialized training for criminal justice professionals and the development of community partnerships in forensic mental health. Other areas of interest include secondary trauma among law enforcement officers and examining offending or offending risk and victimization through a trauma-informed lens. Dr. Bratina’s publications have appeared in the Journal of Ethnicity in Criminal Justice, International Journal of Police Science and Management, Police Practice and Research, Abuse: An International Impact Journal, Salus: An International Journal of Law Enforcement & Public Safety, the Journal of Correctional Health Care, and the Journal of Community Mental Health.

Forensic Mental Health Framing Integrated Solutions Second Edition

Michele P. Bratina

Designed cover image: © Evgeny Gromov / Getty Images Second edition published 2023 by Routledge 605 Third Avenue, New York, NY 10158 and by Routledge 4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2023 Michele P. Bratina The right of Michele P. Bratina to be identified as author of this work has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. First edition published by Routledge 2017 Library of Congress Cataloging-in-Publication Data A catalog record has been requested for this book ISBN: 978-0-367-63669-2 (hbk) ISBN: 978-0-367-63554-1 (pbk) ISBN: 978-1-003-12018-6 (ebk) DOI: 10.4324/9781003120186 Typeset in Times New Roman by codeMantra Access the Support Material:

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Contents Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xii Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvi Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxvi

CHAPTER 1 An Overview of the Mental Health–Criminal Justice Nexus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 Mental Health: Definitions, Prevalence, and Common Terminology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 Intersections of Criminal Justice and Mental Health: Justice-Involved PwMI . . . . . . . . . . . . . . . . . . . . . . . . . .16 Service Utilization/Treatment Engagement. . . . . . . . . . . . . . . . .19 Challenges in Managing Justice-Involved PwMI . . . . . . . . . . . .25 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

CHAPTER 2 Historical Responses to Mental Illness . . . . . . . . . . . . . . . . 39

Advancements in Psychosurgery . . . . . . . . . . . . . . . . . . . . . . . . .39 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 Societal Responses to Mental Illness: Thematic Eras . . . . . . . . .42 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

CHAPTER 3 The Sequential Intercept Model . . . . . . . . . . . . . . . . . . . . . 65

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65 Why Diversion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 Mental Illness and the Criminal Justice System: An Integrative Framework. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 Key Diversion Points. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 Research on the SIM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80

CHAPTER 4 Intercept Zero: Community Services . . . . . . . . . . . . . . . . . . 87

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 Components of Intercept 0: Prevention, Response, and Ultimate Diversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88 Response: The Crisis Care Continuum . . . . . . . . . . . . . . . . . . .102 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109

CHAPTER 5 Intercept One: Law Enforcement. . . . . . . . . . . . . . . . . . . . 119

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .120 Police as First Responders to Citizens in Crisis . . . . . . . . . . . .127 Specialized Police Responses to Crisis Events . . . . . . . . . . . . .129




Additional Complexities of LEO–Citizen Encounters: Responding to Special Populations . . . . . . . . . . . . . . . . . . . . . .145 The Mental Health and Well-Being of Police . . . . . . . . . . . . . .151 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .159

CHAPTER 6 Intercept Two: Initial Detention/Initial Court Hearings . 173 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173 Post-Booking Diversion: An Overview . . . . . . . . . . . . . . . . . . .175 Diversion Strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177 Determining Diversion Program Effectiveness . . . . . . . . . . . . .179 Processing and Disposition . . . . . . . . . . . . . . . . . . . . . . . . . . . .180 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .193

CHAPTER 7 Intercept Three: Jails/Courts . . . . . . . . . . . . . . . . . . . . . . . 199

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .199 Part One: Beyond Initial Detention—PwMI Incarcerated. . . . .201 Part Two: Diversion Strategies at Intercept Three. . . . . . . . . . .209 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .231

CHAPTER 8 Intercept Four: Reentry . . . . . . . . . . . . . . . . . . . . . . . . . . . 241

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .241 Section One: Reentry for People with Mental Illness (PwMI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .243 Section Two: Effective Reintegration and the Role of Professional Service Providers . . . . . . . . . . . . . . . . . . .250 Section Three: Best Practices in Reentry Programming for PwMI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .253 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .261

CHAPTER 9 Intercept Five: Community Corrections . . . . . . . . . . . . . . 269

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .270 Mental Health and Community Corrections . . . . . . . . . . . . . . .271 Interagency Cooperation, Intra-Agency Collaboration, and Systems Integration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .277 Resistance to Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .280 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .284

CHAPTER 10 Trauma and Approaches to Trauma-Informed Care . . . . . 291 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .292 What Is Trauma? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .292 Trauma-Informed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .306 The Juvenile Justice System’s Response to Trauma . . . . . . . . . 311 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .320

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CHAPTER 11 Conclusions and Future Directions . . . . . . . . . . . . . . . . . . 329

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .329 Review of the Issues and Suggestions for Change . . . . . . . . . .330 Take-Home Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .341

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .347

Preface The criminal justice–mental health nexus is a profound topic in that it touches on every population in the field of criminal justice—juvenile and adult male and female offenders, probationers and parolees, sexually violent predators, the aging adult prison population, and victims of crime and serious abuse. Through a multifaceted approach to learning and understanding the crime–mental health relationship, readers will be able to more effectively gauge the issues presented and the various ways in which they might become positive change agents in the field. Prior to my career in academia, I had the fortunate experience of working for the Florida Department of Children and Families (DCF), Judicial Circuit 19, and Substance Abuse and Mental Health Program Office (SAMH). I did not realize it at the time, but Dr. George Woodley, program administrator and all-around amazing human, had the keen ability to predict my future when he hired me in the summer of 2010. In the position of “Forensic and Children’s Mental Health Coordinator,” I was quickly forced to navigate multiple systems of care, as I was responsible for the direct oversight of contracted programs that provided an array of substance use and mental health services to children, adolescents, and adults—many of whom were justice-involved. During that time, I witnessed a substantial amount of trauma and abuse and the resistance of service providers who were unable or unwilling to venture across systems to make a change. On the other hand, I also observed glimpses of great healing and progress and the development of partnerships between people and agencies in such places one would least expect. Due to threats of restructuring and the elimination of many SAMH positions, including my own, I resigned from SAMH and accepted a tenure-track faculty position in Pennsylvania. Still in Florida and preparing for the move, I accepted a temporary contracted position as a “systems integrator,” working for what was then referred to as the “Managing Entity”; while there, I reunited with providers and families in the same four county region for which I had oversight while employed with SAMH, with the addition of one county (Palm Beach). The meetings I facilitated in that position involved individuals from multiple systems of care, including juvenile justice and criminal justice systems, child welfare, drug and alcohol/substance use, education, and several others—and we were engaging in information sharing beyond anything I had experienced before. So much of this text comes from that perspective. Though it has now been about ten years since my time as “practitioner,” I continue to be inspired by advocates, providers, patients, and persons with lived experiences of trauma, mental illness, and substance use. I am also highly motivated by my students, who consistently demonstrate to me the reasons why I must continue to absorb knowledge and disseminate it. The scope of this book is broad because it approaches the subject matter from a multidisciplinary perspective, including relevant concepts and issues in the fields of social work, psychology, law, counseling, and special education. The reader will benefit from getting the latest developments in areas such as prisoner rights to treatment and juvenile justice—particularly, more recent developments related to psychiatric

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crisis and treatment during the COVID-19 pandemic, current directions in diversion opportunities and crisis response, and trauma-informed care. Instructors will benefit from having access to pedagogical tools and activities that corroborate with the major sections of the book. Furthermore, each chapter ends with a list of key concepts/ acronyms (italicized throughout the chapter) and a list of discussion questions so that the instructor can assess, and students can apply what they have learned throughout the course. The progression and current state of systems of care as they relate to psychiatric and co-occurring substance use disorders deserve much discussion so that students interested in forensic mental health studies can formulate an accurate perception of the importance of the model in practice.

STRUCTURE OF THE TEXT The bulk of the text is designed as a conceptual “walk through” the justice system; however, in contrast with typical criminal justice–related texts, the discussion at each level is based on key diversion points and offers suggestions and solutions for positive systematic changes. Using the Sequential Intercept Model (SIM) as a guide (discussed in more detail in Chapter 3), the chapters attempt to fuse practical and academic knowledge to present an accurate vision of forensic mental health. Before delving into the core intercept points as identified in Chapters 4–9, some essential background factors must be identified and clarified further for the reader. Coauthored with Dr. Ford Brooks, Chapter 1 provides a glimpse as to our conceptualization of “mental illness” and its general prevalence rates. The chapter also introduces the concept of forensic mental health and outlines key differences inherent between the mental health and justice systems in the context of the “language” spoken and challenges encountered by each. The purpose for leading the rest of the text with this section is to understand some of the conflict that has historically bounded individuals to an independent philosophy that does not allow or support change. In this way, the reader quickly begins to understand that most failed systems lead to multiple encounters with the same population of individuals. Chapter 2 traces the historical treatment of persons with mental illness in the United States, with some comparative information from places outside the United States. Most importantly, the chapter introduces the idea of stigmatization and provides a context for the transformation in which society has criminalized mental illness. The Sequential Intercept Model (SIM) is presented to the reader in Chapter 3, along with supporting literature, with a description for the remaining structure of the book. In Chapter 4, Dr. Kelly M. Carrero and I delineate the crisis continuum in the context of Intercept 0, the first interception point in the SIM, which is followed throughout the bulk of this text. The information provided foreshadows the probable reasons why the initial interception with the justice system happens in the first place. Chapters 5–9 provide concepts, literature, research, and case examples for each of the remaining diversion points for justice-involved offenders; fresh perspectives are introduced with the contributions of Jesse S. Zortman and Dr. Michael E. Antonio in Chapter 6—also



co-authored by Meghan Kozlowski and this author. Though following along with the SIM map, the reader will soon notice that the material in these chapters is presented in a format that is like the more traditional criminal justice textbook—policing, courts, corrections—in that order. Research indicates that trauma is a significant underlying factor in the life course of both offending and victimization, and this conversation is honored in Chapter 10 of this iteration of the text. Dr. Alida Merlo brings her expertise on trauma-informed care and the juvenile justice system to provide a framework for understanding the effects of childhood trauma and the need for trauma-informed perspectives in our management and treatment of vulnerable persons. The concluding chapter synthesizes research and practice to illustrate the salience of systems integration and interagency collaboration. Several key policy initiatives are presented and discussed, including improvements to the crisis continuum and Extreme Risk Protection Order legislation. Several pedagogical tools are provided that can be used alongside the text to bridge theory and practice, including varied classroom activities and experiential learning projects, case vignettes, and questions for discussion. The tools are designed to provide learners with opportunities to further develop their knowledge and ability to critically analyze the issues presented, but also to increase their opportunities to practice collaboration and, in some cases, cross-disciplinary approaches in responding to issues that affect multiple systems. The goal of these activities is to allow learners the opportunity to read first-hand accounts of the nature of the work involved so that they might enhance their skill at decision making, and further explore the required academic preparation for varied human service–related occupations they may not have considered before now.

PEDAGOGICAL TOOLS Embedded in Chapter 3 is an illustration of the SIM for reference when navigating through the text, as well as for use with activities requiring learners to identify and discuss various diversion points. Spotlight features that may include tables/figures and photos pertaining to programs, agencies, and case studies are provided throughout the chapters; also, in selected chapters, there is a section that presents featured practitioners and their perspectives on several pertinent issues discussed in the text. These “Practitioner’s Corner” sections are designed to give students/readers some insight on careers in the field that may involve the divergence of criminal justice and mental health. Other pedagogical tools include “Thinking Critically,” “Comparative Perspectives,” “Policy & Practice,” and “Fast Fact” text boxes throughout the chapters that present key issues for discussion and other critical thinking activities. There is also a glossary of key terms at the end of each chapter.

ANCILLARIES Chapters outline specific challenges presented by this population for police, probation, parole, and other actors; students are provided the chance to apply what they have learned to “real-world” scenarios that are provided for each chapter. Along with

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these case studies are possible questions to enhance learning in and out of the classroom (e.g., take-home writing assignments). Sample exams and other thought-provoking in-class activities are also available. A webliography is also provided corresponding with chapter content that links to relevant educational videos, including seminars, monologues, panel presentations, and two PBS/Frontline documentaries, The New Asylums and The Released, and other media content (particularly news sources) are provided as supplemental learning resources.

Contributors Michael E. Antonio, PhD, is an Associate Professor of Criminal Justice at West Chester University, West Chester, PA. He earned a Bachelor of Science Degree in Psychology from Ursinus College, Collegeville, PA and a Doctorate in Law, Policy, & Society from Northeastern University in Boston, MA. Dr. Antonio served as the Senior Research Scientist in the Criminal Justice Research Center (College of Criminal Justice, Northeastern University) on the Capital Jury Project (CJP) (2000–2005). The CJP was a National Science Foundation–funded study that examined jurors’ decision-making process in capital cases. Research findings from the CJP have been cited in numerous court opinions and have impacted public policy issues about the imposition of capital punishment in the United States. From 2006 to 2013, he served as the Lead Research Scientist and Evaluation Manager for Pennsylvania’s Department of Corrections (PADOC) and Pennsylvania’s Board of Probation & Parole (PBPP) in Harrisburg, PA. Dr. Antonio’s published research includes evaluation findings about support for treatment and rehabilitation programming in PADOC among correctional staff and incarcerated populations. Cheryl Arutt, PsyD, is a Licensed Clinical and Forensic Psychologist in private practice based in Los Angeles, California. As a Specialist in trauma recovery and post-traumatic growth, she helps people understand and update adaptations to the source of distress that have outlived their usefulness, inspiring them to navigate life from a place of wholeness within and beyond the consulting room. She has provided forensic evaluations, expert testimony, and consulting services for Criminal and Civil proceedings in State and Federal Court. A certified Rape & Domestic Violence counselor for decades, she also serves on the Board of PAVE, Promoting Awareness | Victim Empowerment. She regularly speaks nationally and internationally about trauma issues. Dr. Arutt is a certified Eye Movement Desensitization and Reprocessing (EMDR) clinician. She is a Member of EMDR International Institute (EMDRIA) and the American Psychological Association. Ford Brooks, EdD, Licensed Professional Counselor (LPC), Nationally Certified Counselor (NCC), Certified Alcohol and Drug Counselor (CADC), is Professor of Counselor Education, Department of Counseling, and College Student Personnel at Shippensburg University in Shippensburg, Pennsylvania. Dr. Brooks holds a doctorate in counseling from The College of William and Mary and a master’s degree in rehabilitation counseling from Virginia Commonwealth University—Medical College of Virginia, with a specific focus on alcohol and drug counseling. He has been a Counselor Educator for 24 years and prior to that worked as a Counselor for 14 years in addiction treatment. He most recently was the Counselor in residence through the National Board for Certified Counselors, where he worked for three months in Thimphu, Bhutan, as a Clinician in the psychiatric ward. Jeni Brown is a self-described 44-year-old person in Long Term Recovery. An advocate for MMIW, and Indigenous People, Recidivism, Reentry, Women’s Rights,

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and addiction, she has 4 years and 11 months clean at the time of this writing. Jeni is also a previously incarcerated woman who has done 12 years in and out of Prison in Juneau Alaska. She is presently out on parole and has been for the last three years; her sentence will be complete in March 2022. Jeni is a native Alaskan and is full blooded Tlingit from the Raven Clan; she presently works for Central Council Tlingit and Haida Indian Tribes of Alaska, in the Community Behavioral Services department as a Family & Community Engagement Specialist and is taking classes to become a Behavioral Health Aide. Kimberly Bunch-Crump, PhD, BCBA-D, is an Assistant Professor in the Department of Educator Preparation at North Carolina Agricultural and Technical State University. She earned her doctorate in special education at the University of North Carolina at Charlotte. Dr. Bunch-Crump has a bachelor’s degree in criminal justice with a minor in juvenile delinquency and in her early profession worked for several years in community corrections as a Probation Officer. Before entering academia, Dr. Bunch-Crump supported individuals with behavioral health disorders, their families, and the providers who serve them through the implementation of community-based programs (counseling, in-home interventions, wrap-around, psychosocial rehabilitation, case management) and services (training, consultation). Her research interests focus on the identification of behavioral practices to promote social justice in education. Kelly M. Carrero is an Associate Professor with tenure in the Department of Psychology & Special Education at Texas A&M University—Commerce. She earned her doctorate in special education, with an emphasis on behavioral disorders at the University of North Texas. Prior to entering academia, Dr. Carrero served children and youth identified with exceptionalities and behavioral concerns in a variety of settings (including adjudicated youth with substance abuse disorders in a joint program between juvenile justice probation and behavioral health providers). Research projects serve as a vehicle for positive social change and advocacy for children identified with exceptionalities and challenging behaviors (including autism spectrum disorders). Specifically, she is interested in identifying (a) demographic disparities in the special education evidence-base, (b) interventions that promote social capital and agency for people with exceptionalities who are from diverse backgrounds, and (c) culturally responsive and socially valid practices in research and service delivery. Dr. Carrero serves her profession as a Reviewer for several journals and an active Member of the Council for Exceptional Children (CEC) and its respective divisions. Jacqueline A. Carsello, MS, has conducted research about corrective rape in South Africa, the deadnaming and overkill of transgender women, and the stigmatization and sterilization of the LGBT community and people with mental illness. She has assisted with research relating to substance abuse, hearing voices, and crisis intervention team programs. She has presented her research at Academy of Criminal Justice Sciences conferences, an American Society of Criminology conference, an International Post Graduate Course on Victimology, Victim Assistance, and Criminal Justice, a Northeastern Association of Criminal Justice Sciences conference, and a Regional Undergraduate Student Research Conference.



Giovanni Chiarini is an Attorney at Law (Bar Council of Piacenza, Italy), admitted as Assistant to Counsel at the International Criminal Court list. Giovanni is a PhD candidate specialized in International and Comparative Criminal Procedure at Insubria University (Como, Italy), and was a Visiting Researcher at the Université Côte d’Azur (Nice, France), at UCC (Cork, Ireland), and at Universität zu Köln (Cologne, Germany). Craig A. DeLarge is a Digital Healthcare Strategist and Mental Health Advocate at The Digital Mental Health Project, where he produces education programs and research which help improve the adoption of digital technology in the mental and behavioral health spaces. He is also Director, Strategic Marketing at Ksana Health, a digital mental health startup in the passive remote sensing space. His career is focused on “improving health” and “developing leaders.” In his career, as a Digital and Healthcare Marketer, Strategist, and Educator, he has managed world-class firms like Novo Nordisk, GlaxoSmithKline, Merck & Co., Takeda, and Johnson & Johnson. He had also taught at Temple University’s Fox Business School, Thomas Jefferson University—East Falls (formerly Philadelphia University), Chestnut Hill College, St. Joseph’s University, and Penn State University—Great Valley. He holds a bachelor’s and a master’s degree in Marketing and Design Management from Philadelphia University (USA) (BSc) and the University of Westminster (UK) (MBA). He is currently a Graduate Public Health Student at King’s College, London, anticipating graduation in 2022. He is further a Certified Professional Leadership Coach and published Author of The WiseWorking Handbook (2014). He resides in Philadelphia, PA, USA David A. Dinich, M Ed, is the Administrator for the PA Psychiatric Leadership Council, a group comprising community-oriented psychiatrists, along with other stakeholders in the public behavioral health system. The group is succeeding in its mission to recruit and retain more psychiatrists to work in Pennsylvania’s rural and underserved areas, as well as impact upon those areas that affect access to the best psychiatric services. He is also the President of both the Family Training and Advocacy Center (FTAC) and Forensic System Solutions (FSS), both non-profit organizations, the first working to increase family inclusion in behavioral health, and the second involved in training and consultation to the courts and county behavioral health entities. Both groups have initiated new ways to address issues in their respective fields. Jim Fouts, LSW, is the Director of Forensic Systems Solutions. He is a Trainer and Consultant working throughout the Commonwealth on issues related to Forensic Mental Health and Crisis Services. He has worked with Police and Crisis Intervention Services for over 35 years. Jim is a Certified CIT Trainer. He is also a Trainer for the Pennsylvania’s Keystone Crisis Intervention Team (KCIT). Jim is the Facilitator of the Pennsylvania Forensic Interagency Task Force. Gretchen Frank, Senior Policy Analyst, Behavioral Health Division, The Council of State Governments Justice Center, provides technical assistance

Contributors xix

to Pennsylvania counties participating in the Stepping Up Initiative through the Pennsylvania Stepping Up Technical Assistance Center. Before joining the CSG Justice Center, Gretchen was a policy analyst for the New York City Department of Health and Mental Hygiene, where she worked to ensure that the city and state were enacting equitable policies focused on the mental health and well-being of the city’s children and families. She previously worked as a child welfare attorney for the New York City Administration for Children’s Services. She received her BS from Cornell University and her JD from the University at Buffalo Law School. Holly A. Grimm, MSW, LCSW, BCN, CMHIMP, is a Co-owner and Clinician at Brandywine Valley Counseling and Neurofeedback Center in West Chester, Pennsylvania. She is a Licensed Clinical Social Worker, a Certified Mental Health Integrative Medicine Professional, and an ACE certified Health Coach, and is Board Certified in Neurofeedback. She specializes in trauma work and using a holistic approach to creating life changes. Holly Grimm is a trained Eye Movement Desensitization and Reprocessing (EMDR) Clinician. She is a Member of the National Association of Social Workers and the Association for Applied Psychophysiology and Biofeedback. Todd L. Grimm, LPC, BCN, CAADC, is a Co-owner and Clinician at Brandywine Valley Counseling and Neurofeedback Center in West Chester, Pennsylvania. In addition to being a Licensed Professional Counselor, he holds an advanced certification in alcohol and drug addiction and is Board Certified in Neurofeedback. He works with a variety of issues including trauma, addictions, and stress management. Todd Grimm is a trained Eye Movement Desensitization and Reprocessing (EMDR) Clinician. He belongs to the American Psychological Association, the International Society for Neurofeedback and Research, and the International Society for the Study of Dissociation. Risë Haneberg, Deputy Division Director, Behavioral Health Division, The Council of State Governments Justice Center, provides technical assistance to county system improvement projects, the Stepping Up Initiative, and Justice and Mental Health Collaboration Program grantee sites. Before joining the CSG Justice Center, Risë served as the Criminal Justice Coordinator for Johnson County, Kansas, from 2008 to 2014. In that role, Risë provided staff support to the Johnson County Criminal Justice Advisory Council and facilitated the coordination of criminal justice–related activities for the district court, the sheriff’s and district attorney’s offices, the Department of Corrections, the Court Services Department, and the Johnson County Mental Health Center. Her work in Johnson County involved both the juvenile and adult divisions, and major projects included a Justice and Mental Health Intercept Project, Second Chance Reentry, the Juvenile Detention Alternatives Initiative, and Justice Reinvestment at the local level. Risë previously served as the Chief Court Service Officer of the 10th Judicial District Court in Johnson County and began her career in criminal justice as a juvenile probation officer in 1979. Risë holds a BS in criminal justice from Wichita State University and an MPA from the University of Kansas.



William D. Kewer, Chief of Police, Middletown Police Department, Middletown, Rhode Island, has been in law enforcement for over 33 years, starting his career as a Police Officer in Yarmouth, Massachusetts on Cape Cod. Shortly thereafter, he joined the ranks of the Connecticut State Police in 1990, holding all ranks from Trooper to Lieutenant Colonel when he retired to serve as the Chief of Police with the Middletown Rhode Island Police Department. Meghan Kozlowski, MA—University of Maryland, College Park, is a Doctoral Candidate in the Department of Criminology and Criminal Justice at the University of Maryland, College Park, where she earned her master’s degree in 2018. She currently serves as a Research Analyst for the Maryland Crime Research and Innovation Center and the Baltimore Police Department. Her research interests include criminal justice responses to persons with mental illness, stigma and collateral consequences (particularly related to health and mental health), program evaluation, and evidence-based policy. Meghan’s work has been published in Social Science & Medicine; Criminology, Criminal Justice, Law, & Society; and the Journal of Community Psychology. Loran B. Kundra, JD, MSS, LSW, CPS, is a Behavioral Health Consultant, a Licensed Attorney, a Licensed Social Worker, and a Certified Peer Specialist. She received her Juris Doctor in 1992 from the University of Pennsylvania Law School and her master’s degree in Social Work in 2009 from Bryn Mawr College Graduate School of Social Work and Social Research. She completed her Certified Peer Specialist training in 2010. Ms. Kundra has worked in the area of mental health for the past 25 years, as a Clinician, Researcher, and Administrator. She has also served on the Board of Directors of a local affiliate of the National Alliance on Mental Illness (NAMI Main Line PA) for over nine years. During that time, she has led the community outreach efforts for the affiliate. Ms. Kundra has conducted a variety of presentations and workshops on the issues of recovery and mental health, parenting with mental illnesses, and peer support. In addition, through her professional work and her work with NAMI, she has been involved in anti-stigma outreach efforts to schools and universities, churches, and other groups in the community. She has authored and co-authored peer-reviewed publications about parenting with mental illness, the liability of mental health peer support groups, the need for peer support organizations for social workers with mental health issues and licensing statutes for mental health professionals and how they affect those professionals who have mental health issues. Charlene Lane, PhD, LCSW-R, is Associate Professor/Social Work Interim Department Chair, Program Director, and Faculty Development Fellow at Messiah University, Pennsylvania is a Licensed Clinical Social Worker in both Pennsylvania & New York, with over 20 years of clinical and administrative experiences. She obtained a BA degree in Psychology from York College (CUNY), master’s degree (MSW) in Clinical Social Work from New York University (NYU), and a PhD from Adelphi University (all in New York). Her research interest focuses on older adults aging in their respective communities. Dr. Lane partnered with her colleague, Dr. Michele P. Bratina, and conducted research on the lived experiences of individuals aged 55 and older who are growing old in four prisons

Contributors xxi

in Central Pennsylvania. She plans to continue to investigate the experiences of older adults in their respective communities, with specific emphasis on the impact of their mental health issues and aging. Dr. Lane is passionate about Social Justice issues and the creation of inclusive excellent curriculums. Sean Lauderdale, PhD, is an Associate Professor in the Department of Psychology and Special Education at Texas A&M University—Commerce. Dr. Lauderdale received his PhD in Clinical Psychology from Texas Tech University and completed his clinical internship and postdoctoral studies in Geropsychology at the Veterans Affairs Palo Alto Health Care System, where he provided extensive psychological assessment and therapeutic services to veterans. Dr. Lauderdale has worked with a range of clients, from children to older adults, in a range of settings including outpatient mental health, inpatient psychiatric units, geropsychiatric units, skilled nursing facilities, and assisted living facilities. Dr. Lauderdale specializes in psychological assessment and has provided extensive services for individual clients and organizations, such as Children’s Protective Services, Adult Protective Services, and the Social Security Administration. Within the area of assessment, Dr. Lauderdale has studied assessments of various types of dementia in older adults, such as Alzheimer’s disease. Dr. Lauderdale has initiated and facilitated several programs providing free psychological screening and mental health education services to older adults living in rural and urban communities. Dr. Lauderdale’s clinical work focuses on a range of topics across depression, anxiety, dementia, and caretaking for individuals with dementia. Currently, Dr. Lauderdale teaches graduate courses in psychological assessment, psychotherapy (Cognitive-Behavioral Therapy), and psychopharmacology as well as undergraduate courses in abnormal and developmental psychology. Dr. Lauderdale’s research interests include assessment and interventions for older adults, anxiety-driven indecisiveness, cognitive risks associated with anxiety, public stigma for military veterans and others with mental health disorders, and consumer responses to advertisement for prescription medications for mental disorders. Justin M. Lensbower, MS, LPC, Health Services Administrator, Primecare Medical, Inc. is Director of Mental Health Services Franklin County Jail Chambersburg, Pennsylvania. Justin has direct oversight of the medical and mental health contract for the medical department at Franklin County Jail in Chambersburg, Pennsylvania. He conducts suicide and risk assessments, advises the jail administration on how to manage those with significant medical and mental health needs, monitors and coordinates psychiatric medication for the inmates, and oversees the sexual offender group treatment program. He also supervises employees who are pursuing an LPC and students working at the jail who are enrolled in the clinical master’s in counselling internship program at Shippensburg University for the past 13 years. Alida V. Merlo, PhD, is a Distinguished University Professor of Criminology and Criminal Justice at Indiana University of Pennsylvania, where she joined the faculty in 1995. Previously, she taught for 20 years at Westfield State University in Massachusetts. She conducts research and publishes in the areas of juvenile justice and criminal justice policy. She is the Co-author with Peter J. Benekos of The Juvenile Justice System: Delinquency, Processing, and the Law, 9th Edition,



Reaffirming Juvenile Justice: From Gault to Montgomery, and Crime Control, Politics and Policy, 2nd edition. She is the co-editor (with Peter J. Benekos) of Controversies in Juvenile Justice and Delinquency, 2nd edition; and co-editor (with Joycelyn M. Pollock) of Women, Law, and Social Control, 2nd edition. Her recent journal publications can be found in the Trauma, Violence, & Abuse, the Journal of Drug Issues, Criminal Justice Policy Review, Victims and Offenders, the Asian Journal of Criminology, and Police Practice and Research. She is a Past President of the Academy of Criminal Justice Sciences. Prior to her career in academia, she was a Juvenile Probation Officer and Intake Supervisor for the Mahoning County Juvenile Court in Youngstown, Ohio. She received her PhD in Sociology from Fordham University, and her MS in Criminal Justice from Northeastern University. Chief Anthony M. Pesare (ret.), assumed command of the Middletown Police Department on August 30, 2004, and retired in December 2018. Prior to joining the Middletown Police Department, he served as Dean of the School of Justice Studies at Roger Williams University and was a Member of the Rhode Island State Police, where he served the department for 24 years. During his career he was the recipient of 20 division commendations, one special division commendation and six commendations from outside agencies. He has been a frequent presenter on topics related to criminal procedure and organized crime and has lectured at the Rhode Island State Police Training Academy, the Rhode Island Bar Association, and the Rhode Island Chapter of Certified Fraud Examiners. He is an Adjunct Professor at Salve Regina University and Roger Williams University. Chief Pesare (ret.) is also a Certified Instructor in the National Council for Behavioral Health’s Mental Health First Aid for Adults and the Public Sector. While Chair of the RI Police Officers Standards and Training Commission legislation was passed requiring all sworn police officers to be trained in Mental Health First Aid and the POST was given the responsibility for implementing the training. He received his BS degree in Administration of Justice from Roger Williams University, his Master of Public Administration from the University of Rhode Island, and his Juris Doctor from the New England School of Law, Boston, Massachusetts. He is licensed to practice law in the State of Rhode Island as well as the Federal District of Rhode Island. Angela M. Proctor, PhD, has been working with at-risk children and families since 2001. She holds a bachelor’s degree in Psychology and a master’s degree in Marriage and Family Therapy from Harding University in Searcy, AR. Angie completed her PhD in Educational Psychology from Texas A&M University in Commerce, TX. Angie has partnered with the Karyn Purvis Institute of Child Development out of Texas Christian University since 2009 training and implementing their Trust-Based Relational Intervention (TBRI) as a TBRI Practitioner, Mentor, and Trainer. Dr. Proctor is the Founder of Trust-Based Counseling Services providing various services, including in-home intensive interventions for children and families, virtual and in-person parent coaching, trauma-informed parenting classes, and trauma-informed training for schools, as well as professional trainings. Angie has devoted her life and education to helping children who come from traumatic backgrounds.

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Melissa Reuland (she/her) is a Senior Advisor to the Transform911 project at the University of Chicago Health Lab, where she supports work on developing and executing national roundtables and supporting topic-focused working groups and highlighting critical research. Ms. Reuland is also a Senior Research Program Manager at the Johns Hopkins School of Medicine, where she manages translational research in home-based dementia care coordination programs. Ms. Reuland’s past work includes advising the Policing Program at the Vera Institute of Justice, and national initiatives at the National Police Foundation, and managing research programs at the Council of State Governments (CSG) Justice Center and the Police Executive Research Forum (PERF). Ms. Reuland holds an MS in Criminal Justice from the University of Baltimore, and a BA in Psychology from the University of Michigan. James Ruiz, PhD, now deceased, was a Professor Emeritus of Criminal Justice School of Public Affairs Penn State Harrisburg, Middletown, Pennsylvania. James (Jim) Ruiz received his PhD from the College of Criminal Justice at Sam Houston State University, Master of Arts in Criminal Justice from the University of Louisiana at Monroe, and his Bachelor of Arts and Associates of Arts in Criminal Justice from Minot State University. His previous teaching experience includes serving as an Instructor at The University of Louisiana at Lafayette, Teaching Fellow at Sam Houston State University, and Assistant Professor at Westfield State College. He began his career in criminal justice as a Police Officer with the New Orleans Police Department in 1967 serving in the Patrol, Communications, and Mounted Divisions, as well as the Emergency Services Section and National Crime Information Center (N.C.I.C.). He retired in 1985. Some of his publications have appeared in Police Quarterly, American Journal of Police, the Journal of Police and Criminal Psychology, Criminal Justice Ethics, International Journal of Public Administration, International Journal of Police Science and Management, The Critical Criminologist, Police Forum, and Texas Law Enforcement Management and Administrative Statistics Program Bulletin. He is the author of The Black Hood of the Ku Klux Klan and co-author of The Handbook of Police Administration. His research interests included police administration and supervision, ethics in policing, police interaction with persons with mental illness, use of force, canine deployment, and the Ku Klux Klan. Emily Sandon is a Licensed Professional Counseling (LPC) in the State of Ohio. Ms. Sandon received her MA in Mental Health Counseling from Boston College, 2018; and a BA in Psychology and Social Behavior and a minor in Civic and Community Engagement from the University of California, Irvine, 2014. Ms. Sandon has experience working with all ages across the life span with diverse mental health expressions. Specifically, Ms. Sandon’s academic and professional focus centers around the intersectionality of criminal justice, psychology, and history. Ms. Sandon’s goal is to continue to engage with the restructure of a system that is rooted in evidence-based practice, collaboration, and overall sustainability of the lives that it effects. Brian D. Satterfield is a Certified Peer Specialist and published Author. He is the Founder of Decide 2 Evolve—an agency promoting chronic illness recovery (—and a Mental Illness and Trauma Liberation



Advocate, Educator, and Speaker. He is the author of A Mental Health Survival Guide: How to Manage the Severities of Multi-Mental Health Diagnosis, an Amazon #1 bestseller across three categories. It is a memoir of his severe struggles associated with coping with a psychiatric comorbidity (the co-occurrence of two or more mental health diagnoses) and is full of documented skills, tools, and tips he developed as an action plan to cope and manage. Cori Seilhamer, MS, LCC, is the Mental Health Program Specialist and CIT Coordinator at the Franklin/Fulton County Mental Health/Intellectual Disabilities/ Early Intervention Office in Chambersburg, Pennsylvania. Cori completed her BS in Public Service from The Pennsylvania State University in 1994. After working in the human service field for eight years, she decided to begin a master’s program at Shippensburg University. To foster her progressing career goals, she chose the community counseling track. Cori continued to work full time and be the mother of three children. Her family was her priority, so her college pursuit took eight years. Since graduating in 2011, Cori has found a passion for disaster response services. She has served in disaster recovery centers during times of flooding. She has also assisted the local community victims and assisted families and neighborhoods during times of fire and missing persons. But it was during her field placements in the Franklin County Jail that her interest in developing a relationship between the mental health and the criminal justice systems took vision. Her drive to assist her community has resulted in her pursuit to create the South-Central Crisis Intervention Team (CIT) in Franklin County. Currently, there are over 40 members of local law enforcement and first responders working with the mental health community to try and divert persons living with a mental illness into treatment/support instead of the criminal justice system. Jeff Smith, DSc, MPA, has been in law enforcement for over 33 years, serving in all capacities from patrol to investigations and from line-level to management. He is a Member of several professional organizations, and he has served as an expert witness in several areas, to include police policy. Smith is passionate about police encounters with people with mental illness (PwMI). He has worked locally to educate and inform law enforcement and resource organizations. He is currently on the board of directors of Behavioral Health of Georgia. Sandy Smith is an Assistant Professor in the Department of Elementary, Early, and Special Education at Southeast Missouri State University. She earned her doctorate in Educational Psychology, with an emphasis on Special Education from Texas A&M University. Dr. Smith began her career in education as a Paraprofessional for children with emotional and behavioral disorders (EBD). After supporting students with EBD at both the elementary and secondary levels, Dr. Smith began coaching teachers on classroom and behavior management. She continues to serve as an Educational Consultant in general and special education settings. Dr. Smith’s research interests include Positive Behavior Interventions and Supports (PBIS), coaching classroom management, and interventions students with EBD. Dr. Smith is an active Member of the Association of Positive Behavior Supports and the Council of Exceptional Children.

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Leah Vail Compton, MA, MBA, is currently employed with the Florida Department of Children and Families Headquarters as the State Community Forensic Liaison. In this position, she oversees the statewide forensic community system of care. She provides technical support to community stakeholders, writes reports for leadership, analyzes data, develops policy, and leads special projects supporting the decriminalization of persons with mental illness. Prior to this role, Ms. Vail Compton was Vice President of Forensic Services at Meridian Behavioral Healthcare, in Gainesville, Florida. Under her leadership, Meridian’s forensic program was awarded “Excellent in Behavioral Healthcare Management” by the National Council for Behavioral Health in 2018. Miriam Therasia van der Spek, BS—West Chester University, West Chester, Pennsylvania, is a Graduate Student pursuing her master’s degree in Criminal Justice at West Chester University, where she earned her bachelor’s degree in the same subject in 2020, graduating with honors. In 2019, she was selected to present her research in gender, violence, and media at the Annual Meeting of the Academy of Criminal Justice Sciences, and later that same year she was recognized by the College of Business and Public Management (West Chester University) as an Outstanding Student in Criminal Justice. Miriam is also a Member of the Tri-Alpha Honor Society (first-generation scholars) as well as the current President of the Nu Beta Chapter of Alpha Phi Sigma, the National Criminal Justice Honor Society. Jesse S. Zortman is a Psychotherapist in south central Pennsylvania. He has over seven years of clinical experience working with both adjudicated youth and adult offenders in a variety of settings. Currently, he serves as the Lead Clinician for outpatient forensic mental health services at York and Adams County prisons. Prior to this, he spent ten years working as a Program Analyst and Research Manager for the Pennsylvania Board of Probation and Parole and Pennsylvania Department of Corrections. From 2018 through mid-2021, he served as Chair for the Department’s Research Review Committee (RRC). Mr. Zortman received his Bachelor of Arts (BA) in Psychology from Shippensburg University of Pennsylvania, Master of Arts (MA) in Criminology from Indiana University of Pennsylvania, and Master of Arts (MA) in Counseling Psychology from Immaculata University. His primary research interests include forensic mental health, life course criminology, subcultural theory, differential association, community supervision, integrative therapy, and the real-world application of evidence-based practices. He has published in a number of academic journals, including the Journal Offender Rehabilitation and Journal of Community Corrections.

Acknowledgments I thank my mentor and friend, Dr. Alida V. Merlo, for her guidance, encouragement, and support throughout this process. Her belief in my ability to do great things is tremendously appreciated. This book has been strengthened with contributions made by Dr. Michael E. Antonio, Dr. Ford Brooks, Dr. Kelly M. Carrero, Ms. Meghan Kozlowski, Dr. Alida V. Merlo, Chief (Ret.) Anthony M. Pesare, and Mr. Jesse S. Zortman. I thank them for their commitment to addressing the intersections of mental health and criminal justice, and the overrepresentation of persons with serious mental illness in jails and prisons. Significant contributions were made by Dr. Cheryl Arutt, Dr. Angela Proctor, Jacqueline A. Carsello, Kylie Hoffman, Rachel A. Orlando, Abbey Uricher, and Miriam Therasia van der Spek. Their contributions provided this text a refreshing perspective that is reflective of issues not previously addressed in the first edition. Also, I am grateful to all the practitioner-contributors who work tirelessly in the field, and who continue to show compassion and kindness, even in the most difficult of circumstances. Their wisdom and experiences enhanced the text. In addition, I would like to acknowledge the multidisciplinary team of staff, providers, and administrators who I met professionally at the Florida Department of Children and Families, Substance Abuse and Mental Health Program Office, and Judicial Circuit 19. Without you and your incredible faith in the possibility for change, I would not have been inspired to write this book. A special thank you to Dr. George Woodley, our very interesting and wise leader, for mentoring me in my early career, and for demonstrating the true meaning of trauma-informed care. He sparked and guided my interest in mental health and the system’s response. To the team at Routledge-Taylor & Francis, Ellen Boyne and Kate Taylor—thank you for your support and editorial skills. I would also like to extend my sincere appreciation to all the staff involved in the production of this manuscript, including Francesca Tohill and Assunta Petrone. In closing, I thank my family for their constant love and support. My father’s memory keeps me company, and the strength and resilience of my mother, Fran, and sister, Gia, inspire my own journey. I reserve the most heartfelt gratitude to my munchkin, for all the time generously sacrificed while I was working. I look forward to the adventures ahead, and hope you know you have always been, and will remain, the most important part of my life.



An Overview of the Mental Health– Criminal Justice Nexus Michele P. Bratina and Ford Brooks Armed with what was believed to be an arsenal of weapons and two canisters of tear gas, James Egan Holmes, a 24-year-old former honor student and graduate school dropout, entered a local multiplex in Aurora, Colorado, on July 21, 2012 (see Figure 1.1), and opened fire on random moviegoers as they watched the midnight premier of The Dark Knight Rises. Holmes had purchased a ticket for the film and entered the theater as a “regular” patron. Shortly after the film began, however, he left through the exit door only to return moments later donned in protective gear from head to toe and a long black coat and sporting neon orange– colored hair. Allegedly referring to himself as “The Joker” to his soonto-be victims, Holmes released the gas and then killed 12 and wounded dozens of moviegoers before being arrested in the theater parking lot. Initially, the incident was depicted by some media outlets as an act of domestic terrorism and Holmes as a terrorist (Holden, 2012; Sidhu, 2012). As the case unfolded in the media, Holmes’s mental health history came under the microscope, and disturbing images of him, with unkempt hair and his eyes seemingly bulging, were splattered about the news and social media. Holmes was presented to the public as a violent and crazed madman whose actions might have been the result of an untreated (or undertreated) mental illness (Healy & Turkewitz, 2015). Reports of his previous engagement in counseling sessions with multiple therapists emerged, as did a letter he supposedly mailed to a psychiatrist he was acquainted with at the University of Colorado, shortly before the shooting—these actions served as evidence and were supportive of his more recent mental state. Holmes eventually pled not guilty by reason of insanity but was found guilty and sentenced to life imprisonment in July 2015. Discuss: What are some of the negative things you have heard about people with mental illness? What are some of the positive things you have heard about people with mental illness?

DOI: 10.4324/9781003120186-1



CHAPTER 1 Mental Health–Criminal Justice Nexus

 Figure 1.1 Aurora, Colorado. Location of the Movie Theater Shooting Source:, via Wikimedia Commons

INTRODUCTION Just as in similar cases before and after this, including shootings perpetrated by: • • • • • • • • • • • • • • • •

Seung-Hui Cho (Virginia Tech, 2007) Jared Loughner (Tucson, Arizona, shooting involving Congresswoman Gabby Giffords, 2011) Adam Lanza (Sandy Hook Elementary School, 2012) Aaron Alexis (Washington Navy Yard, 2013) Elliot Rodger (near University of California, Santa Barbara, 2014) Dylann Roof (Charleston church shooting, 2015) Stephen Paddock (Las Vegas music festival shooting, 2017) Nikolas Cruz (Stoneman Douglas High School; Parkland, FL, 2018) Jarrod Ramos (Capital Gazette newsroom, 2018) Connor Betts (Oregon District bar, Dayton, OH, 2019) Patrick Wood Crusius (Walmart, El Paso, TX, 2019) Robert Aaron Long (Georgia massage parlors, 2021) Ethan Crumbley (Oxford High School, Michigan, 2021) Frank James (Subway train shooting, New York City, NY, 2022) Peyton Gendron (Tops Supermarket shooting, Buffalo, New York, 2022) Salvador Rolando Ramos (Robb Elementary School, Uvalde, Texas, 2022)

Holmes’ actions were received by the public as those of a crazed lunatic who should be feared and isolated from the rest of society, if not executed. The violence is unacceptable, and the random nature of the offenses has cast a stigma on mental illness that, in effect, contributes to a phenomenon that has been referred to as the criminalization of mental illness (Dvoskin et al., 2020; Fisheret al., 2006; Slate et al., 2013).

Introduction 3

The media tales, however, are not confined to people with mental illness (PwMI) as perpetrators of violence; in fact, many stories that have emerged in recent years involve the actions of criminal justice officials who have invoked negative attention related to the justice system’s treatment of PwMI in its custody. Whether violence and victimization are perpetrated by or against PwMI, the intersections of mental health and criminal justice have become one of society’s major social problems to address. Throughout the past decade, all three primary justice-involved agencies—policing, courts, and corrections—have been implicated (Beck & Maruschak, 2001; DeMatteo et al., 2013; Hartford et al., 2006; Heilbrum et al., 2015; National Alliance on Mental Illness; “Mental illness facts and numbers,” 2013). Consequently, challenges are presented for police, probation, parole officers, and a variety of additional corrections officials in terms of addressing the prevailing stigmatization of all parties involved and generating methods to manage the increasing number of juveniles and adults with serious behavioral and mental health issues who have violated the law (DeMatteo et al., 2013; Griffin et al., 2015). Despite increasing access and support for mental health programming, there is still a significant gap in the amount of training criminal justice officials actually receive, and practitioners in varied roles express levels of unpreparedness in this context (Applebaum et al., 2001; Brandt, 2012; Deane et al., 1999; DeHart & Iachini, 2019; Kane et al., 2018; Lamb et al., 2002; Van Deinse et al., 2018; Wainwright & Mojtahedi, 2020). Given these challenges, students who are interested in pursuing careers in the criminal or juvenile justice fields or, more generally, in human services–oriented positions, benefit from acquiring a basic understanding of mental illness and the extent to which criminal justice professionals encounter PwMI during their work. Furthermore, for the sake of future policy implications, aspiring professionals must also learn the various intersections of mental illness and criminal justice and how to serve as positive change agents at numerous intersectional points along the process.

What Is Forensic Mental Health? The primary aim of this book is to present issues and possible solutions as they relate to forensic mental health. The term “forensic” relates to something that involves engagement with the courts or the legal system and is often used to reference the application of scientific methods to investigate crime. A broad definition that has been so eloquently offered by Mullen (2000) refers to forensic mental health as an “area of specialisation that, in the criminal sphere, involves the assessment and treatment of those who are both mentally disordered and whose behaviour has led, or could lead, to offending” (p. 307, original emphasis). As it pertains to this textbook, forensic mental health refers to examining behaviors of adults (aged 18 or older) with psychological disorders or other behavioral health-related needs who are involved in the legal system (“justice-involved” or “forensically involved” persons). While the subject of child and adolescent behavioral/


CHAPTER 1 Mental Health–Criminal Justice Nexus

FAST FACT 1.1 FORENSIC MENTAL HEALTH VS. CRIMINAL PROFILING For many people who hear the concept, for the frst time, “forensic mental health” takes on a connotation related to forensic science and criminal profling, both of which drive students to seek careers in crime scene investigations (CSI) or positions working in forensic crime labs. Although positions such as crime scene investigator and crime lab technician may involve interrelated areas of study and are certainly worth pursuing, these are diferent than forensic mental health. Specifcally, forensic mental health is less about investigative technique and the development of psychological profles and more about systemic responses to persons with mental illness who have violated, or who are at risk of violating, the law. Consequently, forensic mental health services refer to services available or received by justice-involved persons who have psychological disorders (as will be discussed later, under the law, the issues must cause serious functional impairment to qualify for services). Additionally, careers in forensic psychology may lead to positions involving criminal profiling, but it is important to note that forensic psychology as a field has many different sectors (e.g., police psychology, victimology, correctional psychology, etc.).

mental health and substance use is an important area of study in our analysis of the system of care, depth of information and discussion is best reserved for its own single work. In this book, people with mental illness who may or may not be forensically involved (i.e., accused of or charged with a criminal law violation) are referred to in a few different ways, depending on the context of the discussion. This may include people with mental illness (PwMI), as has already been referenced. It may also include people with lived experience (PWLE) of mental illness, substance use, or both (co-occurring disorders or CODs); people with serious mental illness (PwSMI or SMI) or with severe and persistent mental illness (SPMI); and people with serious psychological disturbances/disorders (PwSPD). In the context of use of services, individuals may be referred to as clients or consumers (of mental health, substance abuse, and other services), and patients (in forensic hospitals or other treatment-based facilities). In the following sections, the concepts of mental health and mental illness are briefly defined and discussed, including the fundamental facts about prevalence and representation in the general U.S. population and in the justice system. It is our intention to provide a basic understanding, at the same time, dispel some of the myths related to this population.

Mental Health: Defnitions, Prevalence, and Common Terminology 5

THINKING CRITICALLY 1.1 PERSON-FIRST LANGUAGE Please keep in mind that the person must be discussed separately from the disorder (i.e., “a person diagnosed with bipolar disorder” rather than “a bipolar”). In the feld, this is referred to as person-frst language. Challenge yourself as you move through the materials and discuss them with friends, co-workers, and classmates. Are you using person-frst language in your interactions? It is presumed that most individuals, if asked, would not be in favor of incarceration as a viable answer to the housing or treatment needs of PwMI. Unfortunately, however, that is exactly what happens. In fact, a concept that will be returned to later in the text is that of “mercy bookings,” which refers to police making the decision to arrest PwMI in crisis merely because they know that is the only way many individuals will gain access to care. Some advocates believe that these conditions persist because of the stigma that is attached to and surrounds mental illness. Stigma can be defined as a set of negative judgments, attitudes, or beliefs about a group of people that results in unfair prejudice and discrimination (Corrigan & Penn, 1999). Despite efforts to raise awareness and education about the common occurrence of mental health problems among U.S. adults and youth, persistent stigma makes getting help difficult for many people. Discuss: Put mental health status aside for a moment. In other times and places multiple persons or groups of persons have been singled out and mistreated by members of society. Can you think of specifc examples of stigmatized groups and the ways in which they were outcast or mistreated? What were the motives of those who were stigmatizing?

MENTAL HEALTH: DEFINITIONS, PREVALENCE, AND COMMON TERMINOLOGY Defning Mental Illness Mental illness can be described as the presence of a mental, behavioral, or emotional disorder that has been diagnosed by a licensed clinician, excluding intellectual and developmental disabilities (e.g., autism) and disorders primarily related to substance abuse (Substance Abuse and Mental Health Services Administration [SAMHSA]; “Key substance abuse indicators,” 2021). Duration and intensity of symptomology are additional dimensions accounted for when making a diagnosis of mental illness, both of which must meet criteria set forth by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (American Psychological Association [APA], 2013). This manual, more commonly known as the DSM-5, is used by licensed doctors and mental health practitioners as a guide for diagnosing psychological disorders and, therefore, informing subsequent treatment approaches.


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The phrase “mental illness” is used to briefly reference an extremely varied, complex group of conditions experienced by individuals from all cultural and socioeconomic backgrounds. Furthermore, the terms mental illness, mental health, mental/psychiatric/psychological disorders, behavioral health, and emotional behavioral health may be used interchangeably—though their unique applications will be introduced, where appropriate, throughout this text. It should also be noted that mental illness and substance use are frequently co-occurring (occurring together) (National Alliance on Mental Illness [NAMI], 2013), a point that is discussed in more detail later in this chapter and noted throughout the book. Finally, although the primary focus of this book relates to mental health and the administration of justice in the United States, it is instructive to understand the prevalence of mental illness and access to treatment worldwide and how comparative systematic responses could potentially inform policy in our country. Such issues will be presented throughout the remainder of the book where information is available to report, such as in the case of global prevalence rates, which are presented in “Comparative Perspectives” segments 1.1 and 1.2 below.

COMPARATIVE PERSPECTIVES 1.1 PREVALENCE OF MENTAL ILLNESS Estimates suggest that approximately 450 million people worldwide have suffered from mental health or behavioral disorders at some point in their lifetime (World Health Organization [WHO], 2015). In the United States alone, national prevalence data indicate that approximately one in every five persons in the general population will be diagnosed with any mental illness during their lifetime, with 14 being the average age of onset for most mental health disorders (NAMI, 2021). Cross-national comparisons in prevalence rates have also been examined, and differentials have been observed between the United States and other countries. In fact, according to data derived from a survey sponsored by WHO, the United States shares the lead spot with New Zealand in its prevalence rates for depression, anxiety, mood disorders, and disorders related to impulsivity and substance use among individuals who self-reported specific indicators during the reporting period of 2002–2005 (7.7 percent and 10.9 percent, respectively) (Countries Compared by Health, 2016). Figure 1.2 provides a snapshot of comparative data on the prevalence of bipolar disorder. Collectively, anxiety disorders are the most prevalent among all U.S. adults (aged 18 years and older) each year, followed by depression, post-traumatic stress disorder (PTSD), and bipolar disorder (NAMI, 2021c).1

Mental Health: Defnitions, Prevalence, and Common Terminology 7

 Figure 1.2 Comparative Mental Health Statistics

Source: Global Burden of Disease Collaborative Network. (2017). Global Burden of Disease Study 2016 (GBD 2016) Results. Institute for Health Metrics and Evaluation (IHME).


• •

Internationally, deaths from substance abuse (drug or alcohol overdose) have been steadily on the rise since the 1990s, with over 350,000 deaths resulting from substance use disorders in 2017. More than half of those deaths occurred to people under the age of 50. These numbers are found to be greater in the United States (higher rates of drug usage) and in Eastern Europe (higher rates of alcoholism). There are an estimated 27 million persons with substance abuse disorders in the European Region (as designated by the World Health Organization [WHO]). In the European Region, there are an estimated 137 million persons living with some form of mental or substance abuse disorder. This is roughly 15 percent of the region’s population.


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Barriers to Mental Health Services •

The most signifcant barriers to mental health services are seen in South Asia and the Middle East by way of severe stigmatization. Among many cultures in both regions, asking for help or showing weakness is greatly discouraged, and having mental health problems is associated with a sense of shame, disgrace, or disrespect. Unfortunately, the stigmatization only serves to exacerbate symptoms, as the internalization of mental health problems can result in higher levels of emotional distress, a leading factor in depression and suicide.

Sources: 1. Ritchie, H., & Roser, M. (December 5, 2019). Drug Use. Our World in Data. Retrieved from 2. World Health Organization [WHO]. MNH_FactSheet_ENG.pdf ( (2019) Barriers to Mental Health Services 3. World Health Organization [WHO]. MNH_FactSheet_ENG.pdf ( (2019) Mental Health Disorders MH by region

Categorizing Mental Illness Regardless of the diagnosis, related symptoms and methods of treatment affect people in different ways. For example, some diagnoses, such as schizophrenia (discussed below), may symptomatically become more serious or debilitative in some individuals—to the point where symptoms seriously affect the degree to which the individual functions in daily life; for others, symptoms could be quite manageable. Also, modes of treatment, including medication management, may produce varying effects across participants, improving symptoms for some, but not for others (NAMI; “Mental Health Conditions,” n.d.). Thus, mental illness can be viewed as falling along a continuum, with least serious on one side and most serious on the other. As a general definition for the purposes of this book, mental illness refers to a clinical diagnosis that may be serious enough to impair an individual’s overall well-being and ability to function in daily life, including in matters of physical health. In relation to data collection and reporting, mental illness has been classified into two categories, depending on the level of functional impairment: (a) Any mental illness (AMI) and (b) Serious mental illness (SMI).

Any Mental Illness (AMI) Data from 2020 indicate that 21 percent of American adults, or 52.9 million individuals, reported having AMI (new and existing cases) in the past year (SAMHSA, 2021). “Fast Fact” 1.2 provides brief descriptions of several high-prevalence disorders in the United States among adults.

Mental Health: Defnitions, Prevalence, and Common Terminology 9

FAST FACT 1.2 AMI: OVERVIEW OF PREVALENT PSYCHOLOGICAL DISORDERS AFFECTING ADULTS IN THE UNITED STATES Anxiety Disorders: Symptoms entail excessive worrying and apprehensive feelings beyond the typical worry that is appropriate to a situation. These feelings are intense, excessive, and persistent and can be overwhelming/ difcult to manage. There are several types of anxiety disorders: generalized anxiety disorder, phobias, and panic disorders; afects 19–20 percent of the U.S. population. Major depression: Symptoms may include strong feelings of sadness, emptiness, or hopelessness that last all day long for at least two weeks and interfere with daily social situations. Can involve irritability and/or physical symptoms such as fatigue, difculty sleeping, and weight changes; afects about 7 percent of adults. Mood disorders: Characterized by dramatic shifts in mood, cycling between periods of extreme highs (intense happiness, impulsivity, irritability) and lows (intense hopelessness and sadness/sorrow); afects 3–4 percent of the U.S. adult population. Obsessive-compulsive: Presence of persistent thoughts, urges, or images, sometimes requiring repetitive behaviors that interrupt daily activities; 1.2 percent prevalence rate over a 12-month period. Thought disorders: Abnormalities experienced in one or more of the following fve domains—disorganized thinking, disorganized motor behavior, delusions, hallucinations, and negative symptoms (e.g., lack of emotion); afects about 1 percent of U.S. adults. Stressors and trauma: Involve feelings of extreme anxiety and stress following exposure to a traumatic event; post-traumatic stress disorder (PTSD) is the most common. Trauma type can be sexual, physical, or emotional, and may be directly or indirectly experienced. Afects about 8 million people in the United States, with a higher proportion of women. Sources: 1. National Alliance on Mental Illness (NAMI); “Mental health by the numbers” (2021c). Retrieved from 2. National Institute of Mental Health (NIMH); “Mental health information” (2021). Retrieved from 3. Substance Abuse and Mental Health Services Administration (SAMHSA) (April, 2020); “Mental Health and Substance Use Disorders”. Retrieved from

Serious Mental Illness (SMI) For mental health diagnoses to be categorized as SMI, symptoms are often disabling due to the level of chronicity, degree of functional impairment in one or more major life activities, and a person’s response to accessible treatment options (medication and therapeutic intervention). (Cocozza & Skowyra, 2000; Jones et al., 2004). For instance, schizophrenia, which is


CHAPTER 1 Mental Health–Criminal Justice Nexus

symptomatically linked to hallucinations and delusional thinking, is categorized as a SMI due to the substantial interference or limitations associated with basic living skills and self-care experienced by a large majority of those who have the illness. When symptoms are persistent, chronic, and always disabling, the condition may be referred to as severe and persistent mental illness or SPMI. An estimated 14.2 million people, or 5.6 percent of the adult U.S. population, reported having a SMI in 2020, which represents 1 in 20 people. For both SMI and AMI, the highest prevalence rates are found among lesbian, gay, or bisexual persons, women, and individuals who report their ethnicity as non-Hispanic, and their race as “mixed/multiracial” (SAMHSA; “Key substance use and mental health indicators,” 2021). For that year (2020), the highest prevalence rates of AMI and SMI were found among persons 18–25, followed by those between the ages of 26 and 49. During the coronavirus disease 2019 (COVID-19) pandemic, concerns about mental health (and substance use) have grown considerably. Most reviewed studies have reported negative effects including symptoms of post-traumatic stress, anger, and confusion. Figure 1.3 provides a snapshot of data pertaining to perceived negative effects of COVID-19 in a national sample of U.S. adults with AMI and SMI and no mental illness. As can be seen in the bar chart, in Quarter four of 2020 (October to December), adults who had AMI or SMI in the past year were more likely than adults who did not have mental illness to perceive that the COVID-19 pandemic negatively affected their mental health “quite a bit or a lot.”2

 Figure 1.3 Perceived COVID-19 Pandemic Efect on Mental Health Services: Among Adults Aged 18 or Older Who Received Services; Quarter 4, 2020 Source: SAMHSA (2021). Retrieved from

Mental Health: Defnitions, Prevalence, and Common Terminology 11

Serious and Persistent Mental Illness (SPMI) and Justice-Involvement. There is a high likelihood that those suffering from persistent mental illnesses who are adults have been a part of the community mental health system for years, sometimes decades, and are often referred to by practitioners as “frequent flyers.” As stated before, clients with persistent/chronic mental illnesses impact the system in that there are substantial needs that are required to be addressed which typically start with medication evaluation. Common with clients who suffer from SPMI are bouts in jail, time spent in outpatient or inpatient care, along with emergency room visits and housing needs. The legal system, for many, becomes the community “family,” whereby legal authorities act as surrogate parents, and therefore, provide parameters, structure, and attention in the form of probation guidelines, incarceration, and parole requirements. The expectation is that the local community provides the treatment services; however, in contemporary times, the care and structure, if not provided by mental health program staff, are provided by those in corrections or law enforcement. As will be referenced throughout the remainder of this text, due to stigma, structural changes in the mental health care system, and a significant lack of resources in many communities across the nation, the criminal justice system has become the de facto mental health system. Officers of the court, law enforcement, emergency responders, and probation/parole officers, both adult and adolescent, will need continued training in assessment of signs, knowledge of referral resources, and a basic understanding of the therapeutic process and relationships between all of these factors and crime or irrational behavior in the community. The top presenting serious mental health symptoms and disorders in both jail and prison settings are mania or manic episodes, bipolar disorder, major depression, and psychosis/psychotic disorders, notwithstanding the diagnosis of substance use disorder (SUD) (Fazel et al., 2016; Lamberti et al., 2020). In fact, almost 75 percent of all incarcerated persons (both state and federal) were dependent or abusing alcohol/drugs prior to their offense (Bureau of Justice Statistics, 2006). Anxiety and PTSD are also prevalent diagnoses among justice-involved persons with mental illness, and the sufferer may not have developed any symptoms until post-detention or incarceration. Symptomology related to each disorder and subsequent risk for justice-involvement is presented in “Fast Fact” 1.3. These disorders can significantly impact social and interpersonal relationships. Evaluation, stabilization, and medication are important in the treatment. For community law enforcement, these consumers may be very challenging and become well known to officers. In that way, the officers become community contacts that can facilitate hospitalization and initiate harm prevention through referrals. For instance, many of the consumers who suffer from psychotic disorders are non-compliant with their medications, oftentimes resulting in deterioration of symptoms and bizarre


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FAST FACT 1.3 SMI: DESCRIPTIONS OF KEY SYMPTOMOLOGY FOR MAJOR DISORDERS AND THE RELATED RISK FOR JUSTICE-INVOLVEMENT Anxiety Disorders, including Post Traumatic Stress Disorder (PTSD) Key Symptoms: Anxiousness, extreme anxiety, panic, and impairment in social functioning in those sufering from an anxiety disorder. Panic disorders are included in this category and can have no signifcant origin but can be quite disabling. The observer could see agitation, rapid movements, fearful expressions, and avoidant behavior (APA), 2013. Post-traumatic stress disorder (PTSD) presents symptoms including intrusive recollections of the traumatic event, dreams of the event, acting or feeling as if the trauma were re-occurring, intense distress at exposure to internal or external cues or triggers, physiological reactivity. The person may also have trouble recalling the event and may experience feelings of detachment and restricted afect as well as difculty with sleeping, anger outbursts, hypervigilance, and difculty concentrating. About 3.6 percent of U.S. adults aged 18 to 54 (5.2 million people) have PTSD during a given year. About 30 percent of the men and women who have spent time in war zones experience PTSD. One million war veterans developed PTSD after serving in Vietnam. PTSD has also been detected among veterans of the Persian Gulf War, with some estimates running as high as 8 percent (Smith, 2014). Risk for Justice-Involvement: Daniel (2008) reported a high rate of veterans’ contact with the criminal justice system where 40 percent of veterans who sufer from PTSD are noted to have committed a violent crime since their completion of military service. In numbers, this would be close to 120,000 criminal acts by veterans sufering from PTSD. One signifcant study examined prosecutors’ willingness to ofer treatment options to veterans with PTSD instead of criminal charges (Wilson et al., 2011). The research indicated how prosecutors were generally willing to extend treatment options over criminal charges to veterans with PTSD, thus illustrating some eforts to address the national crisis. PTSD, veterans, and veteran’s court are discussed again later in Chapters 5, 7, and 10. Bipolar Disorder Key Symptoms: Characterized by extreme mood swings that include episodes of mania or hypomania and depression. According to the DSM-5, more than 90 percent of individuals who experience a single manic episode will continue to have episodes in the future; furthermore, 60 to 70 percent of manic episodes occur immediately before or after a major depressive episode. Multiple iterations of the disorder are included in the diagnostic manual: Bipolar I and II with variations of mixed, hypomanic, and unspecifed (APA, 2013). Risk for Justice-Involvement: Depending on the point in time when law enforcement is in contact with the individual, behavioral observations may refect a swing in mood from severely depressed and suicidal, to having grandiose ideas, minimal sleep, and agitation. Those working in jails and prisons will be able to monitor and assess more clearly; those working in the community may need repeated contact to determine the proper type of diagnosis.

Mental Health: Defnitions, Prevalence, and Common Terminology 13

Major Depressive Disorder Key Symptoms: Individuals with Major Depressive Disorder (MDD) may be suicidal, severely depressed, and may experience anhedonia (loss of capacity to experience pleasure; Defnition of anhedonia, 2016), a lack of motivation, reduced appetite, and difculty with sleeping. Sleep is either episodic or constant and disrupts the regular sleep cycle of clients. Sadness and tearful moments can also be a part of the depression. Fits of anger and out-of-control rage can also be part of depression when emotions are suppressed, and the additions of alcohol and other drugs are part of in the equation. Diminished emotional expression and a decrease in self-motivated activities can also be attributed to this problem. An individual with a very fat afect or expression of any emotion and a decrease in activities can sit for lengthy periods of time without much movement (APA, 2013). Risk for Justice-Involvement: Based on the research, it appears that incarceration can lead to some mood-related serious psychological disorders, such as MDD, and have signifcant implications for postrelease from prison and ongoing parole compliance. It also seems clear that although individuals may come into prison with depressive symptoms, depression can also develop because of incarceration (American Sociological Association [ASA], 2013). The Federal Bureau of Prisons has a clinical practice guideline outlining the diagnosis and treatment of depression and would be recommended to readers for additional information on the treatment of depression (Federal Bureau of Prisons [BOP], 2014). Mania Key Symptoms: Manic episodes consist of a distinct period of mood elevation and irritability for at least a week. Symptoms include grandiosity, infated esteem, sleep disturbance and/or needing less sleep, cognitive disorganization, racing thoughts, and distraction of goal focus, as well as involvement in pleasurable activities with a high possibility for painful consequences. Three of these symptoms need to be present to meet the diagnostic criteria (APA, 2013). Risk for Justice-Involvement: With a manic episode, the behavior will impact the functioning of the person socially and vocationally and may require hospitalization in order to attain stabilization. The difculty for law enforcement here is diferentiating this behavior and someone under the infuence of drugs or alcohol. The way in which to rule that out would be with a drug/alcohol screening test. PCP, cocaine, and methamphetamine use can mimic manic behavior. A thorough psychiatric history will need to be conducted to rule that out for treatment purposes. Psychotic Disorders Key Symptoms: Psychotic disorders include disorders such as Schizophrenia, Schizoafective Disorder, Delusional Disorder, Brief Psychotic Disorder, Psychotic Disorder Related to a General Medication Condition, and Substance-Induced Psychosis. To qualify as a psychotic


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disorder, symptoms would include one or more of the following: delusions, hallucinations, disorganized speech, negative symptoms (e.g., anhedonia, social withdrawal), and anosognosia. These are defned in detail below. Delusions. A delusion is a symptom of psychosis that refers to a person having fxed beliefs that confict signifcantly with the present experience. Persecutory delusions occur when an individual believes that one is going to be harmed or harassed by a person or group. Referential delusions occur when the individual believes that signs, cues, and environmental movements are all being directed at them. For example, the cofee shop gave out a cup without a top which means someone is watching them from above. Grandiose delusions are such that the person believes they have exceptional abilities, fame, or wealth, none of which are accurate. Erotomania delusions are when the individual believes a person is in love with them which in fact they are not. Examples include those who stalk celebrities because they feel as though they have a special relationship and are admired by the celebrity. Hallucinations. A hallucination is characterized by an occurrence of sensory perception (taste, smell, hearing, touch, sight) without any type of external stimulus. Hearing voices or auditory hallucinations are most common with this disorder. This can also be drug and alcohol induced. Disorganized speech. The ofcer may encounter a PwMI who is talking incoherently and appears disconnected from thought to thought; this is referred to as disorganized speech or “word salad” (Slate et al., 2013). A grossly disorganized individual may go from bouts of childlike laughter to irritability and agitation in short amounts of time, unrelated to any type of substance use (APA, 2013). Negative symptoms. Negative symptoms represent the absence or gradual disappearance of normal thoughts, feelings, or behaviors. More common defcits include anhedonia, avolition (lack of motivation), social withdrawal, and fat afect. These symptoms are most likely to manifest in patients with schizophrenia but have also been observed in patients with other diagnoses (Healthline: “Living with Schizophrenia,” 2020; Lyne et al., 2017). Anosognosia. Anosognosia, meaning “unawareness of illness,” is a common symptom observed in people who experience SMI—most prevalent among those with diagnoses of schizophrenia (30 percent) and bipolar disorder (20 percent). People who sufer from anosognosia lack insight into their condition, and therefore, even in the face of evidence to the contrary, do not believe they are ill. Studies have indicated that anosognosia may be caused by damage in the frontal lobe of the brain due to schizophrenia or bipolar disorder (and in some cases, diseases such as dementia). The primary challenges with this misperception of self on part of the PwMI relate to increased anxiety and confict with others, the avoidance of treatment (often medication), and the potential for reckless or increasingly bizarre behavior (NAMI, 2021a, 2021b).

Mental Health: Defnitions, Prevalence, and Common Terminology 15

FAST FACT 1.4 SUICIDE AS A CONSEQUENCE OF MENTAL ILLNESS Suicide is among the leading causes of death in the United States. In fact, depression, substance use disorders (SUDs), and psychosis have been found to be the most relevant risk factors of suicidal ideation (having thoughts of suicide) and suicide for PwMI (Brådvik, 2018). Data from 2019 shows that 4.58 percent of U.S. adults (11.4 million people) report having serious thoughts of suicide, a fgure that has been increasing every year since 2011–2012 (NIMH, n.d.; Reinert et al., 2021). The data also indicate that 1.4 million adults in 2019 attempted suicide during the past year. Like prevalence data, it is anticipated these statistics do not accurately refect rates amid COVID-19 pandemic/postpandemic conditions, and the efects—fear of contagion, distress, anxiety, depression, and social isolation, to name a few—are likely to persist for months and years to come (Xiong et al., 2020). In fact, suicide prevention and access to crisis care have been identifed as national priorities for 2021–2022 (Reinert et al., 2021). Legislative developments that support an improved continuum for crisis services are well underway, including the passage of 988 as a national crisis line for mental health crisis events and suicide prevention. These and other eforts are discussed in Chapter 4, in the context of Intercept Zero.

behaviors, which may lead to concern for their well-being and the well-being of others. “Fast Fact” 1.4 presents one of the most detrimental adverse mental health outcomes. In addition to suicide/suicidal ideation, disability is also a consequence of serious mental illness, and it can place a significant burden on PwMI and caregivers. Some challenges may include lack of insurance/access to quality care, social support, housing stability, criminal justice involvement, and self-injurious behaviors (SIBs) and/or suicidality (Evans et al., 2016). As will be presented and discussed in more detail throughout the remainder of the text, one’s ability to effectively cope and function with mental illness in the community is critical and becomes a salient factor in understanding maladaptive behaviors, which may lead to disorderly conduct under the criminal law. FAST FACT 1.5 SMI AND RISK OF MORTALITY FROM COVID-19 A recent study of seven countries, including the United States, reported that people with SMI are almost two times more likely to die from COVID-19 than people without SMI. There is also an increased risk for those who misuse drugs or alcohol, which is concerning, given the high likelihood of people with SMI to have a co-occurring disorder. Results were independent of the clinical risk factors (e.g., obesity, cardiovascular disease, and age) and were attributed to other factors, such as barriers in access to care. Source: Fond, G., Pauly, V., Leone, M., Llorca, P. M., Orleans, V., Loundou, A., … & Boyer, L. (2021). Disparities in Intensive Care Unit Admission and Mortality Among Patients with Schizophrenia and COVID-19: A National Cohort Study. Schizophrenia Bulletin, 47(3), 624–634.


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INTERSECTIONS OF CRIMINAL JUSTICE AND MENTAL HEALTH: JUSTICE-INVOLVED P WMI In jurisdictions throughout the nation, officers work with community mental health services and the local emergency room to help stabilize citizens in crisis. Usually, the police are called due to safety issues. Ideally, police departments will act as community points of contact, partnering with the mental health and medical communities to facilitate treatment rather than incarceration. Police responses and partnerships are discussed more fully in Chapter 5.

PwMI Incarcerated The number of PwMI who are justice-involved (in adult and juvenile justice systems) in the United States is substantial. Depending on the data source, estimates show up to 20 percent of persons incarcerated in jail and 24 percent of persons incarcerated in state prison report recent histories of having a diagnosable mental health condition, figures that are higher than the general population, and may even be conservative estimates (NAMI, 2013). In fact, depending on the way in which mental illness is defined, higher rates have been found. For example, in their study of federal, state, and jail correctional populations, James and Glaze (2006) collected data derived from offender mental health history information and clinical interviews. Their conceptualization of “mental illness” included not only recent history, but also current symptoms experienced. As a result, their findings indicated that rates of mental illness were 64 percent in jails and 56 percent and 45 percent in state and federal prisons, respectively. Statistics on mental illness in correctional settings are revisited in Chapter 6 specifically and elsewhere throughout the book. In terms of gender and incarcerated persons, findings suggest that despite their overwhelming representation in correctional populations, men are less likely than women to report mental illness (e.g., 6 percent vs. 11 percent, respectively; Maruschak, 2004). There are also race and ethnicity differentials in the data reported, in which findings indicate that the proportion of White incarcerated persons who report having any mental health issues is significantly larger than that of their Black and Latinx/Hispanic counterparts (using reported symptoms and recent mental health history: 61 percent, 51 percent, and 44 percent, respectively; James & Glaze, 2006). Reasons for these differentials should also be considered and explored moving forward; perhaps lower rates of reporting mental illness reflect the same reasons why people of color (POC) fail to report other social problems (including crime) to those in authority positions, such as mistrust, fear, and embarrassment due to large-scale systematic discrimination and the resulting effects of internalized racism (Smedley, 2012). James and Glaze (2006) also found age differences—in particular, that younger incarcerated individuals (ages 24 or younger) were more likely to report mental illness, though there is

Intersections of Criminal Justice and Mental Health: Justice-Involved PwMI 17

a significant gap in the literature related to age with respect to forensicspecific populations (Brandt, 2012). It is further estimated that about one-third of PwMI who are incarcerated (or about 72 percent) also have co-occurring substance use disorders (CODs) (Ditton, 1999), and that suicide in correctional institutions is a significant social problem—most profoundly among incarcerated persons who have been diagnosed with SPMI (Hayes, 2012). The reasons for such a high prevalence of COD and suicidal ideation among adult correctional populations are plentiful. While largely related to deinstitutionalization3 and stigma, it may also be related to the conditions of confinement, which arguably exacerbate—perhaps even trigger—underlying psychosis for some individuals. These are salient issues in the literature and practice and will be explored in detail in the remaining chapters of this book. See Figure 1.4 for a visual depiction of these and other issues pertaining to SMI.

Justice-Involved PwMI in the Community Additional data have been collected about individuals under correctional supervision in the community. For example, in addition to the study of

 Figure 1.4 Issues Pertaining to Serious Mental Illness

Source: Treatment Advocacy Center. (2016). Serious mental illness: By the numbers. Treatment Advocacy Center. https://


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incarcerated persons, Ditton (1999) examined the prevalence of mental illness among adult probationers, and for the purposes of her data collection, individuals were identified as having mental illness if they were currently experiencing an emotional or mental health condition or had ever been admitted to a state hospital or other treatment program overnight. Whereas incarcerated individuals were much more likely to report an overnight hospital stay than probationers, her findings revealed that 16 percent of probationers (or over 500,000) self-reported having a mental disorder under this definition. It should also be noted that rates of persons without stable housing and individuals having experienced prior sexual and physical trauma or victimization were also found to be significantly higher among PwMI (probationers and incarcerated persons) in her nationally representative sample—a finding that has emerged in other research reports (Hawthorne et al., 2012; McGuire & Rosenheck, 2004; NAMI, 2010), particularly when related to justice-involved women (DeHart et al., 2014; Gunter et al., 2012; Wolff et al., 2012).

Juveniles and Behavioral Health Issues The juvenile justice system does not fare better in terms of its reception of youths who are having behavioral health-related issues. Mental illnesses experienced by young justice-involved persons can include depression, anxiety disorders, PTSD, suicidal tendencies, mood disorders, conduct disorder, and substance use disorder (Riley, 2014). Although it is rare, schizophrenia can also occur in certain youths as an early-onset form of illness. At any given point, it is estimated that at least 90,000 youths reside within correctional facilities in the United States (Burriss et al., 2011; Nelson et al., 2010). Research has indicated that approximately 70 percent of justice-involved youths placed in residential facilities have been diagnosed with one or more serious psychological disorders, and at least 20 percent with an SPMI (NAMI, 2013; Shufelt & Cocozza, 2006; Teplin et al., 2006). For example, in their study of adolescents placed in residential facilities in Cook County, Illinois, Teplin and colleagues (2006) found that 60 percent of boys and 70 percent of girls had received at least one psychiatric diagnosis, excluding conduct disorder. Moreover, researchers have also concluded that an abundance of youths possess multiple diagnoses, referred to as comorbidities (Cocozza & Skowyra, 2000; Teplin et al., 2006). As many as 65 percent of youths experience comorbid issues (such as drug addiction) that are unlikely to be addressed adequately through treatment plans (Kapp et al., 2013; Riley, 2014). Like adults with mental illness under correctional supervision, addiction can be generated by the detention environment or co-occurring as part of the mental illness from which the youth suffer. Regarding youths under supervision in the community, risk assessment tools being utilized at case entry have identified that 50 percent present at intake have an underlying psychiatric diagnosis (Shufelt & Cocozza, 2006).

Service Utilization/Treatment Engagement 19

SERVICE UTILIZATION/TREATMENT ENGAGEMENT For many individuals in both community and correctional settings, behavioral health treatment is one of the primary pieces in the recovery process and may include medication management, counseling or therapy, substance use disorder (SUD) services, case management, and a host of other educational and therapeutic interventions (Lamb & Weinberger, 1998; NAMI, 2015). Depending on funding and the resources available in the locale, the treatment needs of PwMI are sometimes met by what has been perceived as barely adequate programs and planning. This holds true whether we are talking about community-based care, state hospitals, or secure youth or adult placement. It is important to realize that gaps in available and adequate services may be due to several unavoidable barriers, including the high cost of care, lack of communication between providers and agencies, training deficiencies, and lack of structured programs, to name a few (Burriss et al., 2011; Kapp et al., 2013). There is also a high likelihood that individuals with mental health issues will not actively seek out services due to symptoms that are characteristic of their illness, personal financial barriers or restrictions, or because they lack the knowledge of available services (Hartford et al., 2006; Slate et al., 2013). Lack of treatment engagement may also be greatly attributed to reasons related to fear of stigma and ridicule. Specific reasons for not seeking mental health services have been provided by adults surveyed about their perceived unmet past-year mental health care needs; some of the most frequently occurring responses have included the previous factors and the fear of being committed and having to take medication (SAMHSA, 2014). FAST FACT 1.6 SELF-MEDICATION HYPOTHESIS A theory of addiction is based on the idea that people use substances, such as alcohol and drugs, to cope with or mask underlying emotions or trauma that has not been properly treated. Source: Khantzian, E. J. (2003). The Self-medication Hypothesis Revisited: The Dually Diagnosed Patient. Primary Psychiatry, 10(9), 47–54.

POLICY & PRACTICE 1.1 PSYCHOTROPIC MEDICATIONS Only physicians can prescribe psychotropic medications to treat clients suffering from mental and emotional disorders. These medications are used to minimize or eliminate symptoms and have minimal, non-addictive qualities. For many of those incarcerated and on probation or parole, follow up with treatment and psychiatric


CHAPTER 1 Mental Health–Criminal Justice Nexus

visits is challenging. As is common, the wait time to see a psychiatrist is two to three months, and in some cases, longer. Those individuals released from prison may have a gap in mental health services due to the non-payment by insurance. If the wait is too long for a medication review, the client may discontinue or not engage in services. •

Mood stabilizers such as Zoloft, Prozac, and Efexor can be used to treat depression and in some cases depression and anxiety. An individual who has addiction issues will need to be evaluated for a non-addicting medication if anxiety or PTSD symptoms are concurrently diagnosed. These will need to be monitored closely by the physician and treatment providers. Anxiety disorders are typically treated short term with Klonopin, Ativan, or Buspar. Those with addictive potentials such as Ativan and Klonopin are not the best medications to treat anxiety. Physicians with experience in addiction medicine typically do not prescribe addictive potential psychotropic medication to patients sufering from addiction. Clients with bipolar disorder may be put on Depakote or lithium and those with psychotic disorders may be put on Haldol, Risperdal, or Zyprexa. Attention defcit-hyperactivity disorder (ADHD) is often treated using Ritalin or Cylert. Again, those clients with addiction issues will need to be evaluated for alternative non-potentially addicting substances. The use of over-the-counter (OTC) medication has become popular with those in adolescence due to the sedating qualities of the medications. Large quantities used with alcohol and other drugs potentially increase the risk for problems.

General Population Data Data have been collected to determine the extent to which PwMI are utilizing available treatment services for both substance use and mental health. As provided by SAMHSA (2014), utilization is defined differently depending on the ages of the consumers receiving services. For adults (18 years of age or older), mental health service utilization is related to the receipt of treatment or counseling for any problem with emotions, nerves, or mental health that was not related to substance abuse; treatment may be rendered in any inpatient or outpatient setting and may or may not involve the use of prescription medication. For youth aged 12 to 17, mental health service utilization involves treatment or counseling for any emotional or behavioral problem, with services rendered in any of the following settings: (a) the specialty mental health setting (inpatient or outpatient care); (b) the education setting (talked with a school social worker, psychologist, or counselor about an emotional or behavioral

Service Utilization/Treatment Engagement 21

problem; participated in a program for students with emotional or behavioral problems while in a regular school; or attended a school for students with emotional or behavioral problems); (c) the general medical setting (pediatrician or family physician care for emotional or behavioral problems); (d) the juvenile justice setting (received services for an emotional or behavioral problem in a detention center, prison, or jail); or (e) the child welfare setting (foster care or therapeutic foster care). (SAMHSA, 2014, p. 41) Beginning in October 2020, national data were collected to include information about the use of virtual mental health services, including professional counseling, medication, or treatment for mental health, emotions, or behavior over the phone, by e-mail, or through video calling.4 Although one consequence of the COVID-19 pandemic was the movement of many medical services (physical and behavioral health) from in-person to a virtual environment, it should be noted that some virtual mental health-related options (i.e. telehealth), have been available prior to the pandemic; particularly, for use with clients who face barriers to service access (e.g., incarcerated persons, clients in remote/rural settings). Data pertaining to virtual service utilization are presented later in this section. According to results of the 2020 National Survey on Drug Use and Health (NSDUH), the number of adults who received treatment or counseling for past-year (2019–2020) mental health issues was 41.4 million or 16.9 percent; comparatively, for adolescents (12–17 years of age), mental health service usage was 17.3 percent or 4.2 million people (SAMHSA, 2021). For a more detailed look at the treatment landscape over time by type (adults) and across settings (juveniles), additional service utilization data from 2002 to 2020 are presented in Figures 1.5 and 1.6. Between 2019 and 2020, lines are not connected because of methodological changes for 2020; therefore, caution should be used when comparing estimates. As illustrated in Figure 1.5, among adolescents, service engagement has substantially increased in specialized mental health and school-based educational settings over the past 5 years (2015–2020). While there may be a slight increase in services provided in a general medical setting, data suggest that services are less likely to be received by adolescents with emotional and behavioral health needs in both child welfare and juvenile justice system settings. The utilization of mental health services appears to have increased among adults in 2020 (again, caution is used in interpreting data due to methodological changes for 2020). As illustrated in Figure 1.6., adults who used mental health services the year under evaluation were more likely to be treated with prescription medication and to engage in outpatient treatment and least likely to be hospitalized in an inpatient facility.


CHAPTER 1 Mental Health–Criminal Justice Nexus

 Figure 1.5 Sources of Mental Health Services in the Past Year: Among Youths Aged 12 to 17; 2002–2020 Source: SAMHSA (2021)

 Figure 1.6 Type of Mental Health Services Received in the Past Year: Among Adults Aged 18 or Older; 2002–2020 Source: SAMHSA (2021)

Service Utilization/Treatment Engagement 23

“Fast Fact” 1.7 touches on a prevailing issue related to adolescent mental health; that is, the mental health needs of bullied LGBTQ+ (Lesbian, Gay, Bisexual, Transgender, Queer/Questioning+) youth in schools.


Contributor: Jacqueline A. Carsello, MS In the United States, 21 states and Washington, D.C. have expressed anti-bullying laws that include specifications for the protection of LGBTQ+ (Lesbian, Gay, Bisexual, Transgender, Queer/Questioning+) youth (Figure 1.7, GLSEN, 2021). Data from the Crisis Text Line collected from August 2013 through December 2019 indicates that 75 percent of individuals who reach out when in crisis are under 25, 44 percent identify as LGBTQ+, and bullying in school (28 percent) is one of the top issues addressed (Womble, 2021). These data are revisited later by Dr. Sandy Smith, in Chapter 4 of the text. As noted later in the context of Intercept 0 (Chapter 4), one program that has been helpful for some LGBTQ+ youth is the implementation of what is referred to as “safe spaces” in schools—spaces that are free from stigma and in which members of the community can feel secure, safe, and supported. Gay-straight alliances (GSAs) are the most common, though they are only available in 22 percent of schools (Beckerman, 2017; Guidi, 2019). GSAs can help LGBTQ+ youth feel accepted and improve their safety and mental health because the individuals in them are supportive of the LGBTQ+ community. GSAs, or other such clubs, should be implemented in all schools to give LGBTQ+ youth a place to be with peers, to help youth identify others who are allies, and to provide the proper resources for LGBTQ+ youth. Sources: 1. Beckerman, N. L. (2017). LGBT Teens and Bullying: What Every Social Worker Should Know. Mental Health in Family Medicine, 13, 486–494. Retrieved from 2. GLSEN. (2021). Policy Maps. GLSEN. Retrieved from https://www.glsen. org/policy-maps 3. Guidi, S. J. H. (2019). Safe Spaces: A Social Model Response to LGBTQ+ Mental Health. Journal of Integrated Studies, 11(1), 1–10. Retrieved from http://jis.athabascau/index.php/jis/article/view/273/486 4. Womble, A. (February 10, 2020). Everybody Hurts: The State of Mental Health in America. Crisis Text Line. Retrieved from


CHAPTER 1 Mental Health–Criminal Justice Nexus

Enumerated Anti-Bullying and Harassment Laws by State

States with enumerated anti-bullying and harassment legislation that protect students based on sexual orientation and gender identity States that prohibit local school districts from having anti-bullying and harassment policies that specifically protect students on the basis of sexual orientation and gender identity






States without enumerated anti-bullying and harassment legislation




















*As of May 25 2021

















 Figure 1.7 U.S. Map of Laws Protecting LGBTQ+ Youth

Source: GLSEN. “Enumerated Anti-Bullying and Harassment Laws by State.” GLSEN Policy Maps, Updated: May 25, 2021. Retrieved December 28, 2021, from https://www.

Going Virtual Before the COVID-19 pandemic, mental health treatment was typically delivered in person. The COVID-19 pandemic required changes to include the expansion of virtual access to varying types of mental health treatment services. Virtual delivery of mental health treatment has been shown to be effective (McLean et al., 2021; Snoswell et al., 2021). In 2020, 14.9 percent of young adults aged 18–25 (or 4.8 million people) and 13.4 percent of adults aged 26 to 49 (or 12.8 million people) received virtual mental health services in the past year compared to 7.8 percent of adults aged 50 or older (or 8.8 million people) (Figure 1.8). It will be interesting to see how these trends develop over the next several years. Type of Mental Health Service Mental Health Service or Virtual Service

Quarter 1

Quarter 4

Quarter 1

Quarter 4

Quarter 1

Quarter 4

Quarter 1

16.6 (0.53)

18.7 (0.52)

18.5 (0.96)

22.5 (0.97)

17.6 (0.68)

21.1 (0.73)

15.1 (0.93)

6.1 (0.63)


1.1 (0.17)

0.7 (0.10)

1.4 (0.28)

1.4 (0.27)

1.1 (0.20)

1.0 (0.19)

15.6 (0.90)

6.7 (0.62)


8.3 (0.40)

9.4 (0.38)

11.0 (0.80)

12.8 (0.77)

9.8 (0.56)

13.8 (0.61)

1.0 (0.30)

13.0 (0.83)

Prescription Medication

13.3 (0.47)

14.3 (0.47)

12.9 (0.86)

16.1 (0.85)

11.4 (0.56)

15.1 (0.63)

0.3 (0.11)

13.1 (0.84)

18 or Older

Virtual na = not applicable


11.0 (0.40)



14.9 (0.83)



13.4 (0.59)

50 or Older


Quarter 4

7.8 (0.69)

 Figure 1.8 Received Mental Health Services Including Virtual Services in the Past Year: Among Adults Aged 18 or Older; by Age Group and Quarter, 2020 Source: Table adapted from SAMHSA (2021)

Challenges in Managing Justice-Involved PwMI 25

Correctional Data Data derived from a survey of adult state and federal community and confinement-based correctional facilities in the United States in 2000 indicated that an estimated 191,000 of the incarcerated persons surveyed had self-reported some form of mental illness as of midyear. Among the 191,000, one in every eight was receiving behavioral health services. The data were further broken down by type of treatment, and reports indicated that a total of 1.6 percent of incarcerated persons across reporting institutions (n = 17,354) had received 24-hour mental health care, 12.8 percent (n = 137,385) received therapy or counseling, and 9.7 percent (n = 105,336) had received psychotropic medication for their mental health–related illness, compared with 5 percent of the nonincarcerated population of PwMI (Beck & Maruschak, 2001). For a variety of reasons, mental health programming and related reentry services have not been prioritized in jail and prison settings; therefore, issues such as a high incidence of mental health disorders and significant histories of trauma that far surpass that of their nonincarcerated counterparts have further taxed resources that were already sparse. Moreover, research suggests that confined persons with mental illness are quite difficult to treat (Morgan et al., 2012), if not resistant to treatment overall (Lamb & Weinberger, 1998). Based on this resistance and coupled with unique criminal histories that indicate the potential for violence (James & Glaze, 2006; Lamb & Weinberger, 1998), mental health providers are often reluctant to treat them to begin with (Lamb et al., 1999). As a result, a growing number of justice-involved persons with mental illness needing treatment have not been able to obtain it to the extent necessary—an outcome that reflects the noninstitutionalized population experience (Sickel et al., 2014). In contrast to offending populations without mental illness, the lack of engagement for this group is sometimes related to collateral consequences of their incarceration or other involvement in the criminal justice system, such as the loss of Medicare, Medicaid, or disability benefits (NAMI, 2010). Because research indicates that incarcerated adults who have mental health problems are likely to spend an average of four months longer incarcerated than those without (James & Glaze, 2006), the urgency of treatment becomes more imminent. Unless reentry services are implemented during one’s period of incarceration and treatment services are received soon after release (within two weeks), the same individuals who may have been stabilized while inside the institutional setting may quickly decompensate in the community, thereby becoming at risk for repeated encounters with justice and other systems of care (e.g., public welfare). Varying trajectories are examined in more detail later in the book.

CHALLENGES IN MANAGING JUSTICE-INVOLVED P WMI The most primary obstacle between the mental health and criminal justice systems may be a historical resistance to share ideas and to collaborate


CHAPTER 1 Mental Health–Criminal Justice Nexus

(Applebaum et al., 2001; Deane et al., 1999; Lamb et al., 2002). The reasons for this are plentiful, though may revolve around unique philosophies held by each system and the profound language barrier as a result. For example, although police officers are oftentimes regarded as “street psychiatrists,” they would most likely prefer a distinct separation between their role and that played by social workers, in terms of their responses to potentially violent situations. This preference indicates an understandable resistance to any direction that requires them to drop their “guard” during a crisis encounter—particularly those involving persons whose behaviors are viewed as exceptionally unpredictable or unstable (Lamb et al., 2002). However, when phrased in a way that recognizes the possibility of dangerousness and the need for officer (and citizen) safety, new approaches and techniques become more palatable to individual officers and other law enforcement officials. It is at those moments when collaboration is made possible, and change can be accomplished. For the purposes of facilitating productive collaboration among students who are reading this book, it is essential to compare key differences and similarities between the mental health and justice systems. PRACTITIONER’S CORNER 1.1 WHERE MENTAL HEALTH AND CRIMINAL JUSTICE MEETS: WHAT A CRIMINAL JUSTICE PRACTITIONER NEEDS TO KNOW ABOUT MENTAL HEALTH

Contributor: Leah Vail Compton, MA, MBA State Community Forensic Liaison, Florida Department of Children and Families (FL-DCF) The following contribution by Ms. Vail is based on a real case scenario involving a client—a woman we will refer to as “Pam.” Pam lives in Alachua County with her brother and loves to collect dolls and socialize with her family. She also provides respite care for her elderly father by helping her sister in Union County. Her family and friends value her sense of humor, sweet disposition, and caring nature. However, Pam also has schizophrenia, which can change her behaviors; when untreated, she can become violent. Pam became very ill in 2010, which resulted in an altercation with the neighbor, and law enforcement was called. Fortunately, the responding ofcers were Crisis Intervention Team trained and recognized that Pam was ill. The incident still resulted in Pam crawling underneath her mobile home and refusing to come out. Due to their specialized training, the ofcers were able to talk her into coming out and being peacefully taken into custody without incident. However, she eventually was sentenced to probation related to felony charges. She was well known at Meridian, given her history of three state hospital admissions and over 20 Crisis Stabilization Unit (CSU) admissions. When released from the jail, Pam worked with a forensic specialist to attain the reinstatement of benefts, fnancial management, advocacy with the legal system (probation/court), and medication management and to become involved in activities of daily living.

Challenges in Managing Justice-Involved PwMI 27

Surviving the Profession Balancing the needs of the client, their family, the many facets of the criminal justice system, and other stakeholders can be very stressful. That stress is a prime reason for the high turnover rate in the profession. At times the stress will build, and to survive in the feld, the practitioner needs to fnd ways to relieve it. I have found the following to be helpful: • • •

Keep things in perspective. Frequently remind yourself that there will be many disappointments and that you have only limited control of your client’s behavior and the resolution of their cases. Find distractions in your personal life. Socializing with friends, a hobby, and working out on a regular basis are good stress relievers. Use your vacation days and enjoy life outside of work. Finally, share your feelings and concerns with coworkers and family. Many mental health organizations ofer counseling for their employees to counter the stress; don’t be afraid to take advantage of it.

Author’s Note: Crisis Intervention Team (CIT) training is a specialized police-based response designed to resolve police encounters more efectively with citizens experiencing mental health–related crisis. CIT is discussed in more detail in Chapter 5 of the text. A crisis stabilization unit (CSU) is a place in which individuals are evaluated and treated for acute mental health crises. Once found to be clinically stable, the individual may be evaluated for further placement (commitment/incarceration) or discharged back to the community. A CSU can be a stand-alone facility or a designated space in an emergency department of a hospital or other healthcare facility.

PRACTITIONER’S CORNER 1.2 APPLICATION: PUTTING LEARNERS INTO THE PICTURE OF THE FORENSIC MENTAL HEALTH SYSTEM Contributor: Ford Brooks, EdD, LPC, NCC, CADC The following scenarios provide criminal justice/behavioral health professionals (current or aspiring) with an application of the chapter information in hopes of bringing mental health and criminal justice systems together. Periodically revisit these vignettes as you work your way through the remainder of the text, learning of challenges at each interception point in the forensic mental health system. Correctional Issues: Initial Period of Detention Bianca has been incarcerated for the past two months for an outstanding warrant and her most recent arrest for drunk driving. Her family history is signifcant for addiction, and she has experienced an unstable family life. She grew up in the city and eventually started using alcohol and marijuana at the age of nine. She was arrested multiple times as a juvenile and


CHAPTER 1 Mental Health–Criminal Justice Nexus

spent time in a juvenile detention facility. Bianca is 24 years old, biracial (Latina and Black American), withdrew from high school prior to graduation, and has no formal training or military experience. Bianca’s use of alcohol has escalated over the past fve years to the point now that her daily consumption of alcohol is at least eight to ten beers and marijuana. Bianca has experienced episodes of using painkillers, and at the age of 21, she started using heroin because it was less expensive. Her last use of all drugs was the day she was arrested two months ago. During the frst week in jail she underwent a mild to moderate withdrawal including night sweats, agitation, vomiting, dizziness, shakiness with fulike symptoms, and severe headaches. Bianca did not alert staf to her discomfort, as this was the frst time she ever stopped using alcohol and drugs other than during previous brief stints in juvenile detention. In addition to her use of substances, Bianca sufers from anxiety and depressive issues, nightmares, hypervigilance, and has a history of trauma in her family after having witnessed her father shoot and kill her brother. Her father is serving a life term for frst-degree murder. By her report, she is easily startled, has horrible nightmares at least three nights a week, unstable mood most days, and has times where she contemplates suicide. Although she has never made an attempt, she has the means (Bianca owns two un-registered pistols). Bianca is going to be released in two weeks to the community and will be assigned a probation ofcer. Community Corrections: Probation In this scenario, we walk through what the probation ofcer wants to be aware of in the post-jail discharge meeting and recommendations to be made to the judge for the court order. Depending on local mental health resources, Bianca could be referred to a drug and alcohol counselor for assessment and recommendations. In some cases, the county will pick up the cost of assessment and subsequent sessions while the insurance/medical assistance becomes active or re-activated. If there isn’t stopgap funding then the discharging individual needs to wait until funding becomes available, which means time without treatment or therapy and the potential to re-ofend. In addition to a drug and alcohol assessment is the referral for a psychiatric evaluation. In some cases, the incarcerated person has already been evaluated by the jail psychiatrist/counselor. However, if this has not occurred, it needs to be noted by the probation ofcer for consideration in probation orders. The probation ofcer may not be providing therapy; however, a general set of questions would reveal the symptoms of PTSD, and a referral for psychiatric care and medication protocol. The probation ofcer meets with Bianca and determines, based on a short interview, that Bianca’s main issues and arrests have all been alcohol or drug related. Moreover, if she wasn’t using or didn’t have an alcohol and drug issue, she would not be in the criminal justice system. Her brand of trouble with her addiction involves the courts and is symptomatic of how out of control she is with her use. Therefore, an immediate referral

Challenges in Managing Justice-Involved PwMI 29

is made to the county alcohol and drug ofce for assessment and to mental health for a psychiatric evaluation; a referral to a psychiatrist is also made for a medication review. It is helpful to note if the clinician providing the assessment is both an alcohol and drug specialist and one who is knowledgeable and comfortable using the DSM-5, it will help with multiple referrals. In an ideal referral world, Bianca makes an appointment with the drug and alcohol counselor that week, is seen by the mental health counselor the same week, they get releases of information and talk with each other and the probation ofcer and set Bianca up for a medication review. The recommendations would be collective, collaborative, and informed based on the assessments. Again, this would be refective of an ideal system of care. The reality is that Bianca may not get an appointment for a month with either counselor. Further, it is possible that the probation ofcer will have and overwhelming number of probationers on their respective caseload. Moreover, funding for the year at the county is likely to be depleted, and it may take about three months to activate/reactive Bianca’s insurance. Consequently, the client would be out of jail without services and intensive supervision, increasing her risk of violating conditions of probation and possibly re-ofending. Unfortunately, this is where we are in many cities and towns around the country. Relapse occurs, re-ofending occurs, and the client ends up back in jail this time for a longer period and continues to sufer from addiction and PTSD. Most importantly, the client is not, in the truest sense, a “criminal,” rather, acts to obtain/use drugs or alcohol which helps with symptoms of untreated mental health disorders. Although a familiar scenario, there are places around the country that ofer treatment and counseling in the jails, alcohol and drug groups, assessment by psychiatrists for medication post-discharge, and a seamless transition from a therapeutic community in jail to treatment services in the community. Bianca, if in that system, would experience a case manager, moving to the community with her medication and at least a month’s worth of supply until she can meet with the next psychiatrist. She would be referred to a clinician with experience in PTSD and she would immediately enter some type of trauma-informed group treatment for her addiction. Her family would somehow be part of the reintegration into the community and her support network. This all sounds great, however, doesn’t typically happen as presented here. Overwhelming caseloads for probation ofcers, unmotivated clients, gaps in mental health and substance abuse treatment, and of course lack of funding resources are substantial barriers that cannot often be overcome. Local and Regional Police Mary is an on-again of-again city resident who is currently without housing. She was diagnosed with schizophrenia at the age of 17 and has been in and out of the mental health system since that time. She is a 42-year-old White woman. She lives most of her time in supervised


CHAPTER 1 Mental Health–Criminal Justice Nexus

living; however, there are times when she disappears for months on end to diferent towns within hitchhiking distance. Throughout her life, she has known substantial heroin addiction and subsidized her use with prostitution. At the age of 42, she is HIV positive and has contracted hepatitis C. Most of the long-time regional law enforcement know Mary and have done what they could to help her at diferent points in her life to obtain housing, get rides, make it to medical appointments, and at times arrest her so she would have a warm place to sleep and food to eat. Local and regional law enforcement ofcials have learned quite a bit from her with regard to the mental health system, her disorder, and her medical status. Although they may not identify themselves as such, they are part of Mary’s informal mental health treatment team. They listen to her; they understand about her disorder through her fts of yelling at walls and when she tears at her skin to get the “bugs of,” because of her heroin withdrawal. They have repeatedly helped to facilitate transportation and housing for her medical issues. She is part of the community just as law enforcement is an integral aspect of the community’s safety. More and more, jail staf and law enforcement are providing triage assessment and referral and formal/informal treatment to those individuals who— 30 or 40 years ago—would have been placed in an acute (and possibly long-term) state facility for treatment and maintenance. Prevailing issues, and the role and training of correctional staf and law enforcement, are discussed in more detail in Chapters 5–9. Deinstitutionalization has put more and more responsibility on the criminal justice system to take care of people with lived experience (PWLE) with little to no training or preparation other than on the job. This book has been written with this in mind.

TAKE-HOME MESSAGE As briefly discussed here and presented in more detail in later chapters, the number of justice-involved persons who struggle with mental health conditions and trauma, whether preexisting or induced by incarceration, are staggering. As stated, there are several reasons for the overrepresentation of PwMI across the system, but the primary origin has been attributed to a decrease in available inpatient psychiatric beds in state-run hospitals and the rapidly shrinking community mental health services (NAMI, 2010). In short, persons with SMI are no longer able to access necessary treatment and services. As a result, they may begin a cycle of cross-systems encounters as they struggle with lack of adequate care, unstable housing, trauma and PTSD, substance use, periods of incarceration or other criminal justice supervision, and continued crisis events—all leading to their own criminalization. Unfortunately, the communities in which these individuals live are carrying the burden in terms of financial consequences: The estimated cost of incarceration for one year in a state or federal prison is approximately $23,000 for typical inmates; by comparison, the cost of incarceration for persons with SMI increases anywhere from $50,000 to slightly over $100,000, depending on the jurisdiction and available services (Torrey et al., 2014).

Take-Home Message 31

Questions for Classroom Discussion 1 What do you think of when you hear the term “mental illness”? What beliefs have you been taught about mental disorders? Can you distinguish between myths and facts? How? 2 What personal experiences have you had with persons with psychological disorders? What is that person’s relationship to you, and how did their psychological health affect you? 3 What are your feelings about the label—or stigma—associated with having a psychological disorder? Do you think those feelings will have any impact on your professional work? If so, what is the impact? Consider the case of Devin, in Thinking Critically 1.2.

THINKING CRITICALLY 1.2 CASE VIGNETTE: DEVIN “Devin” is an 18-year-old high school senior who is currently employed part-time as a dishwasher at a local restaurant. Throughout middle and high school, Devin has been the target of bullying and is often teased about being overweight and “ugly.” Devin was recently “written up” by an employer for a verbal altercation with a fellow employee. Devin feels rejected by peers and adults and feels that he has always gotten “the short end of the stick.” More recently, Devin has been posting regular rants on social media, arguing that “the day will come” and that “the bullies will get what is coming to them.” Devin has long felt targeted by administrators at the high school, accusing him of oppression and “victimization.” Recently, Devin posted the following on social media: “I fnd myself revelling in the idea of cleansing the school of the oppressors” and “I admire the soldiers who came before me and showed the oppressors what it really means to be afraid.” Since sophomore year, Devin has expressed interest in frearms and has been accompanying an uncle to a shooting range. Devin has recently become obsessed with automatic rifes and has indicated having a fantasy of “shooting up” the restaurant where he currently works. Discussion: It is likely that most people would fnd Devin’s thoughts and emotions to be frightening and disturbing; however, it is very possible that Devin does not meet the criteria for a clinical diagnosis of “mental illness.” Chances are that many individuals reading this book will encounter (or have already encountered) people with SMI in crisis. How will you navigate encounters with individuals who may share the same experiences and worldview as Devin? Consider beliefs you have about mental illness or PWLE in general; how might these afect your responses in the feld?


CHAPTER 1 Mental Health–Criminal Justice Nexus

KEY TERMS & ACRONYMS Anhedonia Avolition • Comorbidities • Co-occurring Coronavirus disease 2019 (COVID-19) • Criminalization of mental illness • Crisis Stabilization Unit (CSU) • Crisis Intervention Team (CIT) • Decompensate Deinstitutionalization • Diagnostic Statistical Manual-5th edition (DSM-5) • Emotional and behavioral disorders (EBDs) Flat afect • Forensic (mental health) Grandiosity Person-frst language Self-injurious behaviors (SIB) • Serious mental illness (SMI) • Severe and persistent mental illness (SPMI) Stigma/stigmatization Stopgap funding Suicidality Suicidal ideation

NOTES 1 We must recognize that prevalence rates for some mental health disorders have substantially increased in the United States and elsewhere as associated with the COVID-19 pandemic; and individuals who are already at risk for manifestation of symptoms (including woman/girl gender, unemployment, student status, and exposure to social media about pandemic) are disproportionally affected (Ettman et al., 2020; Xiong et al., 2020). 2 Percentages may not total 100 percent due to rounding. 3 Beginning in the 1960s, a large-scale treatment philosophy shift had the effect of redirecting tens of thousands of persons with serious mental illness from state hospitals back into community settings where they were expected to receive community-based care. 4 In the fourth quarter of 2020 (October–December), the National Survey on Drug Use and Health (NSDUH) began collecting separate data about access to virtual treatment services; it categorized virtual mental health services separately from services in inpatient or outpatient settings or the receipt of prescription medication.

Bibliography 33

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ChapterHistorical Responses to

Mental Illness

Man is not made better by being degraded; he is seldom restrained from crime by harsh measures, except the principle of fear predominates in his character; and then he is never made radically better for its influence. —Dorothea Dix (American philanthropist and social reformer, 1802–1887)

ADVANCEMENTS IN PSYCHOSURGERY Dr. Walter Freeman, a neuropathologist, and Dr. James Watts, a neurosurgeon, were best known for developing and perfecting a procedure called a leucotomy or bilateral prefrontal lobotomy (Figure 2.1), a type of psychosurgery used on chronic and seriously mentally ill psychiatric patients from the 1940s through the 1970s (mostly inflicted with schizophrenia; Stone, 2001). It is estimated that about 60,000 individuals in Europe and the United States were lobotomized between 1936 and 1956 (Raz, 2008). The procedure, as popularized by Dr. Freeman in the United States, was presented as relatively simple. The patient received nothing more than either local anesthesia or sedation, sometimes accompanied by electric convulsive shock therapy (ECT) and there were only two primary instruments used to perform the surgery—a rubber mallet and a modified ice pick (New, n.d.). Freeman reportedly performed the procedure without gloves or other sterilization tools and many of his patients were still awake during the procedure (Getz, 2009). The eligibility criteria for the surgery included observed symptoms of severe anxiety, depression, or psychosis, and a recommendation, usually initiated by family, but supported by the treating physician. Freeman had personally performed close to 4,000 lobotomies by the 1950s, at which time several psychotropic medications had been introduced to the market and approved by the Food and Drug Administration (FDA). Medication, which was preferable and the least intrusive means to treat mental illness, seemed to alleviate the need for the continued use of psychosurgery, and lobotomies were dismissed as the primary and vogue method of treatment. Although the

DOI: 10.4324/9781003120186-2



CHAPTER 2 Historical Responses to Mental Illness

procedure was largely disfavored and its results were no longer viewed in a positive way, lobotomies were still being performed, though minimally, in the United States and elsewhere.

 Figure 2.1 Leucotomy or Bilateral Prefrontal Lobotomy

Source: Article text by Waldemar Kaempfert; photography by Harris A. Ewing (Saturday Evening Post, May 24, 1941, pp. 18–19). [Public domain] via Wikimedia Commons

Introduction 41

INTRODUCTION Mental illness has long been stigmatized and misunderstood both on cross-national and cross-cultural fronts. Societal views of people who suffer from mental and behavioral health issues across the spectrum have been relatively negative and speckled with erroneous beliefs that relate having mental health issues with antisocial behaviors—particularly violence and crime (Hinshaw & Stier, 2008; Slate et al., 2013). Given such views, it is understandable why treatment for mental illness has been formulated to punish or even eradicate those who suffered from it. From institutionalization and barbaric forms of psychosurgery to the eugenics movement and sterilization, the United States has a dark history of cruel and unusual punishment toward people with mental illness (PwMI) (Diamond, 1961). The distinction between behaviors deemed “normal” and “abnormal” has historically been determined in large part by those members of society having the most (political) power. Consequently, depending on cultural norms of the mainstream (powerful members of society), such definitions change from time to time and from place to place (Sellin, 1938). This process or phenomenon can be referred to as cultural relativism (Pollis, 1996). Those who have the misfortune of falling out of acceptability as defined by the mainstream are stigmatized and oftentimes ostracized by the larger society. Sadly, PwMI represent one of many stigmatized groups that, across time, have been ascribed to a larger group of social deviants, including heretics or witches, addicts, vagrants, immigrants, sex offenders, or other social outcasts (Abrego, 2011; Bratina et al., 2020; Hinshaw & Stier, 2008; Tewksbury, 2005). The following sections retrace the steps of societal responses to mental illness across time. Interestingly, approaches to mental health treatment throughout the eras can be reduced to three concise themes: supernatural, somatogenic, and psychogenic (Farreras, 2015). Furthermore, submerged in the themes are several dichotomous relationships; for example, the rights of PwMI versus the responsibility of the state to keep the community safe from PwMI; stigma versus compassion; confinement versus communal living; spiritual versus biological origins of mental illness; moral treatment versus punishment; and reference to “patient” versus “criminal”. Moreover, these thematic “opposites” are also cyclical in nature. In response to political and public sentiment regarding mental health and treatment, developments in psychiatry, psychology, and medicine, and strong advocacy by highly influential individuals and groups, transformations in law and practice have occurred throughout the course of time. A visual depiction of mental health treatment in the form of a chronological timeline can be found online at Students are encouraged to reference it as they read through the chapter, as it more clearly illustrates underlying perceptions of mental illness and key treatment approaches from each historical era.


CHAPTER 2 Historical Responses to Mental Illness

SOCIETAL RESPONSES TO MENTAL ILLNESS: THEMATIC ERAS Demons, Spirits, and Possession (5000 to 400 BCE) The earliest accounts of mental illness and responding treatments were recorded throughout ancient civilization; in particular, as early as 5000 BCE, among Neolithic and Mesopotamian civilizations (Foerschner, 2010). A substantial influence throughout most of this early history was religion or spirituality. During ancient times, persons so afflicted with mental illness were viewed as immoral creatures who were most likely possessed by demons (Spanos, 1978). Commonly held beliefs were based upon perceptions that such individuals had sorcerous attributes, and therefore, they were subjected to a displeasing response (e.g., punishment) by the gods (Faria, 2013; Shorter, 1997; Spanos, 1978).

COMPARATIVE PERSPECTIVES 2.1 THE RELATIONSHIP BETWEEN STIGMA AND MENTAL HEALTH TREATMENT APPROACHES Supernatural beliefs about mental illness continue to exist in various parts of the world and within various cultures. For example, due to its association with otherworldly and potentially evil and deviant infuences (e.g., masturbation), the stigma attached to mental illness is so profound that PwMI and their family members in places like China, Greece, Morocco, Lebanon, and the United Arab Emirates are likely to immediately seek out traditional healers and pharmaceutical treatment. Unfortunately, many also fnd it easier to hide their afictions from family members and self-medicate until they eventually become so disruptive to society that they are incarcerated (Foerschner, 2010).

Individuals so afflicted were shunned by society and subjected to harsh “cleansing rituals” and moral punishments (Shatkin, n.d.; Shorter, 1997). The responding cure for what was historically referred to as “disease of the mind” revolved around techniques designed to cast away any evil spirits from their bodies. Such attempts included exorcisms, incantations, and other spiritually induced cleansing rituals (Neugebauer, 1979). Individuals were also subjected to painful surgical-like techniques that were primitive by their very nature and not medically safe. For example, a process known as trephination (see Figure 2.2) was commonly used for centuries as a cure for not just mental disease or a defect (presumed to be the result of demonic influence), but also for conditions such as migraines, skull fractures, and epilepsy (Faria, 2013). The practice involved the use of a primitive stone tool to remove sections of the skull in order to release any evil spirits that were hindering an individual’s ability to function as a rational and faithful

Societal Responses to Mental Illness: Thematic Eras 43

 Figure 2.2 Illustration of Neolithic Trephination

Source: Behind the doctor/Logan Clendening. Wellcome Library, London [CC BY 4.0 (] via Wikimedia Commons

member of society. It should be noted that trephination and other more intrusive practices were used in the name of religion or spirituality, including the use of barbaric forms of punishment to obtain submission (Foerschner, 2010). Among ancient Hebrews and Persians, “defying God’s will”—or sinning— (historical/cultural context) was viewed as the ultimate source of mental disease, and only through prayer and spiritual rituals was one able to be healed (Shorter, 1997). Ancient Egyptians were also heavily influenced by deity and in the belief that the trespass thereof was the primary source of mental illness (Foerschner, 2010). Treatment centered on the use of primitive forms of psychosurgery performed by priest-doctors—particularly the continued use of trephination, but also other procedures such as vaginal fumigation for “wandering uterus,” or what was eventually referred to as hysteria among women (now “conversion disorder”). Aside from these surgical methods, the Egyptians were progressive in that they advanced the notion that recreation would alleviate mental distress, and therefore, they promoted involvement in activities such as music, dancing, and participation in the arts to achieve some level of spiritual balance or normalcy (Foerschner, 2010).


CHAPTER 2 Historical Responses to Mental Illness

FAST FACT 2.1 PSYCHOSURGERY There is evidence that trephination and other psychosurgical measures are still being practiced in some cultures today (Gross, 1999). According to Moghaddam et al. (2015), trephination (also known as “trepanation” or “trepanning”) continues to be used in East African native tribes with high survival rates.

Early Medical Model (400 BCE to Middle Ages) The sources of psychopathology continued to remain immersed in superstition and spirituality until sometime between the fifth and third centuries BCE. Early writings indicate that in 400 BCE, Hippocrates, a Greek physician, dismissed the long-held belief that mental illness was the result of sin and evil trepidation. Rather, he argued, it is a natural response to organically borne pathology in the brain of a human being (Foerschner, 2010). Given advancements made by Hippocrates and other medical writers during the classical antiquity period, mental illness was treated as a form or type of medical illness. Early approaches to treatment focused on regulating body chemistry. In brief, medical practice was influenced by humoral theory or

 Figure 2.3 Vintage Marbled Pharmacy Leech Jar

Source: pryzmat/Shutterstock.

Societal Responses to Mental Illness: Thematic Eras 45

humorism—the idea that there are four primary fluids (humors) of the body: blood, phlegm, bile, and black bile. If any of these were to become imbalanced, the body chemistry would be interrupted, and therefore, an individual’s physical health (including brain function) would become dysfunctional (Foerschner, 2010). To return the body to its proper balance, prescribed treatments included purging with laxatives and other concoctions designed to induce vomiting, as well as bloodletting or bleeding (otherwise known as phlebotomy)—which, for some, involved the use of leeches or processes such as “cupping” or “tapping” (Foerschner, 2010; Shatkin, n.d.).

The Middle Ages: Dungeons and a Return to Demonology In the period extending from about 1200 CE through the late seventeenth century, PwMI were responded to somewhat differently depending on the region in which they lived (Foerschner, 2010). For example, PwMI in Eastern societies were mostly living freely in their communities-villages if they were not considered dangerous. In parts of Western Europe, philosophies regarding superstition and mysticism prevailed, and individuals who were considered mentally afflicted were in some societies treated as witches who were inhabited by demons. In certain cultures, PwMI who were unable to care for themselves were cared for and treated by religious orders, but caregiving functions were in most places almost always the responsibility of families (Foerschner, 2010). Given inadequacies in at-home care and, at the extreme end, gross mistreatment of PwMI by family members and other caregivers, institutionalization in asylums became the popular or preferred option, and people who were viewed as chronically ill were lodged in cottages and hospitals with the anticipation of more sophisticated treatment by professionals. The first European facility specifically for people with mental illness was established in Valencia, Spain, in 1407 (“Timeline: Treatments for Mental Illness,” 2021).

Period of Enlightenment (Late 1600s to 1840) POLICY & PRACTICE 2.1 THE EARLY ASYLUMS Patients were shackled to the walls of a cold, dark cell (see Figure 2.4). Naked and starving, they would be standing in their own feces and urine. Sometimes, “caregivers” provided some remnants of scattered straw designed to act as bedding or to provide warmth to the space in which they were confned. They might also be wearing iron cufs and collars to restrict their movement—just enough so that they could eat, but not enough that they could sleep in any other position except for standing (Kazano, 2012; Shorter, 1997).


CHAPTER 2 Historical Responses to Mental Illness

Conditions and Treatment Methods at the Asylum At the beginning of the Enlightenment era, mental disorders were not considered legitimate illnesses; rather, persons so afflicted were perceived as a disturbance to the community. PwMI were frequently abandoned once committed to an asylum because there was no consistency on how to treat them. The clergy played a huge role in treating patients but was only available to those who could afford to send them to the patient (Foerschner, 2010). To a large extent, asylums were used to lift the burden from family members who often neglected to provide proper care. Unfortunately, reports indicated that a large majority of individuals who were employed at the asylums were untrained and sometimes accused of mistreating the patients under their care (Kazano, 2012; Shorter, 1997). In the 1600s, Europeans began to move PwMI out of asylums and into more punitive prison environments. Persons identified as “insane” were treated inhumanely, chained to walls, or kept in dungeons where they were deprived for days, months, and even years of social interaction, nutrition, sleep, and light In terms of treatment during this period, an emphasis on phrenology (brain size, structure, and functions; see Figure 2.5) and physiognomy (form or features of the body—particularly facial expressions) to explain psychopathy was evident, and studies evolving around biological predictors of behavior

 Figure 2.4 Eighteenth-Century Dungeon

Source: Author unknown [Public domain], via Wikimedia Commons

Societal Responses to Mental Illness: Thematic Eras 47

POLICY & PRACTICE 2.2 Eighteenth Century “Treatment” Approaches Two inventions brought to the U.S. by Dr. Benjamin Rush, one of the most well-known physicians in eighteenth century America include the gyrating chair and the tranquilizing chair. The gyrating chair was a spinning apparatus designed to restore equilibrium and increase blood fow to the brain. The tranquilizing chair was designed to control the fow of “infected” blood in a patient’s brain by completely confning the patient to the chair with restraints. Source: Insert Web Graphic here treatments.html

 Figure 2.5 Phrenology

Source: Webster’s Dictionary. (1900). Phrenology. Wikimedia.


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were popular (e.g., Gall in the 1790s; Carlson, 1958; Collins, 1999). Consequently, given the emphasis on determinism, treatment modalities of the past had continued such as purging and bloodletting. More innovative practices were also introduced in prisons and other places where PwMI were confined, including the “gyrating chair,” straitjackets, and the use of physical restraints, which are straps that, when tightened, restrict a person’s movement (Foerschner, 2010). For many, particularly women, their illness was viewed by early European psychiatrists as hysteria, a condition that caused somatic symptoms, including blindness and paralysis, with no apparent medical explanation. In fact, a considerable debate ensued from the early eighteenth century through the middle of the nineteenth century with respect to whether this condition was psychosomatic or neurological. Innovative treatment philosophies were introduced, including a procedure introduced by Franz Anton Mesmer. The procedure, referred to as mesmerism, was based on the perception that hysteria was the result of the imbalance of the body’s magnetic fluid, and treatment involved the use of animal magnetism to restore balance. This practice was eventually replaced with the use of hypnosis, which was supported by a psychogenic explanation for mental illness (particularly hysteria) (Farreras, 2015).

A Shifting Philosophy During the late 1700s, a concern about the harsh methods of mental health treatment grew in Europe and in the original American colonies, which led to occasional reforms. In 1793 Phillippe Pinel instituted what he coined traitement moral (moral treatment) when he took over the Bicêtre insane asylum and removed patients from dungeons (“Timeline: Treatments for Mental Illness,” 2021). Moral treatment assumed a cure for mental illness, and therefore, required more humane procedures, particularly for individuals without chronic disabilities. Places of confinement began to provide more acceptable living quarters and adequate and safe medical care (Floyd, 2015). Despite developments in Europe during the period, mental health treatment in early nineteenth-century America was relatively nonexistent, and PwMI continued to be housed in prisons and jails, almshouses (shelters for people experiencing economic disadvantage), or at home with families who could not properly care for them (Shorter, 1997). Americans reverted to physiology and the notion that insanity was the result of physical impairment within sections of the brain (Neugebauer, 1979). Consequently, treatment practices such as bloodletting were still being used because advancements in medicine and practice had not yet been made readily available. The moral treatment movement continued, however, and both scientific and lay communities began to analyze the role of the environment in behavior and proposed that improvements in the conditions may result in a cure for those minimally afflicted (Foerschner, 2010).

Societal Responses to Mental Illness: Thematic Eras 49

 Figure 2.6 Bethlem Hospital, acquired from the antique print shop. The print is described as a “steel engraving from 1828” and is a print from a book Source:

Persons in charge of early asylums were referred to as superintendents. These individuals were active in their respective communities, and although well educated, their educational backgrounds were not necessarily in the practice of medicine or in understanding human behaviors. The institutions in which they worked were oftentimes located in rural environments—a calculated practice so that patients were far removed from family influences and their previous home environments (Foerschner, 2010; Neugebauer, 1979). The mission of asylums under the moral treatment philosophy was to keep patients engaged through healthy living, which included exercise, religious practice, work, and education. Medications were not regularly dispensed or ingested, and PwMI were to be viewed by all as unfortunate, as opposed to evil, beings.

FAST FACT 2.2 THE ORIGIN OF “BEDLAM” Saint Mary of Bethlehem was a monastery in London, England, that was transformed into one of the most infamous asylums that began admitting patients in 1547. Patients who were chronically mentally ill were often put on public display to be ridiculed for amusement purposes, and those who were only mildly aficted were subjected to panhandling for charity. Due to its reputation for the abuse and severe mistreatment of patients, the facility became known as “Bedlam,” a derogatory descriptor that continues to be referenced today (Figure 2.6) (Foerschner, 2010).


CHAPTER 2 Historical Responses to Mental Illness

Inferior Genetics Given the conditions of asylums, a shortage of qualified administration and staff, restrictions in funding, and extreme overcrowding, this method of treatment was soon replaced. By the mid-1800s, mental illness was attributed to heredity, largely influenced by the Social Darwinism movement. From this perspective, families viewed as genetically inferior would produce offspring who bore the same weak family vices (e.g., alcoholism and masturbation) and therefore, would be at a higher risk for madness (Hinshaw & Stier, 2008; Neugebauer, 1979). People with lived experience (PWLE) of mental illness and/or developmental disorders were often referred to in the stigmatizing language of the time as “imbeciles,” “idiots,” or “feebleminded,” and were subjected to several deplorable methods of “treatment,” including the use of tranquilizing drugs to subdue them (e.g., chloroform) or sterilization. This period of American history was characterized by a eugenics movement to eliminate entire groups of people, including PwMI (Floyd, 2015). During the mid-to-late nineteenth century, asylums became dumping grounds for PwMI. However, because of the overcrowded conditions, lack of treatment options, and funding deficits, many individuals—particularly those with a history of violence—were committed to jails and prisons instead (Floyd, 2015; Foerschner, 2010; Slate et al., 2013). Prison staff often left them unclothed without running water and little food, and many were housed alongside individuals incapacitated for violent crimes. PwMI were chained to the walls of jail or prison dungeons, resulting in a gruesome display of torment and punishment (Shorter, 1997). In attempts to “cure” their illnesses, doctors would employ treatments such as electroconvulsive or shock therapy (ECT). When it was deemed that treatment was unsuccessful, providers would just abandon the individuals, frequently leaving them in worse shape than before (Foerschner, 2010).

Advocacy Movement During her tour of the East Cambridge jail in Cambridge, Massachusetts, in 1841, retired teacher and renowned human rights crusader Dorothea Dix discovered that the incarcerated women with whom she was charged with teaching had not violated any laws, but rather, were suffering from serious psychological disorders. Of particular concern to Ms. Dix was the negligence and willful mistreatment by those who were considered caregivers. Dix wrote on her observations, describing conditions that both incarcerated women and men with psychological conditions had endured—which included filthy and foul-smelling living quarters, the use of chains or other apparatus to secure them to the walls, severe injuries resulting from lashing and other beatings, and self-inflicted (untreated) mutilation (Dix, 1843, as cited in The History of Mental Retardation,1 n.d.). Over a 40-year period after her initial observations, she continued to advocate on behalf of PwMI and succeeded in driving the establishment of 32 state hospitals as asylums.

Societal Responses to Mental Illness: Thematic Eras 51

CRITICAL THINKING 2.1 CRUSADERS FOR THE MORAL TREATMENT OF PWMI Dorothea Dix (Figure 2.7) was a key advocate of the humane treatment of persons with mental illness during the mid-to-late nineteenth century. Although her work had a huge infuence on the development of staterun institutions to house and treat PwMI, there were other infuential fgures at the time whose work contributed toward improved treatment and confnement of persons under supervision by the state—including prisoners and those aficted with chronic mental illness. During an 1871 visit to America, British writer and reformer Charles Dickens had the opportunity to tour the Eastern State Penitentiary in Philadelphia. The following is an excerpt of his original observations with respect to the conditions of solitary confnement. My frm convictions, that independent of the mental anguish it occasions—an anguish so acute and so tremendous, that all imagination of it must fall far short of the reality —it wears the mind into a morbid state, which renders it unft for the rough contact and busy action of the world. It is my fxed opinion that those who have undergone this punishment, must pass into society again morally unhealthy and diseased. There are many instances on record, of men who have chosen, or have been condemned, to lives of perfect solitude, but I scarcely remember one, even among sages of strong and vigorous intellect, where its efect has not become apparent, in some disordered train of thought, or some gloomy hallucination. What monstrous phantoms, bed of despondency and doubt, and born and reared in solitude, have stalked upon the earth, making creation ugly, and darkening the face of Heaven! Suicides are rare among these prisoners: are almost, indeed, unknown. But no argument in favour of the system, can reasonably be deduced from this circumstance, although it is very often urged. All men who have made diseases of the mind their study, know perfectly well that such extreme depression and despair as will change the whole character, and beat down all its powers of elasticity and self-resistance, may be at work within a man, and yet stop short of self-destruction. This is a common case. (Dickens, 1866)

State mental hospitals became very popular throughout the late nineteenth century and into the early-to-mid-twentieth century; consequently, they also became very crowded. By the 1880s, superintendents were largely replaced with neurologists who sought control of the asylums (Floyd, 2015). Although neurologists made some positive contributions, stories emerged in the news regarding exaggerated conditions of patient abuse. Original reports of a low staff to patient ratio and humane treatment were replaced by images of overwhelmed staff and the warehousing of humans, which led to the development of oversight commissions and, ultimately, the re-examination of hospitalization as an effective tool for


CHAPTER 2 Historical Responses to Mental Illness

 Figure 2.7 Portrait of Dorothea Lynde Dix

Source: Bier, C. (2008, July 7). Dorothea Lynde Dix. Retrieved August 8, 2015, from

treatment. As a result, interested parties began to consider the development of community-based treatment options. Other developments at the turn of the century included advancements in medical education and research on psychopathology and insanity as individual topics for study. Asylums were now referred to as hospitals as an early approach to reduce stigma associated with mental illness (Floyd, 2015). Advancements such as these, however, were not able to overcome the persistent view that PwMI were genetically inferior, and so stigmatization and eugenics-based “treatment” approaches persisted into the twentieth century. At about the same time that the United States was the recipient of significant European immigration waves into its cities, Americans became acquainted with the influence of the unconscious mind (Floyd, 2015).

An Era of Psychoanalysis (Late 1800s to Mid-1900s) In previous eras, theories of mental illness had remained grounded in superstition and spiritual forces or in somatogenic explanations for functional impairment in physicality due to illness, genetic inheritance, or some level of brain damage or imbalance. As advancements in research on the human psyche and behavior continued, and with the emergence of psychoanalytic theories and scholars such as Sigmund Freud and Carl Jung, psychogenic

Societal Responses to Mental Illness: Thematic Eras 53

theories for mental illness became more commonly advanced (Foerschner, 2010). This group of theories focused on traumatic or stressful experiences, maladaptive learned associations and cognitions, or distorted perceptions.

FAST FACT 2.3 THE LOBOTOMIST As discussed in the opening paragraph of the chapter, Dr. Walter Freeman had lobotomized close to 4,000 individuals during his career. A 2008 documentary about Freeman was aired on PBS as part of the American Experience series and is titled “The Lobotomist.” The documentary included footage of Freeman performing a lobotomy on one of the candidates, a woman. Students can fnd the documentary in whole and part on youtube. com. Warning: Parts of the video are somewhat disturbing.

Although private psychotherapy sessions were being conducted, most people with psychosis at this time were still receiving custodial care in institutions (Faria, 2013). Unfortunately, conditions in some mental health institutions were still inhumane. In fact, as in previous times, people were writing and publishing on their experiences as patients. For example, in 1908 Clifford Beers, a former patient, published his autobiography titled A Mind that Found Itself, where he described his own dehumanizing experiences in a Connecticut mental institution (Morrissey & Goldman, 1986; Parry, 2010). Under the leadership of Beers, the mental health hygiene movement began, and publicly available accounts of mistreatment of patients generated calls for reform—calls that were answered by the development of a National Committee for Mental Hygiene, an education and advocacy group that later became the National Mental Health Association or MHA (Parry, 2010). Available treatments for chronic psychological disorders during the early-to-mid-twentieth century included an experimental mix of psychoanalysis, medication, and more progressive forms of psychosurgery (Foerschner, 2010; Morrissey & Goldman, 1986). Specific approaches included highly potent drugs, ECT, and insulin-induced comas. Surgery, particularly the prefrontal lobotomy, was commonly used to treat people with schizophrenia (Faria, 2013; “Timeline: Treatments for Mental Illness,” 2021). In fact, Dr. Walter Freeman (discussed in the introduction of the chapter) was considered a pioneer in this method for use in the United States, having performed close to 4,000 lobotomies over the course of his career, which was at its high point in the 1940s (Faria, 2013). Due to continued publicity surrounding mental health reform, President Harry Truman signed the National Mental Health Act in 1946. The act established the National Institute of Mental Health (1949) and created


CHAPTER 2 Historical Responses to Mental Illness

accountability and redirected oversight of state mental health institutions from the state to the federal government (National Institutes of Health [NIH], 2013). Also, during this period, advancements were being made regarding drug therapy for chronic psychological symptoms (e.g., the 1949 advancement of lithium by Australian psychiatrist, J.F.J. Cade, to treat psychosis and, later, bipolar disorder; “Timeline: Treatments for Mental Illness,” 2021).

The Dawn of a New “Error”: Drug Therapy and Deinstitutionalization (1940s to Mid-1980s) As observed in the previous section, psychological health (and corresponding treatment) in the first half of the twentieth century was influenced by theories that emphasized the psychosomatic origins of mental illness, and therefore, the need for psychogenic-based therapeutic interventions. For many, this involved a mix of services they could receive in the community, including individualized therapy sessions, family or group counseling, and medication management. For a small proportion of the population with serious psychological disorders, therapeutic intervention continued to involve secure placement or confinement and the use of painfully intrusive techniques (e.g., shock therapy) and surgical interventions (e.g., lobotomy) (Shorter, 1997). A variety of different styles or approaches to therapy were being introduced and practiced in an office as opposed to a hospital setting. In contrast with previous eras, treatment responses involved an alliance between the patient and therapist that reflected privacy concerns, humanizing responses to treatment, and mutual respect.

The Advent of Drugs and Community-Based Care Despite the changing philosophy, many PwMI continued to be hospitalized due to their chronic or unexplainable conditions (Goldman & Morrissey, 1985). For example, in post–World War II United States, state and private hospitals for PwMI were at their fullest capacities due to the relative ease of commitment procedures. In the 1950s, the first antipsychotic drug, chlorpromazine (Thorazine), was introduced for the treatment of psychosis, and due to its overwhelming effectiveness, was routinely viewed as a cure for chronic mental illness (Slate et al., 2013). Over the next few decades, the advent of this and other antipsychotic drugs such as haloperidol had the effect of dramatically reducing the state hospital populations in favor of community-based treatment and drug therapy. Soon after Thorazine became available in the United States in 1955, a process or phenomenon of rapid deinstitutionalization occurred (Faria, 2013). As an illustration of this point, in 1955 there were 560,000 patients in state psychiatric hospitals in the United States; by comparison, in 1980, this number had dropped to 130,000. Consequently, in addition to the creation of new problems such as serious side effects of the medication, society was faced with a new

Societal Responses to Mental Illness: Thematic Eras 55

problem: the infiltration of thousands of individuals with chronic mental illness into the community.

Antipsychiatry and Skepticism Fueled by these and other developments, the field of psychiatry became vulnerable to discrimination, as laypersons began to question the state’s role in the institutionalization of what seemed like a great majority of poor and powerless sects of society. Moreover, there was now a resounding skepticism as to the meaning of insanity and whether this was more of a socially constructed condition caused by society itself (Morrissey & Goldman, 1985). Consequently, the 1960s witnessed an antipsychiatry movement, led most prominently by counterculture writers such as R.D. Laing and Michel Foucault. Additional supporters of the movement included psychiatrist Thomas Szasz, who published The Myth of Mental Illness, and sociologist Erving Goffman who, in his 1961 book, Asylums, argued that institutionalization over long periods of time produces symptoms of psychosis, thereby perpetuating the need for further institutionalization and isolation from society (“Timeline: Treatments for Mental Illness,” 2021). Also at this time was the release of the film adaption of Ken Kesey’s novel, One Flew over the Cuckoo’s Nest, which became very influential in terms of informing public perceptions of the perils in institutional settings.

 Figure 2.8 The Kennedy Family at Hyannis Port, 1931.

Source: Photograph by Richard Sears in the John F. Kennedy Presidential Library and Museum, Boston [Public domain] via Wikimedia Commons


CHAPTER 2 Historical Responses to Mental Illness

In conjunction with the counterculture response to psychiatry and a wave of human rights movements at the time (including the rights of persons with disabilities), national politics reflected a liberal view that supported the movement in progress (Slate et al., 2013). President John F. Kennedy openly disclosed the disability of his sister, Rosemary (see Figure 2.8), and advocated extensively for persons with mental health and developmental disabilities (Berkowitz, 1980; Mason et al., 1976). The philosophy on mental health treatment was changing again, and the new approach was to provide local care for “the emotionally disturbed” at the neighborhood level to avoid hospitalization, thereby saving money and providing what were perceived to be more effective alternatives (Morrissey & Goldman, 1986). In 1963, the Community Mental Health Centers Construction Act was passed, which provided federal money to develop a network of community mental health centers. Unfortunately, this legislation occurred after mass deinstitutionalization was well underway, and therefore, the resources were quickly depleted. Public support for community-based treatment was lacking as well, as PwMI were often viewed as dangerous, dirty, and unpredictable (Corrigan & Watson, 2002). Such stigmatizing views led to what has been referred to as a not in my backyard (NIMBY) mentality. In some cases, members of the public have fought to keep services such as supportive housing for previously hospitalized persons with chronic mental illness out of their neighborhoods (“Housing First: A Special Report,” National Public Radio [NPR], 2002). The mass deinstitutionalization of the 1960s and 1970s led to multiple social consequences that were presumably unanticipated, including substantial homelessness and transinstitutionalization, or repetitive encounters across multiple systems of care (e.g., public welfare, dependency/foster care, criminal justice, and substance abuse and mental health) (Goldman & Morrissey, 1985; Morrissey & Goldman, 1986). Amidst social and human rights–related reforms, a number of legislative changes regarding commitment procedures had been implemented during the 1970s that toughened the criteria for involuntary commitment, incorporating language that reflects what has been referred to as a “dangerousness standard”; these new requirements had the effect of further stigmatizing PwMI as violent and dangerous individuals—restricting people with chronic illness from getting the help they needed (Hinshaw & Stier, 2008). In addition to changes regarding commitment criteria, further advocacy, training, and research groups surfaced throughout the next decade or so. For example, in 1979, the National Alliance on Mental Illness (NAMI) was founded—a prominent advocacy group that provides research for people with serious psychiatric illness and support for PwMI and their families/caregivers (“Timeline: Treatments for Mental Illness,” 2021). Further developments during the next two decades included the introduction of a new generation of antipsychotic drugs, such as clozapine, used to treat the symptoms of schizophrenia (“Mental Health Medications,” 2015). New-generation drugs appeared to be more effective and had fewer side effects.

Societal Responses to Mental Illness: Thematic Eras 57

 Figure 2.9 Restrictions on Getting Help Source: Author

The Present Condition: Criminalization of Mental Illness (Mid-1980s to?) When the deinstitutionalization movement began, the intention was to have people move from hospitals into community health care establishments and to be immersed into towns and neighborhoods where they would get services, accommodations, and housing. Furthermore, newer-generation psychotropic drugs were keeping symptoms in check for chronically ill PwMI, thereby making it possible for them to function in daily activities. Over a 17-year period following Kennedy’s call for the development of community mental health centers (CMHCs), the federal government spent more than 20 billion dollars to build outpatient clinics that would replace long-term hospitals (Faria, 2013). At the same time, the number of allocated patient beds in state and federal institutions for PwMI had rapidly declined from close to 500,000 in 1970 to well below 100,000 (Torrey et al., 2008). As the funding and resources for treatment and services become depleted, many PwMI are unable to obtain the necessary resources to provide for themselves. In many cases, this has led to displacement (being without stable housing), worsening of symptoms, self-medication, a state of crisis, and the criminalization of PwMI who become incarcerated in local jails for typically inconsequential crimes (e.g., disturbing the peace or vagrancy) (Faria, 2013). Figures 2.9 and 2.10 illustrate this trend. Institutional census estimates have indicated that on any given day, there are approximately 283,000 individuals with serious mental illness who are incarcerated in state and federal jails and prisons in the United States.


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Recent studies suggest that there may be differentials experienced by people of color (POC) with SMI regarding justice-involvement, the incarceration experience, and access to treatment services (For an introductory discussion, see Practitioner’s Corner 2.1.) By comparison, the proportion of persons with serious mental illness who are in public psychiatric hospitals is estimated to be 70,000–30 percent of whom are forensic clients, meaning those who are court involved (“The Criminalization of People,” n.d.-a). As indicated in the previous chapter, a substantial number of American adults (one in five), at least a third of adults in prison, and almost 50 percent of those incarcerated in jails have been diagnosed with a mental health disorder during their lifetime (Bronson & Berzofsky, 2017), most often co-occurring with substance abuse (CODs) (SAMHSA, 2013). CODs are exceptionally high among persons who are without housing (23 percent lifetime prevalence rate), many of whom are returning veterans—a point that will be discussed in more detail later in the book. Treatment and diversion options for forensically involved individuals (in carceral and community settings) comprises a huge area of research. There have also been legal developments around treatment, and precedent has been set regarding several pressing issues related to competency and mental health; these developments are summarized in Chapters 6 and 7. However promising these and other legal developments, most justice-involved PwMI are not accessing treatment while incarcerated for both individual and systematic reasons (Slate et al., 2013). And, despite the watchful eye of the courts, mental health understaffing persists throughout most correctional facilities. Furthermore, the public remains quite fearful of who they perceive as “the mentally ill” and may express little sympathy for them (Byrne, 2000).

 Figure 2.10 The Criminalization of Mental Illness Source: Author

Take-Home Message 59


Contributor: Charlene Lane, PhD, LCSW-R It is difcult to comprehend the plethora of mental health challenges faced by incarcerated individuals from disenfranchised groups without examining the intersectionality between access to mental health services in the penal system. It is no secret there is a disproportionate number of people of color with dual diagnoses who are incarcerated. Many receive an initial diagnosis and treatment only after committing a crime, and upon detention in a correctional facility. Moreover, a sad reality is that there are individuals who were seen by physicians, but not accurately diagnosed or engaged in proper treatment in the community setting prior to incarceration. To comprehend this gap in services, one cannot negate the impact of historical experiences. For example, consider the Tuskegee study, which involved inhumane medical experimentation on enslaved persons and medical dehumanization (brutalization, loss of human characteristics, and deprivation of dignity). In terms of behavioral health, such practices have enabled stigmatization associated with mental illness, and the inability of PwMI to trust health care providers. There needs to be a paradigm as it pertains to mental health providers’ approach to educating, engaging, and establishing positive relationships with individuals from historically disenfranchised groups. Vulnerable persons should not be penalized for making poor choices secondary to a lack of resources and institutionalized barriers. A proactive approach to mental health care in the community would involve health care professionals being an integral part of the crisis response team. As is discussed later in Chapter 4, this is one solution to responding to 911 calls and implementing the appropriate intervention, thus reducing the incarceration of PwMI. Sources: Abram, K. M., & Teplin, L. A. (1991). Co-occurring Disorders Among Mentally Ill Jail Detainees: Implications for Public Policy. American Psychologist, 46(10), 1036. Dumont, D. M., Allen, S. A., Brockmann, B. W., Alexander, N. E., & Rich, J. D. (2013). Incarceration, Community Health, and Racial Disparities. Journal of Health Care for the Poor and Underserved, 24(1), 78–88.

TAKE-HOME MESSAGE The historical responses to mental illness have revolved around three primary philosophies regarding the origins of psychological issues: (a) supernatural theories that attribute mental illness to the presence of evil or sinfulness; (b) somatogenic theories, which identify physical dysfunction or disability as a result of illness, genetic inheritance, brain damage,


CHAPTER 2 Historical Responses to Mental Illness

or imbalance of bodily fluids; and, (c) psychogenic theories, which focus on individual experiences that were traumatizing or stressful, dysfunctional cognitive development or learning, or distorted perceptions of reality. The treatments subscribed to PwMI are largely determined by favored etiological advancement and have historically ranged between drug treatment therapy, institutionalization, and intrusive surgery. Explanations coexist across time and place; thus, corresponding treatment approaches may recycle, despite previous controversy and ineffectiveness. This has been recently observed in the mass incarceration of PwMI for nonserious offenses. The growing number of justice-involved PWLE incarcerated in the United States is cause for great concern. Aside from prison conditions, this population is also challenged by the scant resources available to them during incarceration and upon release. Progressive states have already experimented with the creation of mental health courts (Kondo, 2003, p. 257). Such innovations have been referred to as therapeutic jurisprudence, a concept that will be revisited later in the text. Moving forward, the focus is on treating offenders with mental illness with fairness, compassion, dignity, and respect. It is suggested that such measures will more positively affect treatment outcomes and reduce continued encounters with the justice system.

Questions for Classroom Discussion 1. Identify and discuss specific beliefs or events in history that exemplify each of these etiological theories of mental illness: supernatural, somatogenic, or psychogenic (e.g., hysteria, humorism, witch hunts, and asylums). 2. What do you view as the most restrictive form of treatment for mental illness during history? On what criteria did you base your selection? Research the concept “dual stigmatization”; what does this refer to? What implications does this have about the population of PwMI who are incarcerated? Can you think of any other traits or characteristics that might create additional levels of stigmatization for these individuals? KEY TERMS & ACRONYMS • • • • • • • • • •

Asylum Carceral Cultural relativism Deinstitutionalization Determinism Electroconvulsive “shock” therapy (ECT) Eugenics Humorism Leucotomy or bilateral prefrontal lobotomy Mental health

Bibliography 61

• • • • • • • • • • • •

Mesmerism NIMBY (not in my backyard) mentality Phrenology Physiognomy Psychogenic Social Darwinism Somatogenic Therapeutic jurisprudence Traitement moral (moral treatment) Transinstitutionalization Trephination Tuskegee Study

NOTE 1 No longer viewed as acceptable medical terminology.

BIBLIOGRAPHY Abrego, L. J. (2011). Legal Consciousness of Undocumented Latinos: Fear and Stigma as Barriers to Claims-Making for First-and 1.5-Generation Immigrants. Law & Society Review, 45(2), 337–370. Adejumo, A., & Adejumo, P. (2005). Time to Act against Medical Collusion in Punitive Amputations. British Medical Journal, 330, 1275–1277. Berkowitz, E. D. (1980). The Politics of Mental Retardation during the Kennedy Administration. Social Science Quarterly, 61(1), 128–143. Biascotti, M. C., & Torrey, E. F. (December, 2011). The Impact of Mental Illness on Law Enforcement Resources. Arlington, VA: Treatment Advocacy Center. Brandt, A. L. S. (2012). Treatment of Persons with Mental Illness in the Criminal Justice System: A Literature Review. Journal of Offender Rehabilitation, 51(8), 541–558. Bratina, M. P., Antonio, M. E., & Carsello, J. A. (2020). One Hundred Years of Bad Treatment: A Media Content Analysis Related to the Stigmatisation and Abuse of PwMI and LGBTQIA+ Persons. Abuse: An International Impact Journal, 1(1), 77–96. Byrne, P. (2000). Stigma of Mental Illness and Ways of Diminishing It. Advances in Psychiatric Treatment, 6(1), 65–72. Carlson, H. B. (1958). Characteristics of an Acute Confusional State in College Students. American Journal of Psychiatry, 114(10), 900–909. Collins, F. S. (1999). Medical and Societal Consequences of the Human Genome Project. New England Journal of Medicine, 341(1), 28–37. Corrigan, P. W., & Watson, A. C. (2002). Understanding the Impact of Stigma on People with Mental Illness. World Psychiatry, 1(1), 16–20. Daniel, A. E. (2007). Care of the Mentally Ill in Prisons: Challenges and Solutions. Journal of the American Academy of Psychiatry and the Law, 35, 406–410. Deane, M. W., Steadman, H. J., Borum, R., Veysey, B. M., & Morrissey, J. P. (1999). Emerging Partnerships between Mental Health and Law Enforcement. Psychiatric Services, 50(1), 99–101.


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Diamond, B. L. (1961). Criminal Responsibility of the Mentally Ill. Stanford Law Review, 14, 59–86. Dickens, C. (1842). Except from American Notes. Retrieved from http://law. html Dickens, C. (1866). Pictures from Italy and American Notes (Vol. 17). London: Chapman & Hall. Dix, D. L. (1843). The History of Mental Retardation, Collected Papers. Memorial to the Legislature of Massachusetts. Retrieved July 28, 2015, from Disability History Museum. html?id=737&page=all Dudley, R. G. (2015). Childhood Trauma and Its Effects: Implications for Police: New Perspectives in Policing Bulletin. Washington, DC: U.S. Department of Justice, National Institute of Justice. Faria, M. A. (2013). Violence, Mental Illness, and the Brain—A Brief History of Psychosurgery: Part 1—From Trephination to Lobotomy. Surgical Neurology International, 4, 49.–7806.110146 Farreras, I. G. (2017). History of Mental Illness. In R. Biswas-Diener & E. Diener (Eds.), Noba Textbook Series: Psychology. Champaign, IL: DEF Publishers. Floyd, B. (June 26, 2015). From Quackery to Bacteriology: The Emergence of Modern Medicine in 19th Century America: An Exhibition. [19th Century American Culture]. Mental Health. Toledo: University of Toledo Library Archives. Retrieved from quackery/quack5.html Foerschner, A. M. (2010). The History of Mental Illness: From ‘Skull Drills’ to ‘Happy Pills’. Student Pulse, 2(9). Retrieved from http://www.studentpulse. com/a?id=283 Freeman, W. (1949). Transorbital Lobotomy. American Journal of Psychiatry, 105(10), 734–740. Fuller, D. A., Lamb, H. R., Biasotti, M., & Snook, J. (December, 2015). Overlooked in the Undercounted: The Role of Mental Illness in Fatal Law Enforcement Encounters. Treatment Advocacy Center. Retrieved from Gall, F. J. (1791). Philosophisch-Medizinische Untersuchungen über Natur und Kunst im kranken und gesunden Zustande des Menschen. Wien: Rudolph Gräffer. Getz, M. (2009). The Ice Pick of Oblivion: Moniz, Freeman, and the Development of Psychosurgery. TRAMES, 2, 128–152. Goldman, H. H., & Morrissey, J. P. (1985). The Alchemy of Mental Health Policy: Homelessness and the Fourth Cycle of Reform. American Journal of Public Health, 75(7), 727–731. Gross, C. G. (1999). A Hole in the Head. The Neuroscientist, 5(4), 263–269. Hartford, K., Carey, R., & Mendonca, J. (2006). Pre-Arrest Diversion of People with Mental Illness: Literature Review and International Survey. Behavioral Sciences & the Law, 24, 845–856. Hinshaw, S. P., & Stier, A. (2008). Stigma as Related to Mental Disorders. The Annual Review of Clinical Psychology, 4, 367–393. Housing First: A Special Report [Special Report]. (2002). National Public Radio News [NPR]. Retrieved from housingfirst/resources/index.html IG Ferraras. (2016, August 18). History of Mental Illness [Web Log Post]. Retrieved from

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Kazano, H. (2012). Asylum: The Huge Psychiatric Hospital in the 19th Century US. Seishin shinkeigaku zasshi:Psychiatria et neurologia Japonica, 114(10), 1194–1200. Kondo, L. (2003). Advocacy of the Establishment of Mental Health Specialty Courts in the Provision of Therapeutic Justice for Mentally Ill Offenders. American Journal of Criminal Law, 28, 255–336. Lamb, R. H., & Weinberger, L. E. (2014). Decarceration of U.S. Jails and Prisons: Where Will Persons with Serious Mental Illness Go? Journal of the American Academy of Psychiatry and the Law, 42, 489–494. Lamb, R. H., Weinberger, L. E., & Gross, B. H. (1999). Community Treatment of Severely Mentally Ill Offenders under the Jurisdiction of the Criminal Justice System: A Review. Psychiatric Services, 50(7), 907–913. Lamberti, J. S., Weisman, R., & Faden, D. I. (2004). Forensic Assertive Community Treatment: Preventing Incarceration of Adults with Severe Mental Illness. Psychiatric Services, 5(11), 1285–1293. Lange, S., Rehm, J., & Popova, S. (2011). The Effectiveness of Criminal Justice Diversion Initiatives in North America: A Systematic Literature Review. International Journal of Forensic Mental Health, 10, 200–214. Mason, B. G., Menolascino, F. J., & Galvin, L. (1976). Mental Health-the Right to Treatment for Mentally Retarded Citizens: An Evolving Legal and Scientific Interface. Creighton Law Review, 10, 124. Moghaddam, N., Mailler-Burch, S., Kara, L., Kanz, F., Jackowski, C., & Lösch, S. (2015). Survival after Trepanation—Early Cranial Surgery from Late Iron Age Switzerland. International Journal of Paleopathology, 11, 56–65. National Alliance on Mental Illness. (n.d.-a). The Criminalization of People with Mental Illness. Retrieved from the National Alliance on Mental Illness, The_Criminalization_of_People_with_Mental_Illness___WHERE_WE_ STAND.htm National Institute of Mental Health. (December 7, 2002). Retrieved from http:// Read More: NIMH-National-Institute-of-Mental-Health.html#ixzz3h4hALsby Neugebauer, R. (1979). Medieval and Early Modern Theories of Mental Illness. Archives of General Psychiatry, 36(4). archpsyc.1979.01780040119013 New, W. S. (n.d.). Transorbital Lobotomy. In Encyclopedia. Retrieved from Parry, M. (2010). From a Patient’s Perspective: Clifford Whittingham Beers’ Work to Reform Mental Health Services. American Journal of Public Health, 100(12), 2356. Pollis, A. (1996). Cultural Relativism Revisited: Through a State Prism. Human Rights Quarterly, 18(2), 316–344. Raz, M. (2008). Between the Ego and the Icepick: Psychosurgery, Psychoanalysis, and Psychiatric Discourse. Bulletin of the History of Medicine, 82(2), 387–420. The Johns Hopkins University Press. Retrieved July 22, 2015, from Project MUSE Database. Sellin, T. (1938). Culture Conflict and Crime. American Journal of Sociology, 44(1), 97–103. Shatkin, J. P. (n.d.). The History of Mental Health Treatment [PowerPoint Slides]. Retrieved from Shorter, E. (1997). The Birth of Psychiatry. In E. Shorter (Ed.), A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (pp. 1–8). New York, NY: John Wiley & Sons, Inc.


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Slate, R. M., Buffington-Vollum, J. K., & Johnson, W. W. (2013). The Criminalization of Mental Illness: Crisis and Opportunity for the Justice System (2nd Ed.). Durham, NC: Carolina Academic Press. Spanos, N. P. (1978). Witchcraft in Histories of Psychiatry: A Critical Analysis and an Alternative Conceptualization. Psychological Bulletin, 85(2), 417–439.–2909.85.2.417 Stone, J. (2001). Dr. Gottlieb Burchardt: The Pioneer of Psychosurgery. Journal of the History of the Neurosciences, 10(1), 79–92. Timeline: Treatments for Mental Illness. (December 27, 2021). American Experience—A Brilliant Madness: Timeline. 400 B.C.–1992. PBS. Retrieved from nash-treatments-mental-illness/ Torrey, E. F., Entsminger, K., Geller, J., Stanley, J., & Jaffe, D. J. (2008). The Shortage of Public Hospital Beds for Mentally Ill Persons: A Report of the Treatment Advocacy Center. Arlington, VA: Treatment Advocacy Center. Wallace, C., Mullen, P. E., & Burgess, P. (2004). Criminal Offending in Schizophrenia Over a 25-Year Period Marked by Deinstitutionalization and Increasing Prevalence of Comorbid Substance Use Disorders. American Journal of Psychiatry, 161(4), 716–727.



The Sequential Intercept Model Unfortunately, we force people to break the law in order to get any kind of mental health treatment. —Pete Earley, author

INTRODUCTION As established in the preceding chapter, the deinstitutionalization movement has reshaped the treatment landscape and distinct challenges that persons with chronic mental illness confront in their lives. Appropriate and supportive treatment has often been inaccessible for a variety of reasons, including gaps in health insurance, restricted housing and/or means of transportation, a general lack of insight as to one’s illness (referred to as anosognosia, see Chapter 1), and stigma (Bonfine et al., 2020; Lamb et al., 2004; Morrissey & Goldman, 1986; Munetz & Griffin, 2006; Slate et al., 2013). Due to symptoms directly or indirectly related to their illnesses, some individuals in a community setting engage in behaviors that bring them to the attention of public safety officials (Lamb et al., 2004; Morrissey & Goldman, 1986). Some individuals who are left untreated for whatever reason(s) may find themselves recycling through multiple systems of care in an ongoing spiral. Practitioners working in the forensic mental health system have referred to those in this group as “frequent fliers” (see Chapter 1), and many are chronically involved in encounters with police (Abreu et al., 2017). Moreover, for individuals with chronic mental illness, “survival” behaviors such as panhandling, public urination, and theft of necessities (food, clothing, etc.) may place them directly under correctional supervision (Slate et al., 2013). For an overwhelming number of justice-involved people with lived experience (PWLE), however, diversion to substance abuse and mental health programs yields a reduction in costs and recidivism, improvement in overall health, the opportunity for a better quality of life for the individual, and improvement in the functioning of society (Bonfine et al., 2020; Lamb et al., 2004).

DOI: 10.4324/9781003120186-3



CHAPTER 3 The Sequential Intercept Model

THINKING CRITICALLY 3.1 MENTAL HEALTH IN THE NEWS: THE CASE OF JEROME MURDOUGH Jerome Murdough, a 54-year-old former Marine, had been cold and looking for shelter one chilly Harlem night in 2014. Murdough was back in the United States for about three years—he had returned from serving at least one tour in Japan and now found himself periodically homeless and living in local shelters, fnding warmth at hospitals, and generally roaming the city streets. Murdough had been diagnosed with schizophrenia and bipolar disorder and had been sporadically living with his 75-year-old mother and other family members, including a sister. He was not stable in terms of his medication management and was now actively psychotic and abusing alcohol, according to family members. During his bouts with homelessness and substance abuse, Murdough built a criminal record that contained several criminal convictions for nonviolent ofenses such as trespassing, public consumption of alcohol, and minor drug charges. That night in Harlem, Murdough was picked up and charged with trespassing when police found him curled up in a stairwell so he could keep warm as he slept; he was arraigned and after not being able to post the bail, which was set at 2,500 dollars, he was sent to Rikers Island Jail where he was held for one week before discovered dead in his cell. At the time of his detainment, Murdough was taking psychotropic medications, and due to his mental state, was eventually placed in an isolated cell that had a malfunctioning heating system in the mental observation unit where he was supposed to be subjected to 15-minute suicide checks by correctional staf (see Figure 3.1 for an example of an isolation cell). It was not until four hours after being placed in the cell that Murdough was found slumped over and dead—his body temperature at the time he was discovered was 100 degrees. The medical examiner ruled the death accidental and the cause of death, hyperthermia (Branch, 2015; Mencimer, 2014).

 Figure 3.1 New York, United States. October 19, 2015. Activist Sunsara Taylor Speaks to the Press While

Holding a Sign.

Source: Pacifc Press Media Production Corp. / Alamy Stock Photo

Why Diversion? 67

WHY DIVERSION? Approximately 14 million bookings occur in U.S. jails annually. Of these admissions, it is estimated that approximately 1,100,000 include persons with serious mental illness (“SMI,” see Chapter 1). Almost 75 percent of persons booked also meet the criteria for CODs or substance use disorders (SUDs) (Center for Mental Health Services [CMHS] National GAINS Center, 2007; Hancq et al., 2021). These numbers are concerning for a multitude of reasons, including conflicting philosophies in terms of management and treatment (punishment over treatment), “pains of imprisonment” experienced by PWLE (e.g., victimization risk, gaps in treatment), the strain on available resources, and significant budgetary concerns. For example, available estimates reveal that it costs 60 percent more to incarcerate individuals with SMI as compared with incarcerated persons without SMI needs (Slate et al., 2013). Along with community reintegration concerns, budgeting issues have encouraged the justice and mental health systems to generate an improved model for minimizing the appearance of PwMI in the criminal justice system. The solutions revolve around diverting them to appropriate systems of care. Before going any further, it is essential to briefly discuss what diversion means in the context of this book. There is a distinction depending on whether it is being used in a traditional criminal justice context or a behavioral health context (Steadman et al., 1995). For many criminal justice officials, diversion refers to a point in a case when an offender eschews criminal liability in exchange for participation in a community-based program. In short, upon a formal agreement, charges are not filed or are subsequently dropped. Alternatively, in the behavioral health arena, diversion is more likely to refer to alternative forms of supervision (voluntary or involuntary) that abandon criminal sanctions for those that are treatment-oriented and prevent further penetration into the criminal justice system (What is jail diversion, n.d.-b). In line with the goals of this text, diversion refers to alternatives to legal sanctions that are made available for PwMI who encounter the law in some context (Hartford et al., 2006). Alternatives may be voluntary, or court ordered and may or may not involve continuous supervision by justice personnel (juvenile or adult, community based or institutional). Closely corroborating with the primary structural diversion points in the traditional criminal justice flowchart (see Figure 3.2), such alternatives are ideally available at each interception from pre-arrest/booking to reentry from a correctional facility. The reality, however, is that human services, which includes mental health and substance abuse treatment, have become significantly underfunded and overutilized (Honberg et al., 2011; Johnson et al., 2011). Thus, as a by-product of deinstitutionalization and philosophical shifts from treatment to punishment, a large majority of PwMI have entered the criminal justice system by way of the underlying symptoms of illnesses which were not


CHAPTER 3 The Sequential Intercept Model

properly treated for a myriad of reasons. In fact, a significant proportion of individuals are frequent “cross-over” clients in multiple systems of care (including criminal justice, mental health, child or public welfare, and substance use). To improve the systematic response to this population, there was a need for the development of a conceptualized model of diversion points by which to provide opportunities for treatment and prevent individuals from further penetration into the system of criminal justice. As a result of ongoing discussion and collaboration, the Sequential Intercept Model (SIM) was generated (Munetz & Griffin, 2006).

MENTAL ILLNESS AND THE CRIMINAL JUSTICE SYSTEM: AN INTEGRATIVE FRAMEWORK The SIM is a conceptual mapping tool that was developed by Munetz and Griffin in 2006. One of its most basic functions is to provide a foundation by which key stakeholders in forensic mental health services could conceptualize the system of care in any given jurisdiction. Through the process of identifying gaps in services and available resources, the SIM provides a framework that communities can use to create and organize strategies for those with mental illnesses who have become involved with the law (Griffin et al., 2015). In its original form, the model has five different intercept points and three different graphic depictions—a vertical funnel, a linear flowchart, and a cyclical process (Griffin et al., 2015). In November of 2016, Policy Research Associates (PRA) announced an expansion of the model to include a sixth intercept point—Intercept “0,” which represents early intervention efforts in the community in terms of treatment and other service engagement (Vincent-Roller, 2016). Depending on the jurisdiction and its resources, each intercept point offers different programs and service linkages that can be utilized to prevent deeper penetration into the criminal justice system. Since the model’s inception, dozens of communities around the United States have participated in “systems mapping” workshops or activities, whereby select individuals from various agencies in a jurisdiction/locale (usually a county) gather for approximately a day and a half to collaborate in the creation of a systems map. The map provides a series of steps and respective agencies that justice-involved PwMI might encounter and identifies diversion resources, gaps, and duplications at each intercept point. Community stakeholders may utilize the mapping process as a guide to the implementation of reform efforts. A brief list of jurisdictions that have participated in this process is provided in Figure 3.3.

Police juvenile unit

Nonpolice referrals

Juvenile offenders

Charges filed

Waived to criminal

Intake court hearing

Source: Bureau of Justice Statistics (2016)

 Figure 3.2 Criminal Justice System Flowchart

Informal processing diversion

Formal juvenile or youthful offender court processing



Diversion by law enforcement, prosecutor, or court

Unsuccessful diversion


Refusal to indict Grand jury


Bail or Initial Preliminary detention appearance hearing hearing

Released or Released or diverted diverted

Prosecution as a juvenile


Released Released Charges Charges dropped without without dropped prosecution prosecution or dismissed or dismissed

Prosecution and pretrial services

Note: This chart gives a simplified view of caseflow through the criminal justice system. Procedures vary among jurisdictions. The weights of the lines are not intended to show actual size of caseloads.


Reported and observed crime Investigation

Unsolved or not arrested

Entry into the system

What is the sequence of events in the criminal justice system?



Out of system


Guilty plea









Intermediate sanctions

Revocation Residential placement




Out of system

Out of system

Out of system

Out of system (registration, notification)

Habeas Pardon and Capital corpus clemency punishment







Probation or other nonresidential disposition

Sentencing and sanctions

Convicted Sentencing


Guilty plea


Reduction of charge Charge dismissed


Charge dismissed


Mental Illness and the Criminal Justice System: An Integrative Framework 69


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 Figure 3.3 Examples of Sequential Intercept Mapping around the United States

More about Systems Mapping: A Collaborative Framework Systems mapping workshops are grant funded through the Substance Abuse and Mental Health Services Administration (SAMHSA) GAINS Center for Behavioral Health and Justice Transformation (commonly referred to as the “GAINS” Center). The GAINS Center, which is operated by Policy Research Associates (PRA), is nationally recognized for the collection and dissemination of data that relate to PwMI who are justice involved— particularly in terms of the overall access to services that address mental health and co-occurring substance abuse disorders. GAINS staff provide training and technical support to assist in systems integration and collaboration at all levels throughout individual jurisdictions (GAINS Center, 2016). The outcome of SIM mapping workshops is typically an effective navigation through multiple and diverse systems of care. Participants are guided to produce a “living” document that indicates the gaps in services at each specific inception—with the overarching goals of the workshop to include collaboration, information sharing, and support for funding requests. It should be noted that there have been innovations regarding the use of the SIM as a mapping tool in other settings. For example, it has been utilized to assist first responders and other systems personnel on how to handle a crisis involving veterans more effectively and how to subsequently link them with support services in the community. The model has also been used in various communities to identify gaps in the provision of services and more effective responses to juvenile justice issues. SIM has also been successfully used to facilitate workshops on college campuses and in tribal communities (Rogers, 2015). More recently, the SIM has provided the structure needed to incorporate trauma-informed care (TIC) (see Chapter 10), and workshops have been facilitated among criminal justice personnel—a point that will be revisited later in this book (Rogers, 2015).

Key Diversion Points 71

KEY DIVERSION POINTS To effectively divert adults with serious behavioral health concerns from involvement in the justice system, it is necessary to identify the population early and accurately. Further, proper treatment plans must be developed, and other measures designed to engage them in an array of services tailored to meet their needs. The process of identification should be accomplished using evidence-based screening and assessment tools, and dispositional outcomes should be based on careful (and thorough) evaluation by mental health professionals and the collaboration between parties of interest who are involved in any case (e.g., judges, attorneys, probation, and community-based service providers) (Steadman et al., 1995). The SIM outlines six potential “intercept” points in which personnel in multiple systems and at multiple points of processing could potentially divert PwMI away from further justice involvement (Figure 3.4). In short, in its linear form, it is a familiar structure that can be compared with the traditional criminal justice linear “flowchart” presented earlier, which is often presented to students of criminal justice in introductory courses in college. Like the SIM, the flowchart illustrates the horizontal nature of the criminal justice process from beginning to end and the various vertical points at which offenders can be filtered out of the system. One difference, however, is that it reflects the criminal justice–specific definition of diversion (discussed earlier) in which charges can be dismissed for several reasons such as a lack of evidence or upon agreement to commit to a community-based sanction. By comparison, although the SIM illustrates a similar “filtering out” of the system, the difference is that diversion for justice involved persons is either voluntary or involuntary and PwMI are rerouted into alternative systems of care that may be more appropriate and effective in terms of combating recidivism and improving their general well-being. The goal is not to eschew accountability for those who have mental illness or to disregard the criminal intent to commit the crimes for which they are charged; rather, it is to reduce the criminalization of mental illness and prevent further penetration into the criminal justice system for those persons with mental illness who have engaged in behaviors that are largely the result of the absence of proper treatment (Munetz & Griffin, 2006). Note by the illustration that the SIM is anchored at both ends by “community”; this point is essential in understanding the uniqueness of the model as it applies to PwMI in that the journey through the justice process is wholly dependent on available, accessible, and effective community resources. Because the extent of available resources will be different depending on the locale in which services are rendered, it is preferable to present this information in more general terms, and this is accomplished in the succeeding chapters. Moreover, each intercept point contained in the structural model is presented and discussed in more detail, and supporting research highlighted throughout the remainder of the text. A summary of the model is provided next.


CHAPTER 3 The Sequential Intercept Model

 Figure 3.4 The Sequential Intercept Model—Linear Version

Source: Abreu, D., Parker, T. W., Noether, C. D., Steadman, H. J., & Case, B. (2017). Revising the Paradigm for Jail Diversion for People with Mental and Substance Use Disorders: Intercept 0. Behavioral Sciences & the Law, 35(5–6), 380–395.

Intercept Zero: Community Services (Crisis Aversion) As previously discussed, in some communities, there are significant gaps in community-based services available and accessible for PwMI, including access to transportation, adequate housing, medication, therapy, case management, meaningful daily activities, and crisis services (Figure 3.5) (Slate et al., 2013). Early intervention in the form of community support and consumer engagement in services needed would produce the desired response, that is, the prevention of a behavioral health crisis. The goal of this intercept is to connect individuals to treatment by providing short-term help before there is a behavioral health crisis and to divert individuals from the criminal justice system. To accomplish this goal, community stakeholders must pool together resources that are often underfunded and overburdened to start. At this intercept, an effective community-based behavioral health system adequate enough to prevent criminal justice involvement might include some of the following objectives: (a) Increased support for community-based coalitions designed for education and early intervention programs aimed at trauma-informed care and alcohol and drug-related prevention efforts in the community (and other individualized target issues); (b) An expanded array of treatment options that prioritize the least restrictive level of care and invest in early intervention/prevention, alternatives to psychiatric hospitalization and inpatient care, acute crisis needs, and post-discharge care options in the community setting; (c) Increased funding and support for an expansive crisis continuum to include mobile crisis teams with expanded availability and detox and recovery services for people with SUDs and crisis lines that are alternatives to 911; and, (d) Increased opportunities and funding in support of positions involving peers with lived experience to provide interventions for persons experiencing behavioral health crisis. An essential crisis response system should include the following core elements: (1) Regional or state-wide crisis call centers coordinating in real time; (2) mobile crisis teams that are centrally deployed and available 24/7; and (3) 23-hour crisis receiving and stabilization programs. All services

Key Diversion Points 73

 Figure 3.5 Person without Housing

Source: By Alex Proimos from Sydney, Australia (Mental illness). [CC BY 2.0 (] via Wikimedia Commons

along the crisis continuum of services must be available to anyone, anywhere, and anytime (SAMHSA: “National Guidelines for Behavioral Health Crisis Care”, 2020). Furthermore, services should be inclusive, trauma-informed, and involve coordination of partnerships throughout the community (e.g., law enforcement, behavioral health, and emergency medical services). Specific legislative moves and policy developments in the context of building a more expansive and informed crisis response system are addressed in Chapter 4, wherein Intercept 0, the “ultimate intercept,” is introduced and discussed more fully.

Intercept One: Law Enforcement (Pre-Booking) Decompensation refers to stress or strain that results in behavioral or psychological imbalance; the source of the stress is based largely on restrictions to access any of the services and may directly (or indirectly) place PwMI at risk for contact with law enforcement officials (Lamb & Weinberger, 2014). Consequently, the next diversion opportunity in the SIM occurs when the police or other emergency first responders encounter some sort of crisis in the community. Historically, law enforcement agencies have not provided specialized training for officers on how to deal with and process mental health crises beyond a minimal number of hours received at their academy training (Deane et al., 1999; Lamb et al., 2002; Lew et al., 2014). With an increasing proportion of encounters between police and PWLE, specialized police/policing responses (SPRs) have been designed and implemented by law enforcement agencies in the United States and abroad to provide pre-booking diversion


CHAPTER 3 The Sequential Intercept Model

options that may more effectively address any underlying issues and/or needs related to this group. Examples of these programs can be broadly placed under three categories: (a) police-based crisis intervention teams (CITs), (b) co-responder teams, and (c) follow-up teams1 (Reuland & Yasuhara, 2015). Each of these is briefly explained next, with more detail provided in Chapter 5. In response to several high-profile crisis situations in which PWLE, police officers, or both were injured or even killed in the encounter, communities have rallied in support of the development of specialized law enforcement training programs that focus on crisis identification and intervention. Though taking varied forms depending on the resources and needs of any given jurisdiction, the most frequently adopted model is the Crisis Intervention Team (CIT)—the most widely adopted training curriculum originating in Memphis, Tennessee (referred to as the “Memphis Model”). Training in crisis intervention gives officers (and police dispatchers, in some locales) the skills needed to identify signs and symptoms of mental health disorders and to de-escalate a crisis event (SAMHSA, 2021). Diversion is the goal, and objectives revolve around the philosophy of treatment over incarceration/punishment. Research on the CIT model has generally shown improved safety for the officer and community (primarily measured through decreased use-of-force encounters), a decrease in the number of arrests, and an increase in the number of referrals by law enforcement to mental healthcare for those in need, and decriminalization of those with mental illness. Research on CIT outcomes has been inconsistent, as the success has been measured in a variety of ways, including pre- and post-perceptions of officer-trainees regarding their views of mental illness and PwMI, and the acquired knowledge from training; use of force incidents; and disposition of a crisis call (Browning et al., 2011; Rogers et al., 2019). The success of a CIT relies heavily on collaborative and positive partnerships between law enforcement and mental health practitioners (Reuland et al., 2009)—a point discussed in more detail in Chapters 5 and 11. Depending on the jurisdiction and its available resources, the co-responder model might be the most effective SPR to employ in a crisis. Under this model, police officers team up with clinical mental health professionals to respond to the scene of a crisis event involving a PwMI. The police role is typically to secure the environment and the person(s) involved, whereas the mental health professionals provide consultation as to mental health– related issues and assist with determining the types of services that are needed in any given situation. Depending on the resources, the team may provide follow-up services to the clients to gauge continuity of care and the provision of services (Reuland et al., 2009; Reuland & Yasuhara, 2015). Co-responder models have grown in popularity across jurisdictions in recent years, and the research is growing.

Key Diversion Points 75

Last, follow-up teams are also employed in some jurisdictions to respond to PwMI who have multiple encounters with law enforcement—as referenced in Chapter 1, such individuals are often referred to by police departments (and other practitioners) as “frequent flyers”. The goal of the individual/ team is to provide resource-brokerage, continuity of care (COC), and to encourage treatment-engagement and/or generate individualized plans to reconnect. Depending on the locale, teams may consist of clinicians, social workers, police officers, and/or a combination of practitioners who are specially trained. Follow-up persons work closely alongside mental health practitioners to develop and enrich community partnerships (Reuland & Yasuhara, 2015). SPRs are presented in more detail in Chapter 5, whereas specific models are outlined, and related empirical work is discussed.

THINKING CRITICALLY 3.2 BARRIERS TO TREATMENT AND SERVICES What might be some of the general issues that PwMI must contend with that lead to justice involvement at Intercept One? Access to… … Treatment and medication … Housing …??

Intercept Two: Initial Detention/Initial Court Hearings (Post-Arrest) For some individuals with serious psychological disorders, the circumstances under which they encounter law enforcement do not allow for diversion, but rather, lead to arrest and booking at a local jail or detention center (juveniles). Due to symptoms of their illness and other distinct factors that set them apart from incarcerated persons in the general population, the consequences of imprisonment are felt more profoundly by this class of citizens. Although the booking process itself can produce a substantially traumatic response, the initial detainment period—typically, the first two weeks of confinement—may lead to severe impairment including victimization, exacerbated symptoms and decompensation, induced psychosis, and self-harm—from self-mutilation to suicidal ideation and completion (Heilbrun et al., 2015; Slate et al., 2013). Oftentimes, incarcerated persons with mental health and intellectual/developmental disabilities (I/ DDs) are also targets for cruelty, such as physical and sexual abuse by others who are confined. Bizarre behaviors can cause them to be punished more often, mostly resulting in solitary confinement, which only causes their condition to deteriorate further (Satel, 2003).


CHAPTER 3 The Sequential Intercept Model

Fortunately, the first appearance in court provides another opportunity to divert individuals charged with low-level offenses. Post-arrest diversion procedures are available prior to the preliminary hearing and before the defendant-client enters a plea (Heilbrun et al., 2015). Courts may establish pre-trial services divisions, directly hire mental health professionals, or develop relationships with outside organizations to assess detained persons and advise judges regarding the disposition of the case. In this case, mental health workers advise the court about the possible presence of mental illness, issues of competency (discussed in later chapters), and options for assessment and treatment (DeMatteo et al., 2013; Griffin et al., 2015; Heilbrun et al., 2015). Individuals are also screened for services should they participate in mental health or other treatment courts (see Intercept 3). Intercept 2 post-arrest/booking diversion programs and related empirical findings are further presented and discussed in Chapter 6.

Intercept Three: Jails/Courts (Post-Conviction) To address the needs of PwMI who have committed more serious misdemeanors or felonies and have not been diverted at Intercept 2, several jurisdictions have developed mental health or other specialized courts (e.g., veterans’ courts) that focus on problem solving and treatment rather than punishment (Griffin et al., 2002). Specialized courts are based on the therapeutic jurisprudence model of treatment, collaboration, and wrap-around services, which stands in stark contrast to the adversarial nature of the traditional court system in the United States. Practices in mental health court, such as conditional release and forensic case management, also allow opportunities for PwMI to remain in the community setting if they are meeting the conditions of an individualized program (Liu & Redlich, 2015; Slate et al., 2013). Specialty court clients are still subject to sanctions, however, should they fail to engage in any aspects of the program as prescribed by the collaborative “treatment team”; sanctions may include periods of detention and hospitalization. Using treatment courts, the state can save money, provide community-based therapy, and allow individuals who were once incarcerated to remain in their home environments with minimal supervision. Once “clients” (as they are often referred to by the treatment team) have made it through the program successfully, there is typically a graduation ceremony in the courtroom, and, depending on several factors, charges may be subsequently dismissed (Liu & Redlich, 2015). Juvenile mental health courts (JMHCs) have been implemented in states such as California, Georgia, and Texas (SAMHSA, n.d.-a). Intercept 3 and related research are expanded upon in Chapter 7.

Intercept Four: Reentry (Preparing for Release) Primarily due to the serious nature of the offense, sometimes a PwMI penetrates further into the traditional justice system and is convicted and sentenced to a period of incarceration in a jail or prison. In some cases, an

Key Diversion Points 77

individual may even be committed to a forensic or state hospital directly from detainment. Regardless of the type of supervision or confinement, the point when detained persons are preparing to return to their communities represents another opportunity to connect them with services. Depending on available resources and the receptiveness of administration, several programs are designed to provide incarcerated persons with skills to succeed upon their release and beyond (Griffin et al., 2015). Programs may be accessible within the institution or post-release in a community mental health setting, and typically revolve around issues such as substance use and the development of coping skills or cognitive-based interventions, life skills such as shopping or cooking, and gaining access to human capital, such as job skills and education (e.g., high school diploma and courses for college credit) (Osher & King, 2015). Some of the programs are faith-based or have distinct religious components. As a result of time served and participation in counseling or programming, many justice-involved PwMI have made significant improvements in coping, medication management, and behaviors, and have become genuinely prepared to reenter society again. Others have not had the mental capacity during most of their detainment and may require intensive case management or participation in an assertive community treatment team (ACT or FACT, discussed later in the text) upon release (DeMatteo et al., 2012). To facilitate a more effective transition to the community setting, some departments of corrections have created reentry specialist positions and encouraged the use of boundary spanners—a concept that refers to a liaison who works on behalf of forensic clients to coordinate mental health, judicial, and law enforcement involvement and expectations (Steadman et al., 1995). Such developments have translated into improved outcomes in terms of successful reintegration, particularly when accompanied by procedures designed to encourage (or require) reentry planning for transitional care immediately after an incarcerated person is booked into the facility. To this point, a model known as the APIC Model for Transition Planning is instructive; APIC stands for assess, plan, identify, and coordinate (Osher & King, 2015). The model and its four goals are expanded upon and evaluated in Chapter 8. POLICY & PRACTICE 3.1 AFTERCARE FOR DETAINED PERSONS IN FLORIDA Florida provides a good example of an Intercept 4 diversion strategy. In a memorandum of understanding (MOU) between the state Departments of Children and Families and Corrections (DCF & DOC, respectively), an agreement was made that requires a reentry coordinator (DOC) to maintain contact with a point person (DCF) related to the provision of aftercare services for incarcerated persons with serious mental health and substance use needs in the county for which the individual will be released (CF Operating Procedure No. 155-47, 2009). This partnership centers on the scheduling of initial appointments with local providers for a date within the two-week period after the incarcerated person is released from the facility.


CHAPTER 3 The Sequential Intercept Model

Intercept Five: Community Corrections (Post-Release) Due to the nature of the carceral environment and the limited access to treatment services during their stay, a significant proportion of incarcerated persons with SMI are at high risk of encountering multiple systems of care, and ultimately, coming to the attention of criminal justice personnel again at some point after their release (Lovell et al., 2002). Consequently, specialized parole and probation programs have been implemented in several jurisdictions to ensure that formerly incarcerated individuals get the treatment they need and stay out of jail. Unfortunately, justice-involved PwMI—particularly those with SMI—may not have the ability to comprehend the expectations as to their behavior and may unintentionally violate probation and parole due to such competency-related misunderstandings. For this reason, specialized training programs have also been offered to community corrections personnel to address the signs and symptoms of mental illness (e.g., CIT, discussed in Chapter 5). Furthermore, the engagement of boundary spanners has also improved the communications between clients and their community supervision staff. THINKING CRITICALLY 3.3 SUICIDE IN JAILS AND PRISONS Earlier, you read the story of Mr. Jerome Murdough, a U.S. Marine with SMI who died in his Rikers Island Jail cell due to a malfunctioning heating system and a lack of observation on the part of the correctional staf. Rikers has unfortunately seen its fair share of tragedy regarding PwMI under its watch. During the same year as the Murdough death, another incarcerated man died after sexually mutilating himself; he had been left alone in his cell for seven days. Further, months after these cases, Rikers was the site for another a high-profle case involving the suicide of a man by the name of Fabian Cruz. Cruz, who was 35, had been ordered to be moved to a specialized unit for observation, but when he refused to go, staf simply ignored protocol and returned him to his regular cell; shortly thereafter, he hanged himself (Associated Press, 2015). Suicide is the second leading cause of death in U.S. federal and state prisons (Carson & Cowhig, 2020a) and the leading cause in local jails (Carson & Cowhig, 2000b). Pre-trial detainees have a suicide attempt rate of about 7.5, and sentenced incarcerated persons have a rate of almost six times the rate of men at home. Also, persons incarcerated prior to trial who die by suicide in custody are generally men between the ages of 20 and 25, unmarried, and frst-time defendants who have been arrested for minor, usually substance use-related, ofenses (Daigle et al., 2007, p. 114). Have you ever experienced the loss of someone who has died by suicide? Or maybe you have encountered friends or loved ones who have expressed suicidal ideation? Maybe you have felt your own feelings of despair. How might some of these feelings of helplessness and hopelessness be exacerbated behind jail or prison walls?

Research on the SIM 79

The importance of collaboration and shared knowledge of community resources at Intercept 5 cannot be overemphasized (Slate et al., 2013). As previously stated, clients are shared across multiple systems, including criminal justice, public welfare, veterans’ affairs/services, substance use, aging, and foster care or dependency. The development of strong partnerships between various stakeholders whose services are interconnected in several ways allows forensic-based case managers and reentry coordinators to make appropriate referrals to community providers (for example, mental health, drug and alcohol, juvenile justice). Collaboration among all parties can ensure proper services are being implemented, save resources and funding, and provide for the implementation of ongoing evaluations (Kaffenberger & O’Rorke-Trigiani, 2013). These are the subject matter discussed in Chapter 9 of this text.

RESEARCH ON THE SIM At this point in time, the SIM has been most effectively used as a structural guide to understand the path through forensic mental health and the potential for diversion at each stage in the justice process. In this context, it has also been used as an organizational tool for multisystemic mapping activities throughout the nation. Unfortunately, mapping activities have not netted any empirical data or support thus far. For this reason, the SIM has also been introduced as a descriptive (theoretical) model to identify primary research questions at each stage so that researchers could pursue empirical analyses (Heilbrun et al., 2015). Although research associated with Intercepts 1 and 3 has been examined in some detail (e.g., CIT and specialty court outcomes), other intercepts have had minimal attention in this regard. Of the existing literature, several strengths and limitations are considered and addressed in each successive chapter of this text.


Contributors: Cori Seilhamer, MS, LCC, and Justin M. Lensbower, MS, LPC Police are alerted by a man that his sister, Ellen, was sitting on the porch at a local restaurant with a suitcase for more than an hour and refusing to come home. The restaurant ofered her water while the police contacted the mental health delegate who was dispatched to talk with her. Ellen had walked away from home because she believed her family was poisoning her and she had no intention of returning. The delegate was able to secure an emergency appointment with Ellen’s outpatient counselor, who was able to assess her mental status and get her emergency mental health treatment instead of loitering charges from the criminal justice system.


CHAPTER 3 The Sequential Intercept Model

When a community implements the SIM, it creates opportunities for historically separate disciplines to collaborate to aford treatment to those in need rather than incarceration as the solution. This relationship is helpful for individuals who need services and for law enforcement, as it provides additional support and resources as solutions. This is most efective when each participant strives to understand the other and communicates often with each other to reduce resistance toward potentially competing interests. With declining budgets and a struggling economy, sharing of resources and collaboration becomes even more important for public services. Law enforcement through 911 call centers have become increasingly utilized strategies for accessing the mental health system due to these obstacles. For this reason, it is important that dispatchers are included in the collaborative relationships through the SIM. Author’s Note: A “mental health delegate” is an individual who works for the area (county, state, or region) mental health services ofce; this person has been designated, most likely statutorily, as the key decision-maker in terms of contract oversight and allocation of resources, but also, in making discretionary decisions pertaining to the emergency evaluation and treatment of persons in their jurisdiction who are in crisis.

TAKE-HOME MESSAGE PwMI should not be involved in the criminal justice system at a rate higher than individuals without mental illness (Munetz & Griffin, 2006). Even though critical intercept points have been identified and diversion strategies at each point have been found to be effective to some extent, the SIM as a model of transformation is useless when practitioners lack insight into the signs and symptoms of mental illness. Consequently, proper training becomes key. Additionally, other strategies have been recommended to local governments as a means to support ongoing transformational change; these include the provision of funding incentives, the removal of barriers to services (financial and other restrictions on access), the provision of educational resources related to mental health and substance abuse disorders, changes in legislation and practice so to assist local mental health systems to develop the capacity to acquire data to identify and implement best practices, and the promotion of cross-systems collaboration and information sharing (Vail & Santangelo, n.d.). Despite a positive public response to diversionary efforts, it is quite possible that PwMI do not wish to undergo mental health and/or addiction treatment and, in fact, may willingly seek placement in the justice system. In that case, constitutional and other legal protections must be enforced throughout the process if there is no reason to believe public safety risks are present. As will be discussed in more detail later in the text, should a person with mental illness show a risk for injury to self or others, a legally prescribed

Take-Home Message 81

and qualified entity may move toward an order for psychiatric evaluation, and possibly commitment, for a designated period. State laws are instructive as to commitment procedures, and certain criteria must be met. Now that the structure for the remainder of the book has been introduced, we will begin our journey through the forensic mental health system, keeping in mind that for many, the system is not linear but rather cyclical in nature. Like those who enter the criminal justice system who do not have mental illness, the revolving door phenomena can unfortunately serve to perpetuate a continued life of recidivism and trauma for all who are involved. The following chapter launches us into the SIM with community at intercept zero, also referred to as the “Ultimate Intercept” (Bonfine et al., 2020). Additionally, the chapter outlines a systematic approach to the needs of persons with serious mental illness through the identification of an “ideal” system of crisis care and the most common gaps in services.

Questions for Classroom Discussion 1. In small groups, create outlines in which the group will identify and discuss some of the problems presented at Intercepts 0–5. After about ten minutes, open a class discussion regarding proposed solutions and barriers to them. 2. In your opinion, what do you view as the most important intercept point in the SIM? On what criteria did you base your selection? 3. The SIM has been utilized in various communities and referred to as a “tool for transformation.” It is suggested that the most successful transformations have occurred because of positive and continuous systems collaborations. In the jurisdiction in which you live/work, what agencies and key stakeholders do you think should be involved in SIM mapping workshops and/or systems integration meetings pertaining to justice-involved PwMI?

KEY TERMS & ACRONYMS • • • • • • • • • • • •

Assertive community treatment (ACT) team Boundary spanners Commitment Competency Conditional release Containment Continuity of care (COC) Decompensation Diversion GAINS Center for Behavioral Health and Justice Transformation Mental health delegate Memorandum of understanding


CHAPTER 3 The Sequential Intercept Model

• Resource brokerage • Substance Abuse and Mental Health Services Administration (SAMHSA) • Trauma-informed care (TIC)

NOTE 1 Law enforcement agencies that have developed SPRs have made significant changes in policies and procedures, which have greatly affected traditional policing practices. In addition, a multitude of mental health–based specialized responses have been implemented successfully at the jurisdiction level solely by mental health agencies; however, for the purposes of this text, only programs involving police are referenced.

BIBLIOGRAPHY Abreu, D., Parker, T. W., Noether, C. D., Steadman, H. J., & Case, B. (2017). Revising the Paradigm for Jail Diversion for People with Mental and Substance Use Disorders: Intercept 0. Behavioral Sciences & the Law, 35(5–6), 380–395. Andrews, T. (2003). Mental Health Procedures and Criminal Law. Notes presented at the Meeting of the Pennsylvania Bar Institute, Montour County. Associated Press. (January 2, 2015). Rikers Island Inmate Dies After Suicide Watch Ignored. New York Post. Retrieved from http://nypost. com/2015/01/02/rikers-island-inmate-dies-after-suicide-watch-ignored/ Bonfine, N., Wilson, A. B., & Munetz, M. R. (2020). Meeting the Needs of Justice-Involved People with Serious Mental Illness within Community Behavioral Health Systems. Psychiatric Services, 71(4), 355–363. Branch, C. (January 6, 2015). Tragic Deaths Shed Light on Brutality at Rikers. The Huffington Post. Retrieved from http://www.huffingtonpost. com/2015/01/05/rikers-island-brutality_n_6419632.html Browning, S. L., Van Hasselt, V. B., Tucker, A. S., & Vecchi, G. M. (2011). Dealing with Individuals Who Have Mental Illness: The Crisis Intervention Team (CIT) in Law Enforcement. The British Journal of Forensic Practice, 13(4), 235–243. Burriss, F. A., Breland-Nobel, A. M., Webster, J. L., & Soto, J. A. (2011). Juvenile Mental Health Courts for Adjudicated Youth: Role Implications for Child and Adolescent Psychiatric Mental Health Nurses. Journal of Child and Adolescent Psychiatric Nursing, 24(2), 114–121. Carson, E. A., & Cowhig, M. P. (2020a). Mortality in State and Federal Prisons, 2001–2016 Statistical Tables. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. NCJ 251920. Carson, E. A., & Cowhig, M. P. (2020b). Mortality in Local Jails, 2001–2016— Statistical Tables. Washington, DC: US Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. NCJ 251921. CMHS National GAINS Center. (2007). Practical Advice on Jail Diversion: Ten Years of Learnings on Jail Diversion from the CMHS National GAINS Center. Delmar, NY: Author.

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Daigle, M. S., Daniel, A. E., Dear, G. E., Frottier, P., Hayes, L. M., Kerkhof, A., … & Sarchiapone, M. (2007). Preventing Suicide in Prisons, Part II: International Comparisons of Suicide Prevention Services in Correctional Facilities. Crisis, 28(3), 122–130. Daniel, A. E. (2007). Care of the Mentally Ill in Prisons: Challenges and Solutions. Journal of the American Academy of Psychiatry and the Law Online, 35(4), 406–410. Davis, H. (December 1, 2014). Completes Sequential Intercept Mapping Report for Los Angeles County, Inspires Criminal Justice Reform. Policy Research Associates, Inc. Retrieved July 29, 2015, from la-sim-2014/ Deane, M. W., Steadman, H. J., Borum, R., Veysey, B. M., & Morrissey, J. P. (1999). Emerging Partnerships between Mental Health and Law Enforcement. Psychiatric Services, 50(1), 99–101. DeMatteo, D., LaDuke, C., Locklair, B. R., & Heilbrum, K. (2013). Community-Based Alternatives for Justice-Involved Individuals with Severe Mental Illness: Diversion, Problem-Solving Courts, and Reentry. Journal of Criminal Justice, 41, 64–71. GAINS Center for Behavioral Health and Justice Transformation. (January 7, 2016). Retrieved January 3, 2017, from eNews/august14.html#fourth GAINS Staff Develops SIM Mapping for Duchess County. (August 1, 2014). Retrieved July 29, 2015, from august14.html#fourth GAINS Staff Develops SIM Mapping for NYC Task Force. (July 1, 2014). Retrieved July 29, 2015, from html#third Griffin, P. A., Heilbrun, K., Mulvey, E. P., DeMatteo, D., & Schubert, C. A. (2015). Sequential Intercept Model and Criminal Justice: Promoting Community Alternatives for Individuals with Serious Mental Illness. New York, NY: Oxford University Press. Griffin, P. A., Munetz, M., Bonfine, N., & Kemp, K. (2015). Development of the Sequential Intercept Model. In P. A. Griffin, K. Heilbrun, E. P. Mulvey, D. DeMatteo, & C. A. Schubert (Eds.), The Sequential Intercept Model and Criminal Justice (pp. 21–39). New York, NY: Oxford University Press. Griffin, P. A., Steadman, H. J., & Petrila, J. (2002). The Use of Criminal Charges and Sanctions in Mental Health Courts. Psychiatric Services, 53(10), 1285–1289. Hancq, E. S., South, K., & Vencel, M. (March, 2021). Dual Diagnosis: Serious Mental Illness and Co-occurring Substance Use Disorders [Evidence Brief]. Office of Research and Public Affairs. Arlington, VA: Treatment Advocacy Center. Retrieved from documents/TAC_Co-occuring_Evidence_Brief_March_2021_Final.pdf Hartford, K., Carey, R., & Mendonca, J. (2006). Pre-Arrest Diversion of People with Mental Illness: Literature Review and International Survey. Behavioral Sciences & the Law, 24, 845–856. Heilbrun, K., DeMatteo, D., Brooks-Holliday, S., & Griffin, P. A. (2015). Initial Detention and Initial Hearings. In P. A. Griffin, K. Heilbrun, E. P. Mulvey, D. DeMatteo, & C. A. Schubert (Eds.), The Sequential Intercept Model and Criminal Justice (pp. 57–77). New York, NY: Oxford University Press. Heilbrun, K., Mulvey, E. P., DeMatteo, D., Schubert, C. A., Filone, S., & Griffin, P. A. (2015). The Sequential Intercept Model: Current Status, Future


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Directions. In P. A. Griffin, K. Heilbrun, E. P. Mulvey, D. DeMatteo, & C. A. Schubert (Eds.), The Sequential Intercept Model and Criminal Justice (pp. 276–284). New York, NY: Oxford University Press. Heretick, D. M. L., & Russell, J. A. (2013). The Impact of Juvenile Mental Health Court on Recidivism among Youth. Journal of Juvenile Justice, 3(1), 1–14. Honberg, R., Diehl, S., Kimball, A., Gruttadaro, D., & Fitzpatric, M. (March, 2011). State Mental Health Cuts: A National Crisis. NAMI. Retrieved from NAMIStateBudgetCrisis2011.pdf Johnson, N., Oliff, P., & Williams, E. (February, 2011). An Update on Stat Budget Cuts: At Least 46 States Have Imposed Cuts That Hurt Vulnerable Residents and Cause Job Loss. Washington, DC: Center on Budget and Policy Priorities. Kaffenberger, C., & O’Rorke-Trigiani, J. (2013). Addressing Student Mental Health Needs by Providing Direct and Indirect Services and Building Alliances in the Community. Professional School Counseling, 16(5), 323–332. Lamb, H. R., & Weinberger, L. E. (2014). Decarceration of U.S. Jails and Prisons: Where Will Persons with Serious Mental Illness Go? Journal of the American Academy of Psychiatry and the Law, 42, 489–494. Lamb, H. R., Weinberger, L. E., & DeCuir, Jr., W. J. (2002). The Police and Mental Health. Psychiatric Services, 53(10), 1266–1271. Lamb, H. R., Weinberger, L. E., & Gross, B. H. (2004). Mentally Ill Persons in the Criminal Justice System: Some Perspectives. Psychiatric Quarterly, 75(2), 107–126. Lew, P., Pham, J., & Morrison, L. (August, 2014). An Ounce of Prevention: Law Enforcement Training and Mental Health Crisis Intervention (Publication #CM51.01). Sacramento: Disability Rights California. Liu, S., & Redlich, A. D. (2015). Intercept 3: Jails and Courts. In P. A. Griffin, K. Heilbrun, E. P. Mulvey, D. DeMatteo, & C. A. Schubert (Eds.), The Sequential Intercept Model and Criminal Justice (pp. 78–94). New York, NY: Oxford University Press. Lovell, D., Gagliardi, G. J., & Peterson, P. D. (2002). Recidivism and Use of Services among Persons with Mental Illness after Release from Prison. Psychiatric Services, 53(10), 1290–1296. Mencimer, S. (April 8, 2014). There Are 10 Times More Mentally Ill People Behind Bars Than in State Hospitals. Mother Jones. Retrieved from Munetz, M. R., & Griffin, P. A. (2006). Use of the Sequential Intercept Model as an Approach to Decriminalization of People with Serious Mental Illness. Psychiatric Services, 57(4), 544–549. Osher, F., & King, C. (2015). Intercept 4: Reentry from Jails and Prisons. In P. A. Griffin, K. Heilbrun, E. P. Mulvey, D. DeMatteo, & C. A. Schubert (Eds.), The Sequential Intercept Model and Criminal Justice (pp. 95–117). New York, NY: Oxford University Press. Policy Research Associates. (2010). Final Report: Multnomah County, Oregon, Sequential Intercept Mapping & Taking Action for Change. Retrieved from Reuland, M., Schwarzfeld, M., & Draper, L. (2009). Law Enforcement Reponses to People with Mental Illnesses: A Guide to Research Informed Policy and Practice. New York, NY: Council of State Governments Justice Center.

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Reuland, M., & Yasuhara, K. (2015). Law Enforcement and Emergency Services. In P. A. Griffin, K. Heilbrun, E. P. Mulvey, D. DeMatteo, & C. A. Schubert (Eds.), The Sequential Intercept Model and Criminal Justice (pp. 40–56). New York, NY: Oxford University Press. Rogers, D. (2015). Sequential Intercept Model. Policy Research Associates. Retrieved from Rogers, M. S., McNiel, D. E., & Binder, R. L. (2019). Effectiveness of Police Crisis Intervention Training Programs. Journal of the American Academy of Psychiatry and Law, 47(4), 414–421. SAMHSA’s GAINS Center Awards Training Opportunities to 16 Communities Nationwide. (November, 2012). Retrieved July 29, 2015, from SAMHSA’s GAINS Center Facilitates SIM Workshop in Springfield, MA. (March 1, 2015). Retrieved July 29, 2015, from http://gainscenter.samhsa. gov/eNews/march15.html#third SAMHSA’s GAINS Center Selects Five Communities for Sequential Intercept Mapping Workshops Focusing on Early Diversion. (2015). Retrieved July 29, 2015, from Satel, S. (2003). Out of the Asylum, into the Cell. New York Times, A-29. Sequential Intercept Mapping Final Report. (October 1, 2013). Retrieved July 29, 2015, from Slate, R. M., Buffington-Vollum, J. K., & Johnson, W. W. (2013). The Criminalization of Mental Illness: Crisis and Opportunity for the Justice System (2nd Ed.). Durham, NC: Carolina Academic Press. State of Florida Department of Children and Families. (2009). Mental Health/ Substance Abuse (CF Operating Procedures No. 155–47). Tallahassee, FL. Steadman, H. J., Morris, S. M., & Dennis, D. L. (1995). The Diversion of Mentally Ill Persons from Jails to Community-Based Services: A Profile of Programs. American Journal of Public Health, 85(12), 1630–1635. Substance Abuse and Mental Health Services Administration. (n.d.-a). Juvenile Mental Health Treatment Court Locator. Rockville, MD: SAMHSA. Retrieved from Substance Abuse and Mental Health Services Administration. (n.d.-b). What Is Jail Diversion? Rockville, MD: SAMHSA Gains Center for Behavioral Health and Justice Transformation. Retrieved from Substance Abuse and Mental Health Services Administration. (2021). The Sequential Intercept Model (SIM). Rockville, MD: SAMHSA. Retrieved from Vail, L., & Santangelo, J. (n.d.). The Sequential Intercept Model [PowerPoint Slides]. Retrieved from 19498158/1342644696663/Sequential+Intercept+ Model+Vail.ppt?token= IzZYsMNBcts8wMpEBdbC3Lw4V6c%3D Vincent-Roller, N. (2016, November 23). Introducing “Intercept 0”. [Web Log Post]. Retrieved January 10, 2017, from



Intercept Zero

Community Services Kelly M. Carrero and Michele P. Bratina Jade, who had been diagnosed with schizophrenia and bipolar disorder, began experiencing a mental health crisis while at a public event. An off-duty member of the local police department’s behavioral health unit was also attending the event with family that day. The officer called for backup about an hour after noticing Jade exhibiting unusual behavior that continued to escalate and draw a crowd. Jade hit, bit, and spit on the responding officers as they attempted to coax her away from onlookers and into a “safe space” so they could further assess the situation. One of the officers called for medical assistance. Jade started screaming obscenities and waving her hands in the face of one of the officers. Officers then physically forced Jade to the ground, face down, and handcuffed her. After a few minutes, one of the officers noticed Jade had stopped breathing. They attempted immediate revival, but it was too late. Although the actions of these officers were considered appropriate (they did not use unreasonable force and called for medical assistance early), it is possible that they still may contributed to Jade’s death. What alternative measures could have been taken to help Jade during this crisis?1

INTRODUCTION It is, unfortunately, well-known and understood that people with serious psychological disorders are disproportionately overrepresented in carceral settings (Andreoli et al., 2014; Atkins et al., 1999, Fazel et al., 2016; McBain et al., 2021). Moreover, once incarcerated, people with mental illness (PwMI) are less likely to successfully reenter community settings (Barak & Stebbins, 2020; Draine et al., 2005, Pękala-Wojciechowska et al., 2021). Therefore, preventing the first contact with the legal system/police is often critical to an optimal quality of life and a successful life trajectory for people with SMI. Intercept 0 of the Sequential Intercept Model (SIM; Munetz & Griffin, 2006) is the most recent addition to the SIM (Abreu et al., 2017) and focuses on diversionary efforts that can be installed prior to Intercept 1, which involves interactions with law enforcement. Advocates

DOI: 10.4324/9781003120186-4



CHAPTER 4 Intercept Zero: Community Services

of diversionary strategies proposed the addition of Intercept 0, recognizing the myriad of community-based supports and services that are required for authentic and fundamental diversion—that is, changing one’s course or trajectory—from interaction with the criminal justice system (Abreu et al., 2017; Bonfine et al., 2020; Munetz & Griffin, 2006). Consequently, Intercept 0 seeks to prevent police interactions and divert initial and subsequent criminal justice involvement by leveraging community services as prevention and early intervention strategies for PwMI. Often referred to as the “ultimate intercept,” Intercept 0 leans on an effective, evidence-based, community behavioral health care system that is accessible and cost-effective for all PwMI (Bonfine et al., 2020; McBain et al., 2021; Munetz & Griffin, 2006). Despite the progress being made along the other intercepts of the SIM, scholars urge field practitioners, policymakers, and funding agencies to place more attention on Intercept 0 to achieve the goal of SIM—to provide adequate support and treatments for PwMI and, thus, prevent and divert interactions with the criminal justice system (Compton et al., 2019). People living with mental illness and their loved ones know that crises are part of their lived experiences and are often cyclical in nature (Kalb et al., 2021). It is well understood that continuous, evidence-based treatments and community and social supports are necessary to decrease the frequency and, often, the intensity of the eventual mental health crises that are, unfortunately, often part of the taxonomy of many psychiatric illnesses (American Psychiatric Association, 2015; McBain et al., 2021). In fact, at the conclusion of 2021, the American Psychiatric Association proposed the addition of a new “R” code2 for “Impairing Emotional Outbursts.” The authors of the proposal define impaired emotional outbursts as, “displays of anger or distress manifested verbally (e.g., verbal rages, uncontrolled crying) and/ or behaviorally (e.g., physical aggression toward people, property, or self) that lead to significant functional impairment.” The addition of this code supports the reality that PwMI and their providers understand—that what is often called, “agitation” is simply not an effective description of the profound impact that these episodes can have on a PwMI’s life and overall functioning. Intercept 0 is the space on the SIM that serves to not only prevent but also respond to these acute, yet persistent, crises before the PwMI interacts with law enforcement. In addition to preventing and responding to crisis, Intercept 0 also leverages community supports to mitigate other factors that may result in a PwMI interacting with law enforcement (e.g., unstable housing, substance use, poverty, and unemployment).

COMPONENTS OF INTERCEPT 0: PREVENTION, RESPONSE, AND ULTIMATE DIVERSION When Intercept 0 was introduced, Abreu and colleagues (2017) identified four components: crisis phone lines, crisis care continuum, 911 call centers, and law enforcement dispatchers and specialized police responses. Since its inception, scholars and advocates have urged the field to expand these

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components to include social services, community programs, and advocacy organizations that will ameliorate known contributing factors that result in interactions between PwMI and law enforcement (Bonfine et al., 2020; Kouyoumdjian et al., 2019; Masenthin, 2017; McBain et al., 2021). It is well understood that each intercept along the SIM has some overlap with the preceding and subsequent intercepts (Folk et al., 2021). Therefore, the components of Intercept 0 will be presented as prevention and crisis response efforts (with or without police involvement) that may enable diversion before an arrest is made.

Prevention The medical model of treatment in Western medicine has long taken a responsive, rather than a preventative, approach to care. Contemporary views of health and wellness in Western societies reflect an appreciation for prevention efforts and early intervention efforts to increase mental health literacy (e.g., Jiménez-Chafey et al., 2013; Kutcher et al., 2015; McBain et al., 2021; Ojio et al., 2020). One priority would include training primary care physicians more on awareness of mental disorders and managing said issues (McBain et al., 2021; Muyambi et al., 2021). With respect to PwMI and preventing interactions with the criminal justice system, prevention efforts take three basic forms: (a) destigmatization efforts or normalization, (b) crisis media, (c) accessible social services, including an evidence-based behavioral healthcare system.

Destigmatization Efforts: An International Agenda As previously discussed in Chapters 1 and 2, misconceptions and misinformation about the etiology and expression of symptomology in PwMI perpetuate public stigma. As indicated in Chapter 2 specifically, the stigma most often attached to PwMI is that they are dangerous and prone to violent and/or unpredictable behaviors (Parcesepe & Cabassa, 2013). Again, stigmatizing beliefs about PwMI are widely held by the public and have been perpetuated by stereotyped or sensational media portrayals (Corrigan & Penn, 1999). Understanding this context, it is not surprising that one of the first diversionary approaches should be destigmatization of PwMI. In 1992, the World Federation for Mental Health (WFMH) established the annual World Mental Health Day (Brody, 2004). This global event seeks to heighten awareness and educate citizens of every country about mental hygiene.3 World Mental Health Day is one of many global initiatives promoted by the World Health Organization (WHO) to achieve their objective of increasing awareness and education about mental health and decreasing stigma and deleterious collateral consequences of untreated mental illness (WHO, 2021a). The original and persistent position of the WFMH and WHO is that mental health and wellness promotes healthy relationships among global citizens (consequently, avoiding unnecessary tensions)


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and facilitates achieving global development goals (WFMH, 1948; WHO, 2021a). Advocates, mental health professionals, and policymakers all over the world continue to campaign for destigmatization efforts to be at the forefront of national and international agendas. In May of 2012, at the 65th World Health Assembly, a resolution was adopted that acknowledged the need for a coordinated, worldwide, comprehensive response to mental illness. One year later, at the 66th World Health Assembly, the 194 Member State delegates adopted the WHO’s Comprehensive Mental Health Action Plan for the years of 2013–2020. The language used to describe the intent and overall goal of the comprehensive action plan demonstrates the desire for destigmatization: The vision of the action plan is a world in which mental health is valued, promoted and protected, mental disorders are prevented and persons affected by these disorders are able to exercise the full range of human rights and to access high quality, culturallyappropriate health and social care in a timely way to promote recovery, in order to attain the highest possible level of health and participate fully in society and at work, free from stigmatization and discrimination. (WHO, 2013, p. 9) In September of 2021, the action plan was updated to reflect the effects of COVID-19 and extended until 2030. (WHO, 2021b) Some industrialized nations with full behavioral healthcare systems and established policies protecting citizens with mental illnesses did not respond with radical shifts in policies or practices. National destigmatization efforts led by the government in the United States date back to the 1950s, so it is reasonable that the WHO report did not result in a substantive change in mental illness destigmatization in the United States. However, in 2016, the National Academies of Sciences, Engineering, and Medicine4 (NASEM) published a report dedicated to urging a national shift in efforts for destigmatizing mental illness and eliminating discrimination. In the report, NASEM delineates evidence-based approaches to reducing stigma. All the strategies listed were centered on heightening awareness, educating the general public, and promoting peer social support in the community. The report concludes with six recommendations for the nation to destigmatize mental illness and it calls on the U.S. Department of Health and Human Services, as well as the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) to lead the charge in these efforts. Evidence of shifting national focus to issues of mental health in the United Kingdom was emerging in 2018 when the United Kingdom hosted its first global mental health summit and named its first suicide prevention minister, Jackie DoylePrice. In March 2020, the WHO officially declared the COVID-19 outbreak as a pandemic. While it would be imagined that this worldwide health crisis shifted focus away from the strides being made in mental health efforts, collateral consequences of the pandemic (e.g., job loss, massive deaths, social

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isolation, etc.) only amplified efforts in each sector of society throughout the world. One such effort to educate the public and advocate for resilience and recovery for PwMI that has increased in importance is Mental Health First Aid (MHFA), discussed below. MENTAL HEALTH FIRST AID Mental Health First Aid (MHFA) was developed and implemented first in Australia in 2001. By the end of 2007, there were over 600 instructors and 55 people trained in MHFA in that country (Kitchener & Jorm, 2008). The original curriculum can be delivered over the course of one or two days and is facilitated by certified instructors; revisions have been made to the number of hours, depending on the version and the needs of the community in which it is being offered. The goal of MHFA is to promote a philosophy of resilience and recovery. Consequently, the original MHFA training program revolves around a five-step action plan referred to as ALGEE: Assess the risk of suicide or harm; Listen nonjudgmentally; Give reassurance and information; Encourage the person to get appropriate professional help; and Encourage self-help strategies. The program is typically offered to police officers, emergency personnel, students, school administration, and primary care professionals with a collective goal of reducing the stigma associated with PwMI, helping those in danger of suicide or self-harm, and making referrals to appropriate treatment services (National Council for Mental Wellbeing, 2021a). Training module topics include anxiety, depression and mood disorders, psychosis, suicide, substance use disorders, and trauma (Figure 4.1). In 2006, the need for a youth MHFA program was recognized, and one was developed in Australia with the same

 Figure 4.1 Mental Health First Aid Concept

Source: mental health frst aid 3d crossword by ALMAGAMI is licensed under CC BY-NC-ND 2.0; Retrieved May 9, 2023, from https://


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COMPARATIVE PERSPECTIVES 4.1 SUBSEQUENT ADAPTATION AND ADOPTION OF MHFA IN AUSTRALIA AND BEYOND In Australia, mental health community leaders developed a special adaptation of the Mental Health First Aid program for Aboriginal tribes within the nation. These tribal programs were more sensitive to diferent cultural beliefs but were closely guided by mental health frst aid experts. After some time, other countries began to take a more progressive stance regarding mental health education and frst aid training, and the program was adapted with appropriate cultural and content modifcations in Australia and New Zealand, as well as internationally in Cambodia, Canada, China, England, Finland, Hong Kong, Ireland, Japan, Scotland, Singapore, Sweden, Thailand, the United States, and Wales (Kitchener & Jorm, 2008). Some of these countries are presently in the beginning stages of adaptation.

general foundation as the adult program, but with revisions including the addition of modules on topics such as deliberate self-harm and eating disorders (Kitchener & Jorm, 2008). In the United States, the implementation of the program began in 2007. The Mental Health First Aid Act of 2015 authorized 20 million dollars toward the development of the MHFA course (National Council for Mental Wellbeing, 2021a). Reflective of the original model, participants are trained in (a) recognizing the symptoms of substance use and common serious psychological disorders, (b) initiating referrals to mental health resources, and (c) de-escalation techniques. Statistics show that over 2.5 million people across the United States have been trained in the program and that there are more than 15,000 instructors nationwide (National Council for Mental Wellbeing, 2021a). EMPIRICAL EVIDENCE. Of the scant number of studies that have examined the effects of MHFA on behavioral change, the majority have been conducted outside of the United States and primarily in Australia. Both controlled and uncontrolled studies of the MHFA course (youth, teen, and adult versions) have been undertaken to examine the feasibility of providing the program in schools, at work, and in other community venues; to test relevant measures of student knowledge, attitudes, and behaviors; and to provide initial evidence of program effects. Across varied studies, participants completed a baseline questionnaire and then received the program; many participants also completed a post-test and between a three- and six-month follow-up. Statistically significant direct increases have been found in mental health literacy, confidence in providing Mental Health First Aid, knowledge of mental health and substance abuse resources and the confidence to provide help/make referrals, and indirect improvements in help-seeking intentions and student mental

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health. Furthermore, stigmatizing attitudes have been significantly reduced (see, for example, Hart et al., 2016 [Teen MHFA in Australian secondary schools]; Kitchener & Jorm, 2002, 2004 [Workplace setting in Australia]; Jorm et al., 2004 [Public, rural setting in Australia]). Similar to Crisis Intervention Team (CIT) research (CIT discussed in Chapter 5), the extent to which direct knowledge has translated into behavior is a highly understudied outcome and one with limited support (e.g., see Kitchener & Jorm, 2006: Positive effects related to improvements in helping-behavior reported by recipients of MHFA after a five- to six-month post-training follow-up; as compared with Jorm et al., 2010: Findings revealed that there were no effects on teachers’ support of students with mental health needs in Southern Australia, nor were there improvements in students’ mental health). The essential inquiry that has yet to be extensively tested is whether recipients of MHFA perceive their mental health needs have been met. COMBATTING STIGMA THROUGH AWARENESS EDUCATION In October of 2021, the U.S. Department of Education published guidance on how schools can support child, student, faculty, and staff mental health needs. The guidance is intended to serve as a supplement to the previous federal guidance on (a) students reentering school during COVID (U.S. Department of Education (USDOE), 2021a, 2021b) and (b) the impact of COVID-19 on university students, faculty, and staff (USDOE, 2021c). The report acknowledges the importance of supporting the social, emotional, behavioral, and mental wellness of all students and their teachers. The lack of funding and capacity to support the mental and emotional needs of students, faculty, and staff at schools, including institutions of higher education, needs to be addressed for the guidance to be fully realized. This report is an example of how the pandemic amplified the existing mental health initiatives and efforts. In 2018 and 2019, several states in the U.S. began mandating mental health education be taught in all public schools. Consistent with the evidence-based recommendations for destigmatizing mental illness, these policy adoptions and their implementation should result in an increased awareness of mental health and wellness, as well as a widespread change in the misconceptions and negative stereotyping of PwMI in communities. One source of significant education and advocacy is presented below in “Thinking Critically” 4.1.


Contributor: Loran B. Kundra, JD, MSS, LSW, CPS Cathy McAndrews is a 36-year-old woman with a history of trauma, depression, substance use, and criminal justice involvement. She frst began to struggle with depression after being drugged and raped at a high school party. She went to


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college but dropped out after her frst year and started using drugs. Cathy then became involved with Paul who would often physically abuse her when he was under the infuence of drugs or alcohol. She became pregnant and stopped using drugs; however, within a few months after their son was born, Cathy started using again and she and Paul sent their son to live with Cathy’s mother. Soon they lost their jobs and their house. They started living on the streets and in abandoned houses. They also began to steal from stores and people on the street. After a few months, they got caught by a store owner. They engaged in a high-speed chase with law enforcement and eventually they both were arrested and sent to jail. Cathy spent the frst month in jail going through withdrawal from the heroin she was taking before she was arrested. While in jail, the depression came back in full force. She stopped showering, spent long stretches of time in bed, and stopped eating to the point where she passed out. Slowly, Cathy began to reach out for support. She was seen by the jail psychiatrist who prescribed medication for her depression. She was ofered a plea deal in drug court which allowed her to be transferred to a local substance use rehabilitation center and then a recovery house. A few years after leaving the recovery house, she found a job answering phones at a local chapter of the National Alliance on Mental Illness (NAMI) ( NAMI is a national organization which provides support, education, and advocacy for individuals with mental health conditions and their families. NAMI has state and local chapters as well. When Cathy began working at NAMI, she started attending one of their support groups called NAMI Connections. As she began to share her story, people would express how helpful it was for them to hear about her success in staying clean, working, and raising her son. It wasn’t long before the Executive Director of the local NAMI asked her to start running the support group. NAMI began to add more groups, many of which Cathy organized and led. Eventually, she was hired as a full-time manager at NAMI running all their support groups, educational projects, and fundraisers. Cathy is an excellent example of how people with lived experience can serve as healthy peer supports when community members with PwMI are in crisis. Accessing peer supports in the community can create a sense of belonging for PwMI. Sharing experiences and giving authentic empathy can be healing for peers and their loved ones. Many PwMI, like Cathy, report that helping others with lived experience gives some purpose to their struggle and life. Firsthand experiences with substance use, mental health issues, and trauma increase relatedness and fervor to efectively assist people who are seeking services. After so many years of acting on feelings of low self-worth and struggling with constant suicidal thoughts, Cathy credits NAMI with helping her focus on her mental well-being and to stay sober.

Crisis Media High rates of suicide and suicidality are, unfortunately, the catalyst for many of the global and national mental health initiatives. In addition to destigmatization efforts, suicide prevention and education about suicidality are consistently improving and expanding, as evidenced by policy initiatives

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throughout the past few decades. In 1996, the United Nations (UN) published guidelines for the nations on how to develop and implement national suicide prevention strategies. The WHO has followed up on the UN’s initiative by publishing several reports with guidance for all countries seeking to implement suicide prevention programs (see WHO, n.d.-a). Many countries have implemented strategies, and some have even shared information about their programs with the WHO MiNDbank database for others to review (WHO, n.d.-b). Suicide prevention programs are situated in the same way destigmatization efforts are—that is, the focus is on increased awareness, education of the public, responsible reporting and representation in media, and access to social services and care. A strategy that is very common among all suicide prevention programs is the crisis hotline. A crisis hotline is a phone number that a person in distress can call and speak with a trained volunteer who provides emotional support, emergency counseling, and information about follow-up and accessible social services. In 2005, the SAMHSA and Vibrant Emotional Health started The National Suicide Prevention Lifeline—often referred to simply as Lifeline (Vibrant Emotional Health, 2021). The Lifeline is a national hotline number—comprising over 180 crisis centers across the United States—that connects callers to speak with volunteers at crisis centers closest to the location of the caller. Since introduced to the public in 2005, the Lifeline has answered over 20 million calls. In October of 2020, the National Suicide Hotline Designation Act was signed into law. The act designated the digits 988 to serve as the number needed for people in the United States to call when they are in distress. Starting in July of 2022, people who are in the United States will be able to dial 988 and be directed to Lifeline (Vibrant and 988, 2020). National adopters and crisis care professionals are eagerly seeking close collaboration between 911 and 988 dispatchers so that crisis calls can be handled by the appropriate providers, using best practices for mental health crises—making Intercept 0 a fully realized norm in the United States. The implementation of 988 is revisited later in Chapter 11. CRISIS TEXT LINE Advances in social media and the widespread use of Smartphones have provided additional means for communicating with people who are in crisis. In 2013, the Crisis Text Line (CTL) was initiated (Crisis Text Line, 2021). The CTL is like a crisis hotline except instead of making a call, people in distress can text the number 741741 or send a message to Crisis Text Line on Facebook Messenger to begin interacting with a virtual assistant. As the texter interacts with the virtual assistant, CTL’s texter triage algorithm will determine the texter’s immediate risk level and, consequently, the texter will be connected with a Crisis Counselor within eight seconds (i.e., highrisk texters) to less than five minutes (i.e., lower risk texters). Once connected, the Crisis Counselor acts in a way similar to those in Lifeline and other crisis hotlines—except, it is all via text messaging. According to the CTL’s report published in 2021, less than 1 percent of their conversations


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with texters result in a need to involve emergency services (e.g., mobile crisis units, emergency medical technicians, fire fighters, and police) because of a determination of imminent, life-threatening risk. To contextualize this percentage, in 2020, CTL fielded 48 million messages for a total of almost 1.5 million conversations with texters. Of those 1.5 million conversations, only 8,577 of them resulted in a CTL initiating an immediate dispatch of emergency services to the texter. Most crises reported by texters are related to depression, anxiety, suicidality, and loneliness. In follow up demographic surveys sent to texters, many reported5 being 24 years old or younger (74 percent) and female (81 percent). The reported racial identities of texters were relatively consistent with that of the nation. As discussed below in “Policy & Practice” 4.1, and reported elsewhere in this text, it should also be noted that LGBTQ+ persons are at a high risk for suicide, and are significantly represented in crisis call data. The CTL report, like Lifeline, is a vital contributor for policymakers and mental health professionals to consult with when they seek data on the overall wellness of people in the United States (Figure 4.2) (Womble, 2021).

 Figure 4.2 National Suicide Prevention line (988)

Source: “988 Signboard-like graphic with the motif of USA's suicide prevention phone number. background-landscape” by 7N23 is licensed under CC BY-NC-SA 2.0. Retrieved May 9, 2022, from


Contributor: Sandy Smith, PhD There are more than 73 million youth in the United States under the age of 18. Youth comprise approximately one-third (33 percent) of the U.S. population when older youth under the age of 25 years old are included (U.S. Census Bureau, 2019). Though few national large surveys of youth ask about sexual orientation and gender identity, it is estimated that between 7 percent and 9 percent of youth identify as lesbian, gay, bisexual, transgender, or queer (Wilson et al., 2014). Youth who identify as LGBTQ+ are coming of age at a time of unprecedented LGBTQ+ visibility, yet the challenges they continue to face increase their vulnerability to mental health issues (Fish, 2020) and involvement with the criminal justice system.

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Recent research provides compelling evidence that LGBTQ+ youth are at great risk for experiencing mental health conditions, particularly anxiety and depression (CTL, 2021; National Alliance of Mental Illness, n.d.). Members of this community are more than twice as likely as their heterosexual peers to report experiencing persistent feelings of sadness or hopelessness. Consequently, the risk of suicide of LGBTQ+ students is substantially higher than that of their heterosexual peers. LGBTQ+ youth seriously contemplate suicide at almost three times the rate of heterosexual youth and are fve times more likely to have attempted suicide. Forty percent of transgender adults reported having made a suicide attempt, and 92 percent of them made their attempt before the age of 25. The likelihood of self-harming behaviors by LGBTQ+ students has increased by an average of 2.5 times following an episode of physical or verbal harassment or abuse (The Trevor Project, 2021). Furthermore, due to family rejection or discrimination based on gender identity or sexual orientation, members of the LGBTQ+ community have an approximately 120 percent higher risk of being without housing. The risk is particularly high among Black LGBTQ+ youth. To compound the issue, members of the LGBTQ+ community may struggle to fnd shelters that will accept them and may experience a greater likelihood of harassment and abuse once in these spaces (National Alliance of Mental Illness, n.d.). Loitering and sleeping outside are considered low-level criminal ofenses in many areas, leading to an increased likelihood of people without housing being involved with the justice system (Batko et al., 2020). In addition, to survive, many LGBTQ youth engage in criminalized behaviors such as drug sales, theft, or sex, which increase their risk of arrest and confnement (Grifth, 2019). LGBTQ+ people are overrepresented at every stage of the criminal justice system; members of the LGBTQ+ community are arrested and incarcerated at signifcantly higher rates than heterosexual and cisgender6 people. For many, this involvement begins with the juvenile justice system (Grifth, 2019). Sources estimate that half of LGBTQ+ youth in the United States are “at risk” of being arrested or entering juvenile and criminal justice systems (Mallory et al., 2014). In fact, the percentage of incarcerated LGBTQ+ youth is double that of the general LGBTQ+ youth population (Seip, n.d.). High rates of contact with the criminal justice system continue into adulthood. An analysis of data from the National Survey on Drug Use and Health uncovered that lesbian, gay, and bisexual individuals were 2.25 times as likely to be arrested than their heterosexual peers (Grifth, 2019). Although this paints a dismal picture for LGBTQ+ youth, there are steps that can be taken to increase the likelihood of positive outcomes for this population. It is important to note that systemic change, such as creating alternatives to youth incarceration and reducing discrimination in the juvenile justice system, is crucial (Movement Advancement Project, 2017); however, the process of creating an inclusive and safe environment for LGBTQ+ youth begin with adults in local communities and schools (Human Rights Campaign, 2018). Perhaps the most impactful way to create an inclusive environment for LGBTQ+ youth is to hire and retain LGBTQ+ staf, particularly in schools.


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The 2020 U.S. Supreme Court ruling in Bostock v. Clayton County provides equal-employment protection for all people (Bigham, 2020), yet school districts still fnd ways to push LGBTQ+ staf out of the classroom. In 2017, a two-time teacher of the year in Texas was placed on an eight-month administrative leave for “promoting the ‘homosexual agenda’” because she showed a picture of her wife. She remained employed by the school district but was not allowed to teach. The case was settled in federal court in the teacher’s favor, though the district continued to deny any wrongdoing after the verdict. In September 2021, a teacher in Missouri was informed that he would no longer be allowed to display a rainbow fag in his classroom because parents complained that he might teach their child to be gay (Yurcaba, 2021). He resigned after the superintendent asked him to sign a letter that prohibited him from discussing topics related to LGBTQ+ people in the classroom, essentially banning him from talking about himself in his own classroom. Members of the LGBTQ+ community have a lot to ofer. Many have the skill, talent, and desire to teach. To deny LGBTQ+ staf a place in the schoolhouse is to deny all students the opportunity to beneft from those skills and talents. Because of the life journey many adult members of the LGBTQ+ community have taken, they have the insight, empathy, and experience to relate to all students, especially those who fnd themselves on the fringes of the general population. Plus, LGBTQ+ staf provide the positive role modeling that being “diferent” is okay. When adults accept peers who are “diferent,” it contributes to the development of empathy in children and is likely to create a stronger connection to the school setting—something the LGBTQ+ community desperately needs. In addition to recruiting and retaining staf that represents the demographics of the student population, employees, community members, and parents can participate in training to increase awareness and improve systems of support. The following organizations provide multiple low-cost or free resources to support adults who live or work with LGBTQ+ youth as well as the youth themselves. •

The American Society for the Positive Care of Children (American SPCC) is a national non-proft centered on improving the lives of children in the United States. Their mission is to bring individuals and organizations together to improve the way children are represented, protected, and treated through education, awareness, and advocacy. ( Genders & Sexualities Alliance (GSA) Network is a racial and gender justice organization that empowers and trains LGBTQ+ and allied youth leaders to advocate, organize, and mobilize an intersectional movement for safer schools and healthier communities. Their strategy for fghting for educational justice is to work with grassroots, youth-led groups to empower them to educate their schools and communities, advocate for just policies that protect LGBTQ+ youth from harassment and violence and organize in coalition with other youth groups across identity lines to address broader issues of oppression. ( The Trevor Project identifes as the world’s largest suicide prevention and crisis intervention organization for LGBTQ+ young people. The Trevor

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Project provides crisis services, peer support, research, education and public awareness, and advocacy to support and advocate for LGBTQ+ youth, including: • Ally Training: This provides a basic framework for understanding LGBTQ+ identity and the unique challenges young people often face. • CARE Training: An interactive training for youth-serving adults that focuses on suicide prevention and mental health for LGBTQ+ youth. ( The True Colors Fund works to end homelessness among lesbian, gay, bisexual, and transgender youth. Through a broad continuum of community organizing, public engagement, public policy, research, and youth collaboration programs, the True Colors Fund is working to end homelessness among lesbian, gay, bisexual, and transgender youth by creating systemic change. (

Accessible Social Services, Including Continuum of Care Scholars agree that a person’s mental health is impacted by a variety of environmental, biological, and societal factors. The age-old quandary of whether nature or nurture are responsible for a person’s outcomes has reached relative consensus with the leading ideology that our outcomes are products of both contexts. Not surprisingly, PwMI often experience poverty, unstable housing, food insecurity, and lack of transportation and primary health care (Roy et al., 2014). Not having basic needs met can contribute to—or be the catalyst for—a mental health crisis resulting in PwMI interacting with law enforcement (Hiday & Burns, 2010; Hiday & Wales, 2011). Therefore, many advocates and scholars propose an interagency approach to supporting the mental health and stability of PwMI and people who are at heightened risk of developing a mental illness. Interagency collaboration is an approach to care that involves representatives from multiple, relevant agencies that come together to collaboratively serve the client(s). This approach is promoted in many fields; thus, it can consist of different agencies, but the fundamental principles remain consistent across all interagency collaborative approaches: (a) information sharing, (b) joint decision making, and (c) coordinated intervention (Parker et al., 2018). These points are revisited in Chapter 11 of this text. Adequate mental health services are often difficult to access for PwMI, especially if they are living in rural locations (Andrilla et al., 2018) or are without housing (Hopkin et al., 2020). Calls for comprehensive and accessible mental health care persist in the U.S. and in many other industrialized nations. In 2021, the RAND Corporation published a report outlining three goals for transforming the mental health care system in the U.S.: (a) promoting pathways to care for PwMI, (b) improving access to care, and (c) establishing an evidence-based continuum of care for PwMI (McBain et al., 2021). The report continues to break down each goal with corresponding recommendations based on research and aspiring policy adoption. Of the


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three goals, improving access to care has the most recommendations. It exemplifies where systemic problems are compounded with the accessibility of quality care and mental health services. In December of 2021, the U.S. Surgeon General issued an advisory warning the public of the mental health crisis for the nation’s youth. The Surgeon General recognizes that children and youth mental health and wellness were problematic before the onset of the COVID-19 pandemic. The stressors and conditions associated with living and developing during this unprecedented period have put the nation’s youth at incredible risk for serious mental illness. The advisory was published with the intention of shifting the national focus to the brewing pandemic of mental illness among children and youth so that we can install proactive prevention, intervention, and response programs. The report identified youth from the following groups as being at the highest risk for mental health challenges: (a) youth with intellectual and developmental disabilities, (b) racial and ethnic minority youth, (c) LBGTQ+, (d) low income, (e) youth in rural areas, (f) youth in immigrant households, and (g) special populations (i.e., youth involved in the juvenile justice and/or foster care system, without housing, and/or runaway youth). Of course, there are many children who identify as more than one of the groups and their risk is compounded. Children and youth identified as having the highest risk for mental health challenges are also those who are most vulnerable to experiencing trauma and multiple adverse childhood experiences (ACEs) (Felitti et al., 1998; Stensrud et al., 2019). People who are incarcerated report having higher rates of trauma in early childhood and ACEs than people who are not incarcerated (Stensrud et al., 2019). This further supports the call for prevention and early intervention efforts not only for PwMI but for all people, as a diversionary strategy. For more information on ACEs, the impact of trauma and trauma-informed care, see Chapter 10.


Contributor: Kimberly Bunch-Crump, PhD, BCBA-D Myles Matthews is 16 years old and he was recently banned from the local recreation center for cursing out a volunteer and urinating on their vehicle. Ms. Matthews has had concerns about Myles’ behaviors for several years. When Myles was about 13 years old, Ms. Matthews noticed that he began to question her authority and talk back. She initially attributed his change in behavior to puberty, but his aggression has been increasing for the past year. He raises his voice, swears at her, and hits furniture and walls in fits of rage. Ms. Matthews gets frustrated and the two of them often get into screaming matches. Unfortunately, living with strained relationships and aggression is familiar to her and Myles—when Myles was 5 years old, Ms. Matthews took

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him and his little brother Kaleb (who was 1 year old at the time) and left the abusive relationship with their father. She often wonders if Myles’ behaviors could be attributed to the domestic violence and trauma he witnessed when he was younger. She also worries that Myles’ behaviors may influence and impact his younger brother who looks up to him and has always wanted to be just like him. Ms. Matthews begins receiving frequent phone calls from Myles’ school about his challenging behavior and episodes of verbal and physical aggression. On the most recent occasion, Ms. Matthews took Kaleb to the doctor due to complaints of dizziness and nausea and Myles wanted to go. Ms. Matthews convinced him to go to school instead and agreed to text or call him with information about Kaleb’s health after the doctor’s visit. Myles, awaiting an update about his brother’s health, had his phone out during math class and ignored his teacher’s general reminder to “put phones away.” When the teacher made a personal request for him to put his phone away, Myles cursed and walked out of class. An administrator, unaware of the situation, saw Myles in the hall and prompted him to “go to class.” Myles cursed at the administrator and kicked lockers causing damage. This resulted in an out-of-school suspension and a request for a parent conference. During the conference, the team identifed school interventions and Ms. Matthews shared her concerns about Myles’ behaviors at home. The school counselor suggested community-based services. Myles was assessed by a community-based behavioral health agency and diagnosed with oppositional defant disorder (ODD). He and his family started individual and family-based therapies. During individual therapy sessions, Myles’ therapist will educate him on his diagnosis and teach him how to manage anger and express his feelings in healthier ways. Family therapy will occur in the home and all family members will be involved in the therapy. Therapy goals will include teaching all family members healthy communication practices, how each of them is responsible for their own behaviors, and how they impact the family unit, and family members about the impact and efects their behaviors have on Myles and the overall family climate. In addition, the agency linked Ms. Matthews to a local nonproft ofering parent support groups and workshops for caregivers of individuals with behavioral health disorders (BHDs). The therapist will lead Myles and Ms. Matthews in routine progress monitoring of treatment goals and the team will revise the plan as needed. The World Health Organization estimates that 10–20 percent of adolescents worldwide experience a behavioral health disorder (BHD; mental and substance use disorder) and 50 percent of the US population will experience a BHD sometime in their life. However, most will delay treatment (SAMHSA, 2011); some delay treatment for over a decade (Kessler et al., 2007). As in Myles’ case, half of all BHDs manifest by mid-adolescence; however, many cases go undetected and untreated. The physical, social, and emotional changes experienced during adolescence make teens more susceptible to BHDs. Additionally, changes experienced during puberty can mask BHDs causing some to go undetected. The addition of adverse childhood experiences, such as domestic violence and family separation, increases the chance of developing BHDs (Centers for Disease Control, 2019). It is estimated that 60 percent of US youth with BHD do not access


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behavioral health services (SAMHSA, 2011). Early treatment can help to reduce long-term efects and severity of BHD. Fortunately, Ms. Matthews sought support from a community-based behavioral health provider early. Community-based behavioral health services deliver a variety of services promoting, preventing, and treating BHDs within the community as an alternative to more restrictive approaches (e.g., institutionalization and overreliance on pharmaceuticals). A major goal of behavioral health treatment is to help individuals manage symptoms of behavioral health diagnoses to improve daily functioning in their homes, schools, and communities. Many behavioral health services are covered through private insurances, and some are funded through local, state, and national initiatives. Through the identifcation process, BHDs are confrmed and treated. First, a screening to determine the possibility of a behavioral health problem is conducted. Screenings are usually conducted by a child serving agency (e.g., school, child welfare agency, pediatrician). Next, individuals identifed with a possible problem participate in a comprehensive clinical assessment, conducted by a licensed behavioral health clinician (e.g., licensed social worker or counselor, substance abuse counselor, psychologist, physician, or psychiatrist). The assessment is conducted to determine if there is a disorder, diagnose any identifed disorder, evaluate the extent of the disorder, and make recommendations for treatment. Finally, a person-centered treatment plan is created from the recommendations of the assessing clinician. Treatment can take on a variety of forms to include education and training (e.g., psychosocial education, parenting skills, social skills), case management (e.g., assessment, planning, linkage and referral to support, monitoring and follow up), therapy in a variety of approaches (e.g., cognitive behavior, motivational interviewing) and forms (e.g., individual therapy, family therapy, group therapy, couples therapy), evidence-based practices (e.g., Multisystemic therapy) and a plan for responding to crises. An important part of behavioral health services for youth is the ongoing support and involvement of family members and caregivers.

RESPONSE: THE CRISIS CARE CONTINUUM Effective prevention programs are useful as proactive diversionary approaches; however, crisis response is critical to achieving the mission of Intercept 0. After the deinstitutionalization movement in the 1970s, communities were unprepared to support the diverse needs of community members with severe mental health concerns. Consequently, existing institutions that were not designed to support and treat people living with severe and persistent mental health concerns began absorbing them out of sheer necessity. In addition to jails, local hospitals and emergency rooms became “triage housing” institutions for people with severe mental health concerns. Unfortunately, this response continues to be the norm rather than the exception. When people with mental health concerns are in crisis and brought to hospital emergency rooms, they may be “boarded” at the emergency room

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for an extended period of time until a “bed” becomes available at a psychiatric hospital that can treat their needs—this is called psychiatric boarding (Bloom, 2015; Campbell & Pierce, 2018; Gallagher et al., 2017; Major & VanderBerg, 2020; Nicks & Manthey, 2012). The recommended length of psychiatric boarding is not to exceed four hours; however, in practice, it often extends for several days (Bloom, 2015). Psychiatric boarding continues to be an issue and likely will continue until communities are funded to provide adequate mental health support services, including high-quality, funded, in-patient psychiatric care (Campbell & Pierce, 2018; Gallagher et al., 2017; Nicks & Manthey, 2012; O’Neil, 2016; Zeller, 2018).

Crisis Stabilization Centers To effectively serve people who are in crisis while also minimizing the length of a patient’s stay and the resulting financial burden, some communities have installed crisis stabilization centers (McNeil, 2020). Crisis stabilization centers offer a safe, comfortable environment that provides psychiatric, counseling, and peer support services to community members who are having a mental health crisis (Saxon et al., 2018). The models of crisis stabilization centers, or units, are differentiated based on the amount of time necessary for a person in crisis to become stabilized. For people who can reach stabilization in less than a day, there is the 23-hour crisis stabilization unit model (SAMHSA, 2014). When more than 24 hours is needed to achieve stabilization, people are offered The Living Room Model (American Psychiatric Association, 2021). Both models offer a similar home-like environment with peer support, people trained in de-escalation, and information about follow-up resources (Saxon et al., 2018). Finally, when people need immediate access to professional services—for either diagnostic purposes or psychotropic prescriptions or both—communitybased behavioral health stabilization or short-term residential stabilization services are available.

Mobile Crisis Response In Eugene, Oregon, a mobile crisis program–Crisis Assistance Helping Out On The Streets, or CAHOOTS–responds to 50–60 crisis calls a day (Waters, 2021). CAHOOTS is a mobile crisis response program that dispatches crisis workers–like mental health providers and emergency medical technicians–to de-escalate people with lived experience of mental health and/or substance use (PWLE) who are in crisis and in the community. The program started in 1989 as an extension of the “Bummer Squad”—a group of mental and physical health care workers who went to concerts and other events where drug use was prevalent, to assist “partygoers” who were experiencing a bad drug trip or who had overdosed. Over 30 years later, CAHOOTS is most often called when PWLE are in-crisis and need mental health services or just a brief “wellness check” (see Chapter 5).


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Mobile crisis response teams are being established all over the nation. Phoenix, Arizona has The Crisis Response Network that connects PWLE who are in-crisis with social services, including mental health care, primary health care, and substance abuse centers (Waters, 2021). In 2020, The Crisis Response Network had a mental health care worker staffed at the 911 dispatch center to intercede on calls from or about PWLE in crisis. In Denver, Colorado, the police department collaborates with their mobile crisis response program–Support Team Assisted Response, or STAR (STAR Program Evaluation, 2021; Waters, 2021). The STAR approach with Denver Police Department is different from CAHOOTS in that they pair a mental health specialist with a police officer to go out on calls involving PWLE. Often referred to as the “co-responder model,” STAR not only responds to calls involving PWLE, but the teams also ride in their STAR vans to visit locations within Denver that are known for being where persons without stable housing–many of whom are PWLE–frequently “reside.” Mobile crisis response teams are discussed again in Chapter 5, in the context of law enforcement diversion efforts. Another early intervention effort that has received national attention is presented in “Policy & Practice” 4.3.


Contributors: Gretchen Frank, JD, Senior Policy Analyst, Risë Haneberg, MPA, Deputy Division Director Stepping Up is a national initiative that provides county leaders with the support they need to reduce the number of people with mental illnesses and substance use disorders in local justice systems. The success of the initiative relies on counties taking concrete, collaborative, crosssystems actions to improve outcomes for this population. Stepping Up was launched in 2015 as a partnership among the National Association of Counties, The Council of State Governments Justice Center, and the American Psychiatric Association Foundation. As of September 2021, more than 540 counties have joined the initiative. Stepping Up supplies resources for counties to accomplish the following: to bring the right cross-systems team together for planning and decisionmaking; identify the population to be served; scale strategies that work; implement new, efective policies and practices; and collect data to inform where to focus strategies for the best results, understand the impact of their eforts, and track success. Most of the strategies and solutions involved in reducing the prevalence of behavioral health needs take place outside of, but in partnership with, the jail and require collaboration across many systems and sectors. Many counties are focusing on responses at the very front end of the justice system—even before entry into jail—to ensure that people with mental illnesses and substance use disorders are connected to treatment rather

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than arrested, as appropriate. Implementing co-responder programs and opening crisis diversion centers are two ways that counties are intervening early. For example: •

Co-response eforts in Johnson County, Kansas, have grown from having one co-responder in one jurisdiction to having a mental health professional in 11 of its local police departments and within the sherif’s ofce, providing countywide coverage for at least one shift. In December 2020, Marion County, Indiana, opened its state-of-the-art Assessment Intervention Center in Indianapolis. Since then, the center has implemented a validated screening tool for law enforcement ofcers to use at the scene to help the ofcer determine a person’s appropriateness for diversion from the justice system.

Law Enforcement Assisted Diversion (LEAD) Most of the specialized police responses (SPRs) are considered to be Intercept 1 strategies (outlined in Chapter 5), but a few SPRs result in referrals to community-based mental health care providers and may be solidly housed in Intercept 0. In 2011, representatives from multiple intersections along the criminal justice continuum in Seattle, Washington collaborated to establish the first known pre-booking diversionary program: Law Enforcement Assisted Diversion (LEAD; Beckett, 2014). The LEAD program’s original intent was in response to mass incarceration of people for law violations that warranted treatment, not incarceration (i.e., drug use-related crimes and illegal sex work were the original violations targeted by LEAD). Its intention was to develop and offer law enforcement officers “alternate-system responses independent of the justice system while finding ways to improve relationships between the police and those they serve” (LEAD National Support Bureau, 2021). Since its inception, LEAD programs have been adopted by communities throughout the nation. Police officers working in jurisdictions with a LEAD program, “exercise discretionary authority at point of contact to divert individuals to community-based, harm-reduction interventions for law violations driven by unmet behavioral health needs” (LEAD National Support Bureau, 2021). Due to high interest and increasing demand to adopt LEAD programs in jurisdictions across the nation, the LEAD National Support Bureau was established. The LEAD National Support Bureau is a collective of public health providers who have firsthand experience installing and operating LEAD programs in early adopter jurisdictions. The 2015 convening of President Obama’s Taskforce on twenty-first Century Policing highlighted LEAD as a model program in harm-reduction policing and is now considered a promising practice by the National Institute of Justice (2015, 2019). Officers in communities with LEAD programs report appreciating the “warm-body handoff” to community mental health agencies (Perrone et al., 2021), but


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getting officer buy-in requires strong encouragement from sergeants and other leaders in the adopting police departments (Beckett, 2014). Successful adoption of LEAD Programs requires quite a substantial shift in many police department cultures. Harm-reduction and diversion programs, like LEAD, are likely attractive, yet unlikely to be realized for resource-depleted communities with high rates of PwMI without adequate mental health care services (Andrilla et al., 2018). In “Thinking Critically” 4.2, Dr. Sean Lauderdale instructs as to one vulnerable group and their risk for encounters with police. THINKING CRITICALLY 4.2 PEOPLE WITH DEMENTIA AND THEIR INTERACTION WITH THE POLICE

Contributor: Sean Lauderdale, PhD Case 1: Ms. Gibson is an 83-year-old woman who lives in the same home she and her husband purchased over 50 years ago. Her husband has passed, and Ms. Gibson’s children live in other towns and only visit intermittently. Ms. Gibson has been having memory problems for a few years but because she has few bills that she pays as soon as they come in the mail and only drives in the neighborhood to the local grocery store, these have largely gone undetected. Unbeknownst to her family, Ms. Gibson is in the early stages of Alzheimer’s disease. When speaking on the phone, Ms. Gibson’s children are unaware of the extent of her memory and thinking problems. Because of her intact social skills, they also don’t realize the extent of her thinking problems when visiting. Lately, because of Ms. Gibson’s worsening cognitive problems, she’s become increasingly frightened in the late evening and has started calling 911 for help. Oftentimes, she reports to public safety telecommunicators that people are walking around the outside of her house and trying to enter. Police ofcers have been dispatched to Ms. Gibson’s house several times but found no evidence of anyone trying to enter her home. Case 2: Mr. Townes is 69-year-old man who has had Frontotemporal Dementia for the past several years. He’s recently been investigated for domestic violence following an incident that occurred while his wife was driving him to a medical appointment. For the majority of their 63 years of marriage, Mr. Townes has driven when he and his wife traveled together; however, due to the cognitive impairment associated with Mr. Townes’ dementia, Mrs. Townes has taken over all of the driving. Police were recently notifed after Mr. Townes was reported by witnesses to be striking Mrs. Townes while she was driving. Mr. Townes has no memory of the event and due to his limited verbal abilities associated with his dementia, has been unable to provide any information for the investigation. Mrs. Townes has been reluctant to openly discuss the incident fearing repercussions her husband may experience. Case 3: Mr. Sellers is an 87-year-old man who is diagnosed with Alzheimer’s disease. Although he has memory and other cognitive problems, he still drives his car as his wife and adult children have been reluctant to take this away; however, they have noticed numerous scufs and scratches down the left side of his car. Mr. Sellers has been unable to explain how his car was damaged. In his neighborhood, city workers have placed cones and a wooden barricade in preparation for upcoming road work. Recently on his way to the local cofee

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shop, Mr. Sellers ran through the wooden barricade and over many of the cones until his car came to a stop in the closed lane. Witnesses called the police who found Mr. Sellers frightened, confused, and unable to describe why he ran through the barricade. Dementia is a term describing a family of disorders in which people experience declines in memory and other cognitive abilities that impair daily functioning and self-care abilities. The most common dementia is Alzheimer’s disease, but other types of dementia include Lewy Body Disease, Frontotemporal Dementia, and Vascular Dementia. The frequency of dementia increases with age and older adults (65 years of age and older) are at the highest risk for experiencing dementia. Due to changes in memory, decision-making, judgment, behavioral inhibition, and emotional regulation, people with dementia (PWD) may engage in behaviors that violate the criminal law and are punishable. National crime data from the United States indicated that in 2018, older adults were reported to have been charged and prosecuted for 103,234 crimes, representing 1.3 percent of all crimes charged and cleared (Federal Bureau of Investigation, 2018). This data does not indicate how many PWD committed crimes, but other investigations provide some insight. From a chart review of patients attending a memory disorders clinic in the United States between 1999 and 2012, 204 (of 2,397 or 8.5 percent) PWD were reported to have engaged in criminal behaviors following dementia onset (Liljegren et al., 2015). Most reported crimes were committed by patients with the behavioral variant of Frontotemporal Dementia (bvFTD; 3 percent), followed by patients with Alzheimer’s disease (AD; 2 percent). Among patients with AD, the most commonly reported crimes were trafc violations, theft, and vehicular hit-and-runs. In patients with bvFTD, the most reported crimes were theft, trafc violations, sexual advances, and trespassing. In a similar investigation from Sweden (Liljegren et al., 2019), of PWD seen in a geriatric psychiatry clinic between 1967 and 2013, 18 percent (50 of 281) had a history of interaction with the police. Rates of police interaction (PI) were higher for patients with FTD (25 percent) compared to patients with AD (9 percent) or AD+Vascular Dementia (16 percent). The most common reasons for PI included wandering, aggression, needing medical assistance, and trafc accidents. In domestic violence events investigated by police in New South Wales, Australia from 2005 to 2016, 1,062 people with dementia were believed to be either a victim or person of interest in domestic violence events investigated by police (Karystianis et al., 2020). Given the nature of behaviors exhibited by PWD, police are the most common frst responders to interact with them. Although many police report having frequent contact with older adults, less than a third report believing they are knowledgeable about helping older adults and 95 percent rated having training with older adults as moderately to very important (Brown et al., 2014). Police identifed recognizing the relationship between AD and memory, but fewer recognized how AD may afect behaviors (Sun et al., 2019). Findings also suggest that police familiarity with AD is associated with greater confdence in helping PAD (Sun et al., 2019) and police reported wanting practical, case-based training to help them identify and respond to dementia-related behaviors associated with criminality (Brown et al., 2014). Police have also reported wanting training to



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assess and address symptoms associated with dementia, skills for efectively communicating with PWD, and referring PWD to community resources (Brown et al., 2014). Family caregivers of PWD also describe wanting police and other public services staf to have training to help PWD who were lost, confused, and emotionally upset in public settings (Stanley et al., 2004). Several training programs that have been developed for police, but few have been investigated. The Alzheimer’s Association has free, online training for frst responders covering information about dementia and how to approach PWD who may be wandering, having driving difculties, needing support during a disaster, shoplifting, and being a victim of abuse/neglect (Alzheimer’s Association, 2021). Such a training program would have helped police respond to Mr. Sellers and potentially understand why he was unable to keep his car in a safe lane. Stanley and associates (2004) described a video-based training module teaching police how to help an older adult who was lost and wandering. This training includes two videos depicting police interaction with PWD, specifc procedures for managing wandering, and general information about the symptoms of dementia. The training package also incorporated short, six-minute training lectures that could be delivered during shift changes. Fisher and associates (2020) developed an integrated training program for police and emergency medical technicians (EMT) to address the needs of people with mental health difculties, one of which included an older adult with dementia and cough. In this training, police and EMT interact with trained actors portraying PWD and are required to generate a care and management plan. Local medical and law enforcement experts provide feedback during debriefngs to help police and EMT modify management plans based on expert knowledge. In a more extensive program, Brown and associates (2014) developed a police training program that included a 45-minute, interactive lecture and three experiential trainings. The lecture content covered aging-related issues that may result in a police interaction, including substance use, cognitive impairment, dementia-related behaviors, elder abuse, local aging-related service organizations, and age-related sensory/functional impairment. The experiential trainings demonstrated how age-related changes afect walking, dressing, and taking medications. Prior to the experiential training were discussions about how aging-related impairments would afect an older adult’s ability to follow police instructions, provide information for an investigation, or get into a police car. Based on the training, police reported their knowledge and ability to understand how aging-related changes afect older adults’ interaction with the police and the criminal justice system increased. This training would have helped police respond to Ms. Gibson and Mr. Townes, particularly how to communicate with them and provide referrals to services that may address their needs and prevent them from having further interactions with police. Reforms are needed throughout the criminal justice system, ranging from criminal charging to incarceration and release, to address the unique experiences of PWD (Arias & Flicker, 2020). Some of the potential changes could be based on programs in existence for other special categories of ofenders (e.g., diversion courts for special populations), while others may require re-imagining current procedures (e.g., release from incarceration) to provide increased safety, protection, and wellbeing of PWD interacting with the criminal justice system.

Take-Home Message 109

TAKE-HOME MESSAGE For authentic diversion to be realized for PwMI, a paradigm shift must occur. In recent years, global and national efforts demonstrate a shift has been initiated. As awareness of mental health and wellness increases, the stigma will decrease and, hopefully, PwMI will experience full inclusion in supportive and understanding communities. Social support systems in the forms of community-based care will result in a natural diversion from justice involvement for PwMI. The world stage is poised to embrace preventative mental health care for all people; however, to be effective and have the necessary impact, care will have to be accessible and based on scientific evidence. The adoption of Intercept 0—the ultimate intercept—and its relevant programs and strategies is an encouraging indicator of the movement away from mass incarceration and institutionalization to a less intrusive, more inclusive approach to care for PwMI.

Questions for Classroom Discussion 1. In what ways, if at all, have you seen mental illness being destigmatized over your lifetime? What disorders carry the least stigma, and why do you think they do? 2. As technology advances, what are some other ways people who are in crisis can access a crisis hotline or counselor? Try and think of ways that do not already exist. Do you think more people would access crisis care using the methods proposed? What ethical considerations would each method present that would have to be considered? 3. If you or a friend were in crisis today, what resources would you access? What fears, if any, do you have in accessing those services for you or your friend? What are some counterarguments to your fears in seeking help for you or your friend when in crisis?

KEY TERMS & ACRONYMS • • • • • •

Crisis hotline Interagency collaboration Mental Health First Aid (MHFA) Mental hygiene National Alliance on Mental Illness (NAMI) Psychiatric boarding

NOTES 1 Adapted from Treatment Advocacy Center. (December 23, 2021). Preventable tragedies database. evidence-and-research/preventable-tragedies/preventable-tragedies-database/record/a0h4N000004dH4ZQAU and Martin, R. (July, 2019). After a


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woman died in IMPD custody, an autopsy report leaves more questions. The Indianapolis Star. Retrieved November 11, 2021, from 2 An R Code is a designation that “encompasses symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified, including those involving cognition, perception, emotional state, and behavior” (American Psychiatric Association, 2021). The criteria for a condition to receive an R designation includes: (a) it does not meet criteria for a mental disorder, (b) it needs to be clearly defined, (c) its occurrence is not limited to a singular diagnostic category, (d) its prevalence is frequent enough to be recognized and included, (e) its inclusion would be useful in clinical practice, and (f) it is linked to an existing ICD-10-CM code. 3 According to the American Psychological Association (APA), a term that was formerly used widely, to refer to a scientific approach aimed at education, prevention, and treatment of mental illnesses. 4 The National Academies of Sciences, Engineering, and Medicine was established when the Act of Incorporation was signed by Abraham Lincoln in 1863. It is a non-profit society of experts from the named disciplines who investigate and examine their fields of expertise and advise policymakers in the United States (National Academy of Sciences—, n.d.). 5 Approximately, 20 percent of texters surveyed responded to the demographic survey. Results should be consumed with caution. 6 A term that refers to when one’s gender identity aligns with the gender they were assigned at birth. 7 Adapted from Risë Haneberg, Stepping Up Innovator Counties: Leading the Way in Justice System Responses to People with Behavioral Health Needs (New York: The Council of State Governments Justice Center, 2021),

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Liljegren, M., Naasan, G., Temlett, J., Perry, D. C., Rankin, K. P., Merrilees, J., … & Miller, B. L. (2015). Criminal Behavior in Frontotemporal Dementia and Alzheimer Disease. Journal of the American Medical Association: Neurology, 72, 295–300. Liljegren, M., Waldö, M. L., Santillo, A. F., Ullén, S., Rydbeck, R., Miller, B., & Englund, E. (2019). Association of Neuropathologically Confirmed Frontotemporal Dementia and Alzheimer Disease with Criminal and Socially Inappropriate Behavior in a Swedish Cohort. Journal of the American Medical Association: Network Open, 2, e190261–e190261. Major, D., & VandenBerg, S. (2020). MP59: Exploring Adverse Events in Boarded Psychiatric Patients in Calgary Zone Adult Emergency Departments. CJEM, 22(S1). Mallory, C., Sears, B., Hasenbush, A., & Susman, A. (2014) Ensuring Access to Mentoring Programs for LGBTQ Youth. The Williams Institute. Retrieved from access-mentor-prog-lgbtq-youth/ Masenthin, C. (2017). Peace of Mind: Improving Conflicts between Law Enforcement and the Mentally Ill Homeless While Exploring Sustainable Community Solutions for Care. Kansas Journal of Law & Public Policy, 27(1), 103–124. McBain, R. K., Eberhart, N. K., Breslau, J., Frank, L., Burnam, M. A., Kareddy, V., & Simmons, M. M. (2021). How to Transform the U.S. Mental Health System: Evidence-Based Recommendations. RAND Corporation. Retrieved from RRA889-1/RAND_RRA889-1.pdf McNeil, S. E. (2020). Crisis Stabilization Services. In M. J. Fitz-Gerald and J. Takeshita (Eds.), Models of Emergency Psychiatric Services That Work (pp. 51–59). Cham: Springer. Movement Advancement Project, Center for American Progress, and Youth First. (2017). Unjust: LGBTQ Youth Incarcerated in the Juvenile Justice System. Retrieved from Munetz, M. R., & Griffin, P. A. (2006). Use of the Sequential Intercept Model as an Approach to Decriminalization of People with Serious Mental Illness. Psychiatric Services, 57(4), 544–549. Muyambi, K., Gillam, M., Dennis, S., Gray, R., Martinez, L., & Jones, M. (2021). Effect of Depression Awareness and Management Training on the Attitudes of Rural Primary Health Care Workers. Australian Journal of Rural Health, 29(3), 449–454. National Academies of Sciences, Engineering, and Medicine. (2016). Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. National Academy of Sciences. (n.d.). About the Archives. Retrieved from National Alliance of Mental Illness. (n.d.). Identity and Cultural Dimensions: LGBTQI. Retrieved from National Council for Mental Wellbeing. (2021a). About MHFA. Retrieved from National Council for Mental Wellbeing. (2021b). What You Learn. Retrieved from National Institute of Justice. (2015). TaskForce FinalReport. Retrieved from

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Intercept One Law Enforcement Michele P. Bratina and Anthony M. Pesare D: 9-1-1 Dispatcher UF: Unidentified Female (Suspect’s Sister) D: Lancaster County 9-1-1. Do you need police, fire, or ambulance? UF: Hello? D: Hello. Do you need police, fire, or ambulance? UF: Um … right now I need police assistance. D: Okay. What is the address? *************** D: What township, city, or borough are you in? UF: Lancaster. D: And the phone number you’re calling from? *************** D: Okay and tell me exactly what is going on. UF: Um … my mom um … needs some assistance. Her son is being very

aggressive, and um … he needs help. D: Is that your brother? UF: Yeah. He has mental problems. D: Okay. UF: And she needs help … um … with you bringing him to the hospital or something. She is afraid. She is here at my house right now. D: Okay. What does he have? Is he … UF: He is schizophrenic. (UNIDENTIFIABLE MUMBLING) Yeah, bipolar schizophrenic. D: Okay. And is he there, is he at 306 the Laurel Street now? UF: Yeah. He is in between 236, which is where I am, and the other residence, her house [Suspect’s Mom’s house]. D: Okay and what is he doing? UF: He punched the car, the inside of the car, and he’s trying to break into the door to her house (UNIDENTIFIABLE MUMBLING). D: Oh, okay.

DOI: 10.4324/9781003120186-5



CHAPTER 5 Intercept One: Law Enforcement

UF: Because she is afraid to just go home with him there, D: Right, I understand. And what is his name? UF: Ricardo. Last name M-u-n-o-z. D: M-u-n-o-z? UF: M as in Mary, D: Uh-huh. UF: M-u-n-o-z. D: Okay. So, Ricardo Munoz? UF: Yes. D: And what’s his date of birth? UF: [BLANKED OUT DUE TO PRIVACY REASONS]. D: Okay. And what is your name? UF: [BLANKED OUT DUE TO PRIVACY REASONS]. D: Same last name? UF: Yes. D: Okay. And does he have any weapons on him? UF: Not that I know of. D: Okay. Has he been drinking or doing drugs? UF: No. D: Okay. Alright. We’ll send someone up. They’ll be there as soon as they

can. If anything changes, give us a call back, okay? UF: Okay. Thank you. D: You’re welcome. Bye.

At approximately 4:24 pm, Lancaster police arrived at the residence. Body camera footage shows one of the responding officers being met at the door by the mother of Mr. Ricardo Muñoz, and a few seconds later, Muñoz is seen charging toward the officer with a knife. The officer starts to retreat but draws his weapon. With no dialogue and within seconds, the officer fires four fatal shots at Muñoz.1

INTRODUCTION Available data suggest that anywhere between 1 percent and 10 percent of police dispatches and encounters involve people with mental illness (PwMI); the percentages tend to fluctuate depending on the period, with pre-2000 research indicating a slightly higher percentage of cases than more recently available data (Franz & Borum, 2011; Livingston, 2016). Regardless, statistics also reveal that a substantial proportion of these encounters result in arrest, and at the most extreme end of the spectrum, police shootings (Franz & Borum, 2011; Livingston, 2016; Ogloff et al., 2013). For example, information gleaned from the Washington Post database on fatal police shootings in the United States since 2015 indicates that about a quarter of shootings have involved a PwMI (Tate et al., 2021).

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The association between mental illness, violence, and use of force has been found to be indirect, however. In fact, research on the use of force incidents in cities throughout the United States suggests the likelihood of force and subsequent injury to citizen(s) and/or responding officers is greater when there is mental illness (co-morbidity, in particular) and substance use involved in an incident (Morabito & Socia, 2015; Morabito et al., 2017). This finding has been attributed to perceptions of resistance by citizens in crisis while under the influence and when encountered by police, though a multitude of other factors may be involved, and further research is suggested. By and large, given the extent of public need for services and a relative lack of knowledge pertaining to alternative options, it is easy to understand why public safety officials, including security agents and emergency medical personnel, firefighters, and law enforcement officers (LEOs), are often the first to respond when a person is experiencing a mental health crisis. Unfortunately, some first responders may feel ill-prepared to handle these types of encounters given a general lack of knowledge as to signs and symptoms of mental illness and several other factors that present themselves in a crisis. Traditionally, only minimal attention has been devoted to basic police training programs (i.e., Police Academy) on responding to individuals who might be experiencing psychological or other types of disorders. According to research by the Police Executive Research Forum (PERF), training academies allot approximately 60 hours of training on how to use a gun, but only eight hours of training for strategies to address persons with mental illness (Lowery et al., 2015). There is some evidence this may be changing, as an increasing number of organizational and research reports indicate a “call to action” that recognizes the need for expanding the skill set of officers (new recruits and more seasoned officers), and encourages the incorporation of training that promotes new directions in health and wellness of citizens as well as first responders (e.g., Abramson, 2021; Blumberg et al., 2019; Police1, 2021).

FAST FACT 5.1 EFFORTS TO IMPROVE POLICE-CITIZEN RELATIONS National and regional awards are given to police departments who implement innovative programs that forge better connections with all community members. Police departments have continued eforts to strengthen ties to the communities they serve in a variety of ways. For example, the Providence, RI, police department invites community groups to participate in their CompStat meetings.2 The meetings provide the representatives of these groups a forum in which to discuss the concerns of their constituents. This is a cooperative endeavor with the goal of better policing for the city.


CHAPTER 5 Intercept One: Law Enforcement

Incidents such as the Muñoz shooting in Lancaster, Pennsylvania (transcript provided in the chapter introduction), and other encounters between police and citizens in crisis that result in violence and tragedy, have raised considerable public awareness and controversy surrounding police accountability and preparedness in dealing with individuals who may have psychiatric and other disabilities or special needs. Extant research and mainstream media have well-documented cases of police interactions with people of color (POC) and the deleterious effects of negative police-citizen relationships, including perceptions of police legitimacy and a general mistrust of law enforcement (Shields, 2021). However, recent statistical evidence suggests that those most profoundly affected are gender minority POC with lived experience of mental illness and/or intellectual/developmental disorders (I/ DD). This is especially the case since members of this community have an elevated risk for victimization and limited motivation to report such occurrences for several reasons, including rampant discrimination and bias in the general community and harassment and abuse by police (Shaw, 2020; Shields, 2021). While there have been positive changes recently between LGBTQ+ persons and the police in the areas of police training and specialized units, legal advocacy and diversion programs, and community outreach and policecitizen liaisons (Mallory et al., 2015), this is an area of study that requires new research and policy, and community needs in this context can no longer be neglected (Figure 5.1).

 Figure 5.1 LGBTQ+ Persons and Mental Health Struggles

Source: Mental Health America. LGBTQ+ Communities and Mental Health.

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The International Association of Chiefs of Police (IACP) is attempting to enhance the relationship between police officers and individuals with mental health conditions and/or I/DD with their “One Mind Campaign.” Its goal is to connect police, mental health organizations, and the community in a united front to make a positive impact on the lives of people with lived experience (PWLE). The IACP has asked departments to make a pledge to train officers in Mental Health First Aid (MHFA) and Crisis Intervention Team (CIT) curricula, to develop departmental policy and procedures for responding to calls involving PwMI, and to enter into written agreements with local mental health facilities to create partnerships that will enhance services to PwMI. As of July 2021, 596 agencies have taken the pledge.3

FAST FACT 5.2 ONE MIND CAMPAIGN INFORMATION For more information on the “One Mind Campaign” visit the IACP website at


Contributor: Jef Smith, DSc, MPA Police ofcers respond to calls involving PwMI on a frequent basis. Many times, a person in crisis has caused a disturbance, and police ofcers will handle the situation in a manner best aligned with the overarching training and mission of the police—being peacekeepers. A simple and expedient manner to resolve the disturbance is to arrest the subject for a minor infraction or ordinance violation and take them to jail. Problem solved, right? Wrong—the problem has just grown. The underlying problem cannot be fxed by jail or fne, as neither addresses the actual issue. The recovery of an individual with mental illness is rarely found in the Criminal Justice System. A person cannot be fned or jailed out of Schizophrenia, bipolar disorder, or any other underlying issue on the spectrum. The “quick fx” often leads to the person being released on their own recognizance, not appearing in court, and being wanted later for failure to appear for a court proceeding, thus creating additional burdens on police, courts, and jails. Accordingly, training and education programs such as Crisis Intervention Team (CIT) training which emerged from Memphis, Tennessee, and the Mental Health First Aid training through the National Council for Behavioral Health, are great starts to build the awareness of police ofcers, but they often fall short at a crucial spot. Training ofcers is important, but it becomes useless if the department does not adopt a culture that supports the mission of the training.


CHAPTER 5 Intercept One: Law Enforcement

Leaders in an organization, both formal and informal, should be committed to seeking alternative solutions to arrest. The leaders must demonstrate their dedication by word and deed and create an atmosphere where the front-line ofcers adopt a culture of properly treating PwMI. Agencies who simply provide the training without working to implement the proper use of the training are not working toward meaningful solutions. There must be a strong desire by all members of law enforcement to look for alternative solutions for the initial interaction between a PwMI and law enforcement. Identifying and building a group of available resources and working cooperatively with those resources are required for success. It is incumbent on police leaders to engage with local community resources and maintain a consistent dialogue. Communication at this point is key to the successful implementation of training for police, and the resources. Police leadership can and should take a lead in gathering groups together to begin the networking and collaboration. Too often these groups become disparate silos that never intersect, although their missions have clear intersections for successful implementation. Efective and efcient use of training, building a culture that desires to seek alternatives to arrest, and the proper use of community resources will allow ofcers to fnd another manner to resolve the mental health crises in our communities by adding a tool to their ever-burgeoning tool belt.

This chapter closely examines Intercept 1 of the SIM, which includes diversion opportunities more typically available during encounters with law enforcement and emergency services personnel (Munetz & Griffin, 2006). Emphasis is placed on police–citizen encounters and pre-booking diversion strategies. Additional challenges facing law enforcement and the individuals they serve are also presented and discussed. As articulated in Chapter 4, the reader is encouraged to consider some of the pre-arrest/pre-booking diversion strategies presented here (e.g. CIT and MHFA) that are designed to prevent a crisis (Intercept 0) and would require police-intervention from occurring in the first place. These strategies are designed to keep PwMI out of the criminal justice system, if appropriate. THINKING CRITICALLY 5.1 POLICE-CITIZEN ENCOUNTERS THAT MADE NATIONAL HEADLINES George Floyd, Minneapolis, MN (2020) On May 25, 2020, George Floyd, a 46-year-old Black man, was killed in Minneapolis, Minnesota, while being arrested on suspicion of using a counterfeit $20 bill. During the arrest, Derek Chauvin, a White police ofcer, knelt on Floyd’s neck for over nine minutes after he was handcufed and lying face down. Two other police ofcers assisted Chauvin in restraining Floyd, and a third prevented bystanders from interfering.

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Prior to his being restrained, Floyd had exhibited anxiety and complained about claustrophobia and having difculty breathing; his distress was exacerbated while being pinned to the ground by Ofcer Chauvin’s knee on his neck. At some point, he expressed fear of imminent death. After a few minutes, Floyd stopped speaking and became motionless. Upon a determination that Floyd no longer had a pulse, and despite pleas from bystanders, Ofcer Chauvin refused to lift his knee from Floyd’s neck until he was told to do so by paramedics at the scene. The following day, the incident made national headlines, as cell phone and security videos were released to the public. All four ofcers involved were subsequently fred, and Floyd’s death was determined to be a homicide. Chauvin was charged and later convicted of second-degree unintentional murder, third degree murder, and second-degree manslaughter; he was sentenced to 22.5 years in prison. The other ofcers were charged with aiding and abetting second-degree murder. Chauvin’s trial concluded on April 20, 2021, another ofcer involved in the incident made a plea deal and will be sentenced in September of 2022, and the trial for two other ofcers involved in the incident has been moved and is now scheduled to begin in early 2023. In early 2021, the City of Minneapolis agreed to a $27 million dollar settlement in a wrongful death suit brought by Floyd’s family members. Source(s): Deliso (2021), Hill et al. (2020), and Knopf et al. (2021) Walter Wallace Jr., Philadelphia, PA (2020) On a Monday afternoon in October of 2020, police responded to a third call that day in West Philadelphia at the residence of Walter Wallace Jr., a 27-yearold Black man. According to relatives questioned by the news media, Wallace was having another one of “his episodes.” According to reports, he had been struggling with some serious mental health concerns, including a diagnosis of bipolar disorder, and he had been recently engaged in therapy. Relatives also indicated that normally, Wallace could easily be de-escalated when symptoms emerged. Police dispatched to the third and fnal call were informed that Wallace was in possession of a knife. On the date of the incident, family had called 911 to request an ambulance for Wallace in anticipation of medical intervention, but the police were the frst to respond to the scene. Cell phone video from the scene shows Wallace approaching police with a knife in the street in front of his family home. Police had weapons drawn, and were ordering him to put down the knife, as he continued to approach them. Two of the responding ofcers fred several shots at Wallace, which resulted in his death. “I was telling PD to stop. ‘Don’t shoot my son, please don’t shoot my son,’” Wallace’s mother, Cathy Wallace, told reporters. “And they just shot him.” Reportedly, police were familiar with Wallace due to his struggles with his mental health condition; however, the family has argued that their concerns were not taken seriously, when presented to the police who responded to the earlier calls related to Wallace the day of the shooting. Wallace’s family has fled a wrongful death suit against the ofcers, and they are seeking policing reform, particularly related to police encounters with people who have mental illness and alternatives to deadly force. Source: Ortiz (2020)


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Ryan Shirey, Chautauqua, PA (2021) In February of 2021 27-year-old Ryan Shirey was shot and killed by police responding to a 911 call at the home he shared with his parents. According to a family member, Shirey had been battling mental illness most of his adult life and needed treatment. Police were dispatched to the home for a domestic; reportedly, his girlfriend called the police during a “heated” argument between her and Shirey. Responding ofcers approached Shirey in the basement of the home, where he was found holding what appeared to be a revolver. When he did not comply with the ofcers’ orders to drop the weapon, he was fatally shot. The incident is under investigation at the time of this writing. According to sources, the police had been at the home in the past, and the department should have been aware of Shirey’s mental health issues. Family was concerned that police presence had triggered Shirey’s paranoia, and they are hopeful that the police will learn how to handle these types of calls more efectively in the future. Source: Wojcok and Scott (2021) Patrick Warren Sr., Killen TX (2021) Patrick Warren Sr., a Black man, was fatally shot by police in the front yard of his home during a mental health check. Reportedly, the family called police and asked them to send someone who was trained in responding to a mental health-related crisis, as they were concerned about Warren’s well-being. Apparently, police had been at the home the day before for the same purpose, but the responding ofcer was a “mental health resource ofcer” and was able to convince Warren to voluntarily go to the hospital for a psychiatric evaluation. According to a civil rights attorney who is representing the family, the responding ofcer in this case demonstrated a “hostile” demeanour, and the situation quickly escalated. The events leading up to the shooting remain unclear at present still pending investigation; however, police authorities have noted that the responding ofcer had “encountered an emotionally distressed man.” Contreras frst attempted to use a “conducted energy weapon” (taser or stun-gun); however, it was inefective, so he used his gun. Warren died at a hospital from injuries sustained during the shooting. The Texas Rangers is handling the investigation into the shooting. Video of the incident has been released but, at the time of this writing, there is no conclusive information as to the reasons why Contreras fred his weapon. Contreras, a fve-year veteran of the Killeen Police Department, was placed on administrative leave, which is standard practice in ofcer-involved shootings. Merritt said the ofcer should be arrested immediately. Killeen Police Chief Charles Kimble said there would be a thorough investigation into the shooting. The police department is also conducting a separate Internal Afairs investigation. Source: Burke (2021)

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Portland, Oregon Police Department On June 27, 2000, ofcers in Portland, Oregon responded to a report of a person in mental health crisis holding a rife, while standing on his porch. According to police, the man had made threats to neighbors on previous occasions and was now observed talking to himself. Before making their presence known, responding ofcers were able to observe the man frst, and then once he put the rife down, a specialized team of ofcers trained in CIT approached him and after an extended conversation, were able to get him to turn over the rife and ammunition. He then agreed to go to the hospital for treatment voluntarily. Neighbors reported that previous attempts to engage the man in treatment had been unsuccessful, and that his mental health had substantially deteriorated recently as a result. Police Chief Chuck Lovell commented: This incident highlights the very dangerous and complicated calls our ofcers respond to regularly. It also highlights the mission our ofcers carry out to preserve life and maintain human rights. This call could have had a very diferent outcome. The training we provide our ofcers in crisis intervention enabled these ofcers to navigate a situation that involved race, mental health, and a rife. I commend their work. Source: KATU Staf

POLICE AS FIRST RESPONDERS TO CITIZENS IN CRISIS The gate-keeping function police serve for PwMI in crisis situations has become more pronounced since deinstitutionalization of state hospitals throughout communities in the United States (Lamb & Weinberger, 2014; Wallace et al., 2004) and the subsequent inability of community-based treatment providers to service the growing number of individuals needing support and treatment in community settings worldwide (International Association of Chiefs of Police, 2010; Kopelovich et al., 2021; Russell et al., 2020; Slate et al., 2013). Another development that has increased the visibility of PwMI in the community is state statutes that prescribe more rigid criteria for civil commitment to state hospitals. Lack of community support for people with behavioral health needs and stigma, coupled with inadequate dispatch training and policies on best practices for navigating police encounters with PwMI and other citizens in crisis, can result in increased incarceration for minor offenses (International Association of Chiefs of Police, 2010; Slate et al., 2013). The following section provides an introduction and discussion to diversion strategies at Intercept 1, which are designed to divert PwMI into treatment instead of being arrested or booked into jail (Figure 5.2).


CHAPTER 5 Intercept One: Law Enforcement

 Figure 5.2 First Responders on the Scene

Source: By Eric Buermeyer. Shutterstock.


Contributor: Melissa Reuland, Senior Advisor to the Transform911 project at the University of Chicago Health Lab Egon Bittner frst noted that police ofcers provide “psychiatric frst aid” in 1967 in his seminal work on the how police address situations involving someone with a mental illness in crisis (Bittner, 1967). While much has changed in the last 50 years, some things have stayed the same: police ofcers must respond to people in crisis in the absence of sufcient mental health resources (Fisher et al., 2001). Thousands of communities across the United States and abroad are striving to reduce injury and death in situations involving law enforcement (Saleh et al., 2018) and people in behavioral health (BH) crisis and to improve access to BH services. To achieve these goals, efective approaches include several key elements (Schwarzfeld et al., 2008; Watson et al., 2008): comprehensive initial and ongoing training, multi-system collaboration, specifc policies for ofcers and dispatchers, and enhanced BH resources for police-involved individuals. Agency policies also aim to divert people in crisis from jail to more appropriate BH resources. Policies typically include procedures for ofcers as they encounter the person in crisis that include using de-escalation tools gained in training. Policies also dictate where the person in crisis should be brought if the ofcer deems they meet criteria (e.g., danger to self or others) for emergency involuntary custody. Policies will also refect if streamlined drop of procedures have been developed at BH resources, which would allow ofcers to bypass the emergency department at the hospital if appropriate and help the person access services.

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After many tragic encounters, the practice of diverting some calls involving people in BH crisis to BH alternatives instead of police is growing (Beck et al., 2020). Collaboration with a wide range of stakeholders is vital to developing alternative responses that are equitable, appropriate, and sufcient. These alternatives can include licensed clinical providers, peers, paramedics, or a combination. Calls can be diverted to these resources by the call taker directly, ultimately achieving the goals all stakeholders share. Sources: 1. Beck, J., Reuland, M., & Pope, L. (2020). Behavioral Health Crisis Alternatives: Shifting from Police to Community Responses. Retrieved from 2. Bittner, E. (1967). Police Discretion in Emergency Apprehension of Mentally Ill Persons. Social Problems, 14(3), 278–292. stable/799150 3. Fisher, W. H., Geller, J. I., & Pandiani, J. (2001). The Changing Role of the State Psychiatric Hospital. Health Afairs, 28(3), 676–684. https://doi. org/10.1017/S1566752900000628 4. Saleh, A. Z., Appelbaum, P. S., Liu, X., Scott Stroup, T., & Wall, M. (2018). Deaths of People with Mental Illness during Interactions with Law Enforcement. International Journal of Law and Psychiatry, 58. https://doi. org/10.1016/j.ijlp.2018.03.003 5. Schwarzfeld, M., Reuland, M., & Plotkin, M. (2008). Improving Responses to People with Mental Illnesses: The Essential Elements of a Specialized Law Enforcement-Based Program—CSG Justice Center—CSG Justice Center. Retrieved from improving-responses-to-people-with-mental-illnesses-the-essential-elements-of-a-specialized-law-enforcement-based-program/ 6. Watson, A. C., Schaefer Morabito, M., Draine, J., & Ottati, V. (2008). Improving Police Response to Persons with Mental Illness: A Multi-Level Conceptualization of CIT. International Journal of Law and Psychiatry, 31(4), 359–368.

SPECIALIZED POLICE RESPONSES TO CRISIS EVENTS With the number of encounters between police and PwMI increasing, specialized policing responses (SPRs) have been designed and implemented by police departments nationwide (and abroad) to provide pre-booking diversion options that may more effectively address any underlying issues and/or BH needs. SPRs prioritize treatment over incarceration, when possible. Depending on available resources, extent of community support, and department culture/philosophy, one of three primary types of response “teams” are utilized for dispatch during a crisis event: Police-based specialized police response (sworn officers with special mental health training), police-based specialized mental health response (mental health consultants employed by the law enforcement agency), and mental health–based specialized mental health response (individuals who work directly for providers/agents in the community mental health system) (Compton & Kotwicki,


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2007). As outlined in Chapter 3, examples of these programs can be broadly placed under three categories: (a) crisis intervention teams (CITs), (b) coresponder teams, and (c) follow-up teams (Reuland & Yasuhara, 2015). Each of these is explained in some detail in the next section.

FAST FACT 5.3 THE ROLE OF POLICE IN MEDIATING CRISIS The terms “welfare check,” “well-being check “or “wellness check” (Siegel, 2013) refer to an act by police to seek out persons in the community and ascertain their well-being in a variety of circumstances (NAMI, 2016). It should be noted, however, that a police welfare check should not replace an assessment by a clinician who is more appropriately trained in mental health disorders.

Crisis Intervention Teams To promote the safety of officers, citizens in crisis, and the public during crisis encounters, first responders should be properly trained to understand signs and symptoms of psychological disorders and mental health crisis, and in effective techniques related to stabilization and de-escalation. The Crisis Intervention Team (CIT) model is one of the most well-known SPRs. In fact, it is the most widely adopted police-based specialized police response program in the United States (Gostomski, 2012; Watson et al., 2011) and has gained popularity and been implemented outside the United States in countries such as Australia, New Zealand, Canada, and the United Kingdom (Hartford et al., 2006; NSW Police Force, 2014). The CIT model was originally conceived following a 1987 incident in Memphis, Tennessee, that resulted in Joseph Dewayne Robinson—a man with a history of mental health and substance abuse issues—being fatally shot during a crisis encounter. When Memphis police arrived at the scene, Robinson was wielding a knife and appeared to be cutting himself. After failing to desist and release the weapon, Robinson allegedly began to approach police and was subsequently shot eight times (Heilbrun et al., 2012). As a direct response to this incident, a community task force composed of law enforcement, community mental health providers, addiction professionals, and consumer advocates was established. This task force collaborated and designed the CIT model (Heilbrun et al., 2012, Watson et al., 2011). Prior to the implementation of CIT, most police departments, including the Memphis Police Department, were offering a few hours of academy-based training in crisis intervention (Gostomski, 2012; Hails & Borum, 2003; Pearson, 2014). As of 2019, there were over 3,000 CIT programs throughout the United States and the District of Columbia (Washington, D.C.) (Usher et al., 2019).

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Primary objectives of the Memphis model4 include (a) advanced training, (b) immediate crisis response, (c) safety of officer and consumer, and (d) proper care for persons in crisis (Usher et al., 2019). Under the Memphis model, trainees receive a one-time, 40-hour, week-long training in how to respond to citizens in crisis. Depending on the needs of the community and the size of any given jurisdiction and available resources, training may take place multiple times throughout the year. Various training modules are facilitated by law enforcement personnel, community mental health professionals, educators, family and consumer advocates, and other professionals in related fields. Training sessions cover a variety of topics, including (a) signs and symptoms of mental illness, (b) types of psychotropic medications, (c) de-escalation techniques, and (d) community resources. Two essential elements of the model are officer training and the development and maintenance of criminal justice–mental health partnerships. Training elements that are implemented successfully are expected to produce change in officers’ attitudes, knowledge, and skills (i.e., learning outcomes) and subsequent behavior when encountering PwMI (i.e., behavior outcomes) (Cross et al., 2014). In most communities where CIT is implemented, persons who have attended are a diverse group of first responders, including (a) corrections officers, (b) school resource officers, (c) police and deputy sheriffs, (d) public safety dispatchers, (e) 911 operators, and (f) medical and mental health professionals (“What is CIT?”, 2016). Most of the trainees are self-selected law enforcement volunteers who also come highly recommended by their respective departments (Thompson & Borum, 2006). This (i.e., selection bias) presents a major concern with research on CIT training, in that CIT volunteers may have a predisposition to positive encounters with PwMI (Petersen & Densley, 2018). It should be noted, however, that in an increasing number of jurisdictions, new recruits and veteran officers are required to complete the full 40 hours of CIT training, making more comparative observations possible in future analyses of the program (Cross et al., 2014). Like with other types of training and development, the primary determinant regarding availability is financial and then time restrictions. Given the 40-hour time commitment, departments have been reluctant to “give up” their officers, which results in only a minimum number of CIT-trained officers in many municipalities, and in some, none. This is especially true in rural and frontier5 communities, where community leaders in policing and BH continue to champion for CIT participation with limited resources, and in some cases, waning support (Bratina et al., 2021; Yang et al., 2018). Unfortunately, the number of police calls for services that are related to behavioral health crisis continue to overwhelm departments across the United States (see, for example, Figures 5.3 and 5.4) (Smydo & Lord, 2016). For this reason, several jurisdictions have made accessible abbreviated CIT programs that provide a basic understanding of signs and symptoms of mental illness so that officers can respond to a crisis event more


CHAPTER 5 Intercept One: Law Enforcement

effectively. The continued development and study of outcomes pertaining to such variations have been encouraged (Seo et al., 2020). It must be noted that, while these abbreviated versions are likely to offer some benefit to smaller departments that are impeded by time, money, and accessibility issues, most of the published work on CIT has been focused on the traditional Memphis model. The following section provides a brief overview of this research.

 Figure 5.3 Crisis Calls for Service, Austin, TX Police Department 2016–2018

 Figure 5.4 Crisis Calls for Service, Austin, TX Police Department (2016–2018), by Year Source: Arellano (2019);

Specialized Police Responses to Crisis Events 133

Empirical Evidence Law enforcement agencies that have implemented CIT report positive results (DeMatteo et al., 2013; Pearson, 2014; Seo et al., 2020; Steadman et al., 2000). CIT programs have been successful in (a) improving understanding of signs and symptoms of mental illness, (b) reducing stigma and negative attitudes toward PwMI, and (c) increasing the number of positive police interactions with PwMI overall (e.g., Compton et al., 2006; Wells & Schafer, 2006). For example, Compton and colleagues (2006) reported results of surveys completed by 159 officers following a 40-hour block of CIT training. Findings revealed that there was a reduction in officers’ stigmatizing attitudes related to mental illness (particularly schizophrenia), including improved attitudes regarding aggressiveness of PwMI (i.e., less likely to view PwMI as having an increased potential for violence). Trained officers also reported (a) enhanced knowledge about mental disorders, (b) better attitudes in support of working with local treatment programs, and (c) decreased desire for social distance from PwMI. These results have been mostly supported in the CIT literature (e.g., Compton et al., 2014); however, as it pertains to stigmatizing attitudes/beliefs about mental illness (and PwMI), some inconsistencies have been noted recently. For instance, Haigh and colleagues (2020) found no significant differences in levels of mental illness stigma between officers who had completed CIT training compared to their untrained counterparts. Additionally, among their sample of law enforcement officers from nine different local police departments in the state of New Jersey, Tartaro et al. (2021) found CIT-trained officers to be more likely to hold negative opinions about PwMI as compared to non-CITtrained officers. The extent to which the knowledge translates into behaviors is much less known at this juncture, and more research is needed to draw any conclusions in this regard. For example, one long-term benefit of crisis intervention training should be a reduction in the number of violent interactions between PwMI and the police. Some evaluation of CIT effectiveness in reducing police officers’ use of force against persons with mental illness has been conducted. For instance, Skeem and Bibeau (2008) found that CIT officers used force in only 15 percent of encounters against highly resistant subjects (i.e., high risk of violence). Later, Compton et al. (2011) collected data from 135 police officers belonging to urban police departments in the southern United States. Participants in the sample included 48 CITtrained and 87 non–CIT-trained police officers. Officers were given three scenario-based vignettes depicting escalating situations involving a PwMI. Results revealed CIT-trained officers were less likely to use force to gain compliance from a PwMI. Additionally, when compared with their nontrained counterparts, CIT-trained officers selected actions related to lower use of force. Morabito et al. (2012) corroborated these earlier findings in a comparative study of CIT-trained police officers and police officers who had not been trained in CIT in the city of Chicago (n = 91 vs. n = 125,


CHAPTER 5 Intercept One: Law Enforcement

respectively). Results indicated that, when compared to their untrained counterparts, CIT officers used less force as subject resistance increased. In a later study, Morabito and Socia (2015) examined the relationship between suspects’ mental illness and the likelihood of injury for both officers and suspects during use-of-force encounters in Portland, Oregon, from 2008 to 2011. Of all use-of-force incidents over that reporting period, 11.5 percent involved suspects with mental illness (n = 6,131). It should be noted that CIT training in Portland was universal during the reporting period, so all responding officers in the data set were CIT trained. Findings revealed that, in corroboration with previous studies on use of force overall, incidents in which force is employed are most likely to result in the injury of officers rather than subjects, and further, there are situational characteristics that significantly influence outcomes in both contexts, including race, sex, subject resistance, and the presence of weapons. Regarding mental illness specifically, Morabito and Socia (2015) found that it alone was not a significant predictor of injury; rather, the perceived co-occurrence of substance abuse with mental illness increased the likelihood of injury to both suspect and officer in their sample. This finding corroborates with additional research and is important considering misperceptions of the mental illness–violence relationship. Many jurisdictions have developed CIT data tracking forms, which allow for the collection of crisis call data post-training, and provide some opportunity to examine additional measures of CIT “success,” including call characteristics (e.g., nature of the call, presence of a weapon/drugs/alcohol), injury to officer/ citizen, and disposition outcomes, including decisions to divert citizens to a hospital or some other available crisis treatment facility. Challenges associated with research using these forms include the lack of consistency with tracking form development, gaps in implementation and continued/required use across departments/jurisdictions, and a lack of comparison groups for statistical analysis (in some cases, most officers completing the forms are CIT-trained). Notwithstanding these challenges, recent examinations of these data have indicated an increased likelihood of diversion to treatment by CITtrained officers, even when circumstances would justify an arrest decision (e.g., lethal weapon) (Bratina et al., 2020; Khalsa et al., 2018). Despite a collection of positive outcomes associated with CIT, empirical support is still lacking, especially as it pertains to officer behavioral outcomes (e.g., use of force, arrests, injuries) and consumer perceptions of procedural justice (Seo et al., 2020). It is anticipated that research developments will continue in this area, especially with the growing support for co-responder and other models of crisis intervention that seek to replace an overreliance on police-based crisis response with models led by trained mental health and emergency medical personnel (see Chapter 4), or those which incorporate both police and clinicians.

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FAST FACT 5.4 BY THE NUMBERS—POLICE-PROVOKED SUICIDE INCIDENTS (SUICIDE-BY-COP) Suicide-by-Cop (SBC) is a term used to describe ofcer-involved shootings (OIS) of citizens who are suicidal. This is also referred to as police-provoked shooting. These are incidents in which a citizen in crisis attempts to provoke police into using deadly force (Pillay & Thomas, 2015). SBC was frst identifed as a manner of death in the 1980s. There has been a dramatic increase in the number of SBC-related deaths, and Figure 5.5 (By the Numbers) illustrates characteristics that diferentiate SBC cases from other OIS in a non-random sample of 707 cases from North America.6 In comparison to those involved in other OIS, SBCs subjects appeared to be older men (Mean/average age = 34.5 v. 28.5 years). Ofcers were more likely to deploy less-than-lethal (LTL) force in SBC cases (39 percent v. 29 percent); however, when lethal force was utilized, more deadly force rounds were fred. In SBC cases, subjects are less likely to be armed (36 percent v. 20 percent), but when armed, were more likely to possess a knife (34 percent v. 15 percent) and to fre a gun at ofcers than regular OIS subjects (48 percent v. 32 percent). SBC subjects were more likely to have reported suicidal ideations prior to or during the incident (87 percent v. 1 percent), and in 21 percent of these cases, prior communications were likely to include SBC information. Suicidal communication during an incident and the presence of suicide notes were reported only in SBC cases. Suicidal ideation (2+ months prior to incident) and prior suicide attempts were more likely reported among SBC subjects (86 percent v. 38 percent; 39 percent v. 6 percent). SBC subjects were more likely than other OIS subjects to make threats to harm others, and were more likely to harm civilians, in the combined period prior to the arrival of police and during the incident. Although SBC subjects were less likely to fee during the incident (33 percent v. 66 percent), they tended to exhibit slightly more aggression toward police (90 percent v. 82 percent). SBC subjects were more likely to have a known or probable mental health diagnosis (62 percent v. 22 percent), with a higher frequency of mood disorders and comorbidities (i.e., having two or more disorders) observed in comparison to other OIS subjects (48 percent v. 21 percent and 17 percent v. 10 percent, respectfully). Moreover, at the time of the incident, SBC subjects were more likely to be psychotic, on medication, and under some type of psychological care—and 24 percent of SBC subjects were under the infuence of alcohol at the time of the incident, compared with 6 percent of other OIS subjects. More SBC subjects died during the incident than subjects involved in other OIS (51 percent v. 36 percent). More training and research on SBC and diferentials between characteristics of OIS shootings and SBC cases should be conducted.


CHAPTER 5 Intercept One: Law Enforcement

87% reported suicidal communications prior to or during incident

24% were under the influence of alcohol at the time

Past suicidal ideation = 86% Male/Average age of subject = 34.5 years

Confirmed or probable mental health diagnosis

•Mood disorder: 48% •Two or more disorders: 17% •Thought disorder: 15%

and Prior suicide attempts = 39%

36% (n = 256) SBC cases

Made threats to others =

LTL force deployed = 39%


Status at the time of incident

•Recent behavioral changes: 82% •Relationship problems: 72% •Spiritual issues: 65% •Divorced or separated: 43% •Gang members: 13% •On probation or parole: 38%

21% psychotic 42% on medication

Unarmed subject = 36%

30% under psychological care

SBC subjects were more likely to die during the incident than other subjects involved in OIS (51% v. 36%).

 Figure 5.5 Suicide-by-Cop or Police-Provoked Shootings Source (Graphic): Jacqueline A. Carsello and Author

Co-responder Teams The available research indicates that the existence and success of prebooking diversion programs depend on successful and resourceful collaboration between individuals from multiple systems of care. When successful community partnerships are formed between mental health professionals and practitioners and law enforcement officers, the deployment of police– clinician SPRs—sometimes referred to as “street triage”—can be an effective strategy during a crisis event at Intercept One. Several of these partnerships have been developed with an array of structural components and names, including, for example, a Behavioral Health Response Team (BHRT) (Portland, Oregon), Community Response Team (CRT) (Colorado Springs, Colorado), Crisis Intervention Response Team (CIRT) (Houston, Texas), Crisis Outreach and Support Team (COaST) (Albuquerque, New Mexico), Mental Health Officer team (MHO) (Madison, Wisconsin), Mental Evaluation Unit (MEU) (Los Angeles, California), Psychiatric Emergency Response Team (PERT) (San Diego, California), and Virtual Mobile Crisis Intervention (V-MCI) (Springfield, Missouri). Research on this approach has produced positive results—in particular, a reduction in injuries to officers and an improvement in consumer mental health services linkages (International Association Chiefs of Police [IACP], 2020; Krider et al., 2020). The primary role of co-responders is to employ de-escalation techniques, align PwMI with services to the extent possible, and to minimize public safety risk and injury to officer or consumer. This raises the importance of the need for effective implementation of these teams which includes strong inter-agency collaboration, clear policies and procedures,

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consideration of community needs during team development, effective marketing of the program, and the identification of provider services and funding support (IACP, 2020). A diverse array of modified co-responder models emerged in recent years to fulfil community-specific needs, including multi-professional teams for substance abuse intervention, homelessness, or human trafficking and the implementation of clinical staff in dispatch/911-communications centers to promote early proactive intervention and diversion (Krider et al., 2020). In some communities, police pair-up with existing mobile crisis units (MCUs) to serve in a similar capacity; however, there are barriers to full or complete implementation of a co-responder model as described here. Although introduced and discussed in Chapter 4 as an Intercept 0 strategy, some locals have utilized integrated police and mobile crisis response teams or mobile crisis units (MCU) in the capacity of “co-responder” programs, and it may be helpful to review in this context.

Mobile Crisis Response Teams or Units The advent of MCRTs (or MCUs) began shortly after the passage of the Mental Health Act in 1963 as one response to rapid deinstitutionalization and the philosophical shift away from a reliance on inpatient care to a more community-based approach (Casey, 2015). The MCRT is considered a mental health–based specialized response (Compton & Kotwicki, 2007), and thus, a “team” generally consists of case managers, social workers, psychiatrists, psychologists, and registered nurses who have extensive training on mental health disorders and related treatment options (IACP, 2020; Slate et al., 2013). The primary goal of MCRTs has historically been a “gatekeeping” function—in essence, to more effectively stabilize vulnerable persons who are experiencing an acute crisis event in a community setting, and consequently, reduce the number and duration of inpatient admissions (Carpenter et al., 2013). Cases in which an MCU was dispatched alongside police are reportedly more complex, more time consuming, and oftentimes, the consumers require transportation to a mental health facility or crisis center (Griffin et al., 2015) (Figure 5.6). The primary functions of the MCRTs are to assist in de-escalation; perform crisis stabilization; assess the mental health (and possible substance use) status of people with lived experience (PWLE); provide education, psychological support, and medication management and administration when needed; and, to link the consumer with local community mental health and substance use services. Further, whenever possible, MCRTs have also provided follow-up care (Lord & Bjerregaard, 2014), which is discussed in some detail later. Ideally, the MCRT is available seven days per week, 24 hours a day, and consumers needing assistance will have the ability to call the MCRT directly for a nonthreatening mental health emergency, just as they would call 911 for other emergencies requiring the police (National


CHAPTER 5 Intercept One: Law Enforcement

 Figure 5.6 Emergency Services

Source: By ShapikMedia. Shutterstock [Standard License],

Alliance on Mental Illness [NAMI], 2016). Unfortunately, due to budgetary and other constraints governing counties, municipalities, cities, and towns, mobile crisis units may be understaffed and underutilized; availability may be limited to certain times, days, and by procedural restrictions. In some jurisdictions, the MCRT cannot be dispatched unless accompanied by law enforcement (or until after the arrival of law enforcement). This may present a problem in certain cases, as some incidents/citizens do not involve a public safety risk, and, for many, the presence of law enforcement may increase rather than minimize the likelihood of trauma. For this reason, recommendations have been made to dispatch an MCRT (e.g., CAHOOTS) as an alternative to police in situations where no crime or violence has occurred (Waters, 2021). Formal evaluations of MCRTs are scant, and most of the current research appears to be descriptive in nature. However, available data indicate that MCRTs are cost effective in terms of reducing the need for emergency medical services and the use of arrest. Furthermore, law enforcement and consumers alike have been notably positive about their encounters with the MCRT (see IACP, 2020; Krider et al., 2020; and Lord & Bjerregaard, 2014 for a review of the relevant literature). In review, diversion strategies available at Intercept 1 of the original SIM may include pre-arrest diversion programs, such as Crisis Intervention Teams (CITs) and co-responder teams (Krider et al., 2020; Slate et al., 2013). As presented and discussed here, CIT officers have acquired specialized training on PWLE (including mental illness, substance use, and

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persons with intellectual/developmental disorders), and are especially skilled at the use of de-escalation when there is a need (Slate et al., 2013). Co-responder teams consist of a partnership between law enforcement and case managers, social workers, psychiatrists, psychologists, and a variety of other persons working in helping, human service-oriented professions; these individuals are most likely to have significant training with regard to substance use and mental health disorders (and related crisis events), so if there is a situation that needs to be de-escalated, they can also assist (Krider et al., 2020; Slate et al., 2013). The implementation of CITs and co-response models is becoming increasingly important because the numbers of persons with mental illnesses are growing in the jail/prison population. In fact, estimates have revealed that about 10 percent to 25 percent of U.S. prisoners have a serious mental illness, which includes schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder (Collier, 2014). Regarding incarcerated persons in jails specifically, according to the American Psychological Association (APA), the “rate of serious mental illness in American jails is reported at 14.5 percent for men and 31 percent for women, compared to 4 percent of all adults in the non-institutionalized population” (APA, 2021, “Criminal Justice and Mental and Behavioral Health” section). Because persons with mental health diagnoses are often incarcerated instead of receiving the appropriate psychiatric care, crisis intervention should be utilized to prevent even further decompensation of individuals with a mental illness, to avoid reentry into the prison system if possible, and to expedite recovery. Correctional concerns and diversion efforts are presented in the following chapter.

Police–Clinician Follow-Up Despite community participation in SPR programs such as CIT and successful collaborative efforts at crisis response and intervention (Co-responder and MCRT), persons with mental health-related diagnoses are sometimes arrested and subsequently incarcerated. Furthermore, even individuals who are successfully stabilized and who remain in the community may not have knowledge of or access to the services they need to independently function in daily life. As such, follow-up care should be utilized to prevent decompensation of PwMI, to avoid rearrest/reentry into the prison system, if possible, and to expedite recovery. A follow-up (response) team is a group of individuals, most often led by law enforcement officers, who are specially trained in mental health crisis intervention (e.g., CIT). It is important to note that follow-up programs are often a natural extension of the duties assigned to CIT-trained officers, a co-responder team, and/or MCUs; this type of program/level of care and support is usually reserved for persons with serious mental illness who are frequently encountering the criminal justice system (i.e., “frequent flyers”), and/or contacting police through the use of 911 emergency calls for service


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(Council of State Governments Justice Center [CSGJC] 2021, “Conducting Follow-Up After a Crisis Encounter”). There is no formal model of what a team should look like; rather, the needs of a community will dictate its clientele, composition, and primary tasks. Again, in some communities, follow-up teams involve the collaboration of police and MCUs or just police; in other communities, there may be follow-up teams with specific clientele, such as for adults or juveniles. In still other communities, there may be only one designated follow-up person, and that could be a police officer or a clinician. Furthermore, depending on the jurisdiction, team members may also include community corrections officials (e.g., a probation officer) and behavioral health representatives (e.g., social workers, peer support staff, and nurses) (see Slate et al., 2013 for a comprehensive review of crisis intervention and follow-up teams in varied jurisdictions). The primary function of the team is to evaluate an individual’s engagement in services (e.g., mental health and substance use) after a crisis event has occurred, and, if necessary, to educate as to available resources. It is anticipated that this will reduce the number of repeat 911 calls as well as rearrests. As revealed by the research on CIT, and corroborated by individuals working in the field, a referral for follow-up is usually made by responding officers after a crisis event. At that point, members of the team perform community-based outreach, whereby they visit with citizens face to face to evaluate service engagement and mental health status. They will then provide periodic updates to other members of the team. Given these goals, the need for thorough documentation of PwMI–police encounters (information tracking) and sharing across systems of care is evident. Studies that focus specifically on follow-up teams are difficult to find in a search of the literature; however, there is a growing body of research on multidisciplinary mental health crisis teams in general. Based on overall findings, it is possible to deduce positive effects when follow-up evaluation and referral are connected to crisis intervention. In particular, the evidence reveals that effective follow-up care after a crisis event may reduce the rate of suicide, reduce the likelihood of future contact with LEOs, and improve treatment engagement to some extent (e.g., CSGJC “Conducting Follow-Up,” 2021; Malone et al., 2007).


Contributor: James Ruiz, PhD There are also those infrequent instances when danger is present. We responded to a call in the Garden District of New Orleans regarding a person with mental illness manifesting violent behavior. When we arrived, the

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wife and neighbors were in front of the residence. They advised that the husband had been acting out all morning and had threatened the wife with a knife. It was also learned that he was boiling water in the kitchen. Boiling water is a common weapon in New Orleans. It is more dangerous when grits are prepared in the boiling water as it has a thick consistency that remains in place once poured. It has also garnered the name “Cajun Napalm.” Despite his behavior, there were complications. First, the house was in both his and his wife’s names. If he wanted to tear the house up, that was his right as it was community property. We turned of the natural gas to the house so the stove would be inoperable and waited about 30 minutes to allow any water that he may have been boiling to cool down. We made entry into the house without incident, but we could see he had a butcher’s knife in his right hand. We created a barrier between him and us so if he charged at us, we would have room to retreat. As we were trying to talk him into submission, the right hand holding the knife appeared from in the kitchen and it was thrown. It struck me handle frst in my lower abdomen. I was frozen momentarily waiting for the pain when I heard the knife hit the foor. He fnally surrendered without incident as we negotiated with him to be taken from the house on a gurney and placed into an ambulance so the neighbors would think he was sick and being transported to the hospital. This gave us the opportunity to restrain him to the gurney, and transport him from the scene with no one injured. Because police have little knowledge of the causes of mental illness, and usually conjure up the most violent cases from their past experiences, they arrive on the scene mentally geared up for, and in most cases, expecting a physical encounter. They also tend to want to handle the call quickly as rapid resolution of the call will reduce the possibility of violence. This approach can easily turn into a self-fulflling prophecy. In many cases, police ofcers are given a commitment order from a coroner or medical examiner directing them to “present the body of Joe Smith at” some hospital. To the police, this amounts to an arrest warrant. When a person decides not to go with the police peacefully, that creates a “resisting arrest” scenario, and from there the situation tends to spin out of control. From the perspective of the person with mental illness, s/he may or may not be aware of what is going on. In most cases, they are aware, and they are not violent. These calls for service are usually the result of the person refusing to take or lying about whether they have taken their medication, thus causing the symptoms of the illness to manifest. In many cases, persons with mental illness report that the efects of the drugs are worse than the mental illness. When the police arrive, and attempt to take the person, usually from their home to a hospital, the person refuses to go because s/he has either been to the hospital and has bad memories, and/or they are just afraid. As for the police, they, too, are afraid, and are interested in resolving the call as quickly as possible. This is a very volatile mix that usually leads to use of force, injuries, and at times death.


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Police Discretion during a Crisis Encounter Police are given the primary responsibility of responding to, resolving conflict of, and ensuring the safety of PwMI who cannot care for themselves under the doctrine of parens patriae (Latin for “the state as parent”) (Curtis, 1976; Slate et al., 2013). Thus, regardless of the community/jurisdiction and type of diversion strategies available, police generally have discretion to invoke five to six possible outcomes during a mental health crisis: do nothing, arrest, request the dispatch of a MCU, provide community-based information/referrals, refer, and possibly transport a willing consumer to a crisis stabilization unit (CSU), or initiate an involuntary emergency commitment for evaluation. Of these options, the involuntary commitment option is the most controversial, and hence, it is discussed in more detail next.

Commitment Statutes and the Role of Police Under the authority of state statute, police in every state across the nation have the authority to initiate an involuntary commitment order requiring a person who presents as a danger to self or others to be transported to a mental health facility for an emergency evaluation. Depending on the structure of the community-based mental health system and the clientele served (children or adults, persons with physical health needs, men or women), the facility could be a hospital emergency room, a separate crisis stabilization unit (CSU), or some other designated receiving facility (Figure 5.7: Local emergency room). Two things should be noted here: First, if the circumstances allow, a PwMI in crisis will be given the opportunity to go for an evaluation voluntarily; should the individual refuse to go willingly and/or if the situation is such that it prevents this option (e.g., escalating violence toward self or others), a LEO may initiate an involuntary order and transport that person for the evaluation. The time for which the individual can be held involuntarily for evaluation is usually between 48 and 72 hours in most states, after which time a designated individual (most likely, a physician) may request a longer period of hospitalization if appropriate. It is also possible that a civil commitment process will be initiated. Examples of involuntary emergency commitment statutes are presented in the following “Policy & Practice” segment. POLICY & PRACTICE 5.2 EMERGENCY EVALUATION COMMITMENT LAWS IN THE UNITED STATES Alaska: ALASKA STAT. § 47.30.705 [Where there is] probable cause to believe that a person is gravely disabled or is sufering from mental illness and is likely to cause serious harm to self or others of such immediate nature that considerations of safety do not

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allow initiation of a court-ordered screening investigation … the person [may] be taken into custody and delivered to the nearest evaluation facility. District of Columbia: D.C. CODE ANN. § 21–521. An accredited ofcer or agent of the Department of Mental Health of the District of Columbia, or an ofcer authorized to make arrests in the District of Columbia, or a physician or qualifed psychologist of the person in question, who has reason to believe that a person is mentally ill and, because of the illness, is likely to injure himself or others if he is not immediately detained may, without a warrant, take the person into custody. Florida: FLA. STAT. § 394.463(1) [A] person may be taken to a receiving facility for involuntary examination if there is reason to believe that the person has a mental illness and because of his or her mental illness: (a) 1. The person has refused voluntary examination after conscientious explanation and disclosure of the purpose of the examination; or 2. The person is unable to determine for himself or herself whether examination is necessary; and (b) 1. Without care or treatment, the person is likely to sufer from neglect or refuse to care for himself or herself; such neglect or refusal poses a real and present threat of substantial harm to his or her well-being; and it is not apparent that such harm may be avoided through the help of willing family members or friends or the provision of other services; or 2. There is a substantial likelihood that without care or treatment the person will cause serious bodily harm to himself or herself or others in the near future, as evidenced by recent behavior. Hawaii: HAW. REV. STAT. § 334–59 (d). If a police ofcer has reason to believe that a person is imminently dangerous to self or others, or is gravely disabled, or is obviously ill, the ofcer shall call for assistance from the mental health emergency workers designated by the director. Upon written or oral application of any licensed physician, psychologist, attorney, member of the clergy, health or social service professional, or any state or county employee in the course of employment, a judge may issue an ex parte order [upon specifed conditions.]Rhode Island Rhode Island: R.I. GENERAL LAWS § 40.1-5-7(a) (1)(a) Any police ofcer may take an individual into protective custody and take or cause the person to be taken to an emergency room of any hospital, by way of emergency vehicle, if the ofcer has reason to believe that: (1) The individual is in need of immediate care and treatment, and is one whose continued unsupervised presence in the community would create an imminent likelihood of serious harm by reason of mental


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disability if allowed to be at liberty pending examination by a licensed physician; or (2) The individual is in need of immediate assistance due to mental disability and requests the assistance. (b) The ofcer making the determination to transport will document the reason for the decision in a police report and travel with the individual to the hospital to relay the reason for transport to the attending medical staf. Source: Treatment Advocacy Center. Emergency Hospitalization for Evaluation (2018). Retrieved August 25, 2021, from https://www.

Police transport of a PwMI to a crisis or receiving center for a mental health assessment is viewed as a preferred diversion strategy at Intercept 1 (Figure 5.7). Unfortunately, however, officers are sometimes faced with constraints that prevent optimal diversion outcomes. In the case of emergency evaluation options, these constraints largely revolve around the manner of reception by mental health service providers at the receiving point. Officers indicate that the outcome of a mental health crisis call, including those involving criminal behaviors and/or violence, are sometimes dependent on their perceptions of the level of difficulty that will be encountered at the emergency department (ED) or CSU. For LEOs who are not trained in CIT or some other model of crisis intervention, trepidation is based on discomfort with a lack of knowledge on what constitutes mental illness and, on the logistics involved in the process of initiating an emergency evaluation. In fact, police have reported that the arrest decision may take less time and provide a better outcome (easier and immediate access to treatment/ medication).

 Figure 5.7 As a Diversion Strategy at Intercept 1, Police Will Often Transport Individuals in Crisis to a Local Emergency Room for Mental Health Evaluation and Crisis Stabilization Source: Wikimedia Commons. (2005). [Mayo Clinic’s St Marys Hospital, Emergency Department entrance. I; Knowledge Seeker, took this photograph on September 27, 2005]. [Photograph]. Wikipedia. Licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.

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Arrest may lead to consistent engagement in mental health and/or substance abuse treatment, something that many consumers will not receive (willingly or otherwise) in a community setting (Morabito, 2007). As a result of these and other obstacles previously discussed, research reveals that police are reluctant to initiate commitment paperwork and instead have developed informal decisions to manage PwMI whom they encounter in the field (Deane et al., 1998; Morabito, 2007). Moreover, despite the increasing amount of training that LEOs are exposed to on the identification of mental health and substance use disorders and on proper de-escalation techniques, the lack of resources available in the communities in which they serve creates obstacles that are difficult to overcome in the successful management of service calls involving PwMI.

COMPARATIVE PERSPECTIVES 5.1 REDUCING EMERGENCY COMMITMENTS IN AUSTRALIA WITH A CO-RESPONDER TEAM In Australia, police are legally obligated to detain people in crisis if they are a risk to themselves or others, and to take them to a facility where they can receive a mental health assessment. Four percent of all emergency room visits are related to patients with mental health issues, and across the state of Victoria, 24 percent of mental health cases brought to the emergency department have required admission to the hospital. In 2012, the Northern Police and Clinician Emergency Response team (NPACER) was developed to divert the amount of people brought to the emergency department by the police. Over a 27-month period, NPACER was analyzed for efectiveness, and it was found that its implementation resulted in an 84 percent decrease in emergency department visits (down to 16 percent from 100 percent when the NPACER was open), as well as direct access to inpatient mental health services in the community. Source: McKenna, B., et al. (2015). Police and Clinician Diversion of People in Mental Health Crisis from the Emergency Department: A Trend Analysis and Cross Comparison Study. BMC Emergency Medicine, 15(1), 1–6. 10.1186/s12873-015-0040-7

ADDITIONAL COMPLEXITIES OF LEO–CITIZEN ENCOUNTERS: RESPONDING TO SPECIAL POPULATIONS The challenges presented so far in this chapter are becoming salient topics for research and policy exploration. The discussion, however, has revolved around general crisis calls involving adults with mental illness, and no particular emphasis has been placed on additional individual-level characteristics or circumstances of the persons whom first responders will encounter. In this section, the discussion turns toward additional complexities and challenges that may emerge, first, during a crisis event, but also at any other point throughout the criminal justice system.


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Veterans According to a report by the National Council for Behavioral Health (2012), there are approximately 25 million veterans living in the United States, many of whom have been exposed to traumatic events during combat which render them unable to easily reintegrate back into civilian society. In particular, since 2001, 2.4 million active duty and reserve military personnel were deployed to the wars in Iraq and Afghanistan. Of this group, 30% [or] nearly 730,000 men and women will have a mental health condition requiring treatment. Studies have shown that 18.5% of all OEF/OIF veterans7 have post-traumatic stress disorder, Major Depression, or both PTSD and Major Depression. Other Mental Health Disorders are estimated to affect 11.6% of those without PTSD or Major Depression. (“Meeting the behavioral health needs of veterans,” 2012, p. 3) In addition to trauma and generalized mental health problems, other critical (and often related) issues faced by veterans include high rates of suicide, substance use, the absence of available housing, and involvement in the criminal justice system (Richman, 2018). In fact, post-traumatic stress disorder (PTSD) (introduced in Chapter 1), suicide, and substance use are among the most significant issues facing military personnel and their family members. In 2014, an average of 20 veterans (women and men) died by suicide each day—a statistic that reveals a rate double that of the U.S. civilian population (Zoroya, 2016). Unfortunately, for many veterans, the wait list to be seen for any medical condition (including psychological disorders) can take months (U.S. Department of Veteran Affairs [VA], Veterans Health Administration, 2016). PTSD is a potentially serious mental health condition that often develops after a person has experienced a traumatic event or lived through significant trauma over a span of time (National Institute of Mental Health [NIMH], 2016). Typically occurring after a trigger in their environment, those suffering with the disorder may experience stress or fear, even when they are not in any danger. Other symptoms include flashbacks, bad dreams, lack of emotion, depression, tension, being easily startled, and difficulty sleeping (NIMH, 2016) (PTSD is discussed in more detail later, in Chapter 10). Again, these factors may lead to suicidal ideation, or worse, a suicide attempt (Kopacz et al., 2016). Additionally, research indicates that although women in the military may be exposed less to traumatic combat situations, they are more likely to experience other kinds of traumatic events, including sexual harassment, sexual assault, and an overall lack of peer support from their fellow soldiers (Tsai et al., 2012). Most importantly, all these circumstances increase their likelihood for substance use or abuse, victimization, possible justice involvement, and suicide.

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Many veterans with PTSD are prescribed medications once they are finally seen by medical care providers; oftentimes, this further contributes to their issues. Some become addicted or begin to self-medicate with other substances—because either they develop a tolerance to the prescription medications, experience terrible side-effects, or they are unable to continue the prescription for a variety of other reasons (e.g., lack of access to transportation, stable housing, and community-based services). Consequently, these individuals may begin to experience additional high-risk situations, such as loss of employment and personal relationships, and sometimes, a lack of housing (Figure 5.8). An increasing number of programs that specifically target displaced veterans without housing have been conducted by the VA, and case outcomes have improved greatly when programs (employment, healthcare, and housing services) are paired with mental health services (Tsai et al., 2012). Despite reports that an estimated 30 percent to 50 percent of men without housing have served in the military (Tessler et al., 2001), recent data released by the U.S. Department of Housing and Urban Development (HUD) has revealed a significant decrease in this percentage from previous years (U.S. Department of Housing and Urban Development [HUD], 2015). There is some concern that the effects of the COVID-19 pandemic and economic crash will eventually interfere with this progress, and numbers will rise as a result (Lawrence, 2020). Moreover, it must be noted that at-risk veterans without permanent housing are a difficult population to track, and therefore, the data should be interpreted conservatively. Across the United States, efforts in recent years have focused on expanding capacity inside the VA system. Former U.S. President Barack Obama issued an executive order in 2012 titled “Access to Mental Health Services for Veterans, Service Members, and Military Families.” This order called for the VA to hire 800 peer-to-peer counselors and 1,600 mental health professionals, and to establish a small number of pilot projects involving community-based care providers, with the goal of overall improvement in the mental health system (The National Council for Mental Wellbeing, n.d.). Moreover, several jurisdictions have established Veterans’ Treatment Courts, which will be discussed in more detail later in Chapter 7 of this text. Recently, reforms to the VA made during the (former) Trump Administration include improved choice of and access to medical and mental health care services (“VA Choice and Quality Employment Act of 2017”) and expanded benefits, including telehealth options (“Anywhere to Anywhere,” VA healthcare initiative) (The White House, n.d.). Programs designed to aid in access to and distribution of disability benefits and housing for veterans in need have also been reinvigorated—though, again, the effects of COVID-19 on improvements and resounding cuts due to the economic impact have yet to be realized.


CHAPTER 5 Intercept One: Law Enforcement

 Figure 5.8 Broken American Hero Source: By Srdjan Randjelovic. Shutterstock [Standard License],

Despite attempts to provide different types of medical care through “Vet Centers” that are scattered throughout cities in each state, historic barriers to their use include limited supply and choice (allegedly, only 33 percent reported ever using VA services). Veterans without housing—especially those with multiple diagnoses—are much less likely to have ever used VA services or to obtain access should they attempt to use them (Tessler et al., 2001). And further, research findings related to individuals with PTSD can only reveal information related to individuals who are actively seeking/ receiving services, indicating that there is a significant proportion of individuals suffering with co-occurring PTSD or other mental health disorders and substance abuse who are not seeking help. Such individuals are at risk to themselves and others, and a combination of symptoms and maladaptive behaviors may lead to critical encounters with police. Although CIT programs and modified versions of CIT and MHFA do incorporate modules on veterans, the brevity with which the information is delivered is a challenge, and continuing education related to these issues should be considered. Furthermore, police and other first responders who are not able to attend specialized training programs may not have enough knowledge as to the prime issues facing this group. Finally, in the context of self-care among first responders, many of whom are veterans, there is a tremendous amount of stigma that prevents some individuals from seeking services.

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Young Persons with Justice-System Involvement Youth with emotional, mental, and behavioral health (BH) disabilities are more likely to be arrested and incarcerated when compared to their peer counterparts without disabilities (Holmquist, 2013). Moreover, research consistently reveals that justice-involved youths experience a significantly higher rate of diagnosable mental and BH disorders in relation to the general youth population (50 percent to 70 percent vs. 9 percent to 13 percent; see Schubert & Mulvey, 2014). Based upon these trends, there is an increased need for attention on challenges in relation to police encounters with youths who have mental and BH disorders.

School-Related Concerns The most substantial challenges related to police encounters with this population rise from what has been referred to as the school-to-prison pipeline (STPP), which refers to school disciplinary policies and practices that have the effect of isolating, punishing, and restricting educational access for many disadvantaged youth who, as a result, are at risk of becoming entangled in the juvenile justice system (American Civil Liberties Union [ACLU]: “School-to-Prison Pipeline,” 2021). It is important to address this phenomenon when discussing police encounters with such juveniles because the pipeline reflects the prioritization of incarceration over education. Sadly, “twenty percent of youth offenders with emotional or behavioral health problems reported that they were arrested while in secondary schools” (Holmquist, 2013, p. 3). Many negative outcomes related to STPP are a product of the heightened use of zero-tolerance policies that automatically impose severe punishments on students, regardless of any circumstances surrounding an offense (“School-to-Prison Pipeline,” 2021). Such policies have had a detrimental effect on rates of detention, suspension, expulsion, and even arrests among youth (Amurao, 2013). For example, student suspension rates have increased from 1.7 million in 1974 to 2.7 million in the 2015 to 2016 school year—the most dramatic increases being among those students who have a history of abuse and neglect, poverty, physical or mental health disabilities, and who are ethnically and racially diverse (ACLU, 2021; Novak, 2019) Statistics reveal that rates of out-of-school suspension among students with behavioral and mental health disorders far surpass those of students without disabilities, especially students of color (U.S. Commission on Civil Rights, 2019). The STPP has led to more school districts increasing the use of police officers or school resource officers (SROs) as first responders to discipline disruptive students. According to the Center for Problem-Oriented Policing (2017), these sworn officers are expected to maintain three significant roles within schools: law enforcement, law-related counselors, and law-related educators. Current emphasis relies on their role as law enforcement, forcing


CHAPTER 5 Intercept One: Law Enforcement

them to deal with disruptive youth struggling with mental and BH issues and referring them directly to the juvenile justice system. Controversy has emerged regarding the use of SROs in an educational environment for juveniles with mental and BH disorders. The competing missions between schools and the justice system create significant challenges for dealing with youth in general. Many of these challenges are linked to a lack of resources, training, and education related to student behavior as it relates to mental and BH. In short, law enforcement, education professionals, and emergency personnel are not receiving adequate training and knowledge on how to manage students with special needs.

Solutions The most useful solutions for the current issue include the development of crisis intervention–based training and diversion programs geared toward decriminalization of youth. For example, some improvements in police– youth encounters have been seen when first responders are trained in Crisis Intervention Training for Youth (CIT-Y), an expanded version of CIT. Not only can this effective pre-arrest diversion technique be utilized for law enforcement, but it also works with schools, SROs, emergency response services, youth mental health providers, and parents to accomplish various goals (NAMI, 2021: “Designing CIT Programs for Youth”; Skorek & Westley, 2016). CIT-Y training ranges from 8 to 40 hours, depending upon the jurisdiction, and provides a strict curriculum that embraces early intervention by merging with mental health services to prevent youth from becoming involved in the juvenile justice system. In addition to CIT-Y, other diversion programs, many of which would be more appropriately categorized as Intercept 0 early intervention (EI) options, have revealed successful outcomes. Some examples include Children in Crisis (CIC) and Children’s Crisis Intervention Training (CCIT) (Markey et al., 2009). Scholars recommend that diverting youth into community-based services at the earliest point of contact is the most influential and cost efficient. Like the SPRs discussed earlier, through partnerships with local mental health resources, youth-based diversion programs provide necessary treatment while preventing crime and keeping the community safe (Vanderloo & Butters, 2012). CIT-Y and other youth crisis intervention training programs are relatively new; thus, research on their outcomes is extremely limited, though indicative of successful outcomes. There is a decrease in the number of youths who are placed in residential and secure juvenile placement facilities and support for mental health and recidivism outcomes (Vanderloo & Butters, 2012). Findings also show a reduction of symptoms and risk behaviors, improvement in functioning, and a decrease in recidivism rates; however, comparison groups were not matched on demographics or historical data, indicating the need for more research in this area. To produce meaningful results, it is essential that programs provide pre- and post-tests on training

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participants, construct program evaluations outside of training evaluations, and collect baseline data prior to implementing the program to collect supportive empirical evidence (Markey et al., 2009). Another diversion strategy is the use of civil citations as means of providing youth with the opportunity to change their behavior and avoid a felony record. The Florida Department of Juvenile Justice (DJJ) civil citation initiative represents a shift in managing first-time, nonviolent juvenile offenders (Florida Department of Juvenile Justice, “Civil Citation,” 2020). The Civil Citation Program (CCP) allows police officers to issue citations rather than arrest youth ages 8 to 17 who commit misdemeanor offenses. Once cited, youth undergo two psychological assessments to determine criminogenic risk factors. The results of these assessments are then used to create an individualized treatment plan that embraces restorative justice elements, as well as community-based services. If the youth fail to complete their plan, they are then arrested and processed through the traditional juvenile justice system. According to program statistics, CCP has been a successful diversion measure, in that it has improved access to treatment services and provided many youths the opportunity to avoid arrest and further processing through the justice system, with a recidivism rate of only 3 percent. Furthermore, reports indicate that CCP is more cost effective (Florida Department of Juvenile Justice: “Civil Citation,” 2020).

Summary of Key Points Thus Far Consistent with the traditional funnel framework, the SIM can serve as a roadmap to effectively divert PwMI out of the criminal justice system to achieve the greatest impact on recidivism with this population. Diversion strategies are available at the first intercept point. Research indicates that public safety risks are reduced when police and other first responders are trained in de-escalation techniques, have an improved understanding of mental health and substance use disorders, and have the resources to provide appropriate service linkage to those in need.

THE MENTAL HEALTH AND WELL-BEING OF POLICE Current policies, programs, and practices in many jurisdictions do not properly identify and prioritize the mental health needs of police and other criminal justice actors who, in the course of their work, are subjected to trauma and stress on a regular basis. This is especially true more recently, as a wave of anti-police sentiment has swelled, police-citizen relations in many communities (especially in communities of color) are reeling over police use of force and COVID-19, and departments nationwide are challenged with department scrutiny and low officer morale (Westervelt, 2021). The remainder of this chapter provides an introductory discussion of issues pertaining to the mental health and wellness of the police.


CHAPTER 5 Intercept One: Law Enforcement

Police Stress Historically, little attention has been paid to the mental health maintenance of police officers and other first responders who are charged with resolving many of the social problems just set forth in the preceding sections (e.g., persons without housing, PTSD, suicide risk, substance abuse, and co-occurring substance abuse and mental health disorders). What we do know, however, is that police undergo an enormous amount of stress (Ruiz, 1993), and due to the nature of the stress and the intervening trauma they encounter in the field, they are subject to their own mental health and substance use problems (Allison et al., 2019; O’Hara et al., 2013; Violanti et al., 2017). The most concerning issue is that police are even more resistant to seeking help/services than the general population. A great deal of the resistance can be attributed to stigma and role expectations (Karaffa & Koch, 2016; Violanti et al., 2017). Stigma related to mental illness, such as presumptions of dangerousness and instability, was discussed in Chapter 1. Regarding role expectations of police, public perceptions revolve around this ideal moral being who is physically strong, mentally healthy, and emotionally balanced. Any sign of weakness in terms of mental or physical problems may render them incapable of properly doing the job (Karaffa & Koch, 2016). Public criticism (sometimes accompanied by violence) and fatigue due to the hours and on-the-job expectations, as well as dealing with untreated psychiatric conditions, follow them in both their professional and personal lives.

FAST FACT 5.5 COMPASSION FATIGUE Compassion Fatigue: A phenomenon that is directly related to feelings of exhaustion and burnout that helping professionals experience after meeting the physical and emotional needs of the clients they serve (C. Lane, personal communication, June 11, 2016). Negative efects of compassion fatigue may include anger and irritability, increased cynicism, intimacy problems and problems in personal relationships, and suicidal thoughts.

Everyone experiences stress at some time. In fact, some levels of stress may benefit an individual. Regarding policing, experiencing stress may help individual officers avoid dangerous situations and motivate problem-solving responses under a variety of conditions and circumstances. The problem arises, however, when the levels of stress increase in frequency and intensity and persist without help or treatment support. For reasons discussed previously (e.g., stigma), this is often the case with police work. Clearly, police officers encounter stress-provoking situations on a regular basis— some involving the exposure to traumatic events.

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FAST FACT 5.6 TYPES OF INDIRECT TRAUMATIZATION Secondary traumatic stress (STS) may occur when an individual is indirectly exposed to at least one single traumatic event as recounted by another. The afected individual will experience symptoms that mimic posttraumatic stress disorder (PTSD). Vicarious trauma refers to the cognitive changes that may occur because of empathy from cumulative exposure to the traumatic event of another. Burnout refers to work-related emotional exhaustion, which results from occupational stress. There is a growing body of research related to the efects of STS or vicarious trauma and burnout on police, mental health and social workers, and other human services and emergency medical response personnel (e.g., see Cieslak et al., 2014 for a review of the research). Source: National Child Traumatic Stress Network, Secondary Traumatic Stress Committee (2011).

The literature suggests that there are two types of stress associated with police work: organizational and operational. Organizational stress relates to factors such as rotating shift work, department culture, and interpersonal conflicts with other officers. Operational stress refers to the nature of police work and includes factors such as extended periods of boredom that are sharply contrasted with extreme traumatic events that provoke fear and unpredictability (Chae & Boyle, 2013). Unfortunately, untreated, or delayed treatment for stress may lead to an increased susceptibility to other behavioral disorders, including anxiety, depression, and substance use. A continued failure to recognize stress and its effects (mental and physical), and to find a legitimate and safe stress-relief outlet to express feelings of frustration and disappointment, can lead to problems with personal relationships, particularly when substance use (usually alcohol) is also used as a coping strategy. As a result, police and other first responders are susceptible to other psychological consequences which may include, compassion fatigue, self-rejection, and self-directed violence, including the risk of suicide (Chae & Boyle, 2013; O’Hara et al., 2013).


Contributor: William D. Kewer, Chief of Police; Middletown, RI and Lieutenant Colonel (Ret), Connecticut State Police This would be the frst time that I have written my thoughts and experiences on Sandy Hook,8 almost ten years later. I share these opinions and thoughts to cultivate conversation in hopes of promoting and improving police ofcer mental health and wellness for future generations of police ofcers.


CHAPTER 5 Intercept One: Law Enforcement

Over my law enforcement tenure, I have been involved in all aspects of law enforcement and have been very blessed to have overcome many dangerous situations. Police ofcers training and well-being needs have come a long way in the past 30 years. At the start of my career, mental health for police ofcers or any organized peer to peer support programs were non-existent. In the late 1980s, early 1990s most ofcers relied on each other for support to help cope with certain scenes or personal issues. Often times these were your close work friends, your family and close friends outside of work. When defning key characteristics of a good police ofcer, most would describe them as strong, authoritative, knowledgeable, caring and someone who is able to cope and adapt to any situation to protect others, regardless of the stressful event. However, not many people other than those who work in law enforcement truly understand the sights, sounds, and smells a police ofcer will experience over the course of their careers. I always said that police ofcers have a front row seat to the circus of life. If you really think about it, police ofcers see the very good in people and unfortunately the very worst. Police ofcers throughout their careers, see extremely bad things that no training would be able to prepare you for. They will see and experience numerous fatal motor vehicle accidents, suicides, hangings, stabbings, fre fatalities, numerous deaths of all ages and circumstances, co-worker suicides, and unfortunately the possibility of dealing with a horrifc mass shooting with multiple victims to include children, such as the tragic event of Sandy Hook Elementary School. Although ofcers wear many hats, we also look for ofcers who have empathy in the performance of their duties. However, early on in policing there was a certain stigma of weakness attached to those ofcers who may have showed feelings or had difculty in dealing with a certain scene. This stigma is the reason why most ofcers may keep their feelings to themselves and only share those feelings with a select few. Police ofcers need to understand that they are human, and that they are going to have normal emotional reactions to a stressful or critical event. Enhanced peer support programs allow police ofcers to have an outlet, a release valve if you will, to talk about and get through the tough situations they will experience on the job. Although law enforcement has come a long way, there is still much more work left to do in area of police ofcer mental health and wellness. As you go through life, there are many tragic events that you know exactly where you were and what you were doing. Friday, December 14, 2012, just before 10:00 am was one of those crucible moments that would change my perspective on many things, but police mental health and wellness would take center stage in the weeks, months and years following the tragic event at Sandy Hook Elementary. At that time, I held the rank of Lieutenant and was the commanding ofcer of the trafc services unit. I was traveling to headquarters in Middletown, CT when I received a call from one of my troopers who was escorting a prisoner van with another trooper down to Danbury Court. The trooper advised me that they were in Newtown, and asked permission for both troopers to break

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from the escort and respond to Sandy Hook Elementary. Both troopers were directed to immediately respond to the active shooter. The last direction I gave to the trooper was to ensure that he and his partner were wearing their bullet proof vests, team up with responding ofcers and follow the active shooter protocol by immediately entering the school to mitigate the threat. What do say to a person going into a potential life or death situation, “be careful and stay safe.” Immediately after I got of the phone, I got a call from the Lieutenant Colonel of Field Operations, directing me to immediately respond to state police headquarters to facilitate all departmental needs that would be needed, and the monumental tasks associated with a mass shooting of this caliber. Calls from around the state, country and the world came into headquarters ofering resources and those just sending condolences. Both responding troopers who participated in the initial entry to the school and ten other troopers assigned to the accident reconstruction squads played an integral role in the investigation of this tragic event. The accident reconstruction squad assisted the major crime detectives in the mapping of the entire scene. As you can imagine the sights, sounds, and even smells they encountered will forever be etched in their memories. As their commanding ofcer and a leader within the agency, I knew that I had to take proactive steps in supporting and protecting their mental health, as this truly was the most brutal scene anyone could have ever imagined. In 2012, most law enforcement agencies had made great strides in promoting ofcer wellness and implementing peer-to-peer support programs. However, the success of these programs largely depends on the positive involvement by key members of all ranks within the respective agency. Another critical component to any program’s success is confdentiality. Confdentiality is absolutely paramount in order to build trust within the organization, so that members of the team will feel comfortable utilizing the peer-to-peer support services. Unfortunately, this has not always been the case, and peer support programs have failed due to a lack of confdentiality. In the weeks during the investigation, I was compelled to act in a manner that would beneft my personnel in hopes of relieving some immediate stress associated with such a tragic scene, but more importantly for the long-term efects it may have in the months and years to follow. Although the agency had a peer-to-peer support program in place, I quickly realized that due to the size and nature of a national tragedy, combined with the amount of personnel exposed to the investigation, that an event of this magnitude warranted a more proactive response in order to provide the necessary resources to our personnel. I had some great contacts and reached out to our partners with the Federal Bureau of Investigation (FBI), New Haven ofce to convene their professional Critical Incident Debriefng Team, made up of sworn and civilian professionals, to include specially trained agents, counselors, doctors, and clinicians to talk with our trafc unit personnel.


CHAPTER 5 Intercept One: Law Enforcement

At the time, the Trafc Services Unit personnel were all senior experienced road troopers who were among some of the very best that I have ever worked with in my career. In preparation for the debrief meeting, I selected a date upon which I knew everyone was scheduled to work and reserved a volunteer fre station in a small rural town in Connecticut. Prior to the meeting, I personally met with each trooper separately to see if they were okay, and briefy talked about their experience with the investigation. At this time, I informed them and explained the purpose of the upcoming debrief meeting with the FBI. I advised each of them that the debrief meeting would only include members of our unit who were directly involved and discussed the importance of their attendance at the debrief meeting. Although it was not mandatory for anyone to attend, by meeting with them face to face, it made it difcult for them to say no. I told them each that they are all true leaders and just by their commitment to attend the debrief meeting, would encourage others and greatly beneft other members of the team. The FBI Critical Incident Debriefng Team and I arrived at the location early. I wanted to ensure that the tables were in a big square as this was not a presentation, it was a conversation in which you want everyone to be able to participate if they so desire. Of course, you also can’t have a meeting without cofee and breakfast food. The debriefng team and I reviewed the unwritten agenda for the meeting. One by one all invited members of the Trafc Services Unit arrived at the debriefng. People grabbed a cofee and made small talk, which was generally all positive conversation. I was very proud to see that every invited trooper attended. As you might expect, just the mere nature of attending a “debriefng” meeting on such a tragic incident, caused people to feel a little anxious and uncomfortable. I have learned a great deal from others in my law enforcement tenure, and experience teaches many things. One of the biggest attributes taught by experience is the ability to be comfortable, being uncomfortable, no matter what the situation. This debrief meeting was something that you really don’t prepare for, as it was such a tragic event that afected so many people in so many diferent ways. The goal is to make people feel comfortable in hopes of cultivating that uncomfortable conversation, to turn that negative situation into something positive that will assist everyone with the healing process. Having attended numerous debriefs over the years, I have found that you don’t need to talk in order to greatly beneft from a debrief, more importantly you just need to listen. Listening allows you to absorb what others experienced and their thoughts during a critical incident. When listening to people who have been through similar critical incidents together, it causes oneself to look inward and understand that your thoughts, emotions and feelings are no diferent than what others are experiencing. Police ofcers are not super humans, they are just regular people who are asked to perform extraordinary duties. I started of the meeting of with the introductions. The debriefng team introduced themselves, followed by each one of the troopers. After the

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introductions, I thanked everyone for their attendance and summarized the importance of the debriefng and its purpose to support everyone who experienced this unimaginable tragic event. There have been numerous mass shootings in our country since the Columbine High School Shooting in 1999, however Sandy Hook was diferent as most of the victims were tragically just six and seven years of age. I sincerely thanked every one of the troopers in front of the debriefng team for their eforts in the role they each played in the Sandy Hook investigation, and more importantly for their attendance and commitment to support each other now and for years to come. I also let them know that I truly cared for each of them and their well-being. I explained that it is critically important to process such a tragedy because no one had ever experienced what these troopers experienced during this investigation and my hope was that the debriefng meeting would help everyone. As their Commanding Ofcer, it was at this time I excused myself from the debrief meeting, because I was not personally exposed to the working crime scene investigation, and I strongly believed that each of them would be more open to sharing their thoughts within the supportive group environment. The meeting went on for over two hours and not one person left that meeting. For the days and weeks following the debrief, I continued to talk with my personnel who were extremely appreciative of bringing this meeting to fruition. To this day, I still keep in contact with troopers around the anniversary of Sandy Hook. Unfortunately, everyone who was involved in the response and subsequent investigation will always be attached to this national tragedy. Sandy Hook will always be a part of them and the memories of what they experienced will always be triggered by the mere mention of those two words, Sandy Hook. Although law enforcement has come a long way in police ofcer mental health and wellness, it needs to be embedded into each organization and become part of the police culture. This can be better accomplished through established policies, training, enhanced peer to peer support programs, and utilizing early awareness intervention programs.

POLICY & PRACTICE 5.3 MAXIMIZING OFFICER WELLNESS AND SAFETY Communities nationwide have dedicated time and efort to developing resources tailored to minimize stigma and maximize police access to safety and wellbeing. Below is sample of weblinks representing only some of these eforts at the national level: • • • • • ofcer-safety-and-wellness


CHAPTER 5 Intercept One: Law Enforcement

Police Suicide A national suicide fact sheet for the general population of adults reported that in 2019, there were approximately 47,500 deaths by suicide in the United States (which translates to about 1 death every 11 minutes) (Centers for Disease Control [CDC], 2021). According to the report, 12 million adults (aged 18 and older) thought about suicide in 2019, 3.5 million people made a plan, and an estimated 1.4 million attempted suicide. Although existing comparative data on police-specific suicides are inconsistent in terms of reported risk compared with that of the general population, national data on occupational comparisons do consistently report increased risk for suicide among “protective services” or “service” workers, a category that includes police officers (Milner et al., 2013). In one study that examined workplace vs. nonworkplace national suicide rates between the period of 2003–2010, findings indicated that the workplace suicide rate for those in “protective services” occupations was 3.5 times greater than that of U.S. workers overall (Tiesman et al., 2015). In another study based on web surveillance of suicides among LEOs between 2009 and 2013, findings revealed the following demographic trends related to deaths by suicide: A higher proportion of LEO men between the ages of 40 and 44 die by suicide (92 vs. 6 percent, on average across all three years under examination); the average number of years of service among those who die by suicide is about 15 to 19 years; and, most deaths by suicide were among LEOs who ranked below sergeant (O’Hara et al., 2013). In corroboration with other research, the O’Hara et al. study revealed that the weapon of choice is a firearm. Of the web reports where a perceived reason was stated, personal problems of the officer was frequently cited. Most concerning is the finding that, in many cases, there were no observable signs of suicidal ideation or possible imminent attempt. Aside from its profound impact on individual friends, family, and co-workers, police suicide has a resounding impact on the law enforcement community—especially at the department level. Consequently, wellness programming and policy must continue to be forthcoming regarding critical-incident stress management (CISM) and debriefing (CISD)9 and ongoing mandatory psychological assessments of officers—especially considering police-citizen relations in recent years, and the COVID-19 pandemic and its projected aftermath. Effective strategies have included confidential peer-counseling programs, psychoeducation, and prevention training programs (Chae & Boyle, 2013).

FAST FACT 5.7 SUICIDE PREVENTION Contact the National Suicide Prevention Lifeline: Call 1-800-273-TALK (1-800-273-8255)

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You can also connect 24/7 to a crisis counselor by texting the Crisis Text Line. Text HOME to 741741. Both are free and confdential. You’ll be connected to a skilled, trained counselor in your area. Other Resources (some are law-enforcement specifc): Veterans Crisis Line (Veterans only): 1-800-273-8255 & press 1, or text 838255 Cop Line: 1-800-COPLINE Better Help: Talk Space: Here for You Blue:

TAKE-HOME MESSAGE Law enforcement has played an increasingly predominant role in the management of persons experiencing mental health disorders. Thus, their role as first responders is crucial, in that they have the most discretion in resolving disputes involving persons with mental illness and have the best chance of diverting them from the justice system (Franz & Borum, 2011). In the past, mental health and law enforcement have not worked closely together, causing various challenges when dealing with persons with mental illness. Unfortunately, empirical and anecdotal evidence suggests that police often become frustrated with the process of accessing crisis and emergency treatment services. Police have reported encounters with treatment providers who are antagonistic toward them, making efficient consumer linkages and engagement in services difficult, if not impossible (Cross et al., 2014; Franz & Borum, 2011; Ogloff et al., 2013). In many instances LEOs encounter a PwMI who needs services but is either unable to obtain services or does not wish to avail them. Faced with this dilemma, officers sometimes use the criminal justice system as a means of requiring an evaluation and treatment of the PwMI. Petty crimes such as disorderly conduct, trespassing, and violations of alcohol and illegal substance statutes are charged to bring the PwMI into the criminal justice system. It is also an expression of the frustration some officers feel when mental health assistance is limited or unavailable, and unfortunately there are also those officers who refuse to deal with the mental crisis and instead merely arrest the PwMI. This practice has been termed mercy booking (Reisig & Kane, 2014). Limited training and knowledge about mental illness, as well as the inability to obtain adequate resources and alternatives, have also contributed to current problems. The overarching theme of combined perceptions is that budgetary constraints in mental health services have created an overreliance on law enforcement when a mental health crisis occurs. Programs such as CIT and the use of co-responder teams are extremely beneficial in terms of diverting an individual in crisis to mental health services/treatment.


CHAPTER 5 Intercept One: Law Enforcement

Existing research indicates that these training programs increase knowledge among participants, thereby increasing empathy and reducing much of the stigma associated with mental health and substance use disorders at the most crucial point in time—before an individual case penetrates the criminal or juvenile justice system (e.g., see Compton et al., 2006; Jorm et al., 2010). Unfortunately, at the same time, police and other first responders are struggling with job-related stress, which oftentimes leads to their own mental health–related issues. Given the stigma associated with mental illness and recovery, criminal justice officials neglect to engage in treatment services, which present several issues that are only exacerbated during their work. For so many reasons, it is essential that we continue to devise training programs that educate and improve responses to mental illness and co-occurring substance use. It is only when communities improve attitudes and access to services that we can effectively divert PwMI out of the criminal justice system and make significant reductions in the criminalization of mental illness. Many of these challenges are not new, yet further research is needed to test the ways that crisis responders should continue to build on multidisciplinary collaborations—particularly those that involve diversion from further penetration into the criminal justice system. We must continue to train key personnel on how to de-escalate crises and transport consumers to places other than jail for assessment, stabilization, and treatment. Furthermore, process and outcome data must be collected and analyzed and utilized to improve programs. Finally, regarding the mental health maintenance of police and other gatekeepers, department supervisors should be trained in recognizing burnout or compassion fatigue, and policies should be developed and implemented about addressing it. As a related measure, agencies should engage in mandatory critical-incident stress debriefing periods, whether after a traumatic event or at the close of each shift, where officers can safely discuss their concerns and frustrations in a supportive environment and develop useful coping strategies in dealing with both operational and organizational stressors.

Questions for Classroom Discussion 1. What are some of the challenges and needs of LEOs who encounter PwMI who are experiencing a mental health–related crisis? What are some of the challenges and needs of PwMI who encounter LEOs during a mental health crisis? Are these challenges and needs complementary or conflicting? 2. It has often been said that “CIT is not just training.” What do you think is meant by this statement? How else might communities need to respond so that programs such as CIT and co-responders are successful

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at diverting PwMI and maintaining safety for first responders, PWLE, and other community members? 3. How might stigma play a role in the school-to-prison pipeline?

KEY TERMS & ACRONYMS • • • • • • • • • • • • • • • • • •

Burnout Civil citation Compassion fatigue Crisis Intervention Training for Youths (CIT-Y) Mercy booking Mobile Crisis Unit or Team (MCU or MCT) Operation Enduring Freedom (OEF) Operation Iraqi Freedom (OIF) Parens patriae School-to-prison pipeline (STPP) Secondary traumatic stress (STS) Specialized policing responses (SPRs) Suicide by cop Suicidal ideation Tolerance Trigger Vicarious trauma Welfare check

NOTES 1 Transcript is from audio related to fatal police shooting that occurred on September 30, 2020, in Lancaster, Pennsylvania. As transcribed, the audio covers the dispatch of police to a mental health-related crisis call. Taken and slightly adapted from Office of the District Attorney of Lancaster County (2021). Retrieved at 2 In policing, a statistical summary report of crime patterns and police activities in a jurisdiction/geographic area or region. 3 The “pledge” requires 100 percent of officers to be trained in MHFA and 20 percent in CIT. 4 The “Memphis model” of CIT training, although the original format and the most replicated, is not the only model used across the United States (Cross et al., 2014). 5 Primarily located in the Western U.S., Frontier communities are those areas having fewer than ten people per square mile (Haque et al., 2021). 6 Summary of statistics retrieved from the following study: Mohandie, K., Meloy, J. R., & Collins, P. I. (2009). Suicide by Cop among Officer Involved Shooting Cases. Journal of Forensic Science, 54(2), 456–462.


CHAPTER 5 Intercept One: Law Enforcement

7 Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) ( 8 The author is referencing a school-shooting that took place at an elementary school in the U.S. (Connecticut), on December 14, 2012. The shooter, Adam Lanza, took the lives of 26 people, including 20 children between the ages of 6–7 years. 9 Critical Incident Stress Management (CISM) is a comprehensive, multicomponent, and multistage crisis intervention system which incorporates strategies that can be applied to individuals and groups. Critical Incident Stress Debriefing (CISD) is a post-crisis model designed to mitigate symptoms, assess the need for follow-up, and to provide post-incident closure, if possible. For more information, visit

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Ohlheiser, A., & Izadi, E. (August 18, 2015). Judge: N.M. Police Officers Will Stand Trial for 2014 Fatal Shooting of a Homeless Man. The Washington Post. Retrieved January 3, 2017, from Ortiz, E. (October 28, 2020). Family says Walter Wallace Jr., Killed by Philadelphia Police, Needed Mental Health Treatment. NBC News Online. Retrieved from Pearson, V. N. (2014). Police Officers on the Front Line as Mental Health Workers. The Police Chief, 81, 18–19. Pennsylvania Mental Health & Justice Center for Excellence. (July 25, 2013). Specialized Police Response in Pennsylvania: Moving toward Statewide Implementation. Philadelphia, PA: Drexel University. Peterson, J., & Densley, J. (2018). Is Crisis Intervention Team (CIT) Training Evidence-Based Practice? A Systematic Review. Journal of Crime and Justice, 41(5), 521–534. Pillay, P., & Thomas, S. D. M. (2015). Police Contact with Suicidal Individuals: A Comparison of Self-In Flicted Suicidal Behavior and Potential Police Provoked Shooting Incidents. International Journal of Emergency Mental Health and Human Resilience, 17(2), 555–562. Police 1 Roundup. (September 17, 2021). How Police Training Is Being Reformed. Retrieved from roundup-how-police-training-is-being-reformed-MVEzuCl3Iz9jxYhu/ Possis, E., Thao, B., Gavian, M., Leskela, J., Linardatos, E., Loughlin, J., & Strom, T. (2014). Driving Difficulties among Military Veterans: Clinical Needs and Current Intervention Status. Military Medicine, 179(6), 633– 639.–00327 Reisig, M. D., & Kane, R. J. (2014). The Oxford Handbook of Police and Policing. New York, NY: Oxford University Press. Richman, M. (2018). Veterans and the Criminal Justice System. U.S. Department of Veterans Affairs, Office of Research & Development. Retrieved from Russell, C., Ali, F., Nafeh, F., LeBlanc, S., Imtiaz, S., Elton-Marshall, T., & Rehm, J. (2020). Examining Substance Use Services and Treatment Barriers and Needs among People with Lived Experience (PWLE) in Ontario, Canada. Research Square, 1–17. Retrieved from Ruiz, J. M. (1993). An Interactive Analysis between Uniformed Law Enforcement Officers and the Mentally Ill. American Journal of Police, 12(4), 149–162. Ruiz, J. M. (2002). Policing Persons with Mental Illness: The Pennsylvania Experience. Harrisburg: Pennsylvania State Data Center, Institute of State and Regional Affairs, Penn State Harrisburg. Ruiz, J. M., & Miller, C. (2004). An Exploratory Study of Pennsylvania Police Officers’ Perceptions of Dangerousness and Their Ability to Manage Persons with Mental Illness. Police Quarterly, 7(3), 359–371. Schubert, C. A., & Mulvey, E. P. (2014). Behavioral Health Problems, Treatment, and Outcomes in Serious Youthful Offenders. Juvenile Justice Bulletin. Retrieved from Seo, C., Kim, B., & Kruis, N. E. (2020). Variation across Police Response Models for Handling Encounters with People with Mental Illnesses: A Systematic Review and Meta-Analysis. Journal of Criminal Justice, 72, 101752.

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with Non-Workplace Suicides. American Journal of Preventative Medicine, 48(6), 674–682. Tsai, J., Rosenheck, R. A., Decker, S. E., Desai, R. A., & Harpaz-Rotem, I. (2012). Trauma Experience among Homeless Female Veterans: Correlates and Impact on Housing, Clinical, and Psychosocial Outcomes. Journal of Traumatic Stress, 25(6), 624–632. U.S. Commission on Civil Rights, Briefing Report. (July, 2019). Beyond Suspensions: Examining School Discipline Policies and Connections to the School-To-Prison Pipeline for Students of Color with Disabilities. Retrieved from U.S. Department of Housing and Urban Development. (2015). HUD Reports Homelessness Continues to Decline Nationally: Progress Uneven as Some Communities Combat a Housing Affordability Crisis (HUD Press Release No. 15–149). Retrieved from press/press_releases_media_advisories/2015/HUDNo_15–149 U.S. Department of Veterans Affairs. (2016). Patient Access Data. Retrieved from Usher, L., Watson A.C., Bruno, R., Andriukaitis, S., Kamin, D., Speed, C., & Taylor, S. (2019). Crisis Intervention Team (CIT) Programs: A Best Practice Guide for Transforming Community Responses to Mental Health Crises. Memphis, TN: CIT International. Vanderloo, M. J., & Butters, R. P. (2012). Treating Offenders with Mental Illness: A Review of the Literature. Salt Lake City, UT: Utah Criminal Justice Center, University of Utah. Violanti, J. M., Charles, L. E., McCanlies, E., Hartley, T. A., Baughman, P., Andrew, M. E., … & Burchfiel, C. M. (2017). Police Stressors and Health: A State-of-the-Art Review. Policing: An International Journal of Police Strategies & Management, 40(4), 642–656. Von Drehle, D. (2014, May 27). Iraq Vet Killed in Gunfire with Police Was Turned Away by VA Hospital. Time. Retrieved January 3, 2017, from http:// Wallace, C., Mullen, P. E., & Burgess, P. (2004). Criminal Offending in Schizophrenia Over a 25-Year Period Marked by Deinstitutionalization and Increasing Prevalence of Comorbid Substance Use Disorders. American Journal of Psychiatry, 161(4), 716–727. Washington Post. (2021). Fatal Force: Police Shootings Database. Retrieved from Waters, R. (2021). Enlisting Mental Health Workers, Not Cops, In Mobile Crisis Response. Health Affairs, 40(6), 864–869. hlthaff.2021.00678 Watson, A. C., Ottati, V. C., Draine, J., & Morabito, M. (2011). CIT in Context: The Impact of Mental Health Resource Availability and District Saturation on Call Dispositions. International Journal of Law and Psychiatry, 34(4), 287–294. Weaver, C. M., Joseph, D., Dongon, S. N., & Fairweather, A. (2013). Enhancing Services Response to Crisis Incidents Involving Veterans: A Role for Law Enforcement and Mental Health Collaboration. Psychological Services, 10(1), 66–72. Wells, W., & Schafer, J. A. (2006). Officer Perceptions of Police Responses to Persons with a Mental Illness. Policing: An International Journal of Police Strategies & Management, 29(4), 578–601.

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Intercept Two

Initial Detention/Initial Court Hearings Jesse S. Zortman, Michael E. Antonio, Meghan Kozlowski, and Michele P. Bratina Dave is a 32-year-old man who was arrested for aggravated stalking on June 13, 2013. He had only been in California less than one year and was struggling to get on his feet. The arrest report read: “Dave states that he was tired of ‘living on the streets’ and being hungry. He would rather stay in jail than have to worry about stealing food to survive.” The report also noted that he complained to the arresting officer about “nagging voices in his head” and that he purposely violated an injunction to go to jail. Upon intake at the county jail, Dave was screened for potential mental health issues and risk for suicide. The results of the assessments indicated that he may have some history of mental illness, but that he did not pose a risk of self-harm at present. While in jail, Dave was further assessed by mental health staff. After meeting with a public defender, he was evaluated for competency. After two weeks of incarceration in the county jail (and with no record of the competency evaluation results), correctional staff reported that Dave was agitated, pacing, and “gibbering” to himself. One correctional staff member reported that Dave seemed convinced that “the government” was recording every move he makes because they are planning to kill him when staff are not present. Dave has been neglecting his hygiene and he refuses to eat any food, claiming that it is “probably poisoned.” There are multiple and recent accounts by staff and other incarcerated persons of him constantly pacing in his cell and screaming obscenities. Because of the paranoia and restricted eating, Dave has lost more than ten pounds.1

INTRODUCTION Like “Dave” from the case above, individuals with mental health issues are often not diverted after their initial encounter with law enforcement, emergency medical personnel, or mobile crisis teams. There are many reasons for this, and they may include the severity of offense, prior record, lack of police training in crisis intervention, and lack of community-based resources or other pre-booking diversion programs (Compton & Kotwicki, 2007). In such cases, the individual may be transported by police to the local jail or detention center, where they will be officially booked or processed and subsequently screened by correctional intake staff for custody issues, which may include mental health status, risk of

DOI: 10.4324/9781003120186-6



CHAPTER 6 Intercept Two: Initial Detention/Initial Court Hearings

self-harm/suicide, substance use/abuse, and propensity for violence (Compton & Kotwicki, 2007; Fagan & Ax, 2011; Osher et al., 2012). While this course of events certainly places a person with lived experience (PWLE) at risk for further penetration in the traditional justice system, it also moves the individual further along in the Sequential Intercept Model (SIM), thereby presenting opportunities for post-booking diversion strategies—the subject of this chapter (Figure 6.1).

 Figure 6.1 Path to Incarceration; Eastern State Penitentiary; Philadelphia, PA Source: Michele P. Bratina (Author)

FAST FACT 6.1 POLICE ENCOUNTERS IN THE COMMUNITY Findings from a qualitative feld research study with the Chicago Police Department revealed the variety of service calls police receive that are related to mental illness. These mental health-related encounters came from throughout the community including: • • • • • •

Young people in distress Families in distress Co-occurring substance use issues Chronic vulnerability Suicide risks System defcits and inconsistencies

Source: Wood, J. D., Watson, A. C., & Barber, C. W. J. (2021). What Can We Expect of Police in the Face of Defcient Mental Health Systems? Qualitative Insights from Chicago Police Ofcers. Journal of Psychiatric and Mental Health Nursing, 28, 28–42.

Post-Booking Diversion: An Overview 175

Post-booking diversion at Intercept 2 can occur after an arrest, during initial detention, initial hearings, or during assistance by pretrial services (DeMatteo et al., 2013). A substantial part of diversion involves the availability and quality of resources related to the screening and assessment of defendants for mental health and co-occurring substance abuse after they have been arrested and subsequently charged with an offense. It also includes the screening and assessment for the risk of suicide/self-harm in secure confinement (Fagan & Ax, 2011). Diversion programs allow for the complex needs of people with mental illness (PwMI) to be managed in a community-based setting and remove the burden from correctional professionals who likely have minimal, if any, training in mental health intervention (Ryan et al., 2010; Scott, 2020). This chapter provides details about the application and evaluation of several diversion strategies, such as screening and assessment by correctional staff and the effectiveness of system integration in the development of effective jail diversion programming.

FAST FACT 6.2 COUNTY DIVERSION STRATEGIES Most large urban counties, and many smaller counties, have created specialized police response programs, established programs to divert people with mental illnesses charged with low-level crimes from the justice system, launched specialized courts to meet the unique needs of defendants with mental illnesses, and embedded mental health professionals in the jail to improve the likelihood that people with mental illnesses are connected to community-based services. Source: Haneberg, R., Fabelo, T., Osher, F., & Thompson, M. (2017). Reducing the Number of People with Mental Illnesses in Jail: Six Questions County Leaders Need to Ask. Retrieved from bt7vCn5PqXCy96DMcJ5UgN?

POST-BOOKING DIVERSION: AN OVERVIEW Post-booking diversion programs are commonly categorized into three tiers, depending on an offender’s stage in the legal process: pre-arraignment, post-arraignment, and mixed (Steadman et al., 1995). Pre-arraignment programs involve the collaboration of jail and pre-trial services staff who work to negotiate client entry into mental health and other support services, secure client compliance, and obtain court concurrence. The goal at this level is the immediate identification and engagement of individuals needing mental health and/or substance abuse services before invoking the formal court process. Furthermore, pre-arraignment strategies save time and financial resources for the community and prevent criminalization and serious decompensation of a PwMI who would be more effectively served by another system of care (Griffin et al., 2015).


CHAPTER 6 Intercept Two: Initial Detention/Initial Court Hearings

Post-arraignment programs involve the collaboration of staff working in jails, community mental health centers, courts, and probation and pretrial services. Programs at this stage focus on obtaining necessary mental health evaluations, negotiating treatment plans, obtaining program and client agreement, and obtaining satisfactory community supervision mechanisms for the court. A mixed program constitutes a combination of pre- and post-arraignment program organizations, staff, and issues as listed above. It is imperative to note that even the most successful diversion strategies will still require compliance from program participants. As might be expected, diversion staff are a diverse mix of individuals, and may include varied criminal justice and mental health professionals, including correctional staff, substance abuse, and mental health counselors, physicians, probation officers, police, public defenders, and states’ attorneys, pre-trial services coordinators, court officials, and clergy or other ministerial representatives. Consequently, the ability to establish and maintain community partnerships across multiple systems of care cannot be overstated (Figure 6.2). Like diversion staff, individuals served by post-booking diversion programs are diverse in demographic and clinical characteristics, criminal history, and specific mental health needs (Ryan et al., 2010). In particular, diversion programs typically include participants who: (1) are diagnosed with a serious and persistent mental illness, most frequently schizophrenia or other mood disorder; (2) have been hospitalized, visited the ER, and/or received medication for mental health problems or symptoms of mental illness in the three months prior to criminal justice contact; (3) are first time offenders, have fewer prior arrests, and/or less felony charges (than those not chosen for diversion); and/or (4) have spent a significant amount of time in jail within the 12 months preceding the current criminal justice contact (Broner et al., 2004).

 Figure 6.2 The Number and Type of Mental Health Programs Individual County and State Correctional Systems Ofer Vary Greatly by Jurisdiction

Source: Olivier Le Moal;

Diversion Strategies 177

FAST FACT 6.3 PROSECUTORIAL DIVERSION OPPORTUNITIES A 2015 study about Prosecutor-Led Diversion Initiatives gathered national data about how prosecutors’ ofces implemented jurisdictional diversionary programs (Lowry & Kerodal, 2019). Among the small sample of prosecutors’ ofces responding to the survey (n = 220), 121 (55 percent) reported having some diversionary programs available. Common characteristics of these diversionary programs included: • • •

69 percent—screening and assessment procedures to determine eligibility, needed services, and/or supervision requirements 52 percent—program durations of ten months or longer 44 percent—required meetings with case managers, probation ofcers, court appearances, and/or drug testing

Source: Lowry, M., & Kerodal, A. (2019). Prosecutor-Led Diversion: A National Survey. New York: Center for Court Innovation.

DIVERSION STRATEGIES Because institutions, defendants, and communities are different, there is no preferred strategy or successful package of strategies that will be utilized across all cases. Some approaches suggested by Ryan and colleagues (2010) included Assertive Community Treatment (ACT), intensive case management, intensive psychiatric probation and parole, mental health courts, and residential supports. Each of these programs is discussed in more detail in the remaining chapters of the text; however, they merit a brief introduction here. ACT uses a team-based, community approach to supporting PwMI by focusing on continuity of treatment, decreasing hospitalizations, and enhancing social and emotional functioning. Like ACT, intensive case management is a community-based treatment that seeks to facilitate linkage to services and support normal functioning outside of frequent hospitalizations through enhanced community integration. Intensive psychiatric probation and parole are typically enforced by a parole or probation officer who oversees monitoring compliance with conditions of the court which, in some cases, influences the likelihood of a client’s hospitalization or incarceration.

POLICY & PRACTICE 6.1 ACT POLICY IN PENNSYLVANIA In 2018, the Commonwealth of Pennsylvania unanimously passed Act 106. By creating a partnership between health care providers, a judge, and an individual living with mental illness, county agencies could utilize courtmandated treatment to ensure that an individual living with mental illness attends outpatient counseling and adheres to their medication protocol. Attempting to divert as many individuals away from the criminal justice


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system as possible, many lawmakers believed that assisted outpatient therapy (AOT) would aid those with a history of severe mental illness hospitalizations and arrests. Despite these eforts, AOT has been slow in its implementation across Pennsylvania. Pennsylvania’s mental health system has been fnancially stagnant for years, with some counties seeing little-to-no state increase in funding for over a decade (Figure 6.3). Many county-level mental health administrators have claimed that this type of treatment simply cannot be provided without additional funding and resources, particularly as they relate to court costs and training. A large percentage of Pennsylvania counties have opted out of the state’s AOT programs. In addition, some mental health advocates have conveyed skepticism regarding Act 106 and AOT, claiming that the commitment criteria are too ambiguous, and individuals who are coerced into treatment may be hesitant to participate in future support services. Source: Yonkunas, R. (March, 2020). Why Counties Are Not Using This Mental Health Treatment Plan. Fox43 Reveals. Retrieved from

 Figure 6.3 State Capitol Building for the Commonwealth of Pennsylvania, Government Complex, Harrisburg, PA) Source: christianhinkle/123RF Stock Photo;

Intensive psychiatric probation or parole may be mandated by mental health courts: specialized judicial entities made up of criminal justice staff and mental health treatment providers with the goal of benefiting justice-involved PwMI. Though less common than the other diversion strategies described, residential support is a developing approach that provides specialized housing. Given the emphasis placed on utilizing evidence-based practices (EBPs) in the provision of mental health and substance abuse services in recent years, research and evaluation into program effectiveness is clearly necessary to determine similarities, differences, and efficacy of approaches.

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DETERMINING DIVERSION PROGRAM EFFECTIVENESS Post-booking diversion programs are associated with improved criminal justice outcomes (fewer arrests, fewer days incarcerated) and improved clinical outcomes (access to benefits, usage of psychiatric services, and improved clinical functioning) (DeMatteo et al., 2013; Scott, 2020); they may also provide modest saving or be cost neutral (Broner et al., 2004). Ryan and colleagues (2010) suggested that post-booking diversion programs resulted in fewer criminal justice contacts, increased life satisfaction, reduced psychiatric symptoms, reduced psychiatric hospitalizations, reduced alcohol consumption, and increased work stability. Individuals who participated in diversion programs have shown improvement through increased service seeking behaviors for mental health counseling and psychiatric medication management and decreased in mental health hospitalizations (Broner et al., 2004). Haneberg et al. (2017) encouraged local communities and county-level administrators that were considering creating their own diversionary programs to first assess specific community characteristics as a measure for program effectiveness. In “Fast Fact” 6.4, we list six factors of program effectiveness and briefly describe the meaning of each.

FAST FACT 6.4 ASSESSING PROGRAM EFFECTIVENESS Program efectiveness may be determined by the following six factors: Buy-in from all parties •

Key stakeholders (local politicians, governmental commissions, criminal justice agencies, and community) must be accepting of changes for addressing PWLE and are willing to commit resources needed to achieve specifed goals.

Screenings and assessments performed •

The timeliness and frequency for administering thorough screening measures and quality assessments of risk and need must be established. Such information is needed for tracking changes in the prevalence of mental illness and behavioral health needs overtime.

Recording baseline data •

Determine the prevalence of mental health-related incidents, percentage of correctional populations assessed with mental illness, and those currently engaged in treatment programs.

Process analysis •

Thorough examination for how individuals are processed through the local criminal justice system. This includes a review from the initial contact with police ofcers and follows the process to the fnal case discharge.


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Prioritize time and resources •

Set realistic strategies and goals for change and focus eforts on the needs and improvements identifed by stakeholders. Be cognizant of funding streams and what can be accomplished in the specifed timeframe.

Identifying progress •

All projects should clearly list the deliverables to be achieved and the timeframe for doing so. Regularly progress reports to clearly describe evaluation fndings allow stakeholders to remain informed about how programs are being implemented and the results that are being uncovered.

Source: Haneberg, R., Fabelo, T., Osher, F., & Thompson, M. (2017). Reducing the Number of People with Mental Illnesses in Jail: Six Questions County Leaders Need to Ask. Retrieved from https://protect-us.mimecast. com/s/bt7vCn5PqXCy96DMcJ5UgN?

PROCESSING AND DISPOSITION Processing and disposition of PwMI in the criminal justice system at Intercept 2 can be categorized into two parts: screening and assessment and system collaboration. Proper screening and assessment are crucial in identifying those currently diagnosed with a serious and persistent mental illness, those exhibiting symptoms of psychosis who have not yet been diagnosed, and those at risk for behaviors such as suicide or deliberate self-harm. System collaboration illustrates effective practices to aid in the integration of criminal justice and mental health systems as suggested by the SIM. Each component is explained in more detail in the remaining sections of this chapter.

Screening and Assessment As discussed in Chapter 1, in comparison to the public, mental illness is reported at consistently higher rates in correctional facilities. Specifically, in October 2014, the National Research Council (NRC) reported that 64 percent of incarcerated persons in jail, 54 percent of those incarcerated in state prison, and 45 percent of federal incarcerated persons reported mental health concerns. Again, prevalence rates may differ across reports, depending on the way mental illness or mental health disorders are measured. Regardless, to benefit from diversion programs, PwMI must first be appropriately identified within the criminal justice system—primarily during the intake process at the jail. Unfortunately, not all incarcerated persons with mental health disorders are identified in this way. For example, a study by Birmingham and colleagues (2000) found that only 23 percent of incarcerated persons with a current mental illness were identified by correctional staff at intake. Screening and assessment procedures are designed to examine overall mental health, specific disorders, or specific risky behaviors associated with

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mental health such as suicide or self-harm. At Intercept 2, a screening is typically conducted by staff at the jail or juvenile assessment or catchment center. The tools used are relatively brief (e.g., 10–15 questions) and are mostly used to alert staff as to whether there are any significant mental health or substance abuse issues at intake (“red flags”). During an assessment, professionals use multiple approaches to collect significant information about an individual’s mental health profile to complete a thorough psychiatric evaluation. Most commonly, clinicians and other mental health staff use a combination of an individual’s self-report and staff observations. Any interviews are typically conducted in a relatively private setting. Both types of assessments are used to examine the type and severity of any current symptoms as well as to construct treatment history, including all psychiatric treatment, medication, and mental health performance. By considering current symptomatology along with mental health history, conclusions can be made about current levels of cognitive, social, behavioral, and emotional functioning (Lurigio & Swartz, 2006). A significant concern regarding the screening and assessment of incarcerated individuals in criminal justice institutions stems from the fact that these agencies frequently use measures that are developed in-house (by correctional or administrative staff in the facility). Although screening and assessment are crucial in identifying incarcerated individuals with behavioral health concerns, there is no “gold standard” tool that is appropriate for all circumstances in all facilities. While it is important that assessment not add unnecessary work to the already over-flowing workload of criminal justice and mental health professionals, it is equally as important that PwMI are accurately identified and diagnosed using tools that are reliable and valid (Lurigio & Swartz, 2006). To overcome barriers associated with implementing evidence-based screening and assessment tools (especially where budgets may be limited), tools must be quick, free or low cost, validated for use in multiple populations, straightforward, and easy to administer, score, and interpret.

FAST FACT 6.5 SUICIDE IN JAIL, A NATIONAL CRISIS In recent years, closer attention has been paid to the troubling challenges facing local jails across the country. Dubbed a national crisis by the Bureau of Justice Statistics, a total of 104 incarcerated persons have completed suicide in a county jail from 2015 to 2020 in the Commonwealth of Pennsylvania; the Philadelphia County jail system accounted for the most suicides (14), while 37 of the state’s 67 counties reported at least one suicide of an incarcerated person during this time. Source:


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Suicide Screening and Assessment Due to the high rates of suicide in forensic settings, especially among individuals with severe and persistent mental illness, a systematic assessment of suicide risk is necessary in all correctional institutions to comply with prevention efforts. Shea (2002) provided a list of elements that should be included in a systematic suicide risk assessment for individuals involved in the criminal justice system: 1. General clinical evaluation (mental health status exam) 2. Review of relevant records 3. Gathering necessary collateral information 4. Careful exploration of suicidal ideation, behavior, planning, desire, and intent 5. Identifying risk-enhancing factors 6. Synthesizing all the above 7. Using clinical judgment to assess the overall risk level 8. Crafting a risk reduction plan that targets modifiable factors Forensic suicide assessments should include a standardized screening instrument (evidence-based as discussed above) and a clinical interview allowing the offender to elaborate on their own subjective experiences (Figure 6.4). In addition to detainee self-reporting, institutional staff should be aware of clinical factors associated with suicide risk, such as

 Figure 6.4 The Impact of Solitary Confnement or Isolation in Prison Has Been Associated with Incidents of Suicide in Jails and Prisons Source: Jacob Bailey;

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impulsive behavior, severe agitation, increased distress, recent suicide attempts, hopelessness, rage, reckless behavior, social withdrawal, anxiety, dramatic mood changes, and/or lack of sense of purpose (Knoll, 2010). Characteristics unique to correctional suicide risk factors have also been identified and divided into the following categories: historical factors, clinical factors, social factors, environmental factors, and acute items (Table 6.1).

Table 6.1 Correctional suicide risk factors, as taken and adapted from Knoll (2010)

Historical factors • Past suicide attempts • History of psych treatment/mental illness, substance abuse, traumatic life events • Family history of suicide • Chronic physical illness • Conviction of a violent crime against a person • First incarceration Clinical factors • • • • • •

Depression Suicidal ideation Hopelessness Irritation/rage, aggression Psychosis Personality disorder

Social factors • • • •

Recent life crisis Lengthy sentence Recent harassment/bullying Loneliness

Environmental factors • Secure housing/unit/isolation/single cell • First two months’ secured placement • Ligature points accessible Acute items • • • • •

Suicidal plan/intent Available means Acts of anticipation Recent substance use Insomnia

Source: Knoll (2010, pp. 191–192)


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POLICY & PRACTICE 6.2 COUNTY JAILS VS STATE PRISONS There are strikingly similar findings of suicide incidents between county jails and state prison systems. For example, the Pennsylvania Department of Corrections (PA DOC) initiated sweeping changes in the treatment of incarcerated persons with mental illness in 2014. Prompted by the suicide of an incarcerated person at the former State Correctional Institutional at Cresson in 2012, the U.S. Department of Justice (DOJ) conducted a statewide investigation into the treatment of incarcerated persons with serious mental illness (SMI) or intellectual disabilities (ID) within the Pennsylvania prison system. As a result of their statewide investigation, the DOJ concluded that the PA DOC used solitary confinement in a manner which violated the rights of incarcerated individuals with SMI or I/DD. As a result, it was recommended that PA DOC expand its efforts to improve the treatment of individuals incarcerated with mental health issues. Subsequent PA DOC mental health reforms included: • • • • • •

Creation of mental health advocate position Certifed peer specialist program Increased out of cell options for incarcerated persons Expanded classifcation process Enhanced training for corrections ofcers and including Mental Health First Aid Elimination of restricted housing for incarcerated persons with a serious mental illness

In addition to the recommendations set forth by the DOJ, Governor Tom Wolf expressed his support for efective alternatives to assisting individuals with mental illness, including diversionary courts. Source:

Like mental health screening procedures, suicide screening and assessment are also highly variable across institutions and programs. While there is no “gold standard” for assessing and preventing suicides, best practices have been developed for the prevention of suicide among incarcerated persons in jails (Hayes, 1999, 2010, 2011, 2013). Criteria for these best practices include assessment/screening frequency and procedures, behavioral observation, examination of history, interaction and effective staff communication, employee training, attention to individual clinical needs, discharge determination, and/or limiting barriers to treatment.

Assessment/Screening Timeliness and Frequency Hayes (2011) described the initial intake suicide assessment as like taking someone’s temperature. By taking someone’s temperature, one can determine if the person currently has a fever but cannot determine if the

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person will have a cold in the future. Behavior and self-reported expressions at intake are time-limited. These limitations do not undermine the importance of initial suicide screening but do illuminate the management of continuously changing mental health needs of incarcerated persons. Suicide screening must be an ongoing process beginning when the individual is first arrested and brought to jail and ending when the individual is released from the institution. Close attention should be paid to incarcerated individuals who have been placed on suicide watch in the past. Even after discharge from suicide watch, specialized mental health services should be ongoing. Special attention is also warranted during times of increased stress such as admittance to specialized housing units (SHUs) or around parole hearings.

Behavioral Observation Consistent with the importance of continued assessment and screening is the examination of behavior expressed and displayed by an incarcerated individual, even if they deny suicidal ideation at the time of assessment. Successful suicide prevention efforts will encourage behavioral analysis that is indicative of suicide risk such as suicidal statements, plans, gestures, and/or actions. POLICY & PRACTICE 6.3 RESTRICTING HOUSING & SOLITARY HOUSING Some states, such as Delaware, have taken progressive steps to completely eradicate restrictive housing in their state correctional facilities. Struck with a rate of several mental illnesses within its prison population that is double in comparison to the rest of the county, the Delaware Department of Correction has taken progressive steps to help incarcerated persons get specialized treatment and counseling. Touted as making their prisons and 3,400 detained individuals safer, these initiatives are helping persons incarcerated to gain a better understanding of their mental health challenges and how to cope with them more appropriately. Source: recent%20survey%20lists%20Delaware,measure%20in%20its%20prison%20 system.&text=Listen%20to%20this%20story.,Association%20at%20Yale%20 Law%20School.

Examination of History Examination of history refers to the identification of and/or attention to prior risk of suicide and/or prior suicide attempts. Prior suicide attempts are one of the strongest predictors of future suicide attempts. Mental health histories should be available to all direct care staff, most usefully in an electronic mental health record.


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Interaction and Communication Best practices suggest that there should be frequent interaction between incarcerated individuals and correctional, medical, and mental health staff, especially in SHUs. In addition, there should be increased interaction for detained persons placed on suicide precautions. Communication and interaction between staff members is another crucial contributor to limiting suicide of incarcerated persons. Multidisciplinary plans and approaches to care and communication between direct care staff (medical, mental health, and custody) should be devised and maintained. FAST FACT 6.6 SUICIDE PREVENTION FOR INCARCERATED PERSONS For suicide prevention and recommended practices as related to prisoners in the U.S., visit: suicide_prevention.htm

Attention to Individual Clinical Needs During screening, assessment, and continued observation, the clinical needs of individual defendants should be considered when making decisions about watch status, discharge, and treatment planning. For example, security cameras may be efficient for temporarily monitoring an incarcerated person who is at low risk for suicide; however, an individual who is at high risk would most likely benefit from person-to-person interaction. While consistent policies should be enforced, it is also important to include recommendations on a case-to-case basis.

POLICY & PRACTICE 6.4 AIDING MILITARY VETERANS WITH LIVED EXPERIENCE Recognizing the need for diversionary programs that will increase an individual’s chance for success and minimize the likelihood of future criminal behavior, Bucks County, Pennsylvania utilizes a collaborative approach for military veterans (Figure 6.5). A multidisciplinary effort between the Court of Common Pleas, the District Attorney’s Office, the Public Defender’s Office, the Bucks County Bar Association, the County Department of Veterans Affairs, and the U.S. Department of Veterans Affairs, those veterans suffering from mental illness and substance use issues, who committed low-level crimes or nonviolent felony offenses, are eligible for the Bucks County’s Veterans’ Treatment Program. Paired with mentors to identify treatment needs and help veterans obtain services through the Department of Veterans Affairs, the goal for each participant is to:

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reduce the time they are involved in the criminal justice system • reintegrate them into both the community and productive employment

Eligibility Criteria: •

honorably discharged combat veterans from all wars and all branches of the military, including the reserves • those diagnosed with combat-related PTSD, TBI (traumatic brain injury), MST (military sexual trauma), mental health issues, and/or substance abuse problems, all of which resulted in criminal activity

Sources: 1. become-a-veteran-mentor-the-bucks-county-veterans-treatmentcourt-is-looking-for-male-and-female-military-veterans-to-serve.html 2. veterans-treatment-program

 Figure 6.5 Military Personnel and Law Enforcement Ofcers May Sufer from PTSD Resulting from Their Service and Work-Related Experiences

Source: LightField Studios;

Discharge Determination The determination to discharge an incarcerated person from suicide watch must only be made by a qualified mental health professional (MHP). Before discharge, the MHP should conduct a comprehensive suicide risk assessment to ensure an individual has received effective care and is no longer at risk for suicide. In addition, following discharge, released individuals should be kept on a “mental health caseload” for continued monitoring.


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Minimization of Barriers to Treatment When working with incarcerated populations, there are unique barriers to mental health treatment. It is critical that these barriers are minimized when screening and assessing for suicide risk. Professionals should avoid procedures that make suicide precautions seem punitive, while still taking appropriate precautions to identify suicide risk, diminish the risk of suicide, and maintain the safety of all persons incarcerated and staff. THINKING CRITICALLY 6.1 LIABILITY IN THE PENNSYLVANIA DEPARTMENT OF CORRECTIONS (PA DOC) Despite eforts by PA DOC to improve the treatment of individuals incarcerated with mental health issues and to reduce incidents of suicide, as mentioned in this chapter, problems persisted. For example, as reported in the Inquirer in February 2020, the Pennsylvania Department of Corrections reported 19 suicides of incarcerated persons in 2019, which were double the national average and the highest number recorded in state history. Lawsuits fled by the families of several suicide victims against the Department blamed systematic agency failures and insufcient staf eforts for the deaths. These lawsuits become very costly and quickly drain the already marginal resources available for treating the mentally ill in prison. While the Department contended it made the appropriate responses to the increase in suicides, one of the recent lawsuits alleged that a seriously mentally ill person took his own life after spending 30 days in a solitary confnement housing block. Questions to consider: 1. Review the mental health reforms implemented by PA DOC described earlier in this chapter. What other initiatives could the Department have implemented to reduce suicide among incarcerated persons with mental illness? 2. How does PA DOC compare to other state correctional systems today? What measures have other states implemented to reduce suicide among their correctional populations and/or incarcerated persons with mental illness specifcally? Source:

Systems Collaboration A successful diversion strategy at Intercept 2 is one that effectively determines the mental and behavioral health and social needs of the offender, and, if possible, minimizes any further penetration in the traditional justice system by allowing for the provision of services to be rendered in a community setting (Scott, 2020). To achieve this, there must be systemic

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collaborations—professionals from the fields of criminal justice and mental health working together for a common goal that benefits both systems of care and PwMI.

POLICY & PRACTICE 6.5 SELF-AWARENESS AND AVOIDING BURN-OUT While there are many diferent paths and tracks within the profession, a core set of personality traits are identifed as essential to establishing a frm foundation within the feld of forensic psychology. They include traits such as: • • • • •

Strong communication skills Objectivity Critical thinking Attention to detail Compassion

Also, self-awareness becomes a critical component of fnding the right “ft” and a high level of job satisfaction. Working at the crux of mental health and the legal system, even the most competent, resilient, and conscientious individual can become quickly become jaded, pessimistic, or simply “burned-out.” Knowing one’s strengths and limitations can be invaluable pieces of information, particularly when deciding which career path to follow. Indeed, an individual’s skills, personality traits, and abilities are important factors in career planning and counseling, as they contribute to the formation of one’s professional goals. Possessing the ability of introspection during the career planning process can be benefcial in ensuring prospective employees select careers that complement innate personality traits and preferences. Those individuals who are more cognizant of their individual personality traits could be catalysts for benefcial social change, as their skillsets and self-awareness lend themselves to the challenges of the profession. Sources: 1. tips-for-forensic-psychology-career-success/ 2. Washington, D. (2019). Learning models, personality traits, and job satisfaction in forensic psychology practitioners. Walden Dissertations and Doctoral Studies, 7771. dissertations/7771

Steadman and colleagues (1995) found that four components of systems collaboration appeared consistently in the most effective jail diversion programs: integrated services, regular meetings, boundary spanners, and strong leadership. The remainder of this chapter will briefly introduce and explain these key components.


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Integrated services are potentially the most crucial component of all when following the SIM. Integrated services require criminal justice and mental health agencies to regularly coordinate their interactions. The establishment of multidisciplinary groups is also crucial to the success of integrated service models. For example, services may be provided by mental health workers, but they are informed by a collaboration of judges, public defenders offices, district attorneys, probation offices, and jail services. ACT and Forensic Assertive Community Treatment (FACT) are two programs that exemplify integrated services (Figure 6.6).

Figure 6.6 Diversionary Programs Require Collaborations among Many Treatment Specialists and Correctional Personnel Source: ALotOfPeople;


Contributors: Gretchen Frank, JD, Senior Policy Analyst, Risë Haneberg, MPA, Deputy Division Director, and Emily Sandon, MA, LPC Introduced in Chapter 4, Stepping Up is a national initiative that seeks to address the overincarceration of people with serious mental illness (SMI) and co-occurring substance use disorders and was created to support counties in this work. To reduce the number of people who have SMI in jails, counties need to have a clear and accurate understanding of the size of that population. Screening and assessment are essential to identifying who should be connected or reconnected to services and treatment to address behavioral health needs. Such treatment and services may also decrease the likelihood of returning to jail. Some counties utilize clinicians embedded in the jail to complete screenings and assessments, use the results to develop case plans, and connect individuals with behavioral health needs to appropriate services.

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County Spotlight: Pacifc County, Washington In Pacifc County Jail, everyone undergoes screening for mental illness at booking. Positive screens result in a mental health fag in the jail’s electronic management system, which is accessible to public safety professionals in multiple agencies and systems. A jail liaison then refers each person who screens positive to a mental health clinician, who conducts a clinical assessment within 48 hours. The clinician also evaluates the person’s eligibility for a mental health diversion program, which involves early release from jail to treatment and services in the community.2 County Spotlight: Union County, Ohio A criminal justice navigator is located within the Tri-County Regional Jail to provide screening and early identifcation of mental illness and co-occurring substance use disorders following jail admissions. Based on the initial screening, the navigator prioritizes people in custody who have been identifed as needing mental health and/or substance use treatment. Services provided by the navigator include brief intervention and supportive counseling while planning for reentry; coordination of care with community-based treatment providers; and communication with the courts and community partners on behalf of people in custody to support reintegration. More generally, the navigator serves as an educator and information source regarding mental health, substance use, and access to community resources.

ACT As explained earlier in this chapter, the ACT model of care uses a teambased, community approach to supporting PwMI by focusing on continuity of treatment, decreasing hospitalizations, and enhancing social and emotional functioning. Notable elements of ACT include low client-to-staff ratios, high intensity services, assertive outreach efforts, and 24/7 access to care all in a community-based setting (rather than an office setting). ACT utilization with forensic populations showed a decrease in psychiatric hospitalizations and chronic gaps in permanent housing (Beach et al., 2013).

FACT PwSMI in the justice system presents unique risks and challenges. FACT is a specialized variation of the ACT model for justice-involved persons who have behavioral health issues (Lamberti et al., 2004). The FACT model targets various strategies designed to interface with criminal justice processes at key SIM points to prevent future criminal justice involvement. Evidence suggests that FACT supports diversion efforts as FACT participants have significantly fewer jail bookings, greater outpatient contacts, and fewer hospital days than did non-FACT participants (Cuddeback et al., 2020; Cusack et al., 2010).


CHAPTER 6 Intercept Two: Initial Detention/Initial Court Hearings

Key Staf Meetings Regular meetings of key treatment providers and criminal justice professionals are useful for keeping all parties, criminal justice, and behavioral health, informed about protocols, recently admitted and released individuals from the jail, and what services are needed. Participants at these meetings may include pre-trial or probation officers, drug/alcohol specialists, mental health caseworkers, judges, and psychiatrists. Agendas for these meetings can incorporate discussions of newly screened defendants, evaluation procedures, and information sharing about client progress.

Program Leadership It is important that the diversion program administrator or director has a thorough understanding of all system components and informational networks involved in the program. That individual(s) should have strong communication and networking skills because program leaders essentially advocate for diversion, and also must have the ability to demonstrate the importance of the agency or organization’s specific diversion program and diversion, in general, for a variety of people.

Boundary Spanners A boundary spanner, also known as a forensic liaison, serves as the direct manager of interactions between the correctional, mental health, and judicial staff participating in the diversion program. Boundary spanners act as a link to PwMI who are incarcerated, share information with other parties, hold meetings to develop discharge plans, and/or coordinate with the mental health system, psychiatric hospitals, and the probation office to move PwMI through the system. Essentially, boundary spanners are the “glue” that holds all components of diversion together (Steadman et al., 1995). Because of this, a boundary spanner should be someone who has the trust and recognition of people from each of the collaborating systems. The concept of boundary spanners is re-introduced in Chapter 8, where roles related to reentry are examined and discussed. POLICY & PRACTICE 6.6 CONTINUITY OF CARE (COC) Since the deinstitutionalization movement, pathways to mental health care have dramatically changed in the United States. Depending on the circumstance and individual, those who utilize mental health services are often faced with inadequate coordination among service providers, abrupt changes in the provision of services, as well as waiting long periods of time for specialized treatment. Consequently, these individuals may decompensate, and their progression becomes fragmented. Continuity of

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care (COC) is a critical element in the provision and implementation of mental health treatment. Loosely defned as the uninterrupted movement of individuals through the varying elements of the health delivery system, COC entails a series of health care events that are connected, coherent, and consistent with an individual’s needs and context. Empirical research fndings highlight the far-reaching impact of COC on an individual’s overall stability level, ability to function in the community, and overall quality of life. While the concept of COC is often emphasized and touted for its importance, eforts to implement and improve COC are often met with difculties. Lack of coordination, integration, and progress in care among service providers is common, leaving those in need of services frustrated. Source: Adnanes, M., & Steihaug, S. (2013). Obstacles to continuity of care in young mental health service users’ pathways—an explorative study. International Journal of Integrated Care, 13(3).

TAKE-HOME MESSAGE Intercept 2 is important because this is where the course of an individual is to be determined, immediately after being detained by the police. For example, if an officer arrests an individual who is assumed to have some mental health issue, initial detention is where one may be able to determine whether an individual is eligible for diversionary programs. During the booking process, mercy bookings may occur (see Chapter 5), whereby detention is viewed as a preferred outcome to provide shelter and temporary aid for an individual with mental illnesses who has been arrested (Lamb et al., 2002). It is important that an individual has been properly screened for mental illness, competency, substance abuse, trauma, or any other factors that may be related to the offense committed or risk for criminal propensity. Proper screening allows for the possibility of pretrial diversion and allocation of medical services, if need be, assuming there is a strong service linkage to comprehensive services (SAMHSA, 2015).

COMPARATIVE PERSPECTIVES 6.1 RESPONDING TO THE NEEDS OF LGBTQ+ AND ELDERLY CORRECTIONAL POPULATIONS Globally, research collected in European correctional systems showed LGBTQ+ defendants often have unique needs that must be addressed during their incarceration. These individuals may require additional health care treatment for STDs, substance use/abuse, and/or individual counseling for mental disabilities related to victimization through sexual violence or rape. Also, elderly correctional populations (those 55 years or older) were more likely to sufer from mental illness than individuals the


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same age who are not incarcerated. For example, these individuals were disproportionately diagnosed with anxiety, depression, bipolar disorder, schizophrenia, and post-traumatic stress disorders. Moreover, these problems were more likely to be reported among women compared to men. Because of their unique neurological and mental health needs, competent specialists are required to treat elderly and LGBTQ+ individuals inside a correctional facility. Sources: 1. United Nations Ofce on Drugs and Crime. (2009). Handbook on Prisoners with Special Needs. ). 2. Antonio, M. E. (2019). The Increase of Aging and Elderly Inmates in Local Jails, State Prisons, and Federal Correctional Facilities: Likely Causes, Current Problems, and Possible Solutions. In D. A. Mackey, & K. M. Elvey (Eds.), Society, Ethics, and the Law: A Text Reader (Chapter 25, pp. 210–221). Burlington, MA: Jones & Bartlett Learning.

PwMI are re-arrested and reconvicted at an alarming rate and their incarceration is not the answer. This problem can be addressed through a collective effort involving correctional personnel, law enforcement, and community health providers and can save the criminal justice system money by keeping persons with mental illness out of the system for as long as possible. Unfortunately, not all individuals with behavioral health-related concerns are identified at Intercept 2. In fact, some individuals may be ineligible for post-booking diversion. Chapter 7 introduces intercept three issues and diversion strategies, including competency evaluations, the insanity test, potential placement in forensic hospitals, and mental health courts. FAST FACT 6.7 FINDING A CAREER IN THE FORENSIC MENTAL HEALTH (FMH) SYSTEM The feld of forensic psychology is broad and dynamic, integrating elements of psychology into the criminal justice system and reaching nearly all facets of society. Opportunities in the profession are expected to grow in the future, particularly for those with graduate degrees (Master’s-level or higher). For example, the demand for qualifed and driven individuals includes occupations such as: • • • • • •

Corrections Counselor Victim Advocate Licensed Professional Counselor (LPC) Forensic Social Worker Researcher/Analyst Probation Ofcer

Take-Home Message 195

Source: Employment opportunities available for the Commonwealth of Pennsylvania can be found at: careers/pabureau Possible search words for careers working with PwMI may include: analyst, community, counselor, forensic, rehabilitation, social worker, therapist, treatment, etc.

Questions for Classroom Discussion 1. What are the key components of a post-booking diversion program? Which of these components do you think is the most important? Why? 2. What are some foreseeable challenges that could arise for correctional or mental health staff during the screening and assessment process for PwMI? Can you identify some potential solutions to avoid or address these challenges? 3. Case Study/Discussion: Consider the following example related to “Bill” a PwMI. Answer the discussion questions below either individually or as a group. Bill is a 39-year-old white man who was arrested and charged with nearly two dozen misdemeanor counts, ranging from simple assault to trespassing to harassment. These charges occurred during the course of a severe manic episode. Bill’s adult history is filled with a variety of encounters with local law enforcement, often during the course of psychological decompensation. Since his late teens, Bill has struggled tremendously with symptoms related to bipolar disorder, a history of emotional abuse, negative peers, and several major injuries to his head. After Bill’s most recent arrest, he was placed inside the county correctional facility and was assessed as seriously mentally ill. While he was assessed during the first two weeks of his county incarceration, a lack of space at the state hospital required Bill to remain in the county jail for over one year. One evening, he began to rapidly pace his cell and yell obscenities at officer, ripping off his shirt, challenging anyone to fight, and refusing to obey orders. Subsequently, Bill was placed on suicide observation in isolated, restrictive housing. During this period, Bill further regressed, ultimately leading to physical confrontation with a staff member, paranoid delusions, suicidal threats, and thoughts about spiritual possession. Unable to accommodate him due to staffing shortages, lack of programming, and limited bed space for over one-year post-arrest, Bill was finally sent to a state-operated mental health hospital. When he finally was returned to his home, now nearly two years after his initial arrest and assessment, he was described


CHAPTER 6 Intercept Two: Initial Detention/Initial Court Hearings

by friends and family as withdrawn and emotionally blunted. After years of heavy-duty medications and traumatic experiences, Bill was left as a “total shell” of a person. Bill’s fiancé decided to leave him, his mother passed away, and he had a significant number of restitution costs associated with his past criminal charges. Now unable to work in his former occupation due to his criminal charges, plus the inadequacy of mental health services available to him while in jail, Bill wondered how he could possibly regain anything close to his former life. Unfortunately, Bill began to self-medicate using alcohol, further accentuating his bipolar issues and creating more contact with local, law enforcement. Bill said to a police officer, “the system only knows how to medicate people, turn them into zombies, and send them back out into the world to start the same process all over again.”

KEY TERMS & ACRONYMS Act 106 Assertive Community Treatment (ACT) Boundary spanners Evidence-based practices (EBPs) Forensic Assertive Community Treatment (FACT) Post-booking diversion Pre-booking diversion Specialized Housing Units (SHUs)

Questions to consider: Based on concepts addressed in this chapter, what treatment and/or diversionary options would you have implemented with Bill? How could these options have helped Bill and his situation? From a treatment perspective, how can a clinician help instill hope for an individual in a seemingly hopeless situation? Discuss other examples (like Bill’s) that you heard described on news accounts or on social media about improper diversionary decisions with a PwMI and/or how treatment staff efforts are impeded by a lack of resources.

NOTES 1 Note: Adapted from Vail Compton, L. Forensic mental health case vignettes (personal communication, 2015). 2 See National Association of Counites, Pacific County, Wash: Connection to Services through Jail Screening and Referral (Washington, DC: National Association of Counties, 2018), documents/SAMHSA%20Case%20Study%20Pacific%20Final.pdf.

Bibliography 197

BIBLIOGRAPHY Beach, C., Dykema, L., Appelbaum, P. S., Deng, L., Leckman-Westin, E., Manuel, J. I., … & Finnerty, M. T. (2013). Forensic and Nonforensic Clients in Assertive Community Treatment: A Longitudinal Study. Psychiatric Service, 64(5), 437–444. Birmingham, L., Gray, J., Mason, D., & Grubin, D. (2000). Mental Illness at Reception into Prison. Criminal Behavior and Mental Health, 10, 77–87. Broner, N., Lattimore, P. K., Cowell, A. J., & Schlenger, W. E. (2004). Effects of Diversion on Adults with Co-Occurring Mental Illness and Substance Use: Outcomes from a National Multi-Site Study. Behavioral Sciences and the Law, 22, 519–541. Compton, M. T., & Kotwicki, R. J. (2007). Responding to Individuals with Mental Illnesses. Sudbury, MA: Jones & Bartlett Publishers. Cuddeback, G. S., Simpson, J. M., & Wu, J. C. (2020). A Comprehensive Literature Review of Forensic Assertive Community Treatment (Fact): Directions for Practice, Policy and Research. International Journal of Mental Health, 49(2), 106–127. Cusack, K. J., Morrissey, J. P., Cuddeback, G. S., Prins, A., & Williams, D. M. (2010). Criminal Justice Involvement, Behavioral Health Service Use, and Costs of Forensic Assertive Community Treatment: A Randomized Trial. Community Mental Health Journal, 46(4), 356–363. DeMatteo, D., LaDuke, C., Locklair, B. R., & Heilbrum, K. (2013). Community-Based Alternatives for Justice Involved Individuals with Severe Mental Illness: Diversion, Problem-Solving Courts, and Reentry. Journal of Criminal Justice, 41, 64–71. Fagan, T. J., & Ax, R. K. (Eds.). (2011). Correctional Mental Health: From Theory to Practice. Thousand Oaks, CA: Sage Publications, Inc. Griffin, P. A., Heilbrun, K., Mulvey, E. P., DeMatteo, D., & Schubert, C. A. (2015). Sequential Intercept Model and Criminal Justice: Promoting Community Alternatives for Individuals with Serious Mental Illness. New York, NY: Oxford University Press. Hayes, L. M. (1999). Suicide in Adult Correctional Facilities: Key Ingredients to Prevention and Overcoming the Obstacles. Journal of Law, Medicine, and Ethics, 27(3), 260–268. Hayes, L. M. (2010). National Study of Jail Suicide: 20 Years Later. Washington, DC: U.S. Department of Justice, National Institute of Corrections. Hayes, L. M. (2011). Guiding Principles to Suicide Prevention in Correctional Facilities. Baltimore, MD: National Center on Institutions and Alternatives (NCIA). Hayes, L. M. (2013). Suicide Prevention in Correctional Facilities: Reflections and Next Steps. International Journal of Law and Psychiatry, 36, 188–194. Knoll, J. L. (2010). Suicide in Correctional Settings: Assessment, Prevention, and Professional Liability. Journal of Correctional Health Care, 16(1), 188–204. Lamb, H. R., Weinberger, L. E., & DeCuir Jr., W. J. (2002). The Police and Mental Health. Psychiatric Services, 53(10), 1266–1271. Lamberti, J. S., Weisman, R., & Faden, D. I. (2004). Forensic Assertive Community Treatment: Preventing Incarceration of Adults with Severe Mental Illness. Psychiatric Services, 55(11), 1285–1293. Lurigio, A. J., & Swartz, J. A. (2006). Mental Illness in Correctional Populations: The Use of Standardized Screening Tools for Further Evaluation or Treatment. Federal Probation, 70(2), 29–35.


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Osher, F., D’Amora, D. A., Plotkin, M., Jarrett, N., & Eggleston, A. (2012). Adults with Behavioral Health Needs under Correctional Supervision: A Shared Framework for Reducing Recidivism and Promoting Recovery. New York, NY: Council of State Governments Justice Center. Ryan, S., Brown, C. K., & Watanabe-Galloway, S. (2010). Toward Successful Postbooking Diversion: What Are the Next Steps? Psychiatric Services, 61(5), 469–477. Scott, C. L. (2020). Jail Diversion: A Practical Primer. CNS Spectrums, 25(5), 651–658. Shea, S. C. (2002). The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors. New York, NY: Chinchester. Steadman, H. J., Morris, S. M., & Dennis, D. L. (1995). The Diversion of Mentally Ill Persons from Jails to Community-Based Services: A Profile of Programs. American Journal of Public Health, 85(12), 1630–1635. Vail Compton, L. (2015). Meridian Behavioral Health Services [Case Study].



Intercept Three Jails/Courts As part of a behavior modification plan, prison officials had John, an incarcerated person, strip naked and then they denied him bedding and water. John had been diagnosed with bipolar disorder and a psychologist who evaluated his case described these tactics more as a “behavior punishment plan.” According to legal documents from his case (that made its way to the State Supreme Court), John was denied basic behavioral health and medical services to help manage his disorder and the prison officials only exacerbated the issue with their modification plan. In a statement to the media, the Director of Corrections declared that “the mentally ill population” is not one they are trained to deal with; he added, “We are not health care professionals.” An attorney from a national legal advocacy organization that represents incarcerated persons and their families responded in an interview about the case, “This statement does not negate their obligation to provide access to basic health services and treatment to those detainees who require it.”1

INTRODUCTION The three preceding chapters presented several possible diversion strategies available at the intercept points of crisis/possible arrest, pre-booking, and initial detention in a jail setting. Interwoven throughout the discussions were some of the barriers and challenges related to implementing these strategies, such as the lack of funding, community “buy-in,” or prevailing agency philosophies that seem to prefer punishment over treatment. Because of such challenges, it is possible that a PWLE of mental illness and/or substance use will not be diverted before or during the initial stages of the criminal or juvenile justice trial process. Moreover, it may be that the actions or behaviors of the individual during an encounter with police or other first responders may have been serious enough (or violent enough) to warrant an arrest and subsequent detainment (Massaro, 2005). At that point, it is essential that correctional staff properly identify mental health issues and related service needs. As we have learned in Chapter 6, however, it is possible that jail personnel will not have the proper training or tools to effectively screen, assess, and

DOI: 10.4324/9781003120186-7



CHAPTER 7 Intercept Three: Jails/Courts

manage PwMI in that setting. If that is the case and the consumer penetrates further into the criminal justice system, additional strategies can be used at Intercept 3 prior to conviction and sentencing. Consider the case of R.C. R.C. was released from jail more than one year ago after spending about six months at the state hospital under a forensic commitment. They have a long history of schizophrenia with several state hospital admissions and CSU admissions. R.C. was released under a conditional release order (CRO) as not guilty by reason of insanity in Div. V court.2 The charges were violent, as they have violent tendencies when they are off their medications. Their release was carefully coordinated by the forensic specialist to ensure that they had secured appropriate housing with their family. The forensic specialist made sure they were not going to miss any medication dosages by scheduling a medication management appointment the day after the release. The specialist also pre-planned for his days to begin by having them attend groups specifically designed for individuals with chronic illnesses; they started these two days after their release. The forensic specialist also secured their social security and medical benefits. R.C. receives the most intensive forensic services from the team, which they need to help them remain in the community. They are seen at the office at least three times per week, receive a home visit at least twice a month, as well as calls with the team weekly. R.C. reports that this is the best they have ever done and now they have friends.3 R.C.’s case illustrates that successful diversion can take place beyond arrest and after a period of incarceration—especially when two key conditions are present: the resources are available, and the client is actively engaged in services and treatment. Oftentimes, for reasons just discussed throughout the preceding chapters (e.g., stigma, fear of violence, public safety, and lack of community-based resources or cooperation of service providers), PwMI at Intercept 3 find themselves spending a considerable amount of time in secure detention. In fact, reports indicate that PwMI spend more time incarcerated than persons without mental illness for the same, if not less serious, charges such as misdemeanor disorderly conduct, trespassing, and panhandling; they also return to jail more often (Kim et al., 2015; Siller, 2017). Considering that correctional institutions have historically operated as a means to deliver punishment first and not treatment, the representation of PwMI incarcerated is concerning. This chapter is divided into two parts. Part One presents and discusses some of the challenges faced by incarcerated persons and correctional staff during a prolonged period of incarceration for PwMI. In Part Two, solutions to these challenges are introduced, as the chapter outlines key diversion strategy options available at Intercept 3, prior to release, trial, or conviction, including correctional treatment, forensic services, forensic commitment or conditional community release, evaluation for competency and/or insanity, and transfer of a case to specialized mental health courts.

Part One: Beyond Initial Detention—PwMI Incarcerated 201

PART ONE: BEYOND INITIAL DETENTION—P WMI INCARCERATED Correctional and behavioral health system administrators at the state level are aware of a large number of individuals with mental health and substance abuse disorders who are funneling simultaneously through theirs and other public health and welfare-related systems of care (Osher et al., 2012). Unfortunately, as previously stated, most jails, prisons, and juvenile detention centers are not fully equipped to meet the needs of this population. Overcrowding of PwMI and shrinking treatment and programming budgets continue to plague departments of correction in most locations—challenging administration and staff to treat those who may have SMI (and co-occurring substance abuse problems) with limited resources and expertise. As a result, there have been patterns of neglect, mistreatment, and even disregard for the well-being of vulnerable persons (Human Rights Watch, 2003) (Figure 7.1).

 Figure 7.1 Isolation of Confnement

Source: By Ankihoglund. Standard License; Adobe Stock Library

THINKING CRITICALLY 7.1 EXCERPT OF LETTER FROM INCERATED PERSON R.U., NEVADA, JUNE 4, 2002 At one point [and] time in my life here in prison I wanted to just take my own life away. Why? Everything in prison that’s wrong is right, and everything that’s right is wrong. I’ve been jump[ed], beat, kick[ed] and punch[ed] in full restraint four times … Two times I’ve been put into nude four point as punishment and personal harassment … During the time I wanted to just end my life there was no counseling, no programs to attend. I was told if I didn’t take my psych meds I was “sol.” Three times I [attempted suicide] by way [of hanging] myself. I had no help whatsoever days and week[s] and months I had to deal with myself.


CHAPTER 7 Intercept Three: Jails/Courts

Depression, not eating, weight loss, [every day], overwhelmed by the burdens of life. I shift between feeling powerless and unworthy to feeling angry and victimized. I would think about death or killing myself daily. For eight months or a year I was not myself. From Oct 2000 to like Sept or Nov of 2001 … I was just kept into a lock[ed] cell ready to end my life at any given time. Each [time] I would try to hang myself it never work[ed] out. I cut my arms. I really was going thru my emotions and depression … I would rather live inside a zoo. The way I’ve been treated here at this prison I couldn’t do a dog this way. Source: Abramsky (2003) [Human Rights Watch]

General Adjustment Issues As discussed previously, a substantial number of incarcerated persons suffer from major depression, mood disorders, anxiety, and trauma. For some, psychotic symptoms may also be observed, including delusions, disorganized thinking, hallucinations, and bizarre behaviors (some of which are the result of taking psychotropic medications). Moreover, other specialized populations (e.g., geriatric, women, or incarcerated persons with developmental disorders and/or substance use disorders) may have mental health and multiple other medical issues, which results in the increased necessity for screenings, diagnostic exams, and follow-up services. Aside from the complexities associated with these conditions, the most reported issues for PwMI in a correctional setting revolve around barriers to accessing mental healthcare and difficulty in navigating the challenging prison environment (Figure 7.2). The following discussion provides a brief introduction to some of the more common concerns.

Victimization Due to the nature of their illnesses and symptoms which render them vulnerable, PwMI are increasingly exposed to violence and victimization in a jail or prison setting (McLearen & Magaletta, 2011). Multiple reports indicate that women and men with mental illness are disproportionately represented among victims of sexual and other forms of physical violence while incarcerated (Listwan et al., 2014; Torrey et al., 2014; Wood & Buttaro, 2013). Staggering rates of financial, physical, and self-victimization (selfharm, discussed later) have also been found among geriatric individuals incarcerated with mental health concerns (McLearen & Magaletta, 2011). Although they report increased fear of victimization, PwMI will not often reach out for help; perhaps that is because they have been discouraged from doing so or they fear stigmatization or retaliation.

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Figure 7.2 The Prison Environment [Berlin-Hohenschonhausen Memoria] Source: By Matyas Rehak. Standard License; Adobe Stock Library

Disciplinary Issues and Segregation The primary goal of corrections is to manage incarcerated persons efficiently and effectively. To accomplish this, staff are trained in the use of techniques designed to maximize control and institutional safety (Carlson, 2011; Compton & Kotwicki, 2007; Fellner, 2015; Osher et al., 2012). The response to rule-violating behavior, therefore, is often based on traditional principles of punishment rather than therapeutic intervention (Fellner, 2015). In many cases, correctional officers will interpret behavior symptomatic of an incarcerated person’s illness as disruptive, dangerous, annoying, provocative, or disrespectful, and therefore, will initiate disciplinary procedures by charging infractions (Carlson, 2011; Compton & Kotwicki, 2007). Disciplinary infractions require disciplinary hearings, which almost always result in some type of sanction prevailing upon the involved incarcerated individual(s). Sanctions usually come in the form of administrative segregation or additional criminal charges, which may lead to spending more time incarcerated, thereby contributing to overcrowding issues, further decompensation of mental health conditions, and an increase in the costs associated with care and confinement of this population (Carlson, 2011; Torrey et al., 2014). FAST FACT 7.1 COSTS ASSOCIATED WITH INCARCERATING PWMI In Broward County, Florida, it costs $80 a day to house an incarcerated individual without mental illness (MI) but $130 a day to house one with MI. In New York’s Rikers Island Jail, the average stay for all incarcerated individuals is 42 days; for those with MI, it is 215 days. Source: Torrey et al. (2010, p. 10)


CHAPTER 7 Intercept Three: Jails/Courts

Solitary Confnement and Use of Force Use of force (including chemical and physical restraints or physical punishment) and solitary confinement (segregation from the general population) are often utilized by prison officials as a means of controlling or punishing “problematic” individuals who have psychiatric problems. Aside from the forced administration of medication, these correctional strategies have possibly invoked the most controversy; at the same time, however, they have produced the most policy changes regarding the treatment of PwMI who are incarcerated. There is also a substantial literature base as to the subject matter (e.g., Carlson, 2011; Fellner, 2015; Glowa-Kollisch et al., 2016; Metzner & Fellner, 2010).

Use of Force As prescribed by policy and under limited circumstances, corrections officers are authorized to use chemical agents (e.g., “pepper spray”), electric stun devices, arm and leg restraints, and sometimes “hands on” tactics to control aggressive, unresponsive, and unruly incarcerated persons to gain their compliance. Policy typically requires, however, that staff attempt to secure compliance first by using other, less restrictive, means (e.g., de-escalation techniques) (Fellner, 2015). Although statistics on correctional use of force are not readily available, existing reports and anecdotal evidence suggest that staff often respond with excessive violence—in particular, when individuals engage in nonthreatening behavior that could be symptomatic of mental illness, such as screaming or muttering obscenities and urinating in one’s cell (Torrey et al., 2014). Incidents have also been reported where corrections staff continued to use physical force on PwMI beyond what was needed to gain compliance (see, e.g., Fellner, 2015; Winerip & Schwirtz, 2014). The case of Jermaine Padilla in California is instructive as to these reports (“Thinking Critically” 7.2).

THINKING CRITICALLY 7.2 CASE STUDY IN USE OF FORCE: JERMAINE PADILLA IN CALIFORNIA Padilla had been sentenced to a ten-month period of incarceration for a probation violation. Records released later indicate that Padilla had a history of serious mental illness and had been decompensating over the course of about four to fve weeks after being transferred to an administrative segregation unit; some of his behaviors as observed by staf included refusing to eat, urinating and defecating in the cell and smearing feces all over his body, and responding to internal stimuli (auditory hallucinations and delusions). After he refused to voluntarily comply with his treatment regimen (the administration of psychotropic medication), and to protect Padilla from further self-injury, corrections staf were forced to perform a cell

Part One: Beyond Initial Detention—PwMI Incarcerated 205

extraction so that they could administer medication to stabilize him. A recording of the incident was made by staf per procedural guidelines, but it was later used as evidence in a class action suit fled in the district court (Coleman v. Brown, 2013; Fellner, 2015). At the time of this writing, the video, which is approximately 30 minutes long and shows correctional staf using pepper spray to get Padilla to “cuf up” so that he could be medicated, can be found on YouTube at the following weblink:

Researchers have argued that some of the reasons for the increasing misuse of force against prisoners with SMI include a lack of efficient mental health treatment in correctional settings, inadequate use-of-force policies they relate to PwMI, and gaps in the availability of sufficient training programs and supervision (Fellner, 2015). Despite the absence of publicly accessible data on useof-force incidents in U.S. prisons and jails, several egregious incidents have made their way into the mainstream media, including those occurring at the jail complex at Rikers Island, New York (discussed briefly in Chapter 3). We examine a few of these case studies in “Policy & Practice” 7.1 below.

POLICY & PRACTICE 7.1 USE OF FORCE AT RIKERS ISLAND JAIL COMPLEX, NEW YORK, NEW YORK Luis Rosario Rosario, incarcerated at Rikers, got into a verbal altercation with correctional staf in a mental health solitary unit. According to a report fled by Rosario, the staf physically dragged him from the cell and one held him by his handcufs while another beat him—all while their captain watched. The bones in Rosario’s face were broken, and his jaw needed to be wired shut. Mr. Dixon and Mr. Lane Two incarcerated men, each with unique histories of serious mental health problems and periods of solitary confnement at the jail, had allegedly splashed guards with liquid. According to the accounts of clinical staf, a group of correctional ofcers took the men individually into an examination area, where despite the men’s cries for help and for desistance, continued to physically and brutally beat them. This incident took place under the careful observation of correctional superiors. Source: Adapted from Winerip, M. & Schwirtz, M. (July 14, 2014). Rikers: Where mental illness meets brutality in jail. The New York Times. Retrieved from on December 31, 2021. Author’s Note: In 2021, 12 incarcerated individuals died while at Rikers, 5 of them by suicide. After decades of considerable chaos and controversy, Rikers is set to close in 2027.4


CHAPTER 7 Intercept Three: Jails/Courts

Solitary Confnement Referred to as “administrative segregation” by prison staff (Metzner & Fellner, 2010), isolation has also been used for disciplinary or administrative reasons—sometimes in conjunction with or after an incident when force was used—to control the behaviors (or noncompliance) of PwMI in correctional settings. Specialized housing units (SHUs) (Chapter 6) have been designed and utilized by correctional staff to segregate and isolate individuals with special security needs from the general population and to ensure the safety of all incarcerated persons and staff. The use of SHUs to confine PwMI has grown as the number and proportion of PwMI in the correctional setting has grown (Metzner & Fellner, 2010). Once segregated from the general population—for days, months, or even years—individuals in solitary cells are isolated for about 23 to 24 hours a day (under surveillance with no social interaction), with about four to five hours a week allotted for recreation (Fellner, 2015). In some jurisdictions, correctional facilities have entire mental health buildings or housing units that only house those individuals with serious psychological disorders or other classes of incarcerated persons (e.g., sexual predators). Individuals who are classified and placed in these units may have access to treatment programs and specialized staff; however, they are still isolated, segregated, and confined (Carlson, 2011).

FAST FACT 7.2 PSYCHOLOGICAL EFFECTS OF SOLITARY CONFINEMENT Research observations have indicated that solitary confnement may provoke some of the following psychological efects: anger, anxiety, depression, cognitive disturbances, perceptual distortions, obsessive thoughts, paranoia, and psychosis. It is important to note that these maladaptive outcomes have also been observed among incarcerated individuals with no remarkable history of mental illness because of the psychological trauma invoked by the incarceration experience (Metzner & Fellner, 2010). One example is the case of Kalief Browder. Browder, a young man who, at 16 years of age, was incarcerated at Rikers Island Complex following a charge of theft, had sufered tremendous abuse while incarcerated—including multiple physical beatings by other incarcerated persons and correctional staf, signifcant periods of isolation, and about two years of solitary confnement during a three-year period of incarceration awaiting trial on charges for which he was later found innocent. Browder had attempted suicide while at Rikers, and again, after he was released. As a result of his incarceration, Browder sufered from severe psychological trauma, and two years after his release, he died by suicide.5 Prolonged solitary confnement is an extreme form of treatment, prohibited in all circumstances under international law. Source: The Guardian (August 1, 2021); Serious questions raised by solitary confnement in prisons.

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Aside from psychological consequences, additional unfortunate circumstances of solitary confnement include a lack of educational or vocational activities and a higher likelihood of self-harming behaviors. The United Nations and other health and human rights organizations have called for a total ban on the use of solitary confnement for minors because of research indicating the damage it has on brain development. In 2016, the use of solitary confnement/isolation as punishment for children was prohibited in Federal Bureau of Prisons (BOP) facilities, and there have been additional legal, policy, and legislative success at the state and local level in terms of regulations (if not complete bans) on its use with children and adults (The Raben Group, “Solitary Watch,” 2020; Torrey et al., 2014). Author’s Note: Before the COVID-19 pandemic, the estimated number of people in solitary confnement in the United States ranged from 50,000 to 80,000 on any given day. At the height of the pandemic in 2020, up to 300,000 incarcerated individuals were in solitary.6

Self-Harm For people with SMI, the combination of solitary confinement and lack of access to proper treatment and/or medication to control psychiatric symptoms is a futile mix. In this state of isolation, stress, and acute psychiatric crisis, PwMI may often resort to self-injurious behavior (SIB), which may include acts of fatal and nonfatal self-harm, ranging from cutting/lacerations, head banging, ingestion of a foreign body, insertion of items in bodily orifices (including genitals), smearing feces, setting fire to a cell or to oneself, mutilation, overdose, hanging/trauma from ligature, and other suicide attempts (Helfand, 2011; Kaba et al., 2014). Research has indicated that solitary confinement is a strong indicator of SIB. Without access to other coping strategies—positive and negative—(i.e., substance use, social interaction), incarcerated individuals may self-injure to express their desire to escape conditions of extreme isolation (Helfand, 2011; Kaba et al., 2014). Self-mutilation and suicidal behavior have also been found to be quite common among juveniles who are placed in detention facilities (DePrato & Phillippi, 2011). For both juveniles and adults, SIB has been associated with borderline personality disorder/traits, major depression, and a history of suicidal behavior (DePrato & Phillippi, 2011; Helfand, 2011).

Suicide The topic of suicide has been introduced and discussed in the preceding chapters of this book. In the context of Intercept 3, however, it remains a salient concern with respect to the continued correctional management of PwMI who are already at high risk for self-injury. Suicide has been the leading cause of death in local jails each year since 2000. As provided in


CHAPTER 7 Intercept Three: Jails/Courts

Chapter 3, in the context of state and federal prisons, suicide was the second leading cause of death in 2016 (preceded only by illness) (Carson & Cowhig, 2020a, 2020b). Although the rates of prison suicide are lower than rates in a jail setting, both comparatively exceed the rates found in the non-incarcerated (free) population. Some of the contributory factors found to be related to suicide among incarcerated PwMI in jails and prisons include new legal issues, relationship difficulties, isolation, and other stress factors related to the correctional setting (e.g., fear of victimization, violence, and stigmatization). There are also predisposing factors that may include substance use which immediately preceded the most recent incarceration and “recent loss of stabilizing resources, severe guilt or shame over the alleged offense, current mental illness, prior history of suicidal behavior, and approaching court date” (Hayes, 2010, p. 1). Ironically, institutional directives that are designed to prevent suicidal and self-injurious behaviors require that officials employ isolation options, including administrative segregation (solitary confinement) and suicide watch (Kaba et al., 2014). Clearly, corrections officials and staff should collaborate and discuss options that may be more effective in meeting the needs of persons incarcerated and preventing them from further self-harm and possible death. POLICY & PRACTICE 7.2 SUICIDE PREVENTION IN CORRECTIONAL SETTINGS Individuals incarcerated who have expressed suicidal ideation or have previously attempted suicide are often required to undergo one or more of the following suicide prevention measures: The removal of all clothing, and possibly, the wearing of a smock (“turtle suit”) or other antisuicide protective garment or item (e.g., mattress, pillow, blanket) The removal of all bedding and other “anchoring” items that could be used as a hanging device Suicide watch, which may include close observation (10- to 15-minute intervals) or constant observation (no interruption) Hayes (2010, 2013)

Summary of Part One Due to a host of adjustment issues, including those just described, outcomes for justice-involved PwMI often reflect a tragic chain of events that involve relapse and a perpetual failure to comply with conditions of incarceration or community release programs (Massaro, 2005). Reentry concerns are discussed in the next chapter. The good news is that things have been improving in some jurisdictions, including the training of correctional staff and court personnel (Carlson, 2011; Mcneeley & Donley, 2021), the proper

Part Two: Diversion Strategies at Intercept Three 209

classification and placement of incarcerated persons with serious psychological issues, the implementation of specialized housing units, and the utilization of innovative programming to accommodate an array of risks and needs of PwMI and others who have special needs (Ford et al., 2020; Kim et al., 2015).

PART TWO: DIVERSION STRATEGIES AT INTERCEPT THREE Jail-Based Treatment With so many incarcerated PwMI, efforts must be made to either divert individuals into community-based mental health settings (if possible) or to provide best practices in relation to the provision of treatment in prison and jail settings. Aside from initial mental health screenings and evaluations upon intake (discussed in Chapter 6), optimal treatment strategies may include ongoing and consistent observation, screening, assessment, and evaluation for short-term crisis events (“mental health triage”; see “Policy & Practice” 7.3); therapeutic interventions; medication management; and other support programs related to recovery and reentry (e.g., job skills, education, housing, daily living) (Lamb & Weinberger, 1998; Shankar, 2011; Torrey et al., 2014). Furthermore, screening, assessment, and therapeutic interventions should be performed by well-trained and educated mental health professionals who are employed with or contracted by the department of corrections. These individuals would comprise a multidisciplinary psychiatric team that could also make referrals to inpatient psychiatric hospitals when necessary (Lamb & Weinberger, 1998). POLICY & PRACTICE 7.3 MENTAL HEALTH TRIAGE A rapid fow of the jail population and varied and deep needs of justice-involved PwMI require a triage approach to allocate limited behavioral health resources available and to facilitate successful treatment and transition based on risk and need information. Jails and prisons can accomplish this using a three-stage process, referred to as “mental health triage”: 1 2 3

Screening Assessment Evaluation

Brief (eight to ten questions, on average), systematic, and universal screenings can be performed by mental health or trained correctional staf during the booking and/or intake process to determine any immediate risks that may require closer monitoring (e.g., suicide) or a need for further assessment. Trained mental health personnel may perform more indepth assessments within 24 hours of a “positive” screen (i.e., a screen that indicated high risk and a need for further evaluation or preliminary


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intervention); staf may use a variety of (valid and reliable evidencebased) instruments. When an individual’s symptoms warrant the need, a full-scale psychiatric evaluation will be conducted by a licensed clinical psychologist or certifed psychiatrist. Sources: 1. American Psychological Association Services, Inc. (2014, December). Accessed December 27, 2021, at practice/reimbursement/billing/assessment-screening 2. Osher, F., Scott, J., Steadman, H., & Robbins, P. C. (2005). Validating a Brief Jail Mental Health Screen (No. 213805). Final Technical Report. US Department of Justice. Doc.

Therapeutic intervention in jails or prisons has historically been pharmacologically based. In short, when hospitalization for sick persons incarcerated is not an option, staff rely on psychotropic medications to minimize symptoms and maintain control (Shankar, 2011). The complexities associated with administering medication in correctional settings include the overt refusal of treatment, a general distrust of correctional staff, and unpleasant side effects associated with some medications. Moreover, the costs for some psychotropic medications are taxing on correctional budgets, and they generally increase between 15 percent and 20 percent each year (Daniel, 2007). To control costs in this regard, restricted formularies (older-generation psychotropic medications and generic versions) have been used with incarcerated PwMI. This has been a particularly concerning issue because the chemical composition of these formularies may not have the same positive effect on the symptoms as did prior to more progressive medication(s) and, in fact, may exacerbate the mental health condition of the patient because of multiple side effects (Daniel, 2007). Like individuals receiving mental health treatment in the community, optimal outcomes with incarcerated PwMI usually involve a combination of pharmacological and psychotherapeutic interventions. In some jurisdictions, departments of correction have identified specific treatment needs and have been allotted resources to implement programming and therapeutic interventions to meet those needs. For example, recognizing the high rates of victimization and trauma among women in correctional settings, cognitive behavioral approaches, such as dialetical behavior therapy (DBT),7 have been used with some success. Evidence-based trauma-informed approaches to treatment are discussed later in Chapter 10. Therapeutic communities (TCs) have also been adapted for use in correctional settings. TCs emphasize successful trauma intervention and the promotion/development of peer support and counseling. Results have been mixed as to the effectiveness of TCs—in particular, in their ability to effectively serve the needs of a diverse clientele (Loper & Levitt, 2011).

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Peer-Based Services One of the most effective strategies in engaging PwMI in mental health treatment and programs is by offering peer services or peer support programs (PSPs). Available in all 50 states, PSPs have been designated as a best practice by the Substance Abuse and Mental Health Services Administration (SAMHSA) due to the empirical evidence as to their effectiveness in reducing symptoms and hospitalizations and in improving treatment engagement, social functioning, and well-being/self-esteem among consumers (Daniels et al., 2013; “Peer Services,” 2016). Peer-based programs entail the employment of certified peer support specialists (CPS) (or recovery specialists)—individuals who have attained their own significant recovery and who have also been trained to work in a variety of roles, such as a counselor, crisis worker, case manager, wellness coach, and educator. The primary objective is to promote long-lasting recovery by helping people stay out of the hospital and live independently. Peer support professionals are stationed in jails, hospitals, crisis stabilization units, and drop-in centers, and are available to provide support and help locate additional resources in a variety of clinical settings for whatever services are needed (“Peer Services,” 2016). Through their collaborative partnerships with local agencies (e.g., social services, criminal and juvenile justice, veterans’ affairs), support specialists can make sure that justice-involved clients are compliant in their treatment and help them meet the challenges of daily life in tasks ranging from developing and maintaining relationships, grocery shopping, and managing money to taking medication and keeping doctor appointments. In this way, services received through peer support are generally useful for reentry or discharge planning—a point in the system more thoroughly discussed in Chapter 8 of this text. Empirical evidence involving peer-based programming suggests positive outcomes in terms of rapport building between peers incarcerated, avoidance of health-risk behaviors, and reductions in rates of recidivism; however, the statistical findings are still moderate, and more rigorous methodology is needed to draw consistent conclusions (Bellamy et al., 2019; Chinman et al., 2014; Davidson et al., 2018).

Right to Treatment Non-Incarcerated Persons. Under current laws, PwMI in the community setting have the right to seek and continue medical and other therapeutic measures to treat symptoms at their own discretion. Studies have shown that, by allowing patients to control and determine what type of treatment they receive, positive outcomes are more likely achieved (see Rosenthal & Rogers, 2014 for a brief review of the literature). Conversely, forced medication, for example, has been found to make the patient feel as if they have little control over their circumstances, and may cause low self-esteem


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and possible self-harm. Contemporary commitment laws are indicative of a converse viewpoint—one that is based upon a concern for public safety first and foremost. As previous examples from Chapter 5 have shown, when PwMI in the community are regarded as a threat to themselves or others, treatment can in fact be forced upon them by an order of the Court. Incarcerated Persons. Generally speaking, incarcerated persons have no constitutional right to treatment. For justice-involved PwMI, however, constitutional protections may be found under the 8th Amendment—assuring freedom from cruel and unusual punishment. This protection has been extended to an individual’s right to access adequate medical care, which includes psychological or psychiatric services (Estelle v. Gamble, 1976, outlined below in “Thinking Critically” 7.3). A judge may also exercise authority to require correctional treatment plans are implemented to ensure the administration of prescribed medications, the timely response to medical service requests, the provision of individual and group therapy, and the proper facilitation of several other mental healthcare treatment provisions. The following segment presents highlights derived from seminal (i.e., highly influential) U.S. Supreme Court cases involving access to treatment, as well as the right to refuse it, in institutional settings. First, the caption (name) of the case is presented and the year it was decided by the Court; then, the legal issue (question presented to the Court), and finally, the Court’s holding/opinion is stated. Additional summaries of case facts are provided where deemed appropriate. THINKING CRITICALLY 7.3 LEGAL DEVELOPMENTS IN THE RIGHT TO TREATMENT Wyatt v. Stickney (1972) Legal Issue: Do patients in public psychiatric hospitals have a constitutional right to treatment? Court Holding: Yes, people who are involuntarily committed to state institutions because of mental illness or developmental disabilities have a constitutional right to treatment that will aford them a realistic opportunity to return to society. The Court articulated that the following three conditions must be present for treatment programs in public mental health institutions to be considered “adequate and efective” under the Constitution: (1) A humane psychological and physical environment, (2) qualifed staf in numbers sufcient to administer adequate treatment, and (3) individualized treatment plans. Estelle v. Gamble (1976) Legal Issue: Do prisoners8 have a constitutional right to healthcare? An inmate in a state correctional institution brought a civil rights action under 42 U.S.C. § 1983 against the state corrections department medical

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director and two correctional ofcials, claiming that he was subjected to cruel and unusual punishment in violation of the Eighth Amendment for inadequate treatment of a back injury he claimed to have sustained while he was engaged in prison work. Court Holding: Yes. Deliberate indiference by prison personnel to a prisoner’s serious illness or injury constitutes cruel and unusual punishment contravening the Eighth Amendment. Washington v. Harper (1990) Legal Issue: Do incarcerated individuals have a constitutional right to refuse treatment? Court Holding: The Court established that in correctional settings defendants can refuse medication until they become a danger to themselves or others or become gravely disabled. Defendants can refuse medications in the state hospital setting, but because the setting is more therapeutic than a correctional institution per se, it seems to be easier to obtain judicial authorization to medicate involuntarily in a treatment setting. Sell v. U.S. (2003) Legal Issue: Does the U.S. Constitution permit the forced administration of an antipsychotic drug to a mentally ill but nonviolent inmate for the sole purpose of rendering that inmate competent to proceed to trial, even for charges that were serious but did not involve a violent ofense? Court Holding: The involuntary administration of medication for purposes of restoring competence to stand trial was constitutionally permissible only under the following conditions: 1. If the defendant is a danger to him- or herself or others. 2. If the defendant is facing a “serious” charge. 3. If treatment is medically appropriate and is substantially unlikely to have side efects that could undermine the fairness of the trial; and, 4. If treatment is the least restrictive alternative available to further important governmental interests.

Forensic Services Another diversion strategy available at Intercept 3 is the implementation of forensic services, which may include evaluations, case management, and placement in a community outpatient setting or a state hospital. Forensic case management and court-ordered treatment can occur in a secure (inpatient) or community-based (outpatient) setting. Forensic clients released from state hospitals or from jail and ordered to receive community-based care are usually monitored by the court under a conditional release order (CRO, discussed later) (Manguno-Mire et al., 2014). The state allots a select number of “forensic beds” to a county or jurisdiction (Torrey et al., 2010); these beds are located in a secure (forensic) hospital and are


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primarily reserved for felony defendants with SMI who have been committed to the state under the doctrine of parens patriae9 and evaluated by a legally defined “expert” examiner under a court order for competence and/or sanity (“About Adult Forensic Mental Health,” 2014; “Forensic Services: Program Overview,” 2016; New York State Office of Mental Health, 2016; Roesch et al., 1999). Evaluations and legal concepts pertaining to competency and sanity are discussed in more detail later in the chapter; for now, forensic case management and state forensic hospitals are introduced and discussed in some detail.

Case Management A forensic case manager (sometimes referred to as a forensic liaison or forensic specialist) is an individual who is most likely employed by a community mental health provider under contract with the county, region, or state to provide an array of services to justice-involved individuals with SMI in both secure and community settings (Slate et al., 2013; Steadman et al., 1995). FAST FACT 7.3 CAREERS IN THE FORENSIC MENTAL HEALTH SYSTEM For the position of forensic case manager (juvenile and adult), the following qualifcations have been sought: • • • • •

A BA/BS degree in the human service feld from an accredited college or university. One or more years of full-time experience working with adults with mental health disorders. Good organizational skills and the ability to develop partnerships with other service agencies in the community. Excellent communication skills, both verbal and in writing; ability to maintain records. A valid driver’s license, current auto insurance, a reliable vehicle, and a good driving record.

If you have experience working in the behavioral health or criminal justice systems in some capacity, employers see that as an extra bonus (hence, why internships are so important!). Source:; “Position Description,” retrieved at http://www.

Forensic case managers are considered liaisons or boundary spanners (discussed in Chapters 6, 8, and 10), as they are generally responsible for the coordination of services between multiple systems of care. Services provided by forensic case managers may include the coordination of mental

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health evaluations, service planning, service linkage, service coordination, monitoring of service delivery, and evaluation of service effectiveness (Steadman et al., 1995). Case managers assigned to forensic clients who are living in the community are responsible for monitoring compliance with the court-ordered release plan, providing early intervention to avoid revocation of conditional release (discussed shortly), and reporting to the court on progress/compliance. Whether a client is suitable for community placement or secure placement in a forensic hospital will depend on recommendations made by a forensic evaluator, and by the order of the court.

Forensic Hospitals Forensic hospitals are secure treatment facilities that are geared toward housing persons with SMI who have most likely been court-ordered and committed to a state department that oversees mental health services (Powitsky, 2011). Depending on the jurisdiction and/or the mission of the lead agency, organizational differences may be observed across facilities. When individuals (considered “patients” in this context) are admitted into a forensic hospital, they are expected to follow a treatment plan that may include competency training, medication management, group and individual therapy, and participation in a variety of programs tailored to the individual’s specific needs. For patients adjudicated (i.e., formally declared, by a court) incompetent to stand trial (IST)/incompetent to proceed (ITP), the primary goal is to restore competency. For those found not guilty by reason of insanity (NGI or NGRI) due to serious mental illness—NGI patients—it is to secure, stabilize, and treat (“Forensic Facilities,” 2014). ITP and NGI dispositions are discussed in more detail later in the chapter. For now, the following preliminary segment on Sally and Mac may provide a helpful introduction. THINKING CRITICALLY 7.4 COMPETENCY VS. SANITY: THE CASE OF SALLY AND MAC, PART ONE Imagine for a moment that Sally hears voices in her head that tell her to hurt Mac. Let’s say that she ignores them for as long as possible, but then is compelled to listen to them and finally hurts Mac—badly. She is quite vocal about the incident, and suddenly the district attorney (DA) builds a pretty strong case against her. Seems like an open and shut case, right? Well, not necessarily. Once detained in the local jail, some guards notice Sally arguing and carrying on with individuals who are not present, and so they inform the warden that she “just isn’t right.” At this point, it seems there may be an issue regarding her competency to stand trial for the current charges. In fact, to move forward and prosecute someone like Sally, the DA, her defense counsel, or the Court (i.e., the judge presiding over her case) will


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have to order that she be evaluated by a psychologist to determine her competency status. What does this mean? In short, it means that Sally must express a basic understanding of the nature of the charges against her and the adversary nature of the judicial system. She must also be able to cooperate with her defense lawyers. Why is this important? Well, consider this: Imagine that Sally’s defense lawyer explained the charges against her and what might happen if she’s found guilty. Her defense counsel may tell her she is facing assault charges and could possibly be sentenced to 15 to 20 years in prison. Now imagine that after all the explanation, Sally still does not understand what is going on and instead keeps insisting that she be able to watch her favorite programs at home on her television and from her own bed. It’s possible that Sally is so lost in her own world of visions and voices that she is unable to distinguish hallucinations from reality anymore. For these reasons, she might be found incompetent to stand trial (ITP). What does this mean for Sally and her criminal case? Well, we should keep in mind that state law will vary slightly, but it is not uncommon for violent defendants deemed ITP to be committed to state institutions and be subjected to periodic re-evaluations which are sent to the Court. Sometimes, a person may be deemed “non-restorable”—a clinical determination that neither inpatient nor outpatient treatment (involving competency training) will not help the defendant understand the charges against them, signaling that the charges must be dismissed. Other times, a re-evaluation will indicate that the defendant has become competent; in that case, the defendant will be tried on the original charges. There are several ways that a person may be found ITP regarding mental health. One reason is that they are not able to tell the diference between reality and hallucinations or delusions. Another reason is that a person may have a severe developmental disability, which renders it impossible for them to function at a “normal” level physically and/or intellectually. Dementia may also contribute to a person being found with ITP. Competency to stand trial involves an inquiry as to the defendant’s current state of mind. Sanity, on the other hand, is a legal defense based on the defendant’s state at the time of the ofense. It involves a diferent clinical evaluation and is typically introduced at the trial state after competency has been established/attained. What if we determined that Sally was completely sane during the assault on Mac? What if the circumstances here were that Sally had a psychotic break soon after she committed the crime and now was not competent to stand trial? The point is that Sally would still be ITP even though she was not psychologically impaired at the time of the crime. We revisit this case later, to illustrate the insanity defense more clearly.

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Given the various types of patients served, forensic facilities generally have three levels of security: minimum (nonsecure), medium, and maximum. Minimum-security state hospitals are under secured access with locked doors and 24/7 supervision. These facilities are typically used for forensic patients charged with or convicted of misdemeanors and nonviolent offenses, and those with a low risk of elopement (i.e., “running off”). Medium-security state hospitals are fortified by way of electronic fences, controlled access, and limitations on personal items allowed in the facility. Maximum-security state hospitals are normally operated under restricted movement, specialized monitoring, and continuous observation; these facilities are reserved for patients who are charged with felonious crimes and who have been determined to present a risk of violence (“Forensic Mental Health Services,” 2013; “Forensic Services: Program Overview,” n.d.). Commonly, defendants found ITP or NGI are indefinitely committed to the state department which controls mental health services, and are then placed in one of several hospitals across the state. State statutes outline the process of forensic commitment, and the time in which placement must occur is also prescribed by state statute and ranges anywhere from 14 to 30 days. A major issue with forensic secure placement is the lack of available beds and lengthy waitlists mentioned previously, and discussed further in Chapter 11). Given the legal mandate on the limit for which a PwMI can be held in jail after commitment to a treatment facility, there is an enormous amount of pressure on the facilities to effectively manage the waitlists—which can be as long as four months10 (Fuller et al., 2016). Once a person is transported to a forensic facility (usually from jail by the sheriff’s office), the length of stay depends completely on the individual’s participation and response to treatment (Slate et al., 2013). Some reports have indicated that, on average, ITP patients are discharged within a four-month period (Wasserman, 2014); this is in stark contrast with the average length of stay for NGI patients, which is a little over four years (Fuller et al., 2016). If criminal charges are pending or prosecution deferred, a periodic status report must be given to the courts to determine their length of stay or if conditional release becomes an option. Discharge from a forensic hospital does not necessarily mean an individual will be released into the community; in fact, if hospital staff find that some ITP and NGI clients need continued treatment in a secure setting beyond that which can be rendered in the forensic facility, civil commitment is an option that might be considered (Wasserman, 2014). Figure 7.3 provides an aerial view of a forensic hospital in the state of Florida.

Conditional Release A justice-involved PwMI who is detained, whether in a jail, prison, or forensic hospital, and who has demonstrated a low public safety risk, may be given the opportunity for release into the community with conditions—otherwise


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Figure 7.3 Aerial View of the Treasure Coast Forensic Treatment Center, Indiantown, Florida Source: Courtesy of Jim Cheney at Prufrock Communications

referred to as conditional release or “mental health probation” (Slate et al., 2013). The individual will continue to be committed under the designated state department of mental health services, and the department will contract with designated providers to oversee the client’s progress. Factors that judges consider in their decision to grant conditional release include the seriousness of the offense committed, the individual’s behavior while held in jail, the amount of time between the last reported unlawful act and the hearing, whether there are family or friends in the community who are willing to support the individual, and other factors (Dirks-Lindhorst & Linhorst, 2012). Once approved by a treatment team and the state and reviewed and accepted by the client, a judge will sign a CRO that will be accompanied by a conditional release plan (CRP)—a document that sets forth all the conditions the client is expected to follow (see the following example from the state of Florida).

POLICY & PRACTICE 7.4 SAMPLE CONDITIONAL RELEASE PLAN (CRP) An Excerpt of a Conditional Release Plan, as Taken from a Model Order Adjudicating Defendant Not Guilty by Reason of Insanity and Placing the Defendant on Conditional Release a

The Defendant will remain in outpatient treatment for his mental illness during his conditional release period. Such treatment will be provided by the _____________________________ [agency]. All aspects of his treatment will be coordinated by his assigned case manager/forensic specialist; _________________________________________ [name, address, and phone number].

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b The Defendant will reside at ________________________________ [facility, address, and phone number]. Any change in address will be approved by his case manager/forensic specialist and the court shall be immediately notified. c

The Defendant will take psychotropic medication as prescribed by his attending psychiatrist. Periodic psychiatric consultations will be coordinated by his case manager/forensic specialist.

d The Defendant will attend outpatient substance abuse treatment as directed and arranged by his case manager/forensic specialist. e

The Defendant will not drink alcohol or use illegal substances of any kind and may be required to undergo periodic drug screenings as directed by his case manager/forensic specialist.


The Defendant will not possess or use any firearms or other weapons of any kind.

g The case manager/forensic specialist will provide the court with periodic reports regarding compliance with the conditions of release and his progress in treatment. These reports will be submitted every six months or as required by the court. h The conditional release plan has been reviewed by the Defendant. The Defendant understands the conditions of release listed and agrees to comply with them. Source: Florida Department of Children and Families, Adult Forensic Mental Health (AFMH) Model Court Orders and Motions. Retrieved from

Persons in the community under a CRO are usually monitored by a forensic liaison or case manager who provides periodic updates to the court about the client’s status. The majority of clients on conditional release are persons who have been acquitted as NGI; however, in some cases, if the court determines that an individual adjudicated ITP presents a low public safety risk and may be effectively managed in the community, it is possible that the individual will be granted conditional release with community-based competency restoration included as one of the conditions, in addition to mental health treatment and monitoring by the court (Manguno-Mire et al., 2014). The most common methods of monitoring are monthly face-to-face visits with the client, telephone contact, and the development of relationships with community support workers and others who have regular contact with the individual on conditional release. Forensic case managers may also attend programs with their clients and make random visits to the community in which the client resides and/or works. In contrast to traditional community supervision of criminal defendants who are under probation and parole, most conditional release revocations


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are a product of CRP violations rather than the commission of a new crime or violent behavior. For example, CROs have been revoked for the client’s failure to take prescribed medications or to attend scheduled treatment appointments as set forth in the CRP. Research has revealed that conditional release programs have reduced recidivism and minimized the number of arrests and revocations over longer durations than indicated previously (Manguno-Mire et al., 2014; Stempkowski, 2020). To be successful, treatment programs for substance use issues must be provided, as well as close monitoring of mental health symptoms and very intensive supervision for individuals who have a history of failure and rule violations (Hayes et al., 2013; Manguno-Mire et al., 2014). Success is largely reliant on maintaining therapeutic goals. FAST FACT 7.4 FALSE POSITIVES/MALINGERING A false positive refers to a situation where a person is identifed as having a mental health need when there is no actual mental health need present. Also referred to as malingering (feigning symptoms of mental illness), it is important to be aware of false positives, especially in a correctional setting. Incarcerated individuals who do not have a mental illness may believe that reporting symptoms could provide them with an advantage in sentencing, cell or block assignment, or treatment within the facility. Source: Martin, M. S., Colman, I., Simpson, A. I., & McKenzie, K. (2013). Mental Health Screening Tools in Correctional Institutions: A Systematic Review. BMC Psychiatry, 13(1), 1–10.

Therapeutic Jurisprudence (Courts and Court Services) Therapeutic jurisprudence (TJ) refers to a multidisciplinary study of therapeutic and antitherapeutic consequences in relation to the application of the law (Wexler, 2000). A TJ philosophy aims to reform the law to positively impact the psychological well-being of the accused person, recognizing the negative consequences of a punishment without rehabilitative or restorative goals. Traditionally, the criminal justice system has utilized legal sanctions, including incarceration, both to punish “offending persons” and to deter them from further criminal activity. Conversely, the treatment community emphasizes the development and maintenance of therapeutic relationships to help motivate individuals to reduce their dependence on drugs, change their behavior, and take control of their lives. Specialty or problem-solving courts have emerged in recent years as evolving agents of the TJ philosophy, offering competing perspectives on the causes of substance use and addiction, family violence, and mental health and trauma. The following sections offer an introductory discussion of problem-solving courts that cater to the needs of justice-involved PwMI, including drug and mental health treatment court programs. A brief discussion of the veterans’ court is also provided at the end of the section.

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Drug Treatment Court The first drug court was established in 1989 in Miami-Dade County (Miami, Florida), and by the end of 2014, there were close to 3,000 drug treatment courts (DTCs) of all types operating across the United States (e.g., adult, juvenile, family, and DWI) (National Institute of Justice [NIJ], 2006). Drug courts combine intensive supervision, mandatory drug testing, treatment, and incentives to help defendants with substance abuse problems. Among other conditions (described later), drug court involvement requires a client to undergo intensive supervision and mandatory drug testing over a certain period, to be determined by the drug court program team. If any violations are discovered, the prompt utilization of sanctions is imposed to correct the behavior. Alternatively, incentives are used to reward program compliance, as encouragement and support are essential components of a successful outcome and a full recovery for clients (Marlowe, 2012). A drug court “workgroup” or “team” is typically composed of a judge, prosecutor (district or state attorney), defense counsel, treatment provider(s), probation officer(s), law enforcement, and a court coordinator. All these people communicate and work together to come up with a treatment plan for the participant and monitor them to ensure they are staying on their route to recovery (Griffin et al., 2015). Typically, court-involved persons will elect to enter a drug court program as a diversion from the traditional court process or as a condition of probation. Goals, rules, and expectations are explained early in the process; the participant must appear in treatment court on a regular basis to be assessed by the team and to report progress to the court. A program usually consists of individual and group counseling and mandatory drug testing. Participants are provided help with employment, education, healthcare services, and housing services. After the client has successfully completed the program (12 to 18 months, on average), they will likely participate in graduation, and their charges may be dismissed, reduced, or set aside (Office of National Drug Court Policy [ONDCP] “Fact Sheet: Drug Courts,” 2011). Studies have produced positive results regarding reduction in recidivism and prevention of drug use/abuse; however, because of poorly designed research methodologies and an overall lack of rigor, many have failed to produce generalizable results (Griffin et al., 2015; Joudrey et al., 2020; Wilson et al., 2006). According to the literature, more recent methodologies have shown improvement in this regard, and results continue to be quite promising (Gallagher et al., 2021; Griffin et al., 2015; Rossman et al., 2011; Wadkins & Campbell, 2021).

Mental Health Treatment Court Modeled after drug treatment courts, mental health courts (MHCs) emerged in 1997, with the first one implemented in Broward County, Florida (Slate et al., 2013). There are now over 300 MHCs in various states throughout the United States (Burns et al., 2012). Along with the traditional goals of meting


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out justice and keeping the public safe, the central (and non-traditional) goals of MHC include connecting individuals with behavioral health services and providing access to quality treatment, improving psychiatric symptoms, improving the overall quality of life, and reducing recidivism rates (Odegaard, 2007). Participation in an MHC program is voluntary, but participants can be referred by police officers, judges, attorneys, probation officers, case managers, prison staff, family members, and other agencies or individuals who encounter an eligible candidate. MHC programs typically last between 12 and 18 months, during which time participants are expected to be involved in supervision/probation appointments, regular drug testing, judicial review hearings, community service or other pro-social activities, and any additional services needed such as drug and alcohol treatment or support with job placement. FAST FACT 7.5 ROLE OF GENDER IN MENTAL HEALTH COURTS Men with mental illness are more likely to be involved in violent crimes and exhibit violent behavior than women (Ennis et al., 2016). Despite similar recidivism rates, however, women are more likely to be referred to mental health court than men (Ennis et al., 2016).

In most cases, criteria for participation in an MHC require that the defendant must have a current primary diagnosis of a major mental health disorder within the last two years as defined by the DSM-5. The most frequently cited disorders among MHC clients have included schizophrenia, major mood disorder (bipolar disorder, major depressive disorder), and psychotic disorder (schizoaffective disorder) (Odegaard, 2007). The defendant must be assessed by a psychiatrist or psychologist if there is not a current diagnosis to determine that the defendant has a serious mental illness. Although MHC programs accept most misdemeanor clients on the docket, some do not allow felony forensic clients to participate (Griffin et al., 2002). Additionally, like DTCs, MHCs follow a behavioral modification–based model of sanctions and rewards; however, procedural guidelines as to the content and process may differ across programs (Griffin et al., 2012, 2015; Odegaard, 2007). For these and other reasons, MHCs and other problem-solving court programs have been criticized for failing to comply with more formal and consistent procedural guidelines and potentially violating client due-process rights. There have also been concerns raised as to process efficiency, in that research findings indicate a lack of support for swift diversion, which was the original intention of MHC implementation (Griffin et al., 2015). By and large, the research reveals that participation in MHC programs has reduced recidivism and violence among persons with mental illness; it has also been shown to increase engagement in mental health and other

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treatment services (Burns et al., 2012; Hiday et al., 2013; Keator et al., 2013; Lowder et al., 2018; McNiel et al., 2015). Completion of the program has been a determining factor related to recidivism in some studies (e.g., Moore & Hiday, 2006). In terms of improvements in psychiatric and SUD symptoms, the research is conflicting; however, it seems that mental health service delivery depends on the services available and the collaboration among provider agencies in the jurisdiction that delivers the services (Honegger, 2015).

Veterans’ Treatment Court Given the success of specialized mental health and drug court programs in reducing the population of PwMI incarcerated and improving recidivism rates, veterans’ treatment courts (VTCs) were developed to meet the needs of the veteran population increasingly coming into contact with the criminal justice system—in particular, for nonviolent offenses that are largely attributable to post-traumatic stress disorder (PTSD) acquired during deployment and exposure to combat-related situations (Knudsen & Wingenfeld, 2015). VTC programs focus on underlying causes of criminal behavior, and members of the treatment team collaborate to wrap veterans in an array of services so that they can engage in treatment (including trauma-based treatment and proper medications), but also get help with needs such as housing, transportation, and obtaining medical services and other veterans’ benefits (Knudsen & Wingenfeld, 2015). To be eligible for the VTC, individuals must have committed a nonviolent felony or misdemeanor, qualify for Veterans’ Administration (VA) benefits, and have PTSD, substance abuse, or some other serious psychological disorder. Participation in VTC is completely voluntary. Participants will come before judges on a regular basis to discuss their progress, and they will receive support and guidance from veteran mentors, which has been proven to be the most essential, and successful, component of the program (Russell, 2009). Given the relative youth of veteran court programs, empirical evidence of program effectiveness is available, though sparse. Graduation rates and reductions in recidivism are likely measures of success. Figure 7.4 provides an infographic as it relates to the implementation of veterans’ court in the state of Pennsylvania, including program characteristics as well as outcome (i.e., graduation) data.

Matters of the Law: Competency and Insanity The diversion options just presented are critical at Intercept 3 for identifying custody and treatment strategies with justice-involved PwMI at case disposition. There are additional legal issues to consider during the period between an initial encounter with law enforcement and adjudication. If properly trained in behavioral health and crisis intervention, first responders


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Figure 7.4 Veterans Treatment Courts (VTCs) in Pennsylvania

Source: The Unifed Judicial System of Pennsylvania (2021, November 9). Media Resources. Pennsylvania’s Veterans Treatment Courts Make a Diference for Veterans. [Infographic]. media-resources?Resource=131

and correctional staff (including mental health workers) might observe behaviors that, upon further examination, could delay and/or prevent the further processing of an individual through the legal system. Specifically, there are important concerns in relation to two legal concepts: competency to stand trial and the insanity defense. Although briefly introduced earlier in the chapter, these concepts are defined and contrasted next in terms of their primary differences. A case example is also provided for further clarification.

Competency to Stand Trial Basic constitutional rights pertaining to due process make it crucial that a criminal defendant is capable of knowingly, intelligently, and voluntarily participating in the legal process, which particularly entails their own defense. The authority for this rule of law, which pertains to a defendant’s mental state, can be found in the case of Dusky v. U.S., 32 U.S. 402 (1960). Under Dusky, the U.S. Supreme Court held that the basic standard for determining competency is whether “the Defendant has a sufficient present ability to consult with his attorney with a reasonable degree of rational understanding, and whether he has a rational as well as factual

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understanding of the proceedings against him” (Dusky v. U.S., 402, 1960). The requirement of a rational and factual understanding should be underscored here, for a defendant could have a factual understanding of the purpose of a judge and jury yet believe that both have been given orders by Satan to punish him severely. Competency refers to the mental state of the defendant at the present time— not at the time of the offense. Thus, “present” may include any point after the offense has been allegedly committed and during the legal process from initial police custody and interrogation to the expected time of trial and sentencing. The issue as to a defendant’s competency may be raised multiple times during the processing of a case if the defendant’s mental condition changes; the intent is to determine the ability of a defendant to perform a specific function throughout proceedings (Andrews, 2003). Competency is most likely to be determined prior to a trial; however, issues of competency have also been found to surface after sentencing and conviction phases due to capital punishment cases (Slate et al., 2013). If a defendant is found to be incompetent (incompetent to proceed to trial or ITP), the criminal justice process should be temporarily halted, and proceedings should resume only when competency is determined or restored, if at all. FAST FACT 7.6 PSYCHIATRIC ADVANCE DIRECTIVES Like in case of a medical emergency that renders a person incompetent to make important medical decisions, a psychiatric advance directive can be utilized to determine the mental health treatment options for a consumer when that person is in a mental health crisis and is found to be too psychologically impaired to make decisions related to psychiatric care. Unfortunately, advance directives are underutilized. Source: “Psychiatric Advance Directive” (2016), Retrieved at http://www.

State legislation differs slightly with respect to some of the procedural aspects of competency and competency examinations; however, some generalizations can be made. For example, the need for a competency examination is typically initiated by several individuals who have contact with the defendant and, hence, the opportunity for direct observation. Such individuals may include police, correctional staff, the warden of a correctional facility, and forensic mental health staff. More often, however, the issue is raised by counsel—in particular, the defendant’s attorney or public defender (Mental Health Procedures Act [Pennsylvania], 1976). A court may also initiate an examination on its own motion. The burden of proof regarding the defendant’s status is that of the party who raised the issue, and that party will order required evaluations (competency examinations) to be


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conducted. The defendant has a right to have counsel represented during a competency examination, as well as any subsequent hearings pertaining to competency status. Further, the defendant has the right to remain silent and to not participate or answer any of the questions asked by the examiner (Andrews, 2003). The competency examiner may also be ordered by the Court to assess a defendant for mental status at the time of the offense or insanity, a concept that is discussed in more detail next. Depending on several factors related to the client and the charges, as well as available resources in a jurisdiction (i.e., available hospital beds and costs associated with the service), competency restoration may occur in one of three different settings: • • •

Jail Community Forensic treatment center (hospital)

Competency training is much less costly when delivered in a jail setting; however, given the infancy of jail-based programming and the lack of available data, no conclusion has been drawn as to differences in effectiveness as related to outcome (competency restored) and place of delivery (Kapoor, 2011).

Insanity as a Defense In contrast with competency, which requires an evaluation of one’s mental capacity at the present state, a determination that a defendant is not guilty by reason of insanity (NGI/NGRI) is made based on a defendant’s mental state at the time the offense was committed (retrospectively). Insanity is an affirmative defense, and it does not result in a stay of criminal proceedings. Rather, it is introduced later during a trial to attain an acquittal for the defendant, hence, dismissing or ending any prosecution in the criminal court. It’s time to return to Part Two of the case study about Sally and Mac, as it may offer some further clarification as to the legal construct of insanity

THINKING CRITICALLY 7.5 THE CASE OF SALLY AND MAC, PART TWO: THE INSANITY DEFENSE Recall our case study presented at the start of this chapter, involving Sally and Mac. How would the situation be diferent if Sally was not functioning normally at the time of the ofense against Mac? Imagine that Sally comprehends the charges against her and has been able to assist her public defender in preparation for trial; however, at the time of the crime, she was hearing voices and did not really know what she was doing. In that case, Sally’s defense attorney might argue that she is not guilty by reason of insanity (NGI or NGRI).

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Insanity can be a complex concept to explain and, worse yet, to understand. Here is the (very) basic premise: To fnd a person guilty of a crime, the state must prove that the person committed the crime and that they had criminal intent (i.e., mens rea, or a guilty mind). In other words, if a person steals their co-worker’s bicycle because it is the same as theirs and, therefore, they truly believe it is theirs, then they cannot be convicted of theft, which is a crime, because they did not have the necessary intent to commit a crime. In the context of describing how the insanity defense works, this means that a person like Sally, who has a mental illness and lacked awareness of her behavior and the wrongfulness of it, can certainly plead NGRI. This is the insanity defense.

During the pre-trial examination, and upon a motion by the court, an evaluator will be charged with determining the defendant’s criminal responsibility by conducting a mental status at the time of the offense (MSO) evaluation. From a legal standpoint, there are three tests designed to assist in making a determination of insanity: the M’Naghten “right or wrong” cognitive test, the irresistible impulse volitional prong test, and the model penal code test (Feinstein, 2013; Moriarty, 2014). Under M’Naghten and irresistible impulse rulings, the burden is placed on the defense to prove by a preponderance of the evidence that the defendant, at the time of the offense, was operating under a defect of reason from disease of the mind and was unaware of the wrongful nature of the act committed (Feinstein, 2013; Slate et al., 2013). Over the years, criticism has circulated around M’Naghten/irresistible impulse rulings, because they may not take full consideration of the true impact mental illnesses may have on impairing judgment and impulse control. With the 1954 case of Durham v. U.S., a reformed “product” test for insanity was brought about, which disregarded both the M’Naghten and irresistible impulse tests (Moriarty, 2014). The Durham product test set out a ruling that stated, “an accused is not criminally responsible if his unlawful act was the product of mental disease or mental defect” (Moriarty, 2014, p. 12); however, due to the broad nature of this ruling, both state and federal courts rejected it. In 1955, the American Law Institute (ALI) formulated a model penal code test known as the “ALI standard” that essentially combined and rephrased the M’Naghten/irresistible impulse tests (Feinstein, 2013; Moriarty, 2014). Although the ALI standard was favored throughout the courts for many years, the very high-profile John Hinckley case in 198111 prompted yet another reform, known as the Insanity Defense Reform Act (IDRA). IDRA demanded an affirmative defense and burden of proof (Moriarty, 2014). By the early 1990s, attention was shifted back toward the M’Naghten and ALI standards, which eventually had become, and continue to be, the predominant methodologies for evaluating insanity throughout the United States (Slate et al., 2013).


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POLICY & PRACTICE 7.5 EVALUATING DEFENDANTS FOR SANITY An MSO evaluation is designed to determine whether, because of mental disease or defect, a defendant experienced cognitive impairment at the time of the commission of an ofense that renders them unable to be held criminally liable. The evaluation consists of three parts: 1 2 3

Historical information related to the defendant The mental state of the defendant at the time of the ofense The present mental state of the defendant

There have been some developments related to assessment measures in an insanity defense, including the Mental State at the Time of Ofense Screening Evaluation and Rogers Criminal Responsibility Assessment Scales. Current research informs that similar measures to assist in clinical decisionmaking involving MSO are underway. Sources: 1. Adjorlolo, S., Chan, H. C. O., & DeLisi, M. (2019). Mentally Disordered Ofenders and the Law: Research Update on the Insanity Defense, 2004–2019. International Journal of Law and Psychiatry, 67, 101507; 2. 2. Psychwest Clinical and Forensic Psychology. Insanity: Mental State at Time of Ofense (MSO) Evaluation. (n.d.). Retrieved from http://www. 3. Zapf, P. A., Golding, S. L., Roesch, R., & Pirelli, G. (2014). Assessing Criminal Responsibility. In I. B. Weiner & R. K. Otto (Eds.), The Handbook of Forensic Psychology (4th ed.) (pp. 315–351). New York, NY: Wiley Press.

State laws are instructive as to criteria regarding an MSO evaluation or examination. Regarding what specifically constitutes a mental disease or defect, it is when there is a significant impairment to the capacity of the defendant to understand what they have done (Andrews, 2003). In Pennsylvania, for example, if the defendant disagrees with the conclusion of the MSO report conducted by the court-appointed psychiatrist, the court must allow reasonable compensation for the defendant to retain another psychiatrist. Further, in the instance that the court makes a pre-trial determination that the defendant is criminally responsible, the defendant may raise the issue again later to the jury assigned to hear the case (Mental Health Procedures Act, MHPA, 50 P.S. § 7402(e) & § 7402(f)). The insanity defense has not been well received by the public, and this is reflective in jury decisions when it is used. In fact, in the United States, it is invoked in only about 1 percent of all felony cases and is successful in only a small proportion of those (Feinstein, 2013). There is a considerable amount of controversy surrounding the idea of acquittal based upon a criminal defendant’s mental state, and there have been ongoing debates and legislative changes designed to ameliorate public concerns about malingering and unjust acquittals. In some jurisdictions, juries have the option

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of invoking a verdict of guilty but mentally ill (GBMI), which attaches criminal liability and periods of continued incarceration, but acknowledges the defendant’s need for mental health treatment (Adjorlolo et al., 2019; McGraw et al., 1985).

Challenges Regarding the longevity of sentencing and placement, some scholars have found various scenarios where defendants who received NGRI verdicts spent more time in confined psychiatric treatment than individuals who were sentenced to a traditional correctional institution (Fellner, 2006). Current screening and assessment practices present weak areas that need improvement to help retain the defendant’s due-process rights and to reduce correctional concerns, and ultimately, recidivism rates. Presented as the global theme throughout this textbook, behavioral health and criminal justice officials often neglect to communicate with each other, which makes it difficult for them to work collaboratively as a team to help those with serious mental illnesses avoid penetration into the traditional criminal justice system. Unfortunately, this failure to integrate and to share pertinent information has resulted in severe consequences for some individuals. The case of Ralph Tortorici is presented below to illustrate point. THINKING CRITICALLY 7.6 CASE SNAPSHOT: RALPH TORTORICI When an Incompetent Defendant Is Allowed to Stand Trial At 9:10 am on December 14, 1994, Ralph Tortorici opened fre with a.270caliber Remington rife on a group of students gathered in Lecture Center 5 of the State University of New York at Albany, uptown campus. The 26-yearold psychology student held the class of 35 hostages as he nervously paced around, demanding to speak to various university and government ofcials. As a scufe ensued between him and one student, 19-year-old Jason McEnaney, Tortorici’s gun went of, and a single bullet shot and seriously wounded McEnaney. Tortorici was ultimately charged with 14 counts of aggravated assault, kidnapping, and attempted murder; his lawyer subsequently entered a plea of not guilty by reason of insanity. After the shooting, Tortorici’s history of physical and mental illness was uncovered and indicated prior episodes of paranoia, auditory hallucinations, and delusional thinking. When he was evaluated for competency after the shooting, he was deemed incompetent to stand trial and was sent to a secure facility for treatment. During his brief treatment, Tortorici refused to take medications and was still reportedly delusional but was shortly reassessed and found competent to stand trial. Tortorici was quickly sent back to jail to await his trial date. Later, a separate expert for the prosecution concluded that Tortorici was, once again, not competent to stand trial; however, although the report suggested hearings on the matter and


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deference to a sanity assessment until Tortorici could fully participate in the process, the Court denied the request and the trial ensued with Tortorici in absentia. The jury rejected the insanity defense, and Tortorici was convicted on all counts and was sentenced to prison for 20 to 47 years, the maximum sentence permissible under law. Just three weeks after Tortorici was sent to prison, he attempted suicide, and over the course of the next few years, was shuttled back and forth between the prison and a secure psychiatric facility. On August 10, 1999, Tortorici hanged himself with a sheet in his prison cell. Source: Frontline: A Crime of Insanity (2002)

The tragic case of Ralph Tortorici illustrates the complexities involved with disposing of criminal cases involving seriously psychologically disordered defendants and the conflicting perspectives on competency and sanity under the law. As demonstrated here, presiding judges have considerable discretion (and, if elected, political pressure), and may decide to proceed with a trial despite evidence presented by evaluators that a defendant is legally incompetent. Such outcomes indicate the importance of seeking diversion opportunities earlier in the criminal justice process, promoting educational or training sessions that provide information for judges and attorneys related to SMI and how assessments are used in the evaluation process, and developing strategies to improve the integration of criminal justice and mental health partnerships at every stage in case processing. This text is centered on the law as it pertains to PwMI in the U.S., but it is instructive to study law and legal concepts and procedures through a comparative lens. Comparative Perspectives 7.1 illustrates the legal capacity of defendants in the context of the Italian law. COMPARATIVE PERSPECTIVES 7.1 INSANITY & CRIMINAL RESPONSIBILITY IN ITALY Giovanni Chiarini, Criminal Defense Attorney, and PhD Candidate Article 32 of the Italian Constitution is a milestone. This primary norm provides that the Republic safeguards health as a fundamental right of the individual, as well as a collective interest. No one is obliged to undergo any health treatment, except under the provisions of the statutory law, and always with respect to the dignity of the person. But the essence of the Italian criminal law system can be found in Article 27 of the Constitution: Criminal responsibility is “personal.” But what does “personal” mean in this context? How might a person with a serious mental illness clearly understand the negative consequences of their behavior, and therefore, be considered as personally responsible? Article 85 of the Italian Penal Code provides an important rule: No one shall be punished for an act defned by law as a crime if not responsible when committing the act. A person is “chargeable” (“imputabile”) when capable “to intend” and “to will” (“di intendere” e “di volere”). The “capacity to intend” is essentially the

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attitude of a person to understand the positive or negative social value of his actions as well as to foresee its evil consequences. This can be compared with the M’Naghten Rule12 “test for legal insanity” in the United States. The “capacity to will” is fundamentally the attitude to self-determination. If one of those capacities is missing, there is no imputability (criminal responsibility). Moreover, on one hand, Article 97 claims the incapacity to intend and to will for all the people who have not turned 14 years old yet. On the other hand, Article 98 provides a mitigating circumstance with a 1/3 reduction of the fnal sentence for those who have committed a crime in the age range 14 to 18. A similar mitigating circumstance is to be found in Article 89, in the case of “partial mental illness” (“seminfermità mentale”); namely, an only partial reduction of the above-described capacity. Alternatively, a person cannot be sentenced to imprisonment in case of a total lack of the capacity to intend and to will (“infermità mentale”). However, if the person is considered socially dangerous (“pericolosità sociale”), a “measure of safety” shall be applied (“misura di sicurezza”), which is—generally—custody into a hospital specializing in the treatment of mental illness (called “REMS”13). This “measure of safety” has no well-defned temporary limit. Judges periodically evaluate the situation of the patient-defendant (Articles 207 and 208), together with a medical-expert team, to understand the permanence of the social dangerousness. If that dangerousness has expired, the judge shall revoke the measure.

TAKE-HOME MESSAGE From a philosophical viewpoint, the primary role of state correctional agencies is to maintain institutional safety through proper functioning and management of the population. The increase in the number of people with SMI in jails and prisons over recent decades, however, has transformed these facilities into de facto psychiatric institutions. This transformation can be attributed in part to insufficient funding and support by community mental health systems. Regardless of the reasons for the change, it has become clear that corrections staff must be better prepared to interact with detainees who have serious mental health needs. As discussed in Chapter 6, all detainees should be screened and assessed at intake for mental health and substance abuse history and prior treatment regimens, including medication management. Detainees with a history or current presentation of behavioral health symptoms should always be observed for competency and sanity issues. When competency is in question, a criminal defendant may be subjected to a series of evaluations that will render a decision as to whether the case should move forward (competent) or should pause until treatment occurs (incompetent). PwMI should also be screened for suicidal ideation, and proper management and care should be followed continuously for those found to be at risk for self-harm. It is also essential that staff be trained in proper response strategies when encountering PwMI who are experiencing adjustment issues related to their illnesses and symptomology. Strategies to combat stigma and to facilitate respect toward PwMI must be implemented. In some cases, diversion options can be used to filter PwMI out of the traditional criminal justice setting or to manage their care more effectively while


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incarcerated. For example, forensic case management and peer-based programming have been shown to be effective at minimizing adjustment difficulties and increasing treatment compliance. In some instances, detainees may be transferred to secure forensic hospitals, where they are more likely to receive the level of care needed to manage their illness. Finally, problem-solving, treatment-focused courts are used to divert some defendants into a community-based care setting, while integrating into an array of services that are closely managed by a team of criminal justice and behavioral health professionals. Most importantly, successful outcomes rely largely on effective collaboration and partnerships between criminal justice professionals and behavioral health providers and other cross-systems efforts designed to address the complex needs of individuals—needs that cannot be effectively addressed by a single system of care. This subject is further addressed in the remaining chapters of the text.

Questions for Classroom Discussion 1. A variety of problem-solving courts have been implemented for individuals suffering from mental illness and addiction. Why are these courts necessary? 2. What kind of materials would help you better communicate with a person with a mental health disorder? Make a list of tools you think would assist you in better responding to or protecting persons with mental illness. 3. What clues might suggest that a person behaving inappropriately in a jail or prison setting may be either decompensating or contemplating suicide? 4. How does competency affect the criminal justice process? Compare and contrast this with sanity. KEY TERMS & ACRONYMS • • • • • • • • • • • • • • • •

Conditional release order (CRO) Conditional release plan (CRP) CSU Dialectical behavior therapy (DBT) Forensic commitment Forensic liaison Forensic specialist Incompetent to proceed (ITP) or incompetent to stand trial (IST) Mental status at the time of the ofense (MSO) evaluation Not guilty by reason of insanity (NGRI or NGI) Parens patriae Restricted formularies (prescription psychotropic medications) Self-injurious behavior (SIB) Specialized housing units (SHUs) Suicide watch Therapeutic communities (TCs)

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NOTES 1 Adapted from Treatment Advocacy Center. Preventable tragedies database. Accessed December 23, 2021 from https://www.treatmentadvocacycenter. org/evidence-and-research/preventable-tragedies/preventable-tragediesdatabase/record/a0h61000000hFjFAAU. Original source: Great Falls Tribune (2003, October 3). 2 Div. V Court (Division V Court) refers to felony mental health court in that jurisdiction. 3 Note: Adapted from Vail Compton, L. Forensic mental health case vignettes (personal communication, 2015). 4 Source: MRT (December 27, 2021). The Rikers Island Jail Crisis: When Confinement Meets Seclusion: International. Retrieved at 5 Source: Gonnerman, J. (June 7, 2015). Kalief Browder, 1993–2015. The New Yorker (online). Retrieved on December 27, 2021 at https://www. 6 The Raben Group. Solitary Watch (June, 2020). 7 Goals of DBT, a modified type of cognitive behavioral therapy (CBT) used to treat individuals with varying mental health conditions, include teaching mindfulness, coping strategies, emotion regulation, and how to improve interpersonal relationships. 8 The labels “offender,” “defendant,” “prisoner,” and “inmate” are used in case law, legislative and policy documents, and throughout a considerable amount of the research, to refer to incarcerated persons and/or individuals who are court-involved, including PWLE. While this author has attempted to change the reference to “incarcerated” or “incarcerated persons”, “individuals”, or “patients” throughout the text (depending on the context), there are places where negative labels may be used for attribution and/or clarity. 9 Derived from Latin, meaning “parent of the people.” Refers to legal matters in which “a state has third-party standing to bring a lawsuit on behalf of a citizen when the suit implicates a state’s quasi-sovereign interests for the well-being of its citizens.” This is the doctrine under which persons deemed incompetent are given special protection under control of the state. Legal Information Institute [Definition] (2021). parens_patriae. 10 In some states, such as Texas, wait times for a bed in a maximum-security state hospital have reached up to 510 days. Sources: Barer, D. (July 28, 2021). Texas state mental hospitals remain full, hundreds still waiting in jail for beds. 11 In 1981 Hinckley attempted to assassinate then U.S. President Ronald Regan and was ultimately acquitted under a NGRI verdict. This outcome caused a great deal of controversy and was the impetus for restrictions on (and in some states abolition of) the insanity defense (Feinstein, 2013).


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12 Referring to a rule of law established by the English House of Lords in the mid-nineteenth century. The rule, which provided the first test for insanity, was based on an 1843 case in which the defendant was acquitted of murder on the basis of psychological infirmary and lack of capccity to appreciate the wrongfulness of his act. See insanity_defense 13 “Residenza per l’Esecuzione delle Misure di Sicurezza.”

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Intercept Four Reentry Police got a call that a “frightening man was muttering and waving his hands frantically” on a Saturday morning at a local park. When the responding officer approached the suspect (Antonio) to secure identification and to ask him to leave the area, the situation escalated with Antonio striking a passer-by and spitting at the officer while muttering a tirade of words. Antonio, who had been diagnosed with schizophrenia and manic depression in his early 20s, had been off his medication for two months and was suffering from delusions and auditory hallucinations (“voice-hearing”). He was incarcerated in county jail for the incident at the park and was charged with “battery on a LEO” (law enforcement officer) and assault charges. A month into his incarceration, Antonio, stabilized on his medication and attending peer-support groups at the jail, became a model incarcerated person. Within two to three months and at the suggestion of his attorney, Antonio volunteered to participate in a new court diversion program, and he became a positive example of the program’s success. Almost one year after his arrest at the park, Antonio graduated from the program and even received congratulations from the county’s District Attorney. Unfortunately, Antonio was arrested again less than a year later. It was understood that he would need medication and therapy to manage his symptoms, but he was released back into his community with no direction or assistance, and inevitably ended up back in jail. If services were organized prior to his release, he might have been better equipped to handle his illness and more prepared to reenter society.

INTRODUCTION Reentry is defined as the process of leaving jail and returning to society, and it can have a large impact on the individuals being released, as well as on the communities to which they are returning (Gill & Wilson, 2016; Phillips & Spencer, 2013). Approximately 600,000 individuals are released from U.S. jails and prisons each year (Carson, 2015; Harrison & Karberg, 2003)— about one-sixth of whom have a mental illness. The general goal of reentry is to manage the transition of previously incarcerated or incapacitated

DOI: 10.4324/9781003120186-8



CHAPTER 8 Intercept Four: Reentry

individuals back into the larger society (“Offender Reentry,” 2015). For the justice-involved individual, this proves to be a major change in status from that of “imprisoned offender” to “released ex-offender” (Travis, 2000). For individuals with behavioral health and substance use treatment needs, the transition becomes particularly daunting, and the extent to which they have received help identifying their needs and navigating support services in the community may have a profound impact on their likelihood of reoffending (Benson et al., 2011). Like their counterparts without serious psychological disorders, individuals with SMI who are being discharged from correctional settings face several reintegration barriers upon release (e.g., stigma, limited access to treatment and other support services), making recidivism one of the primary concerns. In fact, when compared to other incarcerated populations, reincarceration rates are high among PwMI who experience longer and more frequent periods of incarceration—particularly those who also suffer from substance use and addiction (Draine & Herman, 2007). Consequently, as stated in Chapter 7, many PwMI may find themselves ensnared in a web of multiple encounters with the criminal justice system when deprived of access to proper treatment and support services that meet their social needs (Lurigio et al., 2004). Intercept 4 of the Sequential Intercept Model is the foundation for this chapter and relates to reentry of individuals from state hospitals, jails, and prisons back into their communities. This represents another opportunity to connect them with diversion options. For instance, social services, behavioral-based interventions, and life skills should be integrated into post-release plans to minimize risk and attain successful reentry. It is also important that available services/programs address the unique interpersonal and cultural needs of those being released (Skeem et al., 2013). This chapter describes the process of reentry in the United States as it specifically relates to justice-involved persons with serious psychological disorders. The content is divided into three key sections. The first section provides a general discussion of reentry with some emphasis on special challenges faced by persons with serious mental illness. This includes psychological and social needs and concerns, as well as needs pertaining to employment, housing, co-occurring substance abuse and dependency disorders, and access to public assistance benefits upon release. Reentry models are also presented and discussed. In section two, the institutions responsible for the implementation of reentry initiatives are then outlined briefly, including law enforcement, parole, and community treatment providers. In the final section, specific reentry programs, most considered best practices in forensic mental health, are outlined with respect to their effectiveness. Although the emphasis is placed on the discharge of individuals from correctional institutions, most of the discussion can be applied in any context, and anything referring to hospital discharge specifically is noted.

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FAST FACT 8.1 WHAT IS A “BEST PRACTICE”? Public health programs, interventions, and policies that have been evaluated, shown to be successful, and have the potential to be adapted and transformed by others working in the same feld. Source:

SECTION ONE: REENTRY FOR PEOPLE WITH MENTAL ILLNESS (P WMI) To reiterate and summarize the information presented in previous chapters, American prisons and jails house three times the number of persons with mental illness than do our nation’s psychiatric hospitals—a finding that suggests incarceration is replacing mental health treatment for many individuals in need of care for their illness (Satel, 2003; Slate et al., 2013). Although the “pains” of imprisonment and reintegration back into the community are certainly felt by individuals without psychiatric concerns, there are profound differences with respect to incarcerated persons with SMI—differences that are exponential by comparison (Slate et al., 2013). Some of the challenges were discussed in Chapter 7 but deserve reiteration here. During their incarceration, PwMI are oftentimes targets for cruelty and perpetual victimizations, such as physical and sexual abuse by other persons incarcerated (Crisanti & Frueh, 2011). Furthermore, their strange behaviors (e.g., muttering, pacing, proclaiming delusional beliefs) can cause them to be punished more often, mostly resulting in solitary confinement, causing their mental state to deteriorate further (Satel, 2003; Slate et al., 2013). In fact, there have been numerous accounts—some presented throughout this text—that point to the detrimental failure of correctional staff to pay attention to clear symptoms of distress among incarcerated persons suffering with SMI—symptoms that were predictive of acute crisis (see, e.g., Earley, 2007; “Mentally Ill Homeless Veteran,” 2014; “The New Asylums,” 2013). Although research on reentry indicates that mental illness does not directly cause involvement in crime and delinquency, findings have suggested that mental health status may have an indirect effect. It is argued that having a serious mental health disorder may predispose an individual to risk factors, which predict general offending behaviors and high recidivism rates (Skeem et al., 2012). Thus, although mental health needs should not be ignored, multiple other crime-provoking risk factors must be identified, addressed, and monitored throughout the course of incarceration and beyond.


CHAPTER 8 Intercept Four: Reentry

THINKING CRITICALLY 8.1 WOMEN WITH SERIOUS MENTAL ILLNESS IN THE PRISON SYSTEM The number of women encountering the criminal justice system has been rapidly increasing in the past few decades (Chesney-Lind & Pasko, 2013). More specifcally, women accounted for approximately 22 percent of annual arrests in the United States between 1990 and 1998, and by 1998, the number of women incarcerated, on probation, and on parole increased by 88 percent, 40 percent, and 80 percent, respectively (Chesney-Lind, 2000). The number of incarcerated women overall has increased by 700 percent from approximately 26,000 in 1980 to approximately 222,500 in 2019 (The Sentencing Project, 2018). Additionally, there seems to be a high prevalence of mental health issues among persons incarcerated in prison and jail in general, although such issues are more common among women. For instance, in 2005, about 73 percent of women in state prisons had a mental health problem, compared with 55 percent of men; in federal prisons, 61 percent of women vs. 44 percent of men; and in local jails, 75 percent of women vs. 63 percent of men. These statistics take on special importance for programming designed to assist women incarcerated with mental health issues. Although the implementation of reentry programming seems promising for the ofender population at large, the special needs of women, especially those with mental health concerns, have not always been considered in the design of pre- and post-release reentry programs (Chesney-Lind, 2000; Chesney-Lind & Pasko, 2013). Women often enter the criminal justice system having experienced physical and mental health issues related to their unique histories of violence that often involves sexual, emotional, or physical abuse and other victimizations. Furthermore, women also face challenges regarding child-rearing and parenting or custodial concerns and substance use (Chesney-Lind, 2000; Chesney-Lind & Pasko, 2013). Although the crimes that women commit are more often related to drugs, alcohol, or property crimes and are not likely to be violent, the return or recidivism of high-risk women is imminent because of trauma or other gender-specifc circumstances as described (Bloom & McDiarmid, 2000; Chesney-Lind, 2000; Chesney-Lind & Pasko, 2013; Prichard, 2000). Thus, it is necessary to develop and implement reentry plans that will address the special mental health needs and concerns of women to increase their ability to reintegrate into society and decrease their rates of recidivism.

Factors Related to Recidivism Criminogenic Risk Factors Research conducted with offending populations more generally has identified what has been referred to as the “central eight” criminogenic risk factors, which determine an individual’s likelihood of reoffending (Osher et al., 2012). Contrary to static factors of offending risks, such as age at first arrest and other demographic characteristics that are unchangeable, dynamic risk factors are those that are malleable and can change over time and include:

Section One: Reentry for People with Mental Illness (PwMI) 245

1. Presence of antisocial behavior (early and continuing engagement in antisocial acts) 2. Antisocial personality patterns (low self-control, seeking immediate gratification, aggressive) 3. Antisocial cognition (antisocial thinking patterns, including thoughts favorable toward law-breaking) 4. Antisocial associates (isolation from law-abiding friends, and strong associations with criminals) 5. Family and/or marital (poor/strained relations and relationship quality) 6. School and/or work (poor interpersonal relationships in these settings, and low performance and satisfaction) 7. Leisure and/or recreation (low levels of involvement in pro-social/ law-abiding activities) 8. Substance abuse (tobacco excluded) (Osher et al., 2012) The top four factors (referred to in the literature as the “big four”) are highlighted in bold because, from a treatment perspective, these must be successfully addressed before intervention with the remaining four factors will be effective. Research with offending populations, with or without mental illness, has revealed the predictive power of criminogenic risk factors on recidivism. In particular, findings have revealed that justice-involved PwMI are at risk for reoffending post-release due to the presence of generalized criminogenic risk/needs rather than factors unique to mental illness (e.g., lack of access to medication) (Barrenger & Draine, 2013; Skeem et al., 2014). That is not to say that unmet mental health needs do not contribute to reoffending; as stated previously, research indicates the relationship is more of an indirect one. It is possible that having mental illness indirectly exposes an individual to environments (physical and social) that are conducive to criminal offending—for example, associating with antisocial peers. Although an individual who is successfully managing psychotropic medication may be less likely to strike a police officer during an encounter, that individual may continue to have multiple encounters with law enforcement unless other general criminogenic needs are addressed—in this case, the development of pro-social relationships or involvement in more pro-social activities, such as spending more time at a community drop-in center during certain hours of the day. The influence of environment on successful reintegration of PwMI is discussed in more detail next.

Risk Environments For many PwMI, reentry into the community after a period of incarceration can be a difficult transition. There are multiple risk environments to consider: physical, social, economic, and political (Barrenger & Draine, 2013). The physical environment is simply where the person returns to once released.


CHAPTER 8 Intercept Four: Reentry

It is often found that those reentering go to concentrated areas within urban cities. The communities may lack treatment facilities, housing, employment, education, or social services—essentially any resource for successful reentry (Barrenger & Draine, 2013). There may also be social disorganization in these areas as well. Stigma oftentimes complicates these social struggles, and a combination of limited family support, perceived personal failings, and the realization that few options are available, may make it easier to cycle back into old illegal habits (Draine & Herman, 2007). For political and a host of other reasons (e.g., stigma and policy restrictions on hiring those with a criminal record), there is a lack of financing and employment opportunities for those leaving jails. There are also policies in place that deny those with criminal histories from obtaining benefits such as Medicaid and Supplemental Security Income (SSI). The main difference between PwMI and persons reentering the community without MI is that the former often need access to medications and treatment to help with the continued management of their illness. Unfortunately, however, these are often not provided for beyond the first 30 days after release back into the community setting. There is also a lack of follow-up to determine if these persons are keeping up with medication and treatment plans. Programs and planning have been put in place by the criminal justice and mental health systems in response to these barriers; a few are presented later in the final section of this chapter. POLICY & PRACTICE 8.1 MEASURING RISK FOR VIOLENCE One of the most frequently used assessment tools among clinicians for determining the risk of violence among forensic adult psychiatric patients is the HCR-20. The HCR-20 is a 20-item scale, consisting of ten past-oriented “historical” (H) items, including previous violent behavior and major mental disorder diagnosis; fve present-oriented “clinical” (C) items, such as impulsivity and/or active symptoms of a disorder; and fve future-oriented “risk management” (R) items, including factors like stress and cost–beneft analysis of the criminal act. Responses are based on a three-item Likert scale and range from zero (not at all) to two (defnitely). Scores from items on each of the three scales are then added to determine summative scores on each of the three scales as well as an overall (total) score. The rater is asked to consider the risk factors in the context of their application on a case-by-case basis before making a fnal clinical judgment of low, medium, or high risk (Skeem et al., 2014).

To address the needs related to recidivism, and to attain the most effective public safety outcomes, correctional and behavioral health administrators draw from multiple theoretical frameworks that conceptualize risks, needs, allocation of resources, and the impact of programming on reoffending. In short, these models are useful for administrators seeking treatment strategies that can be empirically tested and are shown to be effective at minimizing recidivism among offenders with mental illness. There are several existing models in this regard, each used by individuals working in distinct systems of care (Osher et al., 2012).

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Models of Reentry Risk-Need-Responsivity (RNR) Model This is an evidence-based model that is most widely utilized by correctional administrators. The model was first developed in the 1980s, became formalized in 1990, and has been used with increasing success to assess the risk of reoffending, determine criminogenic needs (crime-invoking dynamic risk factors), and design culturally specific reentry programming that will rehabilitate offending persons in communities throughout the United States and internationally (Bauer et al., 2011; Osher et al., 2012). The model has three core principles that can be briefly outlined as follows: •

• •

Risk principle: The level of services should be matched with the offender’s risk of reoffending (determined using scientifically based assessment tools). Consequently, individuals who are at high risk will receive the most intensive services (Bauer et al., 2011). Need principle: Dynamic criminogenic needs must be assessed, and treatment and case planning should target these needs. Responsivity principle: It is important to minimize interpersonal and cultural barriers that may prevent an offender from effectively receiving a rehabilitative intervention; individual learning style, cognitive ability, motivation, and physical abilities must be considered when planning and designing treatment options (Osher et al., 2012).

Over the years, RNR has become the most influential model for planning related to the treatment and rehabilitation of offenders. It has been empirically tested numerous times, and because of its positive effects at reducing recidivism, has been distinguished as an effective evidence-based practice (Bauer et al., 2011). It should be noted that the model has been criticized for its inability to work in multiple settings with employees and administrators who are diverse in terms of education, treatment and correctional philosophies, and management practices (Osher et al., 2012). Furthermore, the model is designed for use with correctional goals in mind, and although more recent literature on RNR has promoted the idea of collaboration among criminal justice system actors, the model does not incorporate a framework for integrating goals from multiple systems of care, including the mental health system (Osher et al., 2012).

System Integration/Reentry Services Approaches There are additional reentry models specific to PwMI; in particular, in addition to mapping the individual needs of justice-involved persons and service delivery, they are designed to encourage and support collaboration between multiple systems of care. These include shared responsibility and interdependence (SRI); critical time intervention (CTI); sensitizing providers to the effects of correctional incarceration on treatment (SPECTRM); and assess, plan, identify, and coordinate (APIC) models. The first three models are briefly outlined in the following text box. Given its popularity


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with justice-involved PwMI and the accumulated amount of evidence as to its effectiveness with reentry, APIC is discussed in more detail on its own in the following section. POLICY & PRACTICE 8.2 MODELS REFLECTING A SYSTEMS INTEGRATION APPROACH TO REENTRY Shared responsibility and interdependence (SRI) (formalized by Draine et al., 2005): Focus on individual and community dynamics—not systems centric; ACTION approach, which is a training curriculum that focuses on establishing connections and networking opportunities between individuals from multiple criminal justice and behavioral health agencies; in short, it involves strengthening linkages and information sharing. Critical time intervention (CTI) (formalized by Draine & Herman, 2007): Limited to the point of release; emphasis is placed on strengthening ties between correctional staf and communities. Also provides for the inclusion of ofender services motivational coaching and advocacy and training in problem-solving strategies. Sensitizing providers to the efects of correctional incarceration on treatment (SPECTRM) (formalized by Rotter et al., 2005): Basically, cultural competency training for providers inexperienced about the criminogenic needs of incarcerated persons. It is narrowly designed to specifcally address the ways in which the incarceration experience afects the attitudes and behaviors of justice-involved PwMI. Source: Grifn et al. (2015).

APIC Model The APIC model (assess, plan, identify, and coordinate) was designed by Osher and colleagues in 2003 to organize the transition between jail programming and community-based services for justice-involved persons with MI and/or co-occurring substance abuse disorders. It is considered a best practice model and has been utilized to accomplish effective transitions for consumers and the best possible strategic partnerships between providers of mental health, substance abuse, and an array of other services (Griffin et al., 2015; Osher et al., 2012). APIC is a hierarchal model that first requires the clinical and social needs of the consumer be assessed. These may include interviews, or the examination of documentation related to the psychological, medical, and social needs of the consumer, as well as any strengths. An assessment of public safety risk is also of utmost importance. Next, the case manager and team must plan for different treatment programs and services that are needed for transitional success; ideally, programs will be available/offered during the period of incarceration (even if brief) and the incarcerated individual

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will willingly participate. In the context of community-based care, longterm needs, transportation, housing needs, medical regimens, and connections to medical providers are considered at this stage. Reentry personnel must also ensure that the consumer of services (“the consumer”) has proper identification and medical insurance, and any financial service barriers should be addressed at this time. There may be income and benefit entitlements (e.g., veterans’ benefits, Social Security, food stamps), and the consumer may need help navigating through the application or facilitation process—a point discussed in a bit more detail later in the chapter. Following planning, the team must identify specific programs and resources for the consumer. In this stage, the RNR model (discussed earlier) is instructive, as the consumer’s treatment and supervision should be matched with level of risk or need, and cultural, learning, and other differences must be considered when aligning services. Finally, there must be coordination involved between the consumer, consumer’s family, case managers, and treatment facilities to ensure that there are no gaps (Eno Louden et al., 2015).


Contributor: Brian D. Satterfeld, CPS, Published Author (https:// Michael has been arrested and has three charges: Misdemeanor trespassing, misdemeanor possession of stolen property, and felony destruction of government property. He pleads guilty to all three charges, using free counsel from a public defender. He will serve three to six months in the local county prison. While in prison, Michael states to the prison’s medical staf that he’s become crazy. His present mental state is from two situations. First, Michael’s prescribed psychiatric medicines are expensive—they aren’t provided by the county prison. Thus, the medicines the prison provides Michael confuse him—they’re of diferent colors and diferent sizes. He “cheeks”them, spitting them into his cell toilet 15 minutes after the prison psychiatrist has left. Second, in the community, Michael walked from his apartment complex to his 1:1 weekly counseling sessions with his trusted licensed counselor, Sharon. There are peer-led support groups in this prison and the prison’s medical staf have invited Michael to attend them, but he refuses, responding, “I just talk with Sharon.” Due to state laws, Michael will lose his Supplemental Security Income (SSI) while incarcerated. Additionally, he’ll lose his room at the long-term structured residence (apartment complex), food stamps, clothing vouchers, and active county transportation. Michael’s home plan can be developed due to the knowledge of him having a three-to-six-month sentence. He’s awarded good time behavior,


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equaling fve days a month, reduced toward his overall sentence time. He’s isolated 23 hours a day in his own cell for his protection from the general population. Here’s Michael’s home plan: A scheduled appointment with a communitybased psychiatrist within 30 to 60 days from prison release. He’ll be provided three to seven days’ worth of prison-approved generic medicines. Any physical doctor or community appointments are assigned to his forensic case manager. Also, Michael will have a parole ofcer, supported living worker, forensic peer support/mentor, and fnancial payee—all part of his court-committed community treatment plan. He’ll be required to attend adult psychiatric and/or socialization courses at an adult community-run drop-in center. Or he can work a paid or volunteer job during the week instead of drop-in center attendance. All while having his payee pay weekly fnancial restitution. Author’s Note: The type of counseling Brian is referring to in Michael’s case is referred to as 1:1 (one on one) crisis counseling. This type of counseling is appropriate for individuals who have experienced a crisis or traumatic event; the three primary goals of treatment are safety, stability, and connection (rapport) (American Psychological Association, 2011). Brian’s reference to peer counseling and peer-led groups is indicative of the peer support model, which, as discussed briefy in Chapter 7, involves the development of linkages between persons who have common illnesses and the practice of sharing knowledge and experiences as part of the treatment modal. Peer support staf are most likely to be volunteers who are not compensated; it should also be noted that although certifcation is available and often attained, peer specialists are not required to hold a license or a degree. Consequently, peer support should not replace traditional therapy and services, but rather complement them; medical and mental healthcare should be sought when deemed appropriate and necessary (What Is Peer Support, 2015).

SECTION TWO: EFFECTIVE REINTEGRATION AND THE ROLE OF PROFESSIONAL SERVICE PROVIDERS The importance of effective service coordination for individuals with SMI—in correctional settings or otherwise—cannot be overstated. Though detained persons have the right in most cases to refuse treatment during their incarceration, and especially once released into the community (Andrews, 2003), steps should still be taken to identify the most appropriate course of treatment and services, and discharge planning should begin immediately upon booking at the correctional institution (Osher & King, 2015). Oftentimes, individual treatment needs require a consumer of services to work with a multitude of providers, all of which may be funded through various sources and therefore required to meet conflicting contractual obligations. Consequently, for some, service coordination then becomes a major challenge to successful reintegration (Carlson, 2011). It is therefore essential

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Public Housing, Transportation, Other Social Services (i.e., Veterans Administrations)

Treatment Providers (Substance Use & Mental Health)

Law Enforcement/ Correctional Staff

Faith-Based Communities

 Figure 8.1 Multiple Systems of Care Source: Author

that continuity of care (COC) is maintained through systems integration and collaboration so that critical information sharing among and between correctional staff and treatment providers can take place. To accomplish positive transition, reentry programs should be designed to involve those in the community who can assist the justice-involved person in the process of social integration. In this way, reentry ideally results in the collaborative efforts of a diverse group of stakeholders composed of law enforcement, probation and parole, treatment providers, faith-based organizations, family members of the offending persons, and possibly victims or family members of victims (Yoon & Nickel, 2008). This bidirectionality is illustrated in Figure 8.1.

POLICY AND PRACTICE 8.3 REENTRY FOR PWMI IN THE WAKE OF COVID-19 While there are already many factors which can impede successful reintegration for PwMI, the efects of the coronavirus pandemic exacerbated these issues. Upon reentry, many PwMI were released into shelters or supportive housing which exposed them to the risk of contracting the virus since they cannot socially distance or control the hygienic habits of others (Barrenger & Bond, 2021). The pandemic also made it more difcult to take precautions when receiving medical care since many of these visits must be conducted in person for evaluation. Although the health care


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systems made the switch to telehealth alternatives, this made it extremely difcult for PwMI who did not have a cell phone or internet access. Compounding this issue is the fact that many justice-involved persons are not privy to technological advances and although they may have the tools to access telehealth care, they may not possess the necessary knowledge to accomplish the task (Barrenger & Bond, 2021). These added stressors materialized by the pandemic may also contribute to worsening symptoms, which can inhibit successful reentry.

Unfortunately, due to what is often viewed as competing interests, there has historically been a significant disjunction in the continuity and coordination of services between correctional staff and community service providers for individuals with mental illness who leave correctional settings (Fagan & Ax, 2003). In many jurisdictions, integration practices have been implemented to address and minimize linkage blindness and encourage systematic integration between multidisciplinary service providers, teams, and staff (Osher & King, 2015). In keeping with the theme of coordinated integration strategies, additional guidelines include incorporating risk assessment instruments into decision making, focusing attention on substance abuse, gathering data from multiple sources, and involving multiple parties in discharge and treatment plans (Dirks-Linhorst & Linhorst, 2012). In sum, successful transition planning and reintegration requires that justice, mental health, and substance use system administrators develop a capacity to forge working partnerships with each other and with other community service providers. Effective partnerships have been evidenced in various localities and state systems through the development and maintenance of policies related to formal interagency agreements between public health and welfare and correctional authorities, often referred to as memorandums of understanding (MOUs) (Koyanagi & Blasingame, 2006); one example of a MOU between the Florida Departments of Children and Families and Corrections (DCF and DOC, respectively) was introduced in Chapter 3. In accordance with best practices, interagency agreements should include: • • • • •

Funding incentives Removal of barriers Provision of resources to learn and grow Utilization and sharing of fidelity scales or other evaluation measures Cross-systems mapping/information sharing (Koyanagi & Blasingame, 2006; Vail Compton, n.d.)

COMPARATIVE PERSPECTIVES 8.1 REENTRY TO THE UNITED KINGDOM (UK) The National Health Service (NHS) (UK) recognized the need for persons with mental health problems and/or learning disabilities to have certain community-based treatment and support when being released from

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prison and reentering society (Watkin, 2019). The adopted recommendations were based on a report by Lord Keith Bradley (2009) who outlined the need to establish such support. The UK has diferent teams in place to work with justice-involved PwMI at every stage of their journey in the criminal justice system. The goal of street triage services is to identify PwMI upon their frst encounter with the criminal justice system, to gather information, and to organize the proper health services needed in each case. The UK has also established liaison and diversion teams nationwide to advise the criminal justice system on how to care for, communicate with, and manage PwMI (and other PWLE with specialized needs), as well as to help organize their transition from the criminal justice system to mental health treatment (Watkin, 2019). Upon reentry, there are community-based forensic teams to assist in the facilitation of thorough risk assessment and management strategies (Watkin, 2019).

SECTION THREE: BEST PRACTICES IN REENTRY PROGRAMMING FOR P WMI Preventing reincarceration is a complex task that can be made nearly impossible if risks are not assessed or specialized needs are ignored during reentry planning (Barrenger & Draine, 2013). As discussed previously, when it comes to individuals with mental illness, the focus of reentry has been on connecting justice-involved persons to community-based mental healthcare (and/or substance use providers) for treatment as soon as possible upon release. Unfortunately, many PwMI who return to the community fall into a crisis which may put them at risk of reoffending due to a lack of employment, education, and housing opportunities—a predicament not unlike that of their counterparts who do not suffer from mental illness (Skeem et al., 2014). Based on the principles of RNR (discussed earlier), reentry programming that caters specifically to the individual needs of women, men, juveniles, adults, seniors, and persons with serious mental health and/or substance abuse concerns begins immediately upon intake should be occurring. The following section provides a summary review of varying local, state, and federal reentry initiatives outlined by identified needs.

Examples of Reentry Initiatives Identified Need: Employment According to the reentry literature, securing meaningful employment is a crucial factor related to post-release success for individuals preparing to discharge from a detention facility. Not only is having a job crucial to financial support for day-to-day life, but it is also an important determinant of release eligibility (Baron et al., 2013). For PwMI who are transitioning from a correctional setting, the process of seeking employment appears to be more difficult, and the presence of additional barriers may hinder the ability to secure work. For example, the percentage of justice-involved


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PwMI working or looking for work before or after incarceration is the lowest rate among groups of persons with disabilities. Furthermore, job opportunities that are offered to PwMI are more likely to be entry-level minimum wage positions lacking any opportunities for ambitious pay raises or other career advancements/promotions. These findings may be attributable to several individual-level risk factors, such as psychiatric symptoms or addiction, which may prevent PwMI from obtaining or seeking a position, or to social-structural-level factors, such as restrictive policies and/or stigmatization or a combination of both (see Baron et al., 2013). SUPPORTED/SUPPORTIVE EMPLOYMENT Supportive employment (SE) is a technique that is utilized to help integrate PwMI who have been discharged from state hospitals or correctional settings into the competitive workforce to promote individual well-being and, potentially, the risk for reoffending. The strategy of the program is to assist clients with immediate job placement in paid positions where they will receive intensive on-the-job training and constant support from a job coach (Wehman, 2012). This is unlike vocational rehabilitation programs, which require pre-employment training and the development of job skills first to be eligible for job placement services. Originally designed in the 1980s for individuals with learning disabilities, supported employment programs work well for people who face the most complex challenges—in particular, individuals who have no work history or an intermittent history; who have the dual stigmatization of a criminal record and serious, persistent issues that may include substance use, mental illness, and developmental disabilities; and those who are in need of ongoing supports (Baron et al., 2013; Wehman et al., 2012). Specific versions of supported housing have included individual placement and support (IPS) and augmented supported employment, which basically refers to the inclusion of immediate placement but with other interventions, such as skills training (Kinoshita et al., 2010). Research findings with respect to the effectiveness of SE with forensic clients repeatedly illustrate the effectiveness of IPS in terms of initial job placement (see Morgan et al., 2012), designating SE as an EBP; however, findings are mixed regarding the maintenance of employment over time. For example, studies of IPS have indicated that, whereas 77 percent of consumers become gainfully employed, fewer than 45 percent remain in the same positions over an 18- to 24-month period (Baron et al., 2013). This finding, however, may be explained by individual and structural-level factors or criminogenic needs (e.g., pro-criminal associations) that impede success in meeting program goals (Baron et al., 2013).

Identified Need: Housing As discussed in Chapter 2, individuals with severe mental illness once lived by the hundreds of thousands in state mental institutions; however, the deinstitutionalization movement that began during the 1960s reshaped the

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landscape and the challenges that PwMI confront in their lives (Slate et al., 2013). Appropriate and supportive housing for individuals with mental illness in community settings is generally not available, and if it is accessible, the living conditions are typically substandard and inadequate (“Homelessness and Housing,” 2016). Consequently, persons with mental illness leave critical or habitual care services with insufficient necessities for their housing or support and end up descending into shelters for displaced persons and/or the criminal justice system. Numerous others live nomadically, moving from place to place and with parents or other family members. Besides family, group homes become the foremost housing option for PwMI and others with lived experience (e.g., I/DD, addiction) (Culhane et al., 2002). Unfortunately, PwMI face harsh resistance from neighborhoods where NIMBY (not-in-my-backyard) movements occur due to developments or neighborhoods not wanting housing dedicated to rehabilitating justiceinvolved PwMI (Slate et al., 2013). Thus, the primary needs of persons with SMI who are displaced include the need for decent, affordable housing and the need for supportive assistance. SUPPORTED OR SUPPORTIVE HOUSING Supported housing refers to programs in which there is a combination of housing and services intended as a cost-effective way to help people live more stable and productive lives in a community-based setting (Culhane et al., 2002; Montgomery et al., 2008). Most individuals who qualify for supportive housing services have significant transitional issues and service needs, are typically displaced, with very little income, and tend to have serious mental health issues. An array of services is rendered in the program, ranging from medical and wellness, mental health, substance use management and recovery, vocational and employment, money management, coordinated support, life skills training, household establishment, and tenant advocacy (see, for example, “Supporting Pennsylvanians through Housing,” 2016). Though empirical research on the effectiveness of supportive housing programs with PwMI is limited (Miller & Ngugi, 2009), findings generally support successful outcomes in terms of improving quality of life and cost savings (Culhane et al., 2002; Montgomery et al., 2008). For example, findings have indicated positive outcomes regarding housing retention among veterans in a VA supportive housing program (Montgomery et al., 2014) and formerly incarcerated persons with MI who were released from jail and diverted into a community transitional program in two major Canadian cities in Ontario (Cherner et al., 2014). Further, studies suggest that, on average, it is much cheaper to provide PwMI with supported housing services in the community rather than allowing them to remain displaced. For example, individuals without housing who are mentally ill expend, on average, about $40,000 a year in public services (Culhane et al., 2002). Research has found most of these costs are centered in acute-care hospitals (emergency rooms or crisis units), housing shelters, and incarceration. For


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each person in supportive housing under a combined city and state program, the average costs in public services were reduced by an average of $16,000 per housing unit (Culhane et al., 2002).

Identified Need: Disability Benefits As has been stated elsewhere in this text, a significant proportion of individuals incarcerated in jails, state penitentiaries, and federal prisons are reported to have a history of mental health issues; estimates further indicate that anywhere between 17 percent and 20 percent have a SMI. It has been repeatedly argued that mental illness and “ex-offender” status have a dual stigmatization effect, making reintegration even more complex to navigate. Barriers to housing, employment, and treatment needs may lead to chronic lack of housing and recidivism, and individuals who are uninsured or underinsured are particularly vulnerable to negative outcomes in relation to their ability to access proper (effective) care for their illness and underlying symptoms. For these reasons, two programs are offered through the Social Security Administration (SSA) that can provide eligible PwMI income and other benefits to assist with the transition from a correctional to a community setting; these programs are Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI). There is, however, the matter of being able to effectively navigate the application process. Consequently, interagency planning programs have been implemented to help released persons with program enrollments for which they are eligible—sometimes even before they leave the jail setting (Patel et al., 2014). SSI/SSDI, OUTREACH, ACCESS, AND RECOVERY (SOAR) SOAR is a model that is used to help PwMI determine eligibility requirements, complete enrollment, and receive disability benefits; it is currently available in 50 states. The target population for the program is people who are currently displaced/without housing or at risk for displacement. Research related to the SOAR program has indicated that connecting people in jails and prisons with Medicaid enrollment upon release could significantly improve the reentry process. SOAR can be used as a tool to access Medicaid and Medicare, which can provide the foundation for reentry plans to succeed (Blandford & Osher, 2013).

FAST FACT 8.2 ADVOCACY ORGANIZATIONS: NAMI AND MHA The National Alliance on Mental Illness (NAMI) and Mental Health America (MHA) (formerly the National Mental Health Association) are two of the largest advocacy organizations for consumers, their friends, and family members. Please visit the following websites for more information: http://,

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Identified Need: Case Management and Transition Planning Teams/ACT and FACT ASSERTIVE COMMUNITY TREATMENT (ACT) As an attempt to provide more intensive case management to individuals with SMI who are preparing for reentry from state hospitals or correctional settings, one diversion strategy that has been shown to be effective is the use of multidisciplinary transition teams—in particular, an EBP model known as assertive community treatment (ACT) (Lamberti et al., 2004). ACT was originally designed “to assist persons with severe mental illnesses to function in the community, while attempting to prevent homelessness and hospitalizations” (Slate et al., 2013, p. 467). ACT is a mobile team-based outpatient service model for providing comprehensive psychiatric care and case management supports to people with SMI (Slade et al., 2013). Teams provide high-risk consumers treatment at their home/place of residence and are available 24 hours a day, seven days a week (Slate et al., 2013). ACT is recognized as an effective treatment for persons with severe psychiatric conditions, bipolar disorder, or schizophrenia who are high users of inpatient hospital services and low utilizers of community-based mental health services. It is also a community-based treatment approach for PwSMI having difficulties in daily living activities and social functioning, often including problems with relationships, physical health, addiction, work, daytime activities, and living conditions (Stobbe et al., 2014). The ACT model requires a clinician team leader, normally a social worker or psychologist, as well as one or more nurses, a psychiatrist, and a substance abuse specialist (Slade et al., 2013). These teams work with clients to ensure the continuation of care from a hospital setting to an outpatient practice, ensure functionality in the community, and reduce future hospitalization. Most of the services that are provided occur in a patient’s home, a shelter, or the streets and are not usually provided in a clinic (Weinstein et al., 2011). Many forms of services are provided by assertive community treatment, such as planning and monitoring treatment; taking patients to medical appointments and dentist appointments; representing them at hearings; and helping them manage money, pay bills, and apply for services. Other services that are provided are help with housekeeping, shopping, cooking, transportation, finding and keeping jobs, and housing, while also educating patients about mental illness, drug abuse counseling, and coping with psychotic episodes or crises (Phillips et al., 2001). Considered to be one of the most effective methods for providing services to people with chronic MI, program services can cost annually from $6,000 to more than $12,000 per client, and clients may continue to receive these services indefinitely (Slade et al., 2013); these costs are offset by savings associated with reduced hospitalization or incarceration (Phillips et al., 2001). ACT is considered one of the most effective methods for providing services to people with SPMI, and in 2010, more than 65,000 persons with


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serious mental illness were enrolled in more than 800 assertive community treatment programs in 38 U.S. states (Slade et al., 2013). As stated earlier, research evidence indicates that the program reduces the need for psychiatric hospitalization and emergency medical care, and patients in the program are more likely to find housing, are less likely to be jailed, and usually claim to be more satisfied with this program than with other forms of community treatment (Phillips et al., 2001; Stull et al., 2012). Some negative aspects of these programs that have been identified in the literature include interactions that are seen as intrusive, restricting, and encouraging dependency or practices that seem to produce conflicts over money and medications or that are viewed as authoritative (Stull et al., 2012). FORENSIC ASSERTIVE COMMUNITY TREATMENT (FACT) This program is an incorporation of the original ACT program, but the caseload will primarily consist of PwMI who have also been in contact with the law. It provides intensive and supportive care from multidisciplinary teams in the community. The focus is on the criminal history of the justice-involved person with mental illness (Davis et al., 2008). The FACT team also relies on a predominance of referrals from the criminal justice agencies while also engaging probation officers (Slate et al., 2013). The team provides rehabilitation, counseling, and material support, and helps the consumer find a real sense of belonging in the community. Research indicates it is associated with better functioning in the community and fewer days in jail (Davis et al., 2008). CRITICAL TIME INTERVENTION (CTI) CTI is a case management process that incorporates three different steps to support transitions into the community: transition, try-out, and transfer to care. It follows these steps to create a smoother transition from jail or prison into the community for PwMIs (Draine & Herman, 2010). The length of each stage oftentimes depends on the individual and their motivation for change and help. Linkage to effective community programs immediately after a period of incarceration is a great help to the consumers. The programs that they are connected to may include mental health or community support programs, such as family or substance use recovery and support groups. There is still a need, however, to incorporate more help with basic human needs such as housing and employment. It has been found that many recipients simply go through the steps and do not learn anything due to the lack of motivation from not receiving housing or employment once released (Draine & Herman, 2010). POLICY AND PRACTICE 8.4 THE POSITIVE OUTCOMES OF CTI WITH DISPLACED VETERANS As stated above, CTIs are extremely important for PwMI to retain housing and employment upon reentering their communities. For veterans, this is also prevalent as many will experience mental health issues and

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a lack of housing options. Veterans who are leaving the Department of Veteran Afairs (VA) inpatient care can rely on CTIs to help transition from institutional settings and reenter their communities (Kasprow & Rosenheck, 2007). Veterans who go through CTIs have reported less drug and alcohol use as well as a reduction in psychiatric symptoms (Kasprow & Rosenheck, 2007). For veterans who are receiving care via hospitals or psychiatric facilities, it is important to continue care following discharge to ensure further improvement in mental health and to decrease the rates of readmission to inpatient care (Reid et al., 2021). Studies have suggested that when housing is prioritized frst for CTI clients and a smoother transition for their continuity of care is provided, housing is more often successfully retained and psychiatric symptoms greatly improve (Kasprow & Rosenheck, 2007; Montgomery et al., 2013; Reid et al., 2021).

Some examples of reentry programming have included pre-release education or vocational programs, drug rehabilitation, skill building or work training, supportive housing, and the implementation and use of reentry or specialty courts. As described in the preceding chapter, specialty courts involve a courtroom workgroup or “team” that aims to provide a more therapeutic environment to facilitate the defendant’s journey through the criminal justice system and back into the larger society (Walters, 2013; Yoon & Nickel, 2008). Specific evidence-based reentry initiatives have proven to be effective for persons with SMI. FAST FACT 8.3 THE CASE OF BRAD H. The case of Brad H. vs. City of New York was the frst class action suit in which the court ordered a correctional system to provide discharge planning for incarcerated persons with mental illness. In the 1999 lawsuit fled by the Urban Justice Center, the points of the complaint can be summarized as follows: Incarcerated persons with mental illness at the city’s jails were being subjected to release during the middle of the night, when they were taken to the subway station with less than two dollars and two subway tokens. There was no discharge plan, and therefore, no provisions for the alignment of mental health and other social support services in the community (e.g., housing, transportation, substance abuse treatment, reinstatement of Medicaid and/or Social Security disability benefts) (Jones, 2007; Urban Justice Center, n.d.). The 2003 settlement agreement mandated the city to provide discharge planning to the 15,000-plus individuals incarcerated at the time confned in the jails who received or would receive psychiatric services (Urban Justice Center, n.d.). Discharge planning would begin during incarceration and would continue beyond release; services in this context include mental health treatment during confnement and continuity of care upon release in the form of continued treatment, housing assistance, and assistance with obtaining public benefts and other social services. The settlement also contained a stipulation requiring release during daytime hours and


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provisions for the continued monitoring of the city’s compliance, which has been reinstated every two years (Jones, 2007; Urban Justice Center, n.d.). Although compliance has met with its challenges, the landmark decision has been heralded as most progressive in terms of shaping mental health services provided to incarcerated individuals in New York and across the nation (Jones, 2007).

Barriers to Reintegration Eforts However promising advancements might be from practical, treatment, and legal standpoints, most jails lack adequate treatment facilities for the number of mentally ill persons entering the system—precluding their ability to effectively manage individuals experiencing acute and ongoing crisis (Slate et al., 2013). Further, despite the watchful eye of the courts, mental health understaffing persists throughout most correctional settings, which may oftentimes result in poor or non-existent discharge planning. There is also a significant amount of stigma associated with mental illness, and thus, the public tends to view PwMI as violent and uncontrollable, thereby expressing little sympathy for them (Corrigan & Watson, 2002; Davey, 2013). Ironically, this (mostly media-generated) societal rejection of PwMI has resulted in laws that are detrimental to the well-being of incarcerated persons with mental health issues—particularly as they prepare to return to larger society (Davey, 2013). In contrast, mainstream news media has also uncovered some of the injustices facing PwMI while incarcerated, and thus, strong advocacy and support for change have recently reemerged (see Chapter 2 for historical context). Given more exposure of the circumstances and a broader understanding of the goals of reentry, the outlook appears relatively promising (Figure 8.2). For example, reform efforts at the jail or prison level include

 Figure 8.2 A Photo of Signposts (Hope and Despair)

Source: Taken from:; licensed for use under Creative Commons CCO. [Photograph]. Retrieved from directory-signposts-hope-466935/

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the development of separate treatment units that segregate PwMI from the general population, and the development of jail-based reentry programs continues with effective results. These programs are multidimensional, and many focus on recovery from addiction, education, housing, and the development of job skills. In the context of COC for justice-involved PwMI post-release (communitybased care), there have also been developments that show promise moving forward. Initiatives such as ACT teams, intensive case management, crisis intervention teams (CITs), and supported housing are designed to emphasize post-release treatment for individuals with co-occurring substance abuse and mental health problems and other criminogenic needs (Heilbrum et al., 2015). Although all have been proven effective in reducing recidivism, these services are notoriously underfunded in the public health systems (Slate et al., 2013). However, federal regulations regarding the expanded use of money from Medicaid—the major money provider for persons with mental illness—were anticipated to have an impact post-release access to care for incarcerated and low-income persons (Rogers, 2014). Recent research reports indicate that the Medicaid expansion had a positive impact on access to services for MI and SUD overall, though the extent of the impact is contradictory, and limited in some cases (Fry et al., 2020; Gertner et al., 2019; Han et al., 2020). The effects of expanded Medicaid eligibility in this regard, of course, are premature and therefore should continue to be assessed moving forward.

TAKE-HOME MESSAGE The underlying theme of this chapter is that discharge planning is an extremely valuable tool for the prevention of recidivism and subsequent recycling of individuals between the mental health and criminal justice systems of care. More research should be conducted on the effectiveness of discharge planning so that it may be improved and implemented as an evidence-based practice in multiple settings with forensic populations (e.g., in hospitals, jails, prisons, etc.). The impact of incarceration and impediments to successful reentry is not confined to the inside of a correctional institution. Lack of adequate housing, community and social supports, education, and gaps in employment opportunities are included in the threats to successful reentry into the community, which involves the public at large (Woods et al., 2013). Planning and communication are key to improving the reentry process for those with mental illness and to provide them with the services that best meet their individual needs. To be effective, discharge planning should be a fluid process that ideally begins at intake (whether in a hospital or correctional setting) and continues beyond community reentry. Boundary spanners should provide all PWLE with information that will assist them in making a more successful transition to the community.


CHAPTER 8 Intercept Four: Reentry

Depending on the needs of the individual, reintegration efforts may include focus on the development of skills related to gaining and maintaining employment, coping strategies, motivation, money management, substance abuse and mental health treatment, literacy and education, parenting, wellness education, and adult continuing education. Forensic liaisons can develop and maintain relationships with individuals from multiple systems of care (e.g., police, courts, probation/parole, public welfare, youth and family services, drug and alcohol and mental health services) to facilitate access to services that are needs based and culturally appropriate for the individual consumer.

Questions for Classroom Discussion Read the following case study and consider the remaining discussion questions considering the facts and what you have learned regarding discharge/ transition planning. According to her family, A.L. was an individual who always strived to succeed in all aspects of her life. They reported that she obtained her nursing license with lots of hard work and diligence. However, she struggled with mood swings but lacked the insight to seek any treatment. As time went on, A.L. became so manic that she began to experience delusions and ended up in the streets of Gainesville. She was involuntarily hospitalized several times but never followed up with treatment. Eventually, A.L. was arrested for practicing medicine without a license and incarcerated. She was evaluated for competency and subsequently committed to the Department of Children and Families as incompetent to proceed. She currently sits at the county jail awaiting placement to a state forensic hospital.1 • • • •

Assess A.L.’s clinical and social needs and public safety risks. Develop a plan for the treatment and services required to address A.L.’s needs, both while in custody and upon reentry. Identify required community and correctional programs responsible for post-release services. Coordinate the transition plan to ensure implementation and avoid gaps in care with community-based services.

KEY TERMS & ACRONYMS • Assertive Community Treatment (ACT) Best practices • • • • •

Boundary spanners Department of Veteran Afairs (VA) Dynamic risk factors (DRF) Forensic Assertive Community Treatment (FACT) Individual Placement and Support (IPS)

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• • • • •

Linkage blindness Mental Health America (MHA) Memorandums of understanding (MOUs) National Alliance on Mental Illness (NAMI) NIMBY (not in my backyard)

Social disorganization Social Security Administration (SSA) • • • • •

Social Security Disability Insurance (SSDI) Static factors of ofending risk Supplemental Security Income (SSI) Supportive/supported employment (SE) Vocational rehabilitation (VR)

NOTE 1 Case study adapted from Vail Compton, L. (2015).

BIBLIOGRAPHY Andrews, T. (2003). Mental Health Procedures and Criminal Law. Notes presented at the meeting of the Pennsylvania Bar Institute, Montour County, PA. Baron, R. C., Draine, J., & Salzer, M. S. (2013). “I’m Not Sure That I Can Figure Out How to Do That”: Pursuit of Work among People with Mental Illnesses Leaving Jail. American Journal of Psychiatric Rehabilitation, 16, 115–135. Barrenger, S. L., & Bond, L. (2021). Mental Health and Service Impacts During COVID-19 for Individuals with Serious Mental Illnesses Recently Released from Prison and Jail. The Journal of Behavioral Health Services & Research. Barrenger, S. L., & Draine, J. (2013). “You Don’t Get No Help”: The Role of Community Context in Effectiveness of Evidence-Based Treatments for People with Mental Illness Leaving Prison for High Risk Environments. American Journal of Psychiatric Rehabilitation, 16, 154–178. https://doi. org/10.1080/15487768.2013.789709 Bauer, R. L., Morgan, R. D., & Mandracchia, J. T. (2010). Offenders with Severe and Persistent Mental Illness. In T. J. Fagan & R. K. Ax (Eds.), Correctional Mental Health (pp. 189–212). Thousand Oaks, CA: Sage Publications. Benson, M. L., Alarid, L. F., Burton, V. S., & Cullen, F. T. (2011). Reintegration or Stigmatization? Offenders’ Expectations of Community Re-entry. Journal of Criminal Justice, 39(5), 385–393. Blandford, A. M., & Osher, F. (2013). Guidelines for the Successful Transition of People with Behavioral Health Disorders from Jail and Prison. Delmar, NY: SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation. Bloom, B., & McDiarmid, A. (2000). Gender-Responsive Supervision and Programming for Women Offenders in the Community. Topics in Community Corrections Annual 1, 11–18. Retrieved from class/687/Readings/awomencommcor1.pdf


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Carlson, P. M. (2011). Managing the Mentally Ill from a Correctional Administrator’s Perspective. In T. J. Fagan & R. K. Ax (Eds). Correctional Mental Health: From Theory to Best Practice (pp. 57–75). Thousand Oaks, CA: Sage Publications Inc. Carson, E. A. (2015). Prisoners in 2014. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. Retrieved from CBS New York. (2014). Mentally Ill Homeless Veteran. Retrieved from http:// Cherner, R., Aubry, T., Ecker, J., Kerman, N., & Nandlal, J. (2014). Transitioning into the Community: Outcomes of a Pilot Housing Program for Forensic Patients. International Journal of Forensic Mental Health, 13(1), 62–74. Chesney-Lind, M. (2000). Women and the Criminal Justice System: Gender Matters. Topics in Community Corrections, 5, 7–10. Chesney-Lind, M., & Pasko, L. (2013). The Female Offender: Girls, Women, and Crime. Thousand Oaks, CA: Sage Publications. Connecticut Reentry Program Reduces Recidivism of Mentally Ill Offenders. (2012). Corrections Managers Report, 18(3), 37. Corrigan, P. W., & Watson, A. C. (2002). Understanding the Impact of Stigma on People with Mental Illness. World Psychiatry, 1(1), 16–20. Crisanti, A. S., & Frueh, B. C. (2011). Risk of Trauma Exposure among Persons with Mental Illness in Jails and Prisons: What Do We Really Know? Current Opinion in Psychiatry, 24(5), 431–435. Culhane, D. P., Metraux, S., & Hadley, T. (2002). Public Service Reductions Associated with Placement of Homeless Persons with Severe Mental Illness in Supportive Housing. Housing Policy Debate, 13(1), 107–163. Davey. (2013). Retrieved from why-we-worry/201308/mental-health-stigma Davis, K., Fallon, J., Vogel, S., & Teachout, A. (2008). Integrating into the Mental Health System from the Criminal Justice System: Jail Aftercare Services for Persons with a Severe Mental Illness. Journal of Offender Rehabilitation, 46(3/4), 217–231. Dirks-Linhorst, P., & Linhorst, D. (2012). Monitoring Offenders with Mental Illness in the Community: Guidelines for Practice. Best Practices in Mental Health, 8(2), 47–70. Draine, J., & Herman, D. B. (2007). Critical Time Intervention for Reentry from Prison for Persons with Mental Illness. Psychiatric Services, 58(12), 1577–1581. Draine, J., & Herman, D. B. (2010). Critical Time Intervention. Journal of Community Corrections, 20(1), 11–18. Draine, J., Wolff, N., Jacoby, J. E., Hartwell, S., & Duclos, C. (2005). Understanding Community Re-entry of Former Prisoners with Mental Illness: A Conceptual Model to Guide New Research. Behavioral Sciences & the Law, 23(5), 689–707. Earley, P. (2007). Crazy: A Father’s Search through America’s Mental Health Madness. New York, NY: Penguin Group, Inc. Eno Louden, J., Manchak, S., O’Connor, M., & Skeem, J. L. (2015). Applying the Sequential Intercept Model to Reduce Recidivism among Probationers and Parolees with Mental Illness. In P. A. Griffin, K. Heilbrun, E. P. Mulvey, D. DeMatteo, & C. M. Schubert (Eds.), The Sequential Intercept Model and

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Criminal Justice: Promoting Community Alternatives for Individuals with Serious Mental Illness (pp. 118–136). New York, NY: Oxford University Press. Fagan, T. J., & Ax, R. K. (2003). Correctional Mental Health Handbook. Thousand Oaks, CA: Sage Publications. Fellner, J. (2006). Corrections Quandary: Mental Illness and Prison Rules. Harvard Civil Rights-Civil Liberties Law Review, 41, 391. Frontline. (2005). The New Asylums [DVD]. Retrieved from Fry, C. E., McGuire, T. G., & Frank, R. G. (2020). Medicaid Expansion’s Spillover to the Criminal Justice System: Evidence from Six Urban Counties. RSF: The Russell Sage Foundation Journal of the Social Sciences, 6(2), 244–263. Gertner, A. K., Grabert, B., Domino, M. E., Cuddeback, G. S., & Morrissey, J. P. (2019). The Effect of Referral to Expedited Medicaid on Substance Use Treatment Utilization among People with Serious Mental Illness Released from Prison. Journal of Substance Abuse Treatment, 99, 9–15. Gill, C., & Wilson, D. B. (2016). Improving the Success of Reentry Programs. Criminal Justice and Behavior, 44(3), 336–359. https://doi. org/10.1177/0093854816682048 Griffin, P. A., Heilbrun, K., Mulvey, E. P., DeMatteo, D., & Schubert, C. A. (2015). Sequential Intercept Model and Criminal Justice: Promoting Community Alternatives for Individuals with Serious Mental Illness. New York, NY: Oxford University Press. Han, B., Lai, J., & Yu, H. (2020). Impact of the Affordable Care Act Medicaid Expansion on Utilization of Mental Health Care. Medical Care, 58(9), 757–762. Harrison, P. M., & Karberg, J. C. (2003). Prison and Jail Inmates at Midyear 2002 [No. NCJ-198877]. Washington, DC: Bureau of Justice Statistics, US Department of Justice. Heilbrun, K., DeMatteo, D., Strohmaier, H., & Galloway, M. (2015). The Movement toward Community-Based Alternatives to Criminal Justice Involvement and Incarceration for People with Severe Mental Illness. In P. A. Griffin, K. Heilbrun, E. P. Mulvey, D. DeMatteo, & C. M. Schubert (Eds.), The Sequential Intercept Model and Criminal Justice: Promoting Community Alternatives for Individuals with Serious Mental Illness (pp. 1–20). New York, NY: Oxford University Press. Homelessness and Housing. (2016). Retrieved from homelessness-housing Jones, D. (2006). Discharge Planning for Mentally Ill Inmates in New York City Jails: A Critical Evaluation of the Settlement Agreement of Brad H. v. City of New York. Pace Law Review, 27, 305. Joyce, A. S., Wild, T. C., Adair, C. E., McDougall, G. M., Gordon, A., Costigan, N., … & Barnes, F. (2004). Continuity of Care in Mental Health Services: Toward Clarifying the Construct. The Canadian Journal of Psychiatry, 49(8), 539–550. Kasprow, W. J., & Rosenheck, R. A. (2007). Outcomes of Critical Time Intervention Case Management of Homeless Veterans after Psychiatric Hospitalization. Psychiatric Services, 58(7), 929–935. ps.2007.58.7.929 Kinoshita, Y., Furukawa, T. A., Kinoshita, K., Honyashiki, M., Omori, I. M., Marshall, M., … & Kingdon, D. (2013). Supported Employment for Adults


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with Severe Mental Illness. The Cochrane Database of Systematic Reviews, 2010(1), CD008297. Kondo, L. (2003). Advocacy of the Establishment of Mental Health Specialty Courts in the Provision of Therapeutic Justice for Mentally Ill Offenders. American Journal of Criminal Law, 28, 255–336. Koyanagi, C., & Blasingame, K. (2006). Best Practices: Access to Benefits for Prisoners with Mental Illness. Issue Brief. Washington, DC: Judge David L. Bazelon Center for Mental Health Law. Lamberti, J. S., Weisman, R., & Faden, D. I. (2004). Forensic Assertive Community Treatment: Preventing Incarceration of Adults with Severe Mental Illness. Psychiatric Services, 55(11), 1285–1293. Lehman, A. F., Goldberg, R., Dixon, L. B., McNary, S., Postrado, L., Hackman, A., & McDonnell, K. (2002). Improving Employment Outcomes for Persons with Severe Mental Illnesses. Archives of General Psychiatry, 59(2), 165–172. Lurigio, A. J., Rollins, A., & Fallon, J. (2004). Effects of Serious Mental Illness on Offender Reentry. Federal Probation, 68, 45. Miller, M. G., & Ngugi, I. (2009). Impacts of Housing Supports: Persons with Mental Illness and Ex-Offenders. Olympia, WA: Washington State Institute for Public Policy. Montgomery, E., Hill, L., Culhane, D., & Kane, V. (2014). Housing First Implementation Brief. Philadelphia, PA: VA National Center on Homelessness among Veterans, US Department of Veterans Affairs. Montgomery, A., Hill, L., Kane, V., & Culhane, D. (2013). Housing Chronically Homeless Veterans: Evaluating the Efficacy Of a Housing First Approach to Hud-Vash. Journal of Community Psychology, 41(4), 505–514. Montgomery, P., Forchuk, C., Duncan, C., Rose, D., Bailey, P. H., & Veluri, R. (2008). Supported Housing Programs for Persons with Serious Mental Illness in Rural Northern Communities: A Mixed Method Evaluation. BMC Health Services Research, 8(1), 1. Morgan, R. D., Flora, D. B., Kroner, D. G., Mills, J. F., Varghese, F., & Steffan, J. S. (2012). Treating Offenders with Mental Illness: A Research Synthesis. Law and Human Behavior, 36(1), 37. Morrissey, J. P., & Goldman, H. H. (1986). Care and Treatment of the Mentally Ill in the United States: Historical Developments and Reforms. The Annals of the American Academy of Political and Social Science, 484(1), 12–27. National Institute of Justice. Office of Justice Programs. Offender Reentry. (2015). Retrieved from welcome.aspx Osher, F., D’Amora, D. A., Plotkin, M., Jarrett, N., & Eggleston, A. (2012). Adults with Behavioral Health Needs under Correctional Supervision: A Shared Framework for Reducing Recidivism and Promoting Recovery. New York, NY: Council of State Governments Justice Center. Osher, F., & King, C. (2015). Intercept 4: Reentry from Jails and Prisons. In P. A. Griffin, K. Heilbrun, E. P. Mulvey, D. DeMatteo, & C. A. Schubert (Eds.), The Sequential Intercept Model and Criminal Justice: Promoting Community Alternatives for Individuals with Serious Mental Illness (p. 95). New York, NY: Oxford University Press. Patel, K., Boutwell, A., Brockmann, B. W., & Rich, J. D. (2014). Integrating Correctional and Community Health Care for Formerly Incarcerated People Who Are Eligible for Medicaid. Health Affairs, 33(3), 468–473. Peers for Progress. (2016). What Is Peer Support? Retrieved from

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Phillips, L. A., & Spencer, W. M. (2013). The Challenges of Reentry from Prison to Society. Journal of Current Issues in Crime, Law & Law Enforcement, 6(2), 123–133. Phillips, S. D., Burns, B. J., Edgar, E. R., Mueser, K. T., Linkins, K. W., Rosenheck, R. A., … & Herr, E. C. M. (2001). Moving Assertive Community Treatment into Standard Practice. Psychiatric Services, 52(6), 771–779. Reid, N., Mason, J., Kurdyak, P., Nisenbaum, R., de Oliveira, C., Hwang, S., & Stergiopoulos, V. (2021). Evaluating the Impact of a Critical Time Intervention Adaptation on Health Care Utilization among Homeless Adults with Mental Health Needs in a Large Urban Center: Évaluer l’effet d’une Adaptation De l’intervention En Temps Critique Sur l’utilisation des Soins De Santé Chez Des Adultes Itinérants Ayant Des Besoins De Santé Mentale Dans Un Grand Centre Urbain. The Canadian Journal of Psychiatry. Rogers. (2014). Retrieved from medicaids-new-prisoner-population/ Rotter, M., McQuistion, H. L., Broner, N., & Steinbacher, M. (2005). Best Practices: The Impact of the “Incarceration Culture” on Reentry for Adults with Mental Illness: A Training and Group Treatment Model. Psychiatric Services, 56(3), 265–267. Satel, S. (2003). Out of the Asylum, into the Cell. New York Times, A-29. Skeem, J. L., Hernandez, I., Kennealy, P., & Rich, J. (2012). CA-YASI Reliability: How Adequately Do Staff in California’s Division of Juvenile Justice Rate Youths’ Risk of Recidivism. Irvine: University of California. Skeem, J. L., Winter, E., Kennealy, P. J., Louden, J. E., & Tatar II, J. R. (2014). Offenders with Mental Illness Have Criminogenic Needs, Too: Toward Recidivism Reduction. Law and Human Behavior, 38(3), 212. Slade, E. P., McCarthy, J. F., Valenstein, M., Visnic, S., & Dixon, L. B. (2013). Cost Savings from Assertive Community Treatment Services in an Era of Declining Psychiatric Inpatient Use. Health Services Research, 48(1), 195–217. Slate, R. M., Buffington-Vollum, J. K., & Johnson, W. W. (2013). The Criminalization of Mental Illness: Crisis and Opportunity for the Justice System (2nd Ed.). Durham, NC: Carolina Academic Press. St. Lucie County’s Journey Forward Sets Inmates on Path to Success. (2010). Florida Partners in Crisis: Success Stories, 1–4. Retrieved from http://www. Stobbe, J., Wierdsma, A. I., Kok, R. M., Kroon, H., Roosenschoon, B. J., Depla, M., & Mulder, C. L. (2014). The Effectiveness of Assertive Community Treatment for Elderly Patients with Severe Mental Illness: A Randomized Controlled Trial. BMC Psychiatry, 14(1), 1. Stull, L. G., McGrew, J. H., & Salyers, M. P. (2012). Processes Underlying Treatment Success and Failure in Assertive Community Treatment. Journal of Mental Health, 21(1), 49–56. The Sentencing Project. (2018). Incarcerated Women and Girls | The Sentencing Project. The Sentencing Project. Retrieved from The Sentencing Project. (2002). Mentally Ill Offenders in the Criminal Justice System: An Analysis and Prescription. Retrieved from Travis, J. (2000). But They All Come Back: Rethinking Prisoner Reentry. Washington, DC: US Department of Justice, Office of Justice Programs, National Institute of Justice.


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Urban Justice Center. (n.d.). Mental Health Project. Brad H. v City of New York. Retrieved from Walters, J. H. (2013). The National Institute of Justice’s Evaluation of Second Chance Act Adult Reentry Courts. Program Characteristics and Preliminary Themes from Year. Watkin, F., & Leonard, G. (2019). Community Reintegration of People with Mental Health Problems or Learning Disabilities from Prison. Journals.rcni. com. Retrieved from evidence-and-practice/community-reintegration-of-people-with-mentalhealth-problems-or-learning-disabilities-from-prison-ldp.2019.e2009/abs Wehman, P. (2012). Supported Employment: What Is It? Journal of Vocational Rehabilitation, 37(3), 139–142. Wehman, P., Lau, S., Molinelli, A., Brooke, V., Thompson, K., Moore, C., & West, M. (2012). Supported Employment for Young Adults with Autism Spectrum Disorder: Preliminary Data. Research and Practice for Persons with Severe Disabilities, 37(3), 160–169. Weinstein, L. C., Henwood, B. F., Cody, J. W., Jordan, M., & Lelar, R. (2011). Transforming Assertive Community Treatment into an Integrated Care System: The Role of Nursing and Primary Care Partnerships. Journal of the American Psychiatric Nurses Association, 17(1), 64–71. Woods, L. N., Lanza, A. S., Dyson, W., & Gordon, D. M. (2013). The Role of Prevention in Promoting Continuity of Health Care in Prisoner Reentry Initiatives. American Journal of Public Health, 103(5), 830–838. https://doi. org/10.2105/AJPH.2012.300961 Yoon, J., & Nickel, J. (2008). Reentry & Partnerships: A Guide for States & Faith-Based and Community Organizations. New York, NY: Council of State Governments Justice Center.



Intercept Five

Community Corrections PRACTITIONER’S CORNER 9.1. CONTRIBUTOR: JENI BROWN My name is Jeni Brown. I am 44 years old. I live in Juneau Alaska. I am a fullblooded Tlingit Woman of the Taak Dein Taan Clan, originating from Glacier Bay, Alaska, and moved to Hoonah, Alaska. I work for Central Council Tlingit and Haida Indian Tribes of Alaska in the Community & Behavioral Health Department as the Family & Community Engagement Specialist. I am here to tell my story of incarceration, my recovery, and my reentry to the community. I have four felonies: Three drug charges (misdemeanors in the fourth, second, and third degrees) and hindering prosecution in the frst degree. I have spent all my jail time here in Juneau Alaska, between Lemon Creek Correctional Center and Glacier Manor Halfway House. My sentence began in 2009, and I am currently serving my parole time—I will be of in March 2022. Addiction made me back away from my culture and family and hit “rock bottom” the night before my last arrest. Prior to being incarcerated, I attended a 40-day residential treatment program in Sitka and attended Narcotics Anonymous and Alcoholics Anonymous. Today, I have attributed much of my success to reconnecting with my traditional culture and family. I have participated in peer recovery programs and have been trained to become a peer counselor to work with other women who have been incarcerated and people in early recovery. I have also participated in a CDC Rx Awareness Campaign, and numerous recidivism and recovery panels. Resources that helped me are the following: • • • • • •

AA/NA Support Groups Haven House Members and Board of Directors Central Council Tlingit & Haida Indian Tribes of Alaska Juneau Reentry Coalition Staf Juneau Alliance Mental Health Coalition Staf Glacier Manor Halfway House Staf

DOI: 10.4324/9781003120186-9



CHAPTER 9 Intercept Five: Community Corrections

• • • • • • • •

Akeela House Counselors Tlingit and Haida Regional Housing Staf Juneau Christian Center Pastors Lemon Creek Correctional Center Staf Kara Nelson Search Bill Brady Healing Center Staf Search Behavioral Health Staf Gastineau Human Services Treatment Department

Life after incarceration has been hard but it is worth it—I have been working on my recovery and working with my family for family reunifcation. I am still an advocate for MMIW,1 Women’s Rights, and Indigenous People. Becoming a productive member of the community has been important to me as I had done a lot of damage to this community, and I am strongly trying to “right my wrongs.” As this takes place, I work through my PTSD (post-traumatic stress disorder) and my traumas, so these things don’t run my life and I can live my life peacefully. Who knows, I could become a politician… Source: (J. Brown, personal communication, September 27, 2021).

INTRODUCTION Throughout the preceding chapters, challenges and potential diversion strategies have been introduced and discussed with respect to citizens in crisis and justice-involved persons with mental illness (PwMI) who enter the criminal justice system—from their initial encounter with law enforcement and subsequent arrest (Intercepts 0 and 1), to the point at which the individual is discharged from a period of incarceration and attempts to reintegrate into a community setting (Intercept 4). In line with the traditional criminal justice funnel2, however, the journey through the forensic mental health system may not end there. In fact, consumers of mental health and substance use services who are justice-involved and under community supervision (usually probation) represent another large group to consider for the purposes of community reintegration and the last intercept point in the Sequential Intercept Model ([SIM] Munetz & Griffin, 2006). As was noted at the beginning of the text, the SIM is anchored by “community” at both ends, illustrating the importance of integrative partnerships between multiple agencies. In the context of Intercept 5, communities should be able to provide and encourage the proper utilization of resources, while simultaneously aiding in the reduction of recidivism (i.e., reoffending) and quantifying the effectiveness of resources and supervisory services. However, for several reasons already described, there is a high likelihood that PwMI on community supervision will violate the conditions of probation or parole (Skeem & Louden, 2006). Not only does community supervision present complicated conditions and restrictions to follow, but for many probationers and parolees with low functionality and/or limited access to resources and necessary services,

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 Figure 9.1 Probation

Source: “Probation Ofcers Parking Only” by Roman Tiraspolsky is licensed under CC BY-NC 2.0;

community supervision presents more of a barrier to successful reintegration in the community. Consistent with RNR principles and the framework of APIC and other models presented in Chapter 8, individuals with serious behavioral health needs who are determined to be at high risk for reoffending should receive more intensive (specialized) communitybased supervision to include, among other services, the coordination of closer monitoring and more integrative treatment resources, to include prioritized housing and other service needs (Osher et al., 2012). This chapter presents a framework for reducing recidivism and behavioral health problems among individuals who are under correctional control or supervision in the community (probation or parole) (Figure 9.1). Despite some of the overlap from the preceding chapters, it is meant to provide a description of consumer needs post-commitment (public health or criminal justice systems) and the potential for interagency collaboration, with the goal of identifying and overcoming barriers to adjusting successfully in the community.

MENTAL HEALTH AND COMMUNITY CORRECTIONS In 2019, there were an estimated 4,357,700 adults (1 of every 59 individuals) under the authority of community supervision in the form of probation and parole in the United States (Oudekerk & Kaeble, 2021). According to one report, justice-involved persons with any mental illness make up about 16 percent of all probationers and 5 percent to 10 percent of parolees (Dirks-Linhorst & Linhorst, 2013). When applied to the total number of individuals supervised by community corrections, these percentages show that there are over 640,000 probationers with mental illness and between 420,000 and 450,000 parolees with mental illness (Dirks-Linhorst &


CHAPTER 9 Intercept Five: Community Corrections

Linhorst, 2013). Additional findings suggest that approximately 7 percent to 9 percent of men under some form of supervision (probation or parole) have a serious mental illness (SMI); for those with co-occurring SMI and substance abuse disorders, reports indicate rates of MI as high as 40 percent and 50 percent (Feucht & Gfroerer, 2011; as cited in Osher et al., 2012). To reiterate from Chapter 8, the research also suggests that justice-involved PwMI are more likely than those without mental illness to recidivate (commit a new offense) or violate terms of their release and they are likely to do so more quickly, resulting in their return to prison (Bailliargeon et al., 2009; Skeem et al., 2014). Lack of treatment options and community integration strategies lead to a 60 percent to 80 percent increase in risk of one reincarceration incident and an 80 percent to 140 percent increase in risk of a second reincarceration for justice-involved persons with SMI (Baillargeon et al., 2009). With so many probationers and parolees being reincarcerated for technical violations or the commission of new crimes, there is a need for closer review of risk factors as well as an examination of relevant programs with empirical evidence of effective community reintegration. Again, previous chapters have reviewed some of the same information, but this chapter will identify and discuss potential solutions within the context of the current intercept point.

The Case for Recidivism As discussed in Chapter 8, previous research has shown that psychiatric illness has little direct correlation to recidivism (Skeem et al., 2013; Zgoba et al., 2020). Rather, the presence of a serious psychological disorder increases the likelihood of other factors that are directly associated with criminal activity (i.e., criminogenic risk factors)—the most significant of which include the presence of antisocial personality traits and antisocial cognition (thinking styles conducive to lawbreaking) (Carr et al., 2020; Osher et al., 2012). Four additional indicators that moderately predict recidivism among PwMI include substance use, employment instability, family problems, and low participation in pro-social leisure (Osher et al., 2012; Skeem et al., 2013; Zgoba et al., 2020). Displacement (unstable housing) is also a significant factor (Ostermann & Matejowkowski, 2014).

THINKING CRITICALLY 9.1 IMPORTANCE OF CONTINUITY OF CARE: A CASE STUDY As you read through the following vignette, consider ways by which negative behaviors and, possibly, the culminating violence, might have been prevented. Diagnosed with schizoafective disorder at age 18, and more recently, PTSD and substance use disorder (SUD), Nichole had a history of violence that spanned 10–15 years. She also had a history of transience and lacked stable housing, and was consistently moving between shelters, the residences of

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various family members, and the streets. A simple assault conviction was the most recent incident which led to a 12-month stay in the county jail. Upon release, Nichole was placed into a residential program with parole supervision. Nichole was progressing well in the program. Her parole was soon expiring and, therefore, required visits with her parole ofcer had become less frequent. After having a scufe with one of the other residents over access to the “community television,” in which Nichole threatened violence, the residential coordinator (RC) told her to leave for a few hours to “cool of.” The RC neglected to report the incident to Nichole’s parole ofcer or other law enforcement ofcials. Over the next two weeks, Nichole’s behavior at the residential program became increasingly concerning, as she was easily angered and argued with other residents. She would disappear for hours “to visit family” or to “look for work,” sometimes returning past curfew in the evenings. The RC still neglected to report this behavior to ofcials. In reality, Nichole had been spending more time with random friends and relatives during her “absences” from the program, had stopped taking her prescribed psychotropic medications. She also began using substances again. Almost a month after the fght over the television, Nichole was rearrested for the attempted murder of a nine-year-old boy, the nephew of a man who was staying with Nichole’s family. Nichole stabbed the boy during a psychotic episode at her mother’s apartment.3

Mental Illness (MI) and Substance Use Disorder (SUD) Previous research has shown that as high as 70 percent of individuals with serious mental illness also have a history of substance use (Hartwell et al., 2013). In Figure 9.2, alcohol is depicted as the substance of choice. Justice-involved persons with SMI are more likely to be under the influence

 Figure 9.2 Photo of Beer & Wine Store

Source: “Beer Wine and Skateboard” by MTSOfan is licensed under CC BY-NC-SA 2.0.


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of drugs or alcohol when taking part in criminal activity than those without SMI, and a dual diagnosis of MI and SUD consistently increases the likelihood of recidivism when compared with the presence of MI or SUD independently (Hartwell et al., 2013; Stephens, 2011; Zgoba et al., 2020). For example, in a study conducted by Balyakina et al. (2014), probationers with co-occurring SUD and MI were 22 times more likely to recidivate in comparison with those who only had SUD or MI alone (Balyakina et al., 2014). Despite a strong relationship between substance use and offending behaviors among PwMI, there has been little previous research examining the importance of access to substance use treatment among members of this population (Hartwell et al., 2013). Results of existing research, however, indicate that a substantial proportion successfully access substance use treatment within the two years following their release into the community (Hartwell et al., 2013). However, the underlying success factors seem to pertain to whether treatment was court-ordered as part of a release plan. Only a small proportion of offenders are mandated to seek substance use treatment post-release (Hartwell et al., 2013). This is problematic because PwMI often fail to utilize community-based services with regularity due to barriers previously discussed (e.g., no transportation, lack of benefits/insurance, weak supervision, and poor additional community supports). Another factor that can prevent individuals from seeking treatment relates to the stigma of having serious psychiatric symptoms and using substances— negative perceptions may cause some to avoid taking part in a treatment program (Fox et al., 2018; Hartwell et al., 2013; Stimmel et al., 2019). Many individuals who enter substance use treatment enter detox services, which illustrates that treatment is primarily sought when an individual is in complete crisis and in need of medical attention (Hartwell et al., 2013). Based on these findings, researchers have concluded that information gained from the initial screening processes should be utilized to develop a multidisciplinary treatment plan, whereby substance use treatment for justice-involved persons with serious psychological disorders should be mandated as a stipulation of release through proper coordination and planning (Hartwell et al., 2013; Stephens, 2011; Stimmel et al., 2019). Consider the case of Nichole presented earlier.

COMPARATIVE PERSPECTIVES 9.1 USING TECHNOLOGY TO COMBAT STIGMA IN ASIA Due to the degree of stigmatization of mental illness in Asian countries, implementing programming specifc to serious psychological disorders can be difcult. However, despite this signifcant barrier to treatment and services, technology has become a vital resource for mental health. Various non-proft organizations have created websites that operate in different countries in South Asia, promoting anti-stigma campaigns, while linking people to treatment options. These websites include ePsyClinic

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(India), HealtheMinds (India), (Pakistan), (Bangledesh), (Sri Lanka), International Psychosocial Organisation (IPSO) (Afghanistan), and many others. Sources: 1. Thelwell, K. (April 9, 2020). Youth, Technology and Mental Health in South Asia. The Borgen Project. Retrieved from https://borgenproject. org/mental-health-in-south-asia/. 2. Kapoor, S. (September 20, 2017). How Technology Is Transforming Mental Health Treatment Delivery in South Asia. Mental Health Innovation Network. Retrieved from sep/14/how-technology-transforming-mental-health-treatment-delivery-south-asia.

Communication and Capacity: Additional Barriers to Success Probation and parole service providers must be able to meet the specialized needs of PwMI to reduce recidivism and promote successful community integration. One issue observed at Intercept 5 is the breach in communication between correctional administrators and officers, service providers, and other key stakeholders at various agencies (e.g., school personnel, courtroom case managers, attorneys). Also, probation and parole service providers often lack knowledge with respect to services available for PwMI. Thus, although research has shown that criminal justice supervision does reduce recidivism, training specific to serving probationers and parolees with mental health and substance use issues is likely to result in an increase in the successful release into the community (Ostermann & Matejowkowski, 2014). Resource guides have been designed and used in some communities and made available to individuals working in multiple, but integrated, systems of care. For example, police officers may find it useful to have referral information for local respite care or other crisis management services on hand during a crisis encounter, should diversion be an option (Compton & Kotwicki, 2007). In addition to training and the dissemination of behavioral health resource information to key actors, the focus has been given to the development of more effective transition planning that utilizes an integrative approach to pre-release conditions.

THINKING CRITICALLY 9.2 PROBATION AND PAROLE OFFICER DISCRETION Imagine that you have been convicted of a federal drug crime and you have a history of addiction and mental health issues. You are now in court to be sentenced. Once you hear that you will be spending the next fve years in


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prison, you do not even give a second thought to everything else the judge is saying. You do your time, you are released from prison, and you meet your probation ofcer. At that point, the ofcer, not the judge, decides you need to spend more time confned—this time, in a restrictive inpatient facility. In fact, the judge, fve years ago at sentencing, ordered the probation ofcer to make such a decision.4 Discuss: What if this were your family member, signifcant other, or friend? In consideration of the research discussed earlier, how might the court justify such discretion? In many cases at the time of sentencing, judges give probation ofcers the discretion to decide whether a defendant is released early, unconditionally, or with viable mandated treatment options (Teitelbaum, 2012). These practices have become so commonplace that many do not think twice about these proceedings. However, Article III of the United States Constitution limits judicial power to the courts (Teitelbaum, 2012). Probation and parole ofcers are granted the ability to mandate additional mental health treatment through sentencing guidelines only if the court has reason to believe that the defendant needs psychological or psychiatric treatment approved by the United States Probation Ofce. If there is no basis for mental health treatment or further supervision, the case can be thrown out (Teitelbaum, 2012). Probation is also granted the ability to extend sentencing through community supervision due to their dual status as district court employees and law enforcement ofcers within the federal system. Although probation ofcers are, in fact, delegates of the court, they are still not permitted to make decisions that are essentially considered a deprivation of individual liberty interests of defendants under the U.S. Constitution (Teitelaum, 2012). Possible solutions to maintain the legality of increased mental health supervision by probation ofcers include judges making fnal decisions at sentencing that are not indeterminate (fexible) (Teitelbaum, 2012). A more viable option would have the judge setting a sentence of maxim restriction in which the probation ofcer has the legal discretion to reduce, but not increase, the sentence as they see ft (Teitelbaum, 2012).

Summary of Post-Commitment Needs Due to the increased likelihood of recidivism for PwMI (Osher et al., 2012; Skeem & Louden, 2006; Stephens, 2011), post-commitment needs that may reduce recidivism for this population have been identified (and presented in Chapter 8 of this text): • • •

Substance use screening and monitoring Guidelines for determining effective community mental health treatment and evidence-based practices Better understanding of offender risk level and the identification and continued observation of criminogenic needs (changeable risk factors) during the period of supervision

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• •

Increased community supervision and information sharing across agencies An integrated system of transition planning for offenders with mental illness and provisions in place for unrestricted access to service needs

It is true that justice-involved persons without serious psychological disorders share many of the same needs, and restrictions to meeting their needs, for success in the community as forensic clients (Osher & King, 2015). In addition to the ways to prevent and respond to these restrictions throughout the previously discussed intercepts, at Intercept 5, the most important strategies include: (a) interagency and intra-agency cooperation, (b) ongoing assessment of risk and needs of the clients, and (c) seamless provision of integrated service needs (Louden et al., 2015).

INTERAGENCY COOPERATION, INTRA-AGENCY COLLABORATION, AND SYSTEMS INTEGRATION There are several ways by which a community can work to develop collaborative and multisystemic partnerships to accomplish the effective integration of probationers and parolees with mental illness and co-occurring substance disorder needs. Examples of strategies may include the creation of collaborative committees or teams and the facilitation of community partnership meetings with service providers and key agency leaders to include juvenile and/or adult probation officers, clients, and families (depending on the needs at the time), and other stakeholders in community corrections. Meetings could revolve around practical matters, funding, new programs, research findings, or even the review of problematic cases for multidisciplinary perspectives/input and to engage in the discussion of potential solutions. Furthermore, various agencies involved in the care and supervision of this population should employ individuals who are capable of being trained as effective boundary spanners.5 The ongoing exchange of information between agencies and providers will facilitate and promote positive change and the timely handoff of pertinent information (Osher et al., 2012; Van Deinse et al., 2021). With respect to information sharing, privacy concerns should be noted and respected in the context of successful and respectful provider–client relationships, but also under the provisions of federal, state, and local laws pertaining to sharing of medical records and other personal health information (Petrila et al., 2015). To best understand how justice officials can aid in the development of effective responses to PwMI, findings of best and/or evidence-based practices should be consulted and suggestions for positive changes noted. Existing literature provides support for the ongoing training of direct services staff across systems. For example, training related to problem-solving techniques and available resources for effective supervision could provide probation and parole officers with the skills and information needed to foster client


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compliance and reduce the risk of negative outcomes. Likewise, system-wide trainings for law enforcement officers (including community corrections), public defenders, district attorneys, jail personnel, mental health workers and providers, and courtroom personnel on topics related to MI, substance abuse signs and symptoms, and barriers to reintegration are likely to (a) foster interagency relations, (b) promote sharing of information and resources, and (c) reducing stigmatizing beliefs about PwMI (Louden et al., 2015).

Specialized Probation Specialization and emphasis on a rehabilitative model are ideal for community protection and adequate treatment (Dirks-Linhorst & Linhorst, 2012). Therefore, in addition to system-wide trainings for all active service providers and agents, it is recommended that probation and parole departments designate highly trained, specialized personnel to work with the most highly involved PwMI. The research informs that there are five key features of specialty probation (Skeem et al., 2006, pp. 121–122, as cited in Eno Louden et al., 2015; Van Deinse et al., 2021): • • • • •

Caseloads that consist only of probationers with mental illness Officers have reduced caseloads (M = 48 vs. M = 100 plus) Officers are provided with ongoing training in mental health-related issues Community resources are integrated, so officers may serve on multidisciplinary teams Officers are trained to use problem-solving strategies as compared to punishment and sanctions used in a traditional probation setting, reflecting a therapeutic jurisprudence philosophy

Program options have been examined for their ability to reduce offending behavior for PwMI in community corrections; however, definitive results have not been produced on a consistent basis (Baillargeon et al., 2009; Skeem & Eno Louden, 2006). Findings do show that specialized or specialty mental health probation does in fact increase mental health service access and reduce recidivism—which are its primary goals (Lurigio et al., 2012; Manchak et al., 2014). It is unclear, however, if the reduction in recidivism is due to the treatment programs or to the core principles of specialized probation programs such as FACT (discussed in Chapters 6–8), which incorporate boundary spanning, more intense supervision, and high-quality probation officer–client relationships (Skeem et al., 2011; Van Deinse et al., 2021). All practitioners are to address conditions of release violations on a caseby-case basis to avoid unnecessary violations that can result in a return to incarceration (Dirks-Linhorst & Linhorst, 2012; Terpstra & Mulvey, 2021). Case managers should be cognizant of mental illness and decompensation triggers when considering whether to revoke parole and admit the offender

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back into the system (Dirks-Linhorst & Linhorst, 2012). Also, minor violations such as missing doctor’s appointments or periodic absences from treatment programs should be viewed as treatment issues and not warranting of revocations (Dirks-Linhorst & Linhorst, 2012). Additional guidelines for community monitoring of PwMI include incorporating risk assessment instruments into decision making, focusing attention on substance abuse, gathering data from multiple sources, and involving multiple parties (Dirks-Linhorst & Linhorst, 2012; Terpstra & Mulvey, 2021; Van Deinse et al., 2021). POLICY & PRACTICE 9.1 SPECIALIZED COMMUNITY TRANSITION TEAMS As discussed in Chapter 8, transition planning involves the simple planning of community treatment services and coordination among prison personnel and community mental health providers. One example of transition planning is the Transition from Prison to Community (TPC) program in which correctional staf, law enforcement, and social service providers collaborate with a large focus on planning for the defendant’s release into the community. Research fndings have shown that participation in the TPC program reduces recidivism for all ofenses. FACT programs (more thoroughly discussed in the preceding chapter) have also been implemented with success since the late 1970s. These specialty programs focus more on access to services than transition planning. Persons enrolled in a FACT program who have forensic involvement (criminal charges fled against them) are given 24/7 access to psychiatrists, nurses, social workers, and substance abuse counselors. Research evaluations on the efectiveness of FACT have shown that participation in the program has led to reduced recidivism and a reduction of days spent incarcerated. Sources: 1. Goulet, M. H., Dellazizzo, L., Lessard-Deschênes, C., Lesage, A., Crocker, A. G., & Dumais, A. (2021). Efectiveness of Forensic Assertive Community Treatment on Forensic and Health Outcomes: A Systematic Review and Meta-Analysis. Criminal Justice and Behavior, 00938548211061489. 2. Kondrat, D., Rowe, W., & Sosinski, M. (2013). An Exploration of Specialty Programs for Inmates with Severe Mental Illness: The United States and the United Kingdom. Best Practices in Mental Health, 8(2), 99–108. 3. Marquant, T., Sabbe, B., Van Nufel, M., Verelst, R., & Goethals, K. (2018). Forensic Assertive Community Treatment in a Continuum of Care for Male Internees in Belgium: Results after 33 Months. Community Mental Health Journal, 54(1), 58–65.

Medication-Assisted Treatment (MAT) Medication-Assisted Therapy (MAT) programs involve a combination of therapy and medication (SAMHSA, 2019a). Essentially, treatment providers supplement therapy with drug treatments that assist individuals


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by weaning themselves off the substance(s) that they have been abusing (SAMHSA, 2019a). In the case of opioids, the three most common medications administered in MAT programs include methadone, buprenorphine, and naltrexone (SAMHSA, 2019b). While much research has found MAT to be effective in treating addictions (Green et al., 2018; Lincoln et al., 2018; Russolillo et al., 2018), overdoses have increased as have prescriptions for drugs such as methadone (Kuehn, 2012; Whelan & Remski, 2012). For individuals revolving through institutional corrections and living with SUD or COD (substance use or co-occurring MH/SU disorders), an overdose is most likely to occur within two weeks post-incarceration at a rate that is close to 50 times higher than that of the general population (Troilo, 2018). Despite an increasing number of justice-involved opioid users, many facilities do not allow individuals to start or continue using MAT programs (Green et al., 2018). Some of the primary reasons for this resistance include costs and a lack of resources, potential for illegal distribution of the drugs, stigmatization of participants, potential drug use and drug-related offending, and opposition to the drugs utilized in MAT programs (Kulaga, 2019). Recent reports indicate that some of these challenges are beginning to dissipate. Evaluations of MAT programs reveal generally positive results in conjunction with other traditional treatment programs, including reductions in the risk of death during custody and immediately following release (Lee et al., 2016, 2018; Lincoln et al., 2018; McDonald et al., 2016). There is, however, some conflicting evidence that points to the need for additional examination with more robust methodologies (Velasquez et al., 2019; Wolfe et al., 2011).

RESISTANCE TO TREATMENT Many justice-involved PwMI are resistant to treatment, and despite best efforts by the community team, these individuals may simply not engage in services, and therefore, may decompensate, reoffend, and return to jail and/or prison. To accommodate service needs, any public safety concerns, and the management concerns of providers who collect and report data on utilization, some strategies have been implemented in various locales so to increase—or at the very least, track—consumer engagement. For example, as presented earlier in the text, some jurisdictions have established MOUs (memorandums of understanding) between departments of corrections and community-based providers so to facilitate initial aftercare appointments for incarcerated persons with MI and/or SA needs who are soon to be released from carceral settings. In addition to the benefits of facilitating discharge planning prior to release, this type of system is useful if it is possible to record any missed appointments as “no shows” for data reporting purposes. There have also been more controversial attempts at increasing access to and utilization of services for PwMI who are considered at risk of harming

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themselves or someone else. Research has shown that recidivism among PwMI is a widespread problem in which many factors affect frequently negative outcomes. Swigger and Heinmiller (2014) explain the effectiveness of community treatment orders in which mental health patients are required to receive outpatient community mental health treatment, including forced medication. For example, the use of assisted outpatient treatment (AOT) laws is instructive in this regard.

Assisted Outpatient Treatment Assisted outpatient treatment (AOT) legislation has been passed in 47 states (at the time of this writing, the three states that do not have AOT are Connecticut, Maryland, and Massachusetts) (see Figure 9.3) (Treatment Advocacy Center, 2017). Also called “outpatient commitment,” AOT is designed for individuals who have a poor history of treatment compliance, as it is court-ordered treatment (including medication management), which is often attached as a condition of release for justice-involved individuals with mental health and/or substance abuse needs who are remaining in a community setting. The laws of each state provide specific criteria for patient eligibility. The court must first receive a petition for commitment by a defined group of individuals, often initiated by administrators of a hospital or criminal justice facility. Additional parties that may petition the court include parents/ spouse/adult sibling/adult child of the patient; the patient’s parole or probation officers; and any adult person living with the patient (Mental Illness Policy Org., n.d.). The petition must state the criteria for the patient’s eligibility (under the law) and must include supporting facts, including an affidavit or affirmation from a physician who has examined the patient. Once the court receives the petition and affidavit, a hearing will be scheduled. If the court finds that all criteria have been met for placement in AOT, a treatment plan will be developed that will include case management services or ACT/FACT and a combination of treatment modalities tailored to the individual patient, such as medication, individual or group therapy, alcohol or substance use treatment, supervised living, and any other services prescribed (Mental Illness Policy Org., n.d.). The usage of AOT has been hotly contested in the United States and abroad (Canada; see, e.g., Swigger & Heinmiller, 2014). New York Senate Bill S.7254, or “Kendra’s Law,” ushered in forced community treatment after journalist and photographer Kendra Webdale was shoved from the platform and into the path of a subway train in New York City by a man with schizophrenia, causing public uproar for reform in the mental health field (Swigger & Heinmiller, 2014). Like the New York legislation, Laura’s Law (California) is named after a young woman by the name of Laura Wilcox, a California native, who was shot and killed at the age of 19 years old by a man who had untreated chronic mental illness. Although both pieces of legislation have made it possible to mandate PwMI who are chronically ill, not


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engaged in treatment, and at risk of harm against themselves or others to get the help they need, the media sensationalism surrounding these and other cases prompted negative stereotypes of all PwMI as violent and out of control, much like the cases of James Holmes (Aurora movie theater shooting), Adam Lanza (Sandy Hook Elementary School shooting), and Salvadore Ramos (Uvalde school shooting) incidents presented earlier in this book.

 Figure 9.3 AOT in the United States, 2017

Source: Michele P. Bratina (own work) via

THINKING CRITICALLY 9.3 DEBATE: PROS AND CONS OF AOT Arguments FOR the use of AOT: Reduces arrests Increases medication compliance and access to other forms of treatment Reduces homelessness Reduces hospitalization Reduces crime and violence Reduces caregiver stress Arguments AGAINST the use of AOT: Violates the constitutional rights of those deemed “mentally ill” Lacks robust scientifc research evidence that it is efective Existence of scientifc evidence indicating harm of long-term use of psychotropic drugs (can make patients feel worse and hinder their functional capacities; may increase the risk of suicide and violence) Compromises the “trust relationship” between clinician and patient Sources: 1 2

Mental Illness Policy Org. AOT Data and Facts (n.d.). Retrieved from Whitaker, R. & Simonson, M. (2019, July 14). Twenty Years after Kendra’s Law: The Case Against AOT. Mad in America. Retrieved from https://

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 Figure 9.4 AOT Research Highlights, 2021

Source: Treatment Advocacy Center, Research Summary [Infographic], June 2021. Accessed storage/documents/tac-aot-summary-pdf.pdf


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The current programs are created with the goal to provide services to persons who need them in a much less restrictive manner than if they were detained in an inpatient psychiatric facility (Swigger & Heinmiller, 2014). Unlike in the U.S. justice system, where community mental health supervision is based on the recommendation of a judge or probation officer, community treatment orders are issued by a physician and officers of the justice system compel the patient to comply (e.g., must follow physician’s orders or it is considered a violation). Patients who fail to comply will be issued an order for examination, which serves much like a warrant for the doctor in which police may take the patient into custody and return them to the physician for examination (Swigger & Heinmiller, 2014). AOT has been found to be effective in terms of success related to reducing the likelihood of hospitalization as well as the duration thereof (Esposito et al., 2008; New York State Office of Mental Health, 2005; “Kendra’s Law”). Rigorous empirical research about community treatment orders is relatively limited; however, studies have yielded some positive results as to their effectiveness in increasing service utilization/treatment compliance, reductions in incarceration and housing displacement, caregiver stress, and victimization, and other positive outcomes (Figure 9.4) (Barnett et al., 2018; Beaglehole et al., 2021; Harris et al., 2018; SAMSHA, 2020; “2018 Report to Congress”; Treatment Advocacy Center, 2017). It should be noted that the implementation of AOT is often incomplete or inconsistent because of legal, clinical, official, or personal barriers to treatment.

TAKE-HOME MESSAGE The importance of supportive correctional transition planning cannot be overstated, as knowledge of resources and the ability to make community connections for one’s clients contributes to the development of trustworthy and positive relationships through respect and adequate attention to their case (Dirks-Linhorst & Linhorst, 2012; Terpstra & Mulvey, 2021; Van Deinse et al., 2021). Persons with SMI who are released from jail, prison, or other secure placement and who are under community supervision have an increased likelihood of recidivism when compared to others similarly situated but without SMI. Although there is some evidence of effectiveness with specialty probation and integrative approaches to training and the coordination of services, there is an immediate need for additional research on the effects of supervision and transition planning on a larger scale to institute change. Despite changes in policies and procedures at the agency level, PwMI are still being rearrested and reconvicted at an alarming rate, and continued incarceration is not the answer. This problem can be addressed through a collective effort involving correctional personnel, law enforcement, and community health providers. Some examples of successful strategies

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include the continued use of specialized community corrections officers who are trained in CIT or de-escalation techniques and in trauma-informed care approaches to management and supervision of PWLE who may have a multitude of experiences and unique service needs. MAT programming and supported and other housing programs should be prioritized, along with other methods to assist the consumer in maintaining a stable environment, including supported employment and consistent engagement in treatment programs. Mandatory outpatient treatment (AOT) is certainly an option in most states; however, given the controversy surrounding its use, more research as to its effectiveness is highly recommended, and findings should be considered moving forward. For youth with behavioral health-related concerns on probation, there are juvenile probation officers (JPOs) who have received specialized training and who manage a reduced number of specialized cases. Other programs found to be successful with youth who are being supervised in the community include mentoring and/or after-school programs (Big Brother/Big Sister, YMCA/YWCA), targeted case management, alternative and special education (development of an Individualized Education Plan [IEP]), student assistance teams (SATs), school-based prevention programs, community coalitions, and wraparound based support services (Coldiron et al., 2019; Dillard et al., 2019; Kim et al., 2021).

Questions for Classroom Discussion 1. What kinds of treatment options are available for justice-involved persons with MI and SUDs who are under community supervision? Make a list of tools that you think would assist community corrections officials in better responding to or protecting PwMI. 2. How does the community work to accomplish service engagement for persons with SMI but who are not under criminal justice supervision? 3. Compare and contrast assisted outpatient treatment (AOT) with a commitment to an inpatient psychiatric facility. Identify three pros and three cons regarding AOT.


Assisted outpatient treatment (AOT) Dual diagnosis Respite care Technical violations


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NOTES 1 Missing and Murdered Indigenous Women. articles/what-is-the-mmiw-movement 2 Found in many introductory criminal justice textbooks, a visual depiction of the criminal justice process, representing a declining number of cases that make it all the way through the criminal justice system from arrest through incarceration/reeentry into the community. Depending on the amount of discretion allowable by law, and several other legal (prior record) and extralegal factors (race/gender), most cases will exit earlier in the process. 3 Adapted from Treatment Advocacy Center, Preventable Tragedies, accessed preventable-tragedies/preventable-tragedies-database/record/a0h610000 00hGVAAA2. 4 Adapted from Teitelbaum, A. (2012). Dubious Delegation: Article III Limits on Mental Health Treatment Decisions. Michigan Law Review, 1553–1582. 5 Discussed previously. Refers to individuals who have experience working in multiple systems of care and have the ability and expertise to provide cross-systems perspectives and/or multidisciplinary problem-solving strategies (Bursac et al., 2018).

BIBLIOGRAPHY Baillargeon, J., Williams, B. A., Mellow, J., Harzke, A. J., Hoge, S. K., Baillargeon, G., & Greifinger, R. B. (2009). Parole Revocation among Prison Inmates with Psychiatric and Substance Use Disorders. Psychiatric Services, 60(11), 1516–1521. Balyakina, E., Mann, C., Ellison, M., Sivernell, R., Fulda, K., Sarai, S., & Cardarelli, R. (2014). Risk of Future Offense among Probationers with Co-Occurring Substance Use and Mental Health Disorders. Community Mental Health Journal, 50, 288–295. Barnett, P., Matthews, H., Lloyd-Evans, B., Mackay, E., Pilling, S., & Johnson, S. (2018). Compulsory Community Treatment to Reduce Readmission to Hospital and Increase Engagement with Community Care in people with Mental Illness: A Systematic Review and Meta-Analysis. The Lancet Psychiatry, 5(12), 1013–1022. Beaglehole, B., Newton-Howes, G., & Frampton, C. (2021). Compulsory Community Treatment Orders in New Zealand and the Provision of Care: An Examination of National Databases and Predictors of Outcome. The Lancet Regional Health-Western Pacific, 17, 100275. Binswanger, I. A., Blatchford, P. J., Mueller, S. R., & Stern, M. F. (2013). Mortality after Prison Release: Opioid Overdose and Other Causes of Death, Risk Factors, and Time Trends from 1999 to 2009. Annals of Internal Medicine, 159(9), 592–600. Binswanger, I. A., Nowels, C., Corsi, K. F., Glanz, J., Long, J., Booth, R. E., & Steiner, J. F. (2012). Return to Drug Use and Overdose after Release from Prison: A Qualitative Study of Risk and Protective Factors. Addiction Science & Clinical Practice, 7(1), 3. Binswanger, I. A., Stern, M. F., Deyo, R.A., Heagarty, P. J., Cheadle, A., Elmore, J. G., & Koepsell, T. D. (2007). Release from Prison—a High Risk of Death

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Kim, B.-K. E., Johnson, J., Rhinehart, L., Logan-Greene, P., Lomeli, J., & Nurius, P. S. (2021). The School-To-Prison Pipeline for Probation Youth with Special Education Needs. American Journal of Orthopsychiatry, 91(3), 375–385. Kuehn, B. M. (2012). Methadone Overdose Deaths Rise with Increased Prescribing for Pain. JAMA, 308(8), 749–750. jama.2012.9289 Kulaga, N. (2019). Why All Correctional Facilities Should Provide the Option for Medication-Assisted Treatment. Retrieved from https://www.mdchhs. com/2018/07/18/why-all-correctionalfacilities-should-provide-the-optionfor-medication-assistedtreatment/ Lincoln, T., Johnson, B. D., McCarthy, P., & Alexander, E. (2018). Extended-Release Naltrexone for Opioid Use Disorder Started During or Following Incarceration. Journal of Substance Abuse Treatment, 85, 97–100. Louden, J. E., Manchak, S., O’Connor, M., & Skeem, J. L. (2015). Applying the Sequential Intercept Model to Reduce Recidivism among Probationers and Parolees with Mental Illness. In P. A. Griffin, K. Heilbrun, E. P. Mulvey, D. DeMatteo, & C. A. Schubert (Eds.), The Sequential Intercept Model and Criminal Justice: Promoting Community Alternatives for Individuals with Serious Mental Illness (pp. 113–131). New York, NY: Oxford University Press, USA. Lurigio, A. J., Epperson, M. W., Canada, K. E., & Babchuk, L. C. (2012). Specialized Probation Programs for People with Mental Illnesses: A Review of Practices and Research. Journal of Crime and Justice, 35(2), 317–326. Manchak, S. M., Skeem, J. L., Kennealy, P. J., & Eno Louden, J. (2014). High Fidelity Specialty Mental Health Probation Improves Officer Practices, Treatment Access, and Rule Compliance. Law and Human Behavior, Advance Online Publication. McDonald, R. D., Tofighi, B., Laska, E., Goldfeld, K., Bonilla, W., Flannery, M., Santana-Correa, N., Johnson, C. W., Leibowitz, N., Rotrosen, J., Gourevitch, M. N., & Lee, J. D. (2016). Extended-release Naltrexone Opioid Treatment at Jail Reentry (XOR). Contemporary Clinical Trials, 49, 57–64. Mental Illness Policy Org. (n.d.). Guide to How AOT (Assisted Outpatient Treatment) Works. Accessed December 1, 2021, from https://mentalillnesspolicy. org/aot/assisted-outpatient-treatment-guide.html Munetz, M. R., & Griffin, P. A. (2006). Use of the Sequential Intercept Model as an Approach to Decriminalization of People with Serious Mental Illness. Psychiatric Services, 57(4), 544–549. New York State Office of Mental Health. (2005). Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment. Retrieved from https://omh. Osher, F., D’Amora, D. A., Plotkin, M., Jarrett, N., & Eggleston, A. (2012). Adults with Behavioral Health Needs under Correctional Supervision: A Shared Framework for Reducing Recidivism and Promoting Recovery. New York, NY: Council of State Governments Justice Center. Osher, F., & King, C. (2015). Intercept 4: Reentry from Jails and Prisons. In P. A. Griffin, K. Heilbrun, E. P. Mulvey, D. DeMatteo, & C. A. Schubert (Eds.), The Sequential Intercept Model and Criminal Justice: Promoting Community Alternatives for Individuals with Serious Mental Illness (p. 95). New York, NY: Oxford University Press, USA.

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Ostermann, M., & Matejowkowski, J. (2014). Exploring the Intersection of Mental Health and Release Status with Recidivism. Justice Quarterly, 31(4), 746–766. Oudekerk, B., & Kaeble, D. (2021). Probation and Parole in the United States, 2019. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. NCJ 256092. Petrila, J., Fader-Towe, H., & Hill, A. B. (2015). Sequential Intercept Mapping, Confidentiality, and the Cross-System Sharing of Health-Related Information. In P. A. Griffin, K. Heilbrun, E. P. Mulvey, D. DeMatteo, & C. A. Schubert (Eds.), The Sequential Intercept Model and Criminal Justice: Promoting Community Alternatives for Individuals with Serious Mental Illness (p. 257). New York, NY: Oxford University Press, USA. Russolillo, A., Moniruzzaman, A., & Somers, J. M. (2018). Methadone Maintenance Treatment and Mortality in People with Criminal Convictions: A Population-Based Retrospective Cohort Study from Canada. PLoS Medicine, 15(7), e1002625. Sharma, M., & Bennett, R. (2015). Substance Abuse and Mental Illness: Challenges for Interventions. Journal of Alcohol & Drug Education, 59(2), 3. Skeem, J. L., & Louden, J. E. (2006). Toward Evidence-based Practice for Probationers and Parolees Mandated to Mental Health Treatment. Psychiatric Services, 57(3), 333–342. Skeem, J. L., Winter, E., Kennealy, P. J., Louden, J. E., & Tatar II, J. R. (2013). Offenders with Mental Illness Have Criminogenic Needs, Too: Toward Recidivism Reduction. Law and Human Behavior, 38(3), 212–224. Stephens, D. J. (2011). Substance Abuse and Co-occurring Disorders among Criminal Offenders. In T. J. Fagan & R. K. Ax (Eds.), Correctional Mental Health: From Theory to Best Practice (pp. 235–256). Thousand Oaks, CA: Sage Publications. Stimmel, M. A., Rosenthal, J., Blue-Howells, J., Clark, S., Harris, A. H., Rubinsky, A. D., … & Finlay, A. K. (2019). The Impact of Substance Use Disorders on Treatment Engagement among Justice-Involved Veterans with Posttraumatic Stress Disorder. Psychological Services, 16(4), 564. Substance Abuse and Mental Health Services Administration (SAMHSA). (May7, 2019a). Medication and Counseling Treatment. Retrieved from https:// Substance Abuse and Mental Health Services Administration (SAMHSA). (September 9, 2019b). Medication-Assisted Treatment (MAT). Retrieved from Substance Abuse and Mental Health Services Administration. (2020). 2018 Report to Congress Section 224 of the 2014 Protecting Access to Medicare Act Assisted Outpatient Treatment Grant Program. Washington, DC: US Department of Health and Human Services. Swigger, A., & Heinmiller, B. (2014). Advocacy Coalitions and Mental Health Policy: The Adoption of Community Treatment Orders in Ontario. Politics & Policy, 42(2), 246–270. Teitelbaum, A. (2012). Dubious Delegation: Article III Limits on Mental Health Treatment Decisions. Michigan Law Review, 110(8), 1553–1582. Terpstra, B., & Mulvey, P. (2021). Specialty Probation Officers as Street-Level Bureaucrats: Exploring How Discretion Is Perceived and Employed on a Mental Health Caseload. International Journal of Offender Therapy and Comparative Criminology, 66(6–7), 670–693.


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Treatment Advocacy Center. (2017). Assisted Outpatient Treatment Laws. Retrieved January 1, 2022, from component/content/article/39 Troilo, M. (2018). We Know How to Prevent Opioid Overdose Deaths for People Leaving Prison. So Why Are Prisons Doing Nothing? Prison Policy Initiative. Retrieved from Van Deinse, T. B., Crable, E. L., Dunn, C., Weis, J., & Cuddeback, G. (2021). Probation Officers’ and Supervisors’ Perspectives on Critical Resources for Implementing Specialty Mental Health Probation. Administration and Policy in Mental Health and Mental Health Services Research, 48(3), 408–419. Velasquez, M., Flannery, M., Badolato, R., Vittitow, A., Mcdonald, R. D., Tofighi, B., Garment, A. R., Giftos, J., & Lee, J. D. (2019). Perceptions of Extended-Release Naltrexone, Methadone, and Buprenorphine Treatments Following Release from Jail. Addiction Science & Clinical Practice, 14(1), 37–48. Whelan, P. J., & Remski, K. (2012). Buprenorphine vs Methadone Treatment: A Review of Evidence in Developed and Developing Worlds. Journal of Neurosciences in Rural Practice, 3(1), 45–50. https://doi. org/10.4103/0976-3147.91934 Wolfe, D., Carrieri, M. P., Dasgupta, N., Wodak, A., Newman, R., & Bruce, R. D. (2011). Concerns about Injectable Naltrexone for Opioid Dependence. The Lancet, 377(9776), 1468–1470. Zgoba, K. M., Reeves, R., Tamburello, A., & Debilio, L. (2020). Criminal Recidivism in Inmates with Mental Illness and Substance Use Disorders. Journal of the American Academy of Psychiatry and the Law, 48(2), 209–215.



Trauma and Approaches to Trauma-Informed Care

Alida V. Merlo and Michele P. Bratina

Among the many and diverse cases of which is composed the topic of medico-legal injuries, there is a group altogether different from the rest, and which, hidden in obscurity until the present day, deserves a thorough unveiling. I wish to speak of those deeds, described as acts of cruelty and ill treatment, of which young children fall victim from their parents, their schoolmasters, and all who exert over these children some degree of authority. These stories offer us an opportunity to study new and unusual situations, from a medico-legal viewpoint, by reason of the young age and the constitution of the injured subjects, by reason of the varied injurious agents which are used, and by reason of the serious, often terrible, consequences of this abuse… From the earliest days of their lives, such defenseless beings are destined each day, each hour even, for the cruelest of abuse, are submitted to harsh deprivations, their lives hardly begun are already a martyrdom, such torment, such physical tortures from which the imagination recoils lay waste their bodies, extinguishes the first awakening of their minds and cuts short their very lives. These stories become even more unbelievable because their tormenters are often the ones who gave them life in the first place…. For my part, I am not surprised that one would attempt to invoke some aberration of the sentiments, or a kind of insanity, as an explanation for these acts of ferocious brutality and of mindless violence… But it remains that these cases are multiplying, that they provoke indignation, that they must not catch off guard the physician, often the only one capable of denouncing the crime to the legal authorities, and that they must not remain unknown to the forensic expert enjoined by the courts to explain its true character and to unveil all the circumstances of the deed. For all these reasons, it is my wish that this new research will be well received. —Auguste Ambroise Tardieu, French Forensic Physician (1818–1879)1

DOI: 10.4324/9781003120186-10



CHAPTER 10 Approaches to Trauma-Informed Care

INTRODUCTION According to the Substance Abuse and Mental Health Services Administration (SAMHSA), more than two-thirds of U.S. children have experienced at least one traumatic event before reaching the age of 16 (SAMHSA, 2021; “Understanding Child Trauma”). Worldwide estimates indicate that 70.4 percent of persons will experience at least one type of a traumatic event in their lifetime (Kessler et al., 2017). Moreover, studies also have revealed that biological, social, and psychological consequences of early trauma significantly increase the risk for substance use, the development of mental health disorders, and involvement in crime and delinquency—as offenders and victims (Center on Addiction and Substance Abuse [CASA], 2010; Levenson & Willis, 2018). This is especially the case for justice-involved women and girls (Anderson et al., 2020; Messina & Zwart, 2021). The prevalence of traumatic experiences identified among detained youth and adults has resulted in correctional facilities tailoring programs to fit the specific needs of individuals in these populations; this has been part of a larger trauma-informed care (TIC) movement or approach (Baglivio et al., 2016; Levenson et al., 2015). Research over the past two decades has demonstrated the need for understanding how to approach treatment and management of individuals with histories of trauma from a cross-systems perspective, and the extent to which an integrated and informed service network potentially could minimize the negative effects at various points throughout the life course. This chapter examines trauma and trauma treatment specifically as it applies to children and youth. It begins with a definition of trauma.

WHAT IS TRAUMA? According to the U.S. Department of Health and Human Services, SAMHSA, individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well- being’. (U.S. Department of Health and Human Services, SAMSHA, 2019, para. 2) Trauma can impact a person’s life in various ways, and it occurs in multiple forms, including physical, psychological, and emotional. van der Kolk contends that, “trauma results in a fundamental reorganization of the way mind and brain manage perceptions. It changes not only how we think and what we think about, but our capacity to think” (2014, p. 21). In some cases, like those resulting from incidents of sexual violence, the trauma is repressed or shrouded in secrecy. Even when confronted, victims may deny that it ever

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occurred. In addition, trauma can be ignored when victims report it, creating more psychological strain (Farrell et al., 2019; Rosenberg, 2011). Although in many cases the physiological and psychological damage may be severe, trauma is treatable, and those who have experienced trauma can overcome it through engagement in effective treatment and services facilitated by competent service providers (Read et al., 2005; SAMHSA, 2014a, 2014b).

Trauma Characteristics SAMSHA distinguishes objective characteristics and subjective characteristics of trauma. Objective characteristics are facts. For example, a person was stabbed in a criminal act. Subjective characteristics refer to an individual’s processing of the events and include the individual’s perceptions of them (2014, p. 46). There are single trauma acts or events, repeated or chronic acts/events of trauma, and complex acts of trauma. Acute trauma is a single act at one point in time. When a series of traumatic events occur for the same person, it is known as repeated or chronic trauma. These traumas are sustained, and they might occur during a short period of time or over a person’s lifetime. For example, consider the child who experiences sexual abuse repeatedly. Typically, such recurring events affect individuals, and the victims tend to be less resilient in their ability to cope with the trauma (SAMSHA, 2014). According to SAMSHA, “Individuals in chronically stressful, traumatizing environments are particularly susceptible to traumatic stress reactions, substance use, and mental disorders” (2014, p. 46). The third type is complex trauma. Complex trauma refers to children’s exposure to numerous actual traumatic events and the various long-lasting effects of these events. The traumatic events are severe, chronic, and varied, and they are more likely to occur early in a child’s life (National Child Traumatic Stress Network, Complex Trauma, n.d.-a). They can result in a toxic stress response.

Types of Trauma SAMSHA further categorizes the types of trauma. These include natural traumas, human-caused traumas, individual, group, community, and mass traumas, and traumas associated with war and political terror. There are developmental traumas, and there are system-oriented traumas that can re-traumatize an individual (2014).

Natural Traumas and Human-Caused Traumas Natural traumas are events or experiences that one cannot control like an earthquake, a hurricane, or a disease (SAMSHA, 2014, pp. 33–34). SAMSHA further distinguishes human-caused trauma as intentional or unintentional. Intentional trauma includes homicide, terrorism, and maltreatment


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that involve a perpetrator. By contrast, unintentional human-caused trauma might involve a building or a bridge collapsing. Even though these latter events are the result of humans, there is no pre-meditation associated with them. However, there might be blame (National Child Traumatic Stress Network, Disasters, n.d.-b; SAMSHA, 2014, p. 35).

Individual, Group, Community, and Mass Traumas SAMSHA also categorizes trauma by victims. For example, individual trauma is an act or event that happens to one individual. The victim might be assaulted or have a particular disease. The predominant injuries may be physical. Consider a person who is attacked. Subsequently, the victim can be less willing to report the trauma or seek treatment perhaps due to a perception of a lack of support extended to the community or group previously. Moreover, the assault might result in further psychological trauma for the individual and the family (SAMSHA, 2014, p. 36). Group trauma affects a specific group. This includes firefighters and other first responders who learn of colleagues’ injuries or their death while dealing with an accident or emergency. Recall reading about first responders at the World Trade Center on September 11, 2001, who knew that some of their colleagues did not survive but had to continue to try to rescue and recover victims from the towers. Situations that first responders address as part of their occupation can affect their trauma (SAMSHA, 2014, pp. 38–39). Trauma as it applies to policing specifically was discussed in Chapter 5. Group trauma also can occur in communities or in cultures where the perception of safety or protection is not credible. School children who witness other students attacked or killed at school can experience trauma. Cultural traumas include events that can diminish the culture’s traditions or customs or remove them (SAMSHA, 2014, p. 39), such as racism, microaggressions, and more blatant forms of discrimination (Phipps & Thorne, 2019). Mass trauma can involve a natural disaster or a human-caused intentional act.2 Think of the devastation that occurs when a volcano erupts or after a nuclear power accident (SAMSHA, 2014, p. 40). To understand humancaused intentional acts, recall the mass killings in Buffalo, El Paso, Las Vegas, and Uvalde (noted at the start of Chapter 1).

Interpersonal Traumas Interpersonal traumas usually happen (and sometimes repeatedly) between individuals who know each other such as spouses, intimate partners, parents, or children (SAMSHA, 2014, p. 41). Violent acts associated with interpersonal traumas include intimate partner violence that can involve spouses, or current or former boyfriends/girlfriends. Sexual assault is another example of interpersonal trauma.

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In the aftermath of a sexual assault, victims have described the “Fight/ Flight” response. van der Kolk (2014) contends that “Dissociation is the essence of trauma” (p. 66). Consider this when you read Dr. Arutt’s “Fightor-Flight” narrative.


Contributor: Cheryl Arutt, PsyD, Clinical and Forensic Psychologist3 Humans and animals are wired to run from predators, and, if necessary, to fght for survival. However, when there is little hope of winning the fght and no escape, the parasympathetic nervous system takes control, hyper-stimulating the vagus nerve. We then freeze, like “a deer in the headlights.” This disconnects us from our bodies and feelings to decrease inescapable sufering, slowing the heart rate and increasing the pain tolerance. Victims may dissociate, mentally leaving their bodies. This lesser-known but normal “Freeze” response may be the best protection when the tiger has captured its prey. However, “Freeze” responses also correlate with higher rates of post-traumatic stress disorder (PTSD) than when victims can do something about the threat at the time it occurs. Healing includes learning to reactivate and come out of paralysis once they are safe. Consider the rape myth: “You must have wanted it if you didn’t fght back.” Think of victims’ responses to sexual assault. Many victims realize during a sexual assault that the perpetrator willing to violate a person’s body by threat or force cannot be trusted. The assailant might kill them. They fear for their life. Consequently, they often adopt survival behaviors consistent with trying to avoid being murdered. These may include not fghting back, experiencing a sense of leaving their body, or attempting to evoke the perpetrator’s empathy toward their humanity. “Freeze” is not to be confused with consent. Consent means freely saying “Yes.” This is possible only when there is also an option to say “No” and to have “No” honored. Through this lens, rape is an injury sustained while surviving a life-threatening attack. Often, as with soldiers, survivors may feel guilty about what steps they took to survive. Yet, unlike injured soldiers, society does not award Purple Heart medals4 to sexual assault survivors. Instead, pervasive rape myths often shift the focus to what the victim did or did not do, rendering the perpetrator invisible or less culpable. One key to understanding trauma in victims and witnesses is to know how our bodies cope with overwhelming danger.


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There are consequences associated with trauma. van der Kolk (2014) explains that “The body responds to extreme experiences by secreting stress hormones” (p. 219). Furthermore, People can learn to control and change their behavior, but only if they feel safe enough to experiment with new solutions. The body keeps the score: If trauma is encoded in heartbreaking and gutwrenching sensations, then our first priority is to help people move out of flight-or-fight states, reorganize their perception of danger, and manage relationships. (van der Kolk, 2014, p. 351)

POLITICAL TERROR AND WAR Political Terror and War affect survivors in various ways. The unpredictable nature of terrorism impacts individuals directly and indirectly. Other populations also are affected by trauma. Refugees who leave their home country often do so after being victimized. These events can influence their ability to adjust to the new environment. In addition to that trauma, they may encounter difficulties being accepted when they seek asylum. The prior experiences coupled with difficulties in re-locating can affect their ability to adjust to the new country or culture, along with the possible development of mental health difficulties (SAMSHA, 2014, pp. 43–44). POST-TRAUMATIC STRESS DISORDER (PTSD) According to van der Kolk (2014), several Vietnam veterans, with the help of psychoanalysts Chaim Shatan and Robert Lifton, lobbied the American Psychiatric Association (APA) to establish a new diagnosis: posttraumatic stress disorder (PTSD) (p. 19) (introduced earlier in Chapters 1 and 5). In 1980, the APA first added PTSD as an operational diagnosis in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (Turnball, 1998), though it has been revised. The American Psychiatric Association (Herein, referred to as “APA”) defines PTSD as a serious psychological disorder that can develop when a person is a victim or observes acts that include terrorism, rape, or natural disasters, or has been threatened with grave injury or death (APA, Post Traumatic Stress Disorder, n.d., para. 1). PTSD can affect veterans and non-veterans, all age groups, and diverse racial and ethnic groups. It is estimated that 1 in 11 individuals will have a PTSD diagnosis during their lifetime (APA, n.d., para. 2). According to SAMSHA, women have higher rates of PTSD than men (SAMSHA, 2014, p. 133). Individuals with PTSD can experience a flashback without advance warning. They do not know the length of time that the flashback will last, and it can occur when they are fully alert and awake or when they are sleeping (van der Kolk, pp. 66–67).

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 Figure 10.1 Post-Traumatic Stress Disorder

Source: leremy/iStock.

Children and youth who are exposed to trauma can develop PTSD (Figure 10.1). According to Wopaw and Ford (2004), earlier studies of the extent of the rate of PTSD in the juvenile justice population estimated that PTSD could be identified in from 3 percent to 50 percent of these youth, and that such rates were eight times greater than other community samples of youth (p. 1). However, as Buffington et al. (2010) note, PTSD was first diagnosed in adults; consequently, the definition may not be identical to those children and youth who experience trauma. Trauma can happen to anyone, and multiple exposures to traumatic events across the course of a lifetime are not rare. The development of painful traumatic stress reactions immediately following the trauma (3–30 days) is referred to as Acute Stress Disorder (ASD). A diagnosis of PTSD can be made when the symptoms persist beyond the initial 30 days (Geoffrion et al., 2022). Current research shows that early intervention can prevent PTSD. Prevention and treatment methods for PTSD span a variety of psychological and pharmacological interventions and strategies. Eye movement desensitization and reprocessing (EMDR), trauma-focused cognitive behavioral therapy (TF-CBT) and prolonged exposure therapy (PE) are evidence-based treatments for PTSD (Khan et al., 2018; Miao et al., 2018; Wells et al, 2020). Medications may be used, but they are primarily introduced as a means to help people tolerate their symptoms while engaged in trauma therapy. Another form of treatment is described by Holly and Todd Grimm in the following “Policy & Practice” segment.


CHAPTER 10 Approaches to Trauma-Informed Care


Contributors: Holly A. Grimm MSW, LCSW, BCN and Todd L. Grimm MS, LPC, CAADC, BCN; Brandywine Valley Counseling & Neurofeedback Center5 Brainwaves, which are oscillations in neural activity, can be measured and divided into frequency band components using a quantitative electroencephalogram (QEEG). These components can then be analyzed through magnitude (neuronal activation), connectivity, and other measures. Imbalances in these values prohibit optimal brain functioning, contributing to mental and physical symptoms. Using a QEEG, neurofeedback (NF) can modify neuronal activation and connectivity, thereby addressing these symptoms. During NF, electrodes placed on the scalp record brainwave data. This data is then “fed back” to clients in the form of visual or auditory rewards, modifying brainwaves through operant conditioning. Research has demonstrated NF efcacy with such conditions as afective disorders, anxiety, executive functioning, attention dysregulation, substance abuse, headache and pain management, sleep disorders, and trauma (Hammond, 2011). PTSD is associated with QEEG changes, including increased neuronal activation, dysregulated frequency band ratios, and connectivity changes (Jokic-Begic & Begic, 2003; Kluetsch et al., 2014). Research also has demonstrated NF efcacy with PTSD. Peniston and Kulkosky (1991) compared a group of combat veterans receiving NF to a group receiving traditional therapy. The NF group improved on personality measures, and only 3 of 15 veterans required re-hospitalization, whereas the traditional therapy group showed no change in personality measures and all 14 veterans were re-hospitalized. Another study conducted with 20 children with developmental trauma demonstrated NF-related improvements in behavior, mood, and attention (Huang-Storms et al., 2006). In a controlled study, van der Kolk assigned 52 participants with PTSD to NF or waitlist (van der Kolk et al., 2016). The NF participants demonstrated signifcant improvements in PTSD as well as in the ability to regulate afect. NF has produced encouraging data, demonstrating improvement in many conditions, including PTSD. Importantly, NF does not require the use of therapeutic exposure for trauma, which ofers clients who cannot tolerate exposure-type techniques a way to decrease PTSD symptoms and increase afect regulation. For clients who have already engaged in exposure therapies, it can be a path to further symptom reduction. Sources: 1. Hammond, D. C. (2011). What Is Neurofeedback: An Update. Journal of Neurotherapy, 15, 305–336. 2. Huang-Storms, L., Bodenhamer-Davis, E., Davis, R., & Dunn, J. (2006). QEEGGuided Neurofeedback for Children with Histories of Abuse and Neglect: Neurodevelopmental Rationale and Pilot Study. Journal of Neurotherapy, 10(4), 3–16.

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3. Jokic-Begic, N., & Begic, D. (2003). Quantitative Electroencephalogram (qEEG) in Combat Veterans with Post-traumatic Stress Disorder (PTSD). Nordic Journal of Psychiatry, 57, 351–355. 4. Kluetsch, R. C., Ros, T., Theberge, J., Frewen, P. A., Calhoun, V. D., Schmahl, C., et al. (2014). Plastic Modulation of PTSD Resting-State Networks and Subjective Wellbeing by EEG Neurofeedback. Acta Psychiatrica Scandinavica, 130, 123–136. 5. Peniston, E. G., & Kulkosky, P. J. (1991). Alpha-Theta Brainwave NeuroFeedbacktherapy for Vietnam Veterans with Combat-Related Posttraumatic Stress Disorder. Medical Psychotherapy, 4, 47–60. 6. van der Kolk, B. A., Hodgdon, H., Gapen, M., Musicaro, R., Suvak, M. K., Hamlin, E., et al. (2016). A Randomized Controlled Study of Neurofeedback for Chronic PTSD. PLoS ONE, 11(12), e0166752. doi: 10.1371/journal. pone.0166752

Developmental Traumas According to SAMSHA, developmental traumas are events or experiences that occur during an identifiable developmental stage that affect future physical or mental health, or adjustment (2014, p. 42). Frequently, these traumas are correlated with Adverse Childhood Experiences (ACEs), but they also can occur after events or experiences outside of a particular developmental stage. It is important to understand ACEs and their relationship to trauma.

Adverse Childhood Experiences (ACEs) RESEARCH ON ACES Researchers have augmented our knowledge and understanding of childhood trauma over the last 26 years. From 1995 to 1997, The Centers for Disease Control and Prevention and Kaiser Permanente conducted a study (N = 9,508) that focused on childhood experiences to assess the extent of child abuse and neglect. The study results identified the effects that childhood abuse can have on future health during adulthood (Felitti et al., 1998, p. 245). The findings of the two lead researchers, Dr. Vincent Felitti and Dr. Robert Anda, indicated that as many as 60 percent of the participants in the study had experienced at least one adverse childhood experience (ACE) and about 20 percent reported three or more ACEs (American Academy of Pediatrics, 2014; Felitti et al., 1998). For Felitti et al. (1998), adverse childhood experiences included: emotional abuse; physical abuse; sexual abuse; a mother being treated violently; household substance abuse; household members with mental illness or suicidal tendencies; and an incarcerated household member (p. 245). They found that household substance abuse was most frequently identified, and 25.6 percent of participants reported it. The least prevalent ACE experience was having an incarcerated household


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member, and 3.4 percent of participants reported such an occurrence (Felitti et al., 1998, p. 249). Felliti et al. (1998) found that as the number of these experiences increased, the prevalence and risk for specific outcomes increased: Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had a 4- to 12- fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. (p. 245) The research demonstrated that not only were the various areas of ACEs clearly interrelated but also that individuals who had several categories of exposure as children were likely to experience several health risk factors later in life (p. 250). Furthermore, subsequent research findings have concluded that trauma is the single greatest preventable cause of chronic mental illness, drug and alcohol abuse, suicide, and many other maladaptive outcomes (Felliti et al., 1998; Levenson et al., 2014; Read et al., 2005). The ACE pyramid (Figure 10.2) illustrates trauma outcomes. More recently, Merrick et al. (2018) conducted research on adults who experienced ACEs in 23 states between 2011 and 2014 using the Behavioral Risk Factor Surveillance System (BRFSS). Their study focused on the seven ACEs categories but included an eighth, parental separation or divorce. Using a telephone survey of approximately 214,000 adults aged

 Figure 10.2 Adverse Childhood Experiences (ACE) Pyramid (ACE Presentation Graphics) Source:

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18 or older, Merrick et al. found that more than 61 percent reported having experienced one ACE, and almost 25 percent reported experiencing three or more ACEs. In their sample, emotional abuse was the most prevalent, followed by parental separation or divorce, and household substance abuse (Merrick et al., 2018, p. 1038). These data demonstrate that ACEs persist, and that additional resources designed to prevent and treat trauma are essential. The Adverse Childhood Experiences Pyramid identifies the effects that childhood trauma can produce beginning at birth and lasting until death. The pyramid illustrates that exposure to childhood trauma increases the likelihood of experiencing the effects described at each level, and ultimately how childhood trauma exposure can result in early death (Felitti et al., 1998, p. 256). According to the American Academy of Pediatrics, a “toxic stress response can occur when a child experiences strong, frequent, or prolonged adversity” which “can disrupt the development of brain architecture and other organ systems and increase the risk of stress-related disease and cognitive impairment well into the adult years” (2014, p. 2). This also can make the child at risk for delinquent and criminal behaviors.

Research on Exposure to Violence among Children and Youth Additional evidence regarding children and youth and exposure to violence and victimization and its consequences was documented in the National Survey of Children Exposed to Violence (NatSCEV) study conducted three times from 1990 to 2014 (Finkelhor et al., 2009). In 2009, Finkelhor et al. (2015) found that about 60 percent of the children studied had experienced at least one exposure to violence. In a subsequent study in 2011, NatSCEV II, the previous findings were confirmed. Finkelhor et al. found that “multiple exposures to violence among children and youth continued to be a concern, with nearly one-half (48.4 percent) of NatSCEV II participants reporting more than one type of direct or witnessed victimization in the past year” (2015, p. 2). The researchers also found evidence of “polyvictimization”— where a child or youth is involved in multiple victimizations. According to Finkelhor et al. (2015), the effect of polyvictimization includes “a greater risk of exposure to other forms of violence and accumulation of multiple adversities and trauma symptoms” (p. 2). The U.S. Attorney General from 2009 to 2015, Eric Holder, highlighted the critical NatSCEV I findings, and announced his commitment to prevent and address the cycle of previously victimized children and youth becoming victimizers in the future. He established the Defending Childhood Initiative. Its goals included preventing children and youth from being exposed to violence and attempting to alleviate the negative effects of such violent exposure by endorsing and providing resources through research, grant funding, and education (U.S. Department of Justice, 2010, p. 1).


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Attorney General Holder also created a National Task Force on Children Exposed to Violence (the Defending Childhood Task Force). In 2012, the Task Force completed its report and presented 56 recommendations emphasizing the importance of identifying children and youth victimized by or witnessing violence and affording them treatment and assistance (Listenbee, 2014). Additionally, the Task Force advocated for professionals to undergo training that would enable them to identify and respond to the trauma associated with being exposed to violence and victimization, and for children and youth to be screened for trauma when they enter the system (Listenbee, 2014, p. 6). Children exposed to violence and victimization can demonstrate various effects. These include issues associated with their well-being, developmental problems, school difficulties, mental health challenges, and substance use. When youth are exposed to violence, either as a victim or witness, Finkelhor et al. (2015) found that they also are at risk for future delinquency, violence, and criminality (Merlo & Benekos, 2017, p. 78). There is evidence of their over-representation in the system. For example, Evans-Chase found that “75–93% of youth entering the juvenile justice system have already experienced some type of trauma in their lives compared to 25–34% of the general population” (2014, p. 745). Given these research findings, the relationship between early trauma and subsequent periods of incarceration for some individuals is not surprising. According to Rosenberg (2011), the literature suggests that most people served by public mental health and substance abuse systems have experienced some form of trauma, which may include sexual assault, domestic violence, neglect, and child abuse. Furthermore, research indicates that witnessing violence or being the victim of physical violence during childhood (especially at a very young age) places individuals at a higher risk for incarceration during adulthood (see e.g., Driessen et al., 2006; Greene et al., 2000; Kerig & Becker, 2015; Levenson et al., 2014). The more severe the trauma, the higher the risk for disorders such as alcoholism, depression, drug use, and suicide attempts, along with other adverse experiences. In fact, approximately 50 percent of those who have been diagnosed with bipolar disorder and schizophrenia also meet the criteria for substance use disorder; they are referred to as dual diagnosis clients (Sharma & Bennett, 2015). Despite recognition that early childhood trauma can produce lifelong consequences, there are protective factors that have been shown to counterbalance these effects, leading some children to survive and thrive. Pathways to resilience and recovery, however, require continued research and education as to brain development, cognitive capacity, motivation and ability to regulate emotions and behavior, and the role of the environment (American Academy of Pediatrics, 2014). Advancements in trauma-informed medical and mental-health treatment have also given reason for optimism. According

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to Dr. Nadine Burke Harris, award-winning physician, researcher and advocate, and current California Surgeon General: “This is treatable, this is beatable. The single most important thing facing the nation today is the courage to look this problem in the face and say: ‘This is real. This is all of us.’”6

National Data on Child Maltreatment Prior research and the consequences for children and youth emphasize the importance of identifying who has been victimized, how that can affect them, and prevention efforts. Recent data on children and youth referred to child welfare organizations for possible victimization indicate that child protective services received about 4.4 million referrals for maltreatment in the fiscal year, 2019. The referrals represent an estimated 7.9 million children (U.S. Department of Health & Human Services Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau, 2021, p. 7). State laws and policies stipulate definitions, procedures, and policies to address child maltreatment. Referrals for child maltreatment can be made by various sources. The Department of Health and Human Services categorizes sources as professionals, nonprofessionals, and unclassified. Professionals, also known as “mandated reporters,” make most referrals. State statutes require individuals who interact with children in their occupation or profession to report any possible maltreatment. This includes child-care agency staff, teachers, law enforcement, and medical professionals, and they represent more than two-thirds of referrals made to child welfare agencies. Approximately 16 percent of referrals originate with nonprofessionalsrelatives, neighbors, or friends of the victim. The remaining referrals are from individuals or agencies categorized as unclassified. They might include a person associated with a private agency or organization (U.S. Department of Health and Human Services, 2021, p. 9). In 2019, there were approximately 656,000 victims of child abuse and neglect documented in the United States (p. 20). The national rate of child abuse and neglect is 8.9 victims per 1,000 children in the population (U.S. Department of Health and Human Services, 2021, p. 20). In terms of maltreatment, about 75 percent of the victims are neglected, slightly over 17 percent are physically abused, and approximately 9 percent are victims of sexual abuse. States use the “other” category for victimization that does not match these categories (U.S. Department of Health and Human Services, 2021, p. 22). In terms of perpetrators, the 2019 data indicate that 77.5 percent are a parent of the victim (U.S. Department of Health and Human Services [DHHS], 2021, p. 67). van der Kolk (2014) contends that, …for every soldier who serves in a war abroad, there are ten children who are endangered in their own homes. This is particularly tragic, since it is very difficult for growing children


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to recover when the source of terror and pain is not enemy combatants but their own caretakers. (pp. 20–21) Child victimization is most likely to occur in the first year of a child’s life. The incidence is 25.7 victims per 1,000 children who are the same age in the population. Girls represent a larger percentage (51.4 percent) of victims than boys (48.3 percent) (U.S. Department of Health and Human Services, 2021, p. 21). In terms of race or ethnicity, Native/Indigenous (Classified by DHHS as “American Indian or Alaska Native”) children have the highest rate at 14.8 victims per 1,000 children in the population who are of the same race or ethnicity. The second highest rate is among Black children with 13.7 victims for every 1,000 children in the population of the same race or ethnicity (U.S. Department of Health and Human Services, 2021, p. xi).

Sex Trafficking Data Recently, the Department of Health and Human Services has published additional statistics. When Congress enacted The Justice for Victims of Trafficking Act of 2015, it included an amendment requiring states to report data on cases of sex trafficking of children by caregivers and non-caregivers in their maltreatment statistics. States began to submit these data in 2018. In 2019, 29 states reported 877 victims of sex trafficking. Sex trafficking victims’ demographic characteristics differ from other types of maltreatment. Victims tend to be overwhelmingly girls/women (88.5 percent), older, (over 75 percent are between14 and 17 years of age) (U.S. Department of Health and Human Services, 2021, p. 97), and the perpetrator is a non-relative (51 percent have an unknown or missing relationship to the perpetrator). Furthermore, 41 percent have no parental involvement in sex trafficking (U.S. Department of Health and Human Services, 2021, p. 98).

Efects of Maltreatment on Victims Although the identification or effects of trauma may not be obvious at the time of the referral, the consequences for children and youth victims of maltreatment can be serious. As Smith, Robinson, and Segal (2020) report, abuse and neglect can leave lasting scars on its victims. These can be physical or emotional. Smith et al. (2020) contend that emotional scarring effects can continue throughout life affecting the child or youth’s sense of self, their relationships in the future, and their ability to function at home, at school, and at work (p. 2). Smith et al. (2020) note that when a parent engages in maltreatment, it can affect the child’s ability to trust. This inability can result in unhealthy relationships because of the prior experiences that the child had with parents, or because the child or youth does not know what a healthy relationship involves. Maltreatment also can affect feelings of self-worth. Victims

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believe the negative assessments of themselves that have been uttered sometimes repeatedly. Their feeling of being unworthy can influence their education, vocation, and future. Furthermore, Smith et al. (2020) report that when children are abused, they do not learn how to express their emotions in a safe way. Consequently, they tend to hide these feelings, and they manifest themselves unexpectedly. Adults who have coped with abuse and do not know how to regulate their emotions can experience depression, anxiety, or anger. Alcohol and other drugs are sometimes viewed as coping mechanisms to deal with these feelings (self-medicating, as referenced in several places throughout the text) (Smith et al., 2020, p. 3).

COMPARATIVE PERSPECTIVES 10.1 VIOLENCE IN CHILDHOOD: LATIN AMERICA AND THE CARIBBEAN (LAC) Data from LAC suggest that almost 60 percent of children 0–17 years of age—or over 99 million children—experience physical, sexual, or emotional abuse each year, having a major efect on health and education outcomes and economic opportunity. Moreover, children in the LAC region are fve times more likely to be victims of homicide than children in any place else in the world (largely attributed to gang-related violence). The Pan American Health Organization (PAHO) and LAC governments have made abuse against children a priority. As a result, a number of global initiatives have been implemented to raise awareness and encourage a trauma-informed policy response. These eforts include the “Safe to Learn”campaign (a school-based strategy to end violence and encourage education). Other program and policy initiatives designed to address violence and traumatization in the LAC region include: • • • • • • •

The Trinidad and Tobago Violence Prevention Academy (VPA) Proyecto Sanando Heridas, El Salvador Cure Violence National Centers of Excellence in Youth Violence Prevention (YVPC) INSPIRE (violence against children) RESPECT (violence against women) UNICEF program for Protecting and Preventing Violence against Children

Sources: 1. American Institutes for Research. (April, 2021). Multisector Resource Guide for Preventing Youth Violence in Latin America. [Online Report]. Retrieved from pdf 2. Devries, K., Merrill, K. G., Knight, L., Bott, S., Guedes, A., Butron-Riveros, B., Hege, C., Petzold, M., Peterman, A., Cappa, C., Maxwell, L., Williams,


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A., Kishor, S., & Abrahams, N. (2019). Violence against Children in Latin America and the Caribbean: What Do Available Data Reveal about Prevalence and Perpetrators? Pan American Journal of Public Health, 43, e66. 3. United Nations Children’s Fund (UNICEF). (n.d.). UNICEF for Every Child:  Latin America and the Caribbean [Webpage]. https://doi. org/10.26633/RPSP.2019.66 and end-violence

System Oriented Traumas: Retraumatization As previously noted, youth who have had adverse childhood experiences and been exposed to or victimized by violence are frequently in the juvenile justice system. Retraumatization occurs when individuals feel that they are experiencing previous trauma again. Practitioners and organizations can facilitate retraumatization unintentionally. Agency policies that require 24 hours of isolation upon admission to the residential program, programs that have insufficient resources to provide for the safety and security of residents in a facility, staff shortages that result in a lack of screening of new clients for trauma, or programs that regularly use restraints can trigger prior traumatic experiences. In such settings, youth can be victimized and re-experience the trauma. In their research, Goldsmith et al. (2014) report that various institutional placements can intensify trauma and sustain post-traumatic behaviors and responses. Other research by Barnett et al. (2018) indicates that exposure to trauma is well documented among children and youth who are placed in residential settings that focus on treatment. Researchers find that most of these children and youth have experienced multiple traumas (p. 95). Moreover, removal of a child or youth from their home and the subsequent placement may result in substantial retraumatization—highlighting the need for trauma-informed care policies and practices. It is important to remember that the effects of trauma might be immediate, or they might be delayed. The characteristics of the trauma help determine how the person may deal with the experience or experiences. For these reasons, it is critical that the juvenile justice system endeavor to avoid actions that can re-traumatize youth.

TRAUMA-INFORMED CARE These findings support trauma-informed practices which address the consequences of victimization and provide interventions to break the cycle of hurt and violence. A trauma-informed care approach recognizes the intersection of trauma with health and social problems for which people seek services and treatment (Bowen & Murshid, 2016). Trauma-informed care is conceptualized as an organizational change process centered on a specialized framework intended to promote healing and reduce the risk of

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retraumatization for vulnerable individuals. Components of the framework have been referred to as the “four R’s”: 1. 2. 3. 4.

Realize the impact of trauma and also understand recovery. Recognize symptoms in clients. Respond to applying policy and procedure. Resist the retraumatizing of individuals. (Substance Abuse and Mental Health Services Administration [SAMSHA], 2016)

Within this framework, SAMSHA has outlined the core principles of trauma-informed care, which include safety, trust, transparency, collaboration and peer support, empowerment, choice, and the intersectionality of identity characteristics (Bowen & Murshid, 2016). Safety refers to treatment programs designed to keep the consumer out of danger and to prevent further trauma from occurring. Trust and transparency pertain to the extent to which the agency is transparent in its policies and procedures while maintaining the goal of building trust with staff, clients/consumers, and community members. The collaboration consists of staff viewing clients/ consumers as active partners, which often occurs through peer support, such as peer mentoring (Bowen & Murshid, 2016). Empowerment refers to the agency allowing the client/consumer to have a voice in the decision-making process. The last principle deals with cultural differences that make an individual’s treatment unique. The key to treatment involves compassion and support, and effective approaches will be racially, ethnically, and spiritually relevant as well as gender-specific (Rosenberg, 2011). In the context of forensic mental health, trauma-informed programs operate on the belief that treatment—particularly that which is rendered in a correctional setting—can potentially revictimize individuals who are seeking help. Traditionally, justice system approaches to addressing mental health and trauma would view a history of trauma in an individual as a relatively minor detail while offending behaviors are perceived as significant and dangerous, and the offender, therefore, is viewed as a “deviant” or “criminal.” Conversely, a TIC approach challenges responses that tend to blame and stigmatize individuals. Instead of criminalizing mental health and substance use, the behaviors are viewed through a trauma lens, and the individual is perceived as a potential victim who may be self-medicating to cope with underlying issues.

POLICY & PRACTICE 10.2 EVIDENCE-BASED TREATMENT APPROACHES When Congress enacted the Juvenile Justice Reform Act in 2018, it included provisions to support the use of evidence-based practices to deal with the trauma that youth and their families can experience (Marshall, 2018). The legislation refected the recognition of trauma in justice-involved youth and the importance of research evidence to substantiate efective


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treatments. Although other treatments are utilized, Bufngton et al. (2010, p. 9) identifed four evidence-based treatment approaches for children and youth who have experienced trauma. They include: 1. Cognitive Behavioral Intervention for Trauma in Schools (CBITS): CBITS has been evaluated with youth who have experienced violence and complex trauma. CBITS can be delivered in schools in a group setting, in residential facilities, and additional suitable environments (p. 9). Using mental health professionals, The intervention includes ten sessions that teach small groups of students about cognitive-behavioral skills, several individual therapy sessions, optional work with parents, and one teacher education session. (Dufy & Comley, 2019, p. 9) Research results from two studies indicate “positive interaction efects” in reducing PTSD symptoms and depression (Dufy & Comley, 2019, pp. 9–10). Despite these promising results, Zettler (2021) contends CBITS has not been evaluated with samples of delinquent youth (p. 120). Clearly, more research is essential. 2. Trauma Afect Regulation: Guide for Education and Therapy (TARGET-A): TARGET is a strengths-based approach for education and therapy for trauma victims. It teaches seven skills that are included in the acronym “…FREEDOM (Focus, Recognize triggers, Emotion self-check, Evaluate thoughts, Defne goals, Options, and Make a contribution) that can be used by trauma survivors to regulate extreme emotional states, manage intrusive trauma memories, promote self-efcacy, and achieve lasting recovery from trauma” (National Child Traumatic Stress Network, Trauma Efect Regulation, n.d.-d, para. 1). Evidence indicates that TARGET-A is efective with youth in various settings including correctional facilities, residential placements, and community-based programs. TARGET-A can be practiced in a group, as an individual, and with family. It assists youth and their families in understanding trauma and stress, in developing techniques to help them think more carefully, and to direct, their emotional, cognitive, and behavioral reactions to stress triggers (Bufngton et al., 2010, p. 9). 3. Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): Youth (and their parents, possibly) are taught to process the trauma; handle distressful thoughts, feelings, and behaviors; and improve personal safety and family communication. This approach can be provided over a short period of time in almost any environment (p. 9). In their review, Cary and McMillen (2012) report that their fndings indicate that this strategy was successful in treating young people for PTSD. Zettler (2021) found that research supports the efectiveness of TF-CBT “…in reducing trauma-related symptoms in adolescents, [but] relatively few evaluations have assessed its efectiveness in justice-involved youth…” (p. 121). 4. Sanctuary Model: Bufngton et al. (2010) contend that the Sanctuary Model encourages modifcations in the system based on building and safeguarding a nonviolent, egalitarian, productive community to help individuals heal from trauma. It involves a common language for staf,

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clients, and other stakeholders, and the approach can be modifed in various settings for diverse populations (p. 9). For example, it has been used with youth in residential placement facilities in Pennsylvania and other states (See Merlo & Benekos, 2017). In the 1980s, Sandra Bloom, Joseph Foderaro, and Ruth Ann Ryan developed the Sanctuary Model® in the Philadelphia area. As a psychiatrist, social worker, and nurse respectively, they laid the foundation for a traumainformed, evidence-based approach employing a psychoeducational model that alters the organizational culture and the strategy to help troubled youth (Merlo & Benekos, 2017, p. 96; The Sanctuary Model, n.d.). The acronym S.E.L.F. incorporates the basic components of addressing the problems that occur when children and youth are exposed to violent and traumatic experiences (Bloom, n.d., para. 7). S. Safety: victims have difculty staying safe E. Emotions: victims fnd emotions difcult to manage L. Loss: victims have sufered many losses F. Future: victims have difculty envisioning a future According to Bloom and Streedhar (2008), they “represent the four fundamental domains of disruption that can occur in a person’s life” (p. 52). Evaluations conducted in residential treatment centers that utilize Sanctuary have found that violent behavior among youth has been reduced. However, Zettler (2021) contends that research that examines its efectiveness for youth in community-based settings or on subsequent recidivism after residential placement has not occurred (p. 124). While evidence supports the efectiveness of these four trauma treatment approaches, their impact on justice-involved youth, subsequent youth recidivism, or on youth in community-based settings is still limited (Zettler, 2021). Zetttler (2021) conducted a systematic review of trauma-informed treatments on youth and recidivism, and contends that, “further research is needed to evaluate the array of trauma-informed interventions at each stage of the juvenile justice system” (p. 126). In brief, our knowledge of trauma and trauma treatment has increased. However, additional research on trauma treatment for youth in various settings and its efect on their future behavior are likely to guide future policies.

In addition to evidence-based treatments (presented above), there are organizations that can assist. They offer various types of support and resources designed to help children and youth and to facilitate community efforts to prevent and treat trauma.

The National Child Traumatic Stress Network As part of the Children’s Health Act, Congress established The National Child Traumatic Stress Network (NCTSN) in 2000 (The National Child Traumatic Stress Network, n.d.-e; van der Kolk, 2014, p. 157). The Substance Abuse and Mental Health Services Administration (SAMSHA)


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administers the Network, and it is coordinated through UCLA-Duke University National Center for Child Traumatic Stress (NCCTS) (The National Child Traumatic Stress Network, Who We Are, n.d.-e). According to van der Kolk (2014), it is a “…comprehensive organization dedicated to the

 Figure 10.3 Understanding Childhood Trauma. Hope, Resources, and Tools

Source: SAMHSA (2015). Understanding Child Trauma. National Child Traumatic Stress Initiative.

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research and treatment of traumatized children” (p. 157). The NCTSN includes “…116 currently funded centers and 170 Affiliate (formerly funded) centers and individuals, working in hospitals, universities, and communitybased programs in 43 states and the District of Columbia” (NCTSN, Who We Are, n.d., para. 2). Centers have programs in schools, in the juvenile justice system, child welfare agencies, shelters, military facilities, and group homes (van der Kolk, 2014, p. 353). According to the NCTSN website, the organization has trained over 2 million professionals in trauma-informed care and its members have established over 10,000 state and local partnerships incorporating trauma-informed care in agencies ranging from child services to mental health programs (NCTSN, Who We Are, n.d., para. 4). Figure 10.3 provides information and resources about childhood trauma, contained in a publication by NCTSN (in partnership with SAMHSA).

THE JUVENILE JUSTICE SYSTEM’S RESPONSE TO TRAUMA In the last 20 years, a more reasoned approach to understanding youth and delinquent behaviors has emerged, and it recognizes the impact of early adversity and trauma on childhood development and the risk for subsequent involvement in the criminal justice system. In the juvenile justice system, recognition of trauma has been observed in efforts to provide safe environments to treat the trauma. Trauma-informed practices have been adopted throughout the juvenile justice and child-care systems and effective interventions utilize assessment, intervention, and programs that focus on treating the trauma (Marsh & Dierkhising, 2013). While acute traumatic events can be experienced by most youth, chronic and complex traumas that occur over extended time have the potential to create biological, psychological, and social distress that can result in “severe traumatic stress reactions” such as PTSD in children and youth (Dierkhising & Marsh, 2015, p. 3). The National Child Traumatic Stress Network, Effects (n.d.-c), identifies nine effects of complex trauma; these are presented in “Fast Fact” 10.1.

FAST FACTS 10.1 EFFECTS OF COMPLEX TRAUMA 1. Attachment and Relationships Complex trauma is evidenced in the inability to form attachments and relationships to parents or caregivers. That can extend to other individuals in a child’s life. Such children hesitate to communicate feelings or engage with another person, and this can result in an inappropriate response to teachers, police ofcers, and authority fgures. It can also impair successful relationships with friends or subsequent partners.


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2. Physical Health: Body and Brain Complex trauma also deals with biology. The body’s immune system and its ability to deal with stress are afected. Individuals can over-react to sensory stimulation or under-react to stress, and they may be insensitive to pain or overly sensitive to medical conditions. 3. Emotional Response Complex trauma is manifest in individual emotions. Having experienced varied and intense traumatic events, they have difculty with emotional responses. Individuals may not be able to articulate their emotions or share their emotions and they tend to be fearful and depressed. 4. Dissociation Traumatic events sometimes result in victims dissociating or mentally separating themselves from the experience. Children who dissociate from actual events employ this approach in other situations when the trauma is triggered. When children in a classroom dissociate, they miss valuable learning and the acquisition of knowledge. This adversely afects their interactions with others and their academic progress. 5. Behavior Behavior might be the most obvious efect of complex trauma, and it can be manifested in various ways. Children and youth who engage in delinquent and/or risky behaviors, run away, use illegal substances, and who have a difcult time self-regulating their behavior often react inappropriately due to their prior trauma. 6. Cognition: Thinking and Learning Children with a history of complex trauma can demonstrate difculty thinking clearly, solving problems, and being able to reason in academic settings. They may have learning difculties associated with the trauma that afects their ability to focus on the work and sustain involvement in it. 7. Self-Concept and Future Orientation For abused children, complex trauma is associated with a low self-concept, feelings of self-blame for the victimization, and a failure to perceive a path to the future or a better future. Their sense of hope is diminished, and they do not feel that future planning is viable. 8. Long-Term Health Consequences The previously cited Adverse Childhood Experiences (ACEs) research documents the health efects of traumatic experiences. Victims who experienced trauma are more likely to engage in riskier behaviors like smoking, have higher incidences of chronic illnesses like cancer, and early death. 9. Economic Impact Long-term economic costs of complex childhood trauma are signifcant. In 2007 values, the annual cost of child abuse and neglect was estimated to be $284.3 million per day (National Child Traumatic Stress Network, n.d.-c para. 14). This refers to direct costs like immediate medical care to victims and costs associated with the professionals who

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deal with them; and indirect costs or secondary costs that include the longer-term consequences like mental health treatment, delinquency, and involvement in the adult criminal justice system. Although these costs can be quantifed, other costs do not equate to a specifc dollar amount. Consider the depression, sufering, and quality of life that the victims of trauma experience. Source: National Child Traumatic Stress Network, Efects (n.d.-c) https:// efects

Judges’ Role, Detention Alternatives, and Police Recruit Training Trauma-informed care begins with improving screening or assessing youth for trauma. According to Pickens et al. (2016), there is a need to “improve trauma-informed screening and assessment in service systems” (p. 7). This refers to any agency that has contact with children and youth (e.g., child welfare, juvenile justice, and mental health systems). The goal is to identify trauma victims early, intervene with appropriate services and treatment, and work with youth when they are more predisposed to obtaining assistance (Pickens et al., 2016). Similarly, Olafson, Halladay, and Gonzalez (2016) reviewed trauma treatments and collaborations across systems. They highlight the importance of recognizing the effects of trauma and victimization on delinquency, and endorse early intervention efforts, family involvement, continuity of care, and community-oriented approaches (2016, p. 9). Buffington et al. (2010) emphasized the critical role of the juvenile court judge in understanding trauma and trauma exposure when dealing with children and youth. They note that, “By becoming trauma-informed, juvenile justice personnel aid the juvenile court in its mission of protecting and rehabilitating traumatized youth while holding them responsible for their actions” (Buffington et al., 2010, p. 13). Olafson et al. (2016) highlight a program in which the mental health system and the juvenile court staff work together utilizing a trauma-informed approach in Stark County, Ohio. The juvenile court judge is the primary leader and influence in encouraging and upholding trauma-focused practices and procedures to prevent and treat youth who have experienced trauma. The program has been successful in delivering trauma-focused treatment to children and youth involved in juvenile court for delinquent referrals or dependency cases referred for maltreatment. Olafson et al. (2016) contend that the judiciary has the ability to develop and support court systems that are trauma-informed (p. 8). In one Texas drug court, the presiding judge has taken a trauma-informed approach, which has had some success; this case study is presented in the Policy & Practice segment below.



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Contributor: Angela M. Proctor, PhD, LCDC Judge Carol Clark, from the 321st District Court in Tyler, Texas presided over a drug court for years. It was designed for parents seeking reunifcation after losing custody of their children due to continued drug and alcohol use and abuse. Judge Clark’s desire was to break the cycle of abuse and neglect among this population. After learning about Dr. Karyn Purvis and her model Trust-Based Relational Intervention (TBRI), Judge Clark implemented a trauma-informed approach and the TBRI principles in her courtroom. A 3-Phase Service Plan was developed for each case processed through the 321st District court: PHASE 1: Address the Safety Risk-Get Clean and Safe PHASE 2: Address the Trauma and Parenting Past/Trauma History PHASE 3: Monitored Return Within fve years of implementing TBRI in its drug court, Smith County had the lowest percentage of reconfrmed victims at 9.4%. Between 2008 and 2018 the court had zero jury trials, and all cases were resolved. There also was a reduction in the number of contested hearings. Moreover, 90% of the parents who completed the program did not relapse and remain successful. A vital component that contributed to the program’s success was that Judge Carol Clark required all staf in the program to be trained in TBRI and trauma-informed practices (J. Gregory, personal communication, 2021). She also required the team to meet on a regular basis to discuss the cases and determine what was best for everyone involved. Sources 1. Structure & Characteristics of Judge Carole Clark’s Trauma-Informed Court (n.d.). All Rise for the Good (a) Of the Children. Retrieved July 13,2021 from All-Rise-Video-Companion-Judge-Carole-Clarks(b) Trauma-Informed-Approach-to-Family-Drug-Court-053019.pdf ( 2. Gregory, Jennifer (2021). Personal communication, July 13, 2021.

In the Tennessee Commission on Children and Youth Policy Brief, McCollister et al. (2018) reiterate the finding that youth with a history of trauma are often in the juvenile justice system. They discuss how trauma can be intensified when youth are placed in detention. Youth can perceive a secure custody environment as a dangerous place where self-protection is essential. Detention environments can increase feelings of being threatened, and youth may respond with aggression to protect themselves (p. 3). Consequently, McCollister et al. (2018) contend that detention should be a last resort for youth. Detention does not deal with youth trauma or the unsafe environments that youth often are coming from or returned to after they

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are released. They emphasize alternatives to detention. One such program, the School House Adjustment Program Enterprise (SHAPE) in Memphis, has worked successfully since 2007 with the juvenile court to reduce youth placement in detention for minor violations (McCollister et al., 2018, p. 5). In addition, The Annie E. Casey Foundation’s Juvenile Detention Alternatives Initiative has successfully reduced the number of youth in detention in 39 states (Thurau & Mendel, 2017). Collaboration is a key factor, and law enforcement officers have worked with other community agencies to avoid detaining youth for behaviors that can be addressed more effectively in less punitive settings. For example, in Pima County (Tuscon), Arizona, and Cuyahoga County (Cleveland), Ohio, officers have used alternatives to detention for youth involved in domestic disturbances. In recognizing the trauma associated with detaining youth and the fact that the issues that might have precipitated the incident not being addressed, they collaborate with community agencies to refer these cases for assessment and treatment without detention (Thurau & Mendel, 2017, p. 11). In policing, law enforcement agencies are becoming more aware of trauma and treatment policies. Police academies are requiring more time and training devoted to adolescent development and behavior including brain development. The State of Indiana has adopted this approach, and its training academy has increased the number of classroom hours associated with teaching about youth development (Thurau & Mendel, 2017, p. 14). Introducing recruits to trauma early in their career can inform their practices in the field. Furthermore, McCollister et al. (2018) advocate for creating an environment where youth will feel safe, and where the staff utilizes evidence-based assessments and interventions to address trauma (p. 4). They reiterate Buffington et al. (2010) recommendations that emphasize the importance of making accurate diagnoses for children and youth who have been exposed to adverse childhood experiences (ACEs) and identifying and implementing the appropriate treatment for them. McColliser et al. emphasize that employing evidence-based treatment approaches, engaging in comprehensive data collection, and conducting further analysis of their effectiveness with children and youth who have experienced trauma are essential strategies (p. 5). Similarly, Zettler (2021) advocated for additional research on trauma-informed treatment and its effectiveness in reducing violence and recidivism specifically for juveniles who receive sanctions that are community-based in addition to those that involve placement in residential settings (p. 127). Despite the successful interventions, there are barriers to trauma-informed care that persist. The system of justice involves a commitment to punish violators of the law, and a trauma-informed system that attempts to identify and deal with trauma to reduce delinquent behavior is not necessarily compatible with that perspective (Ezell et al., 2018, p. 516). Consequently, widespread endorsement and application of trauma-informed practices are still evolving.



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Trauma-informed care represents a shift in focus that moves us from thinking, “What is wrong with you?” to considering “What happened to you?”

In their qualitative study, Damian et al. (2018) found that participants, who were providers in Baltimore, stressed the importance of wraparound services to make participation by victims and families more feasible. These include assistance with transportation and childcare to support youth and family involvement in treatment. Damian et al. (2018) also reported the need for more professionals in the field specifically trained to work with youth who have experienced trauma and funding “…to support the development of an infrastructure that formally links child-serving agencies with one another” (p. 276). That system could assist with referrals for treatment and monitor outcomes (p. 276).

THINKING CRITICALLY 10.1 THE CASE OF MAX Max, 15 years old, has been diagnosed with PTSD and ADHD. Max has a distinct history of trauma. He was sexually abused by his biological father from the time he was three, until he turned eight years old. Although his biological Mom knew of the abuse, she did not leave until meeting another man—two weeks after Max’s ninth birthday. At the age of ten, Max was removed from his mother’s home by the state child welfare authority due to repeated incidences of neglect and abuse. Max’s Mom and her boyfriend were doing drugs in Max’s and his new half-sister’s (who was now age one) presence, Max lived in a series of foster homes, and on several occasions, had been placed in detention for property-related ofenses and fghting with other foster youth. Due to the escalation of behavioral issues and the inability to fnd a more permanent placement, Max is now living with his paternal Grandmother (who is 85). His Dad is currently incarcerated for various sex ofenses, and his Mom is undergoing rehabilitation therapy for a crack cocaine addiction. Max is repeating the ninth grade in a mainstream classroom. In class, Max habitually tilts his chair back and taps excessively on his desk with a pencil. This morning, he is doing it—again—during a World History class. When the teacher asks him to stop, Max is defant and uses inappropriate language when verbally redirected. The teacher begins to argue with Max and lecture him about respect for elders in front of classmates, threatening to remove him from class or refer him to the assistant principal for disciplinary action. Some students snicker and whisper the words “stupid” and “retard” toward Max. Consequently, Max gets up, and is ready to storm out of the classroom. On his way out, however, he shouldered his teacher out of the way when she blocked the classroom door. The teacher calls the school resource ofcer (SRO) and informs him that she intends to fle a complaint against Max for assault. Max is arrested,

The Juvenile Justice System’s Response to Trauma

cufed, and removed from school in a police car. Once he is released from detention, Max will be suspended from school for two weeks. Discuss: What were some of Max’s emotional-behavioral health and social needs prior to the incident in the classroom? Can Max’s needs be afected by his removal from the classroom and subsequent involvement with the juvenile justice system? How? What recommendations can you make for changing the outcome for Max and other youth similarly situated?

Schools and Trauma Schools have a unique opportunity to help children deal with trauma. Education, particularly trauma-informed education, affords an opportunity to intervene, treat, and potentially prevent victimization and its accompanying trauma. “Schools can play a significant role in instilling the resiliency necessary to deal with the traumas of neighborhoods or families” (van der Kolk, 2014, p. 353). Trauma-informed education means that teachers and schools recognize trauma and respond to it effectively. Educators are critical in creating a safe environment for youth to flourish, and in emphasizing respect, care, and compassion (Duffy & Comley, 2019). Trauma-informed education also necessitates teaching students the tools to navigate these stressful situations appropriately. Rather than acting out in a classroom, assaulting another student or teacher, or engaging in defiant or aggressive behavior, youth learn coping skills to address the situation in an appropriate manner. When they recognize these signals and adopt coping strategies, students are better equipped to succeed. Trauma-informed schools recognize trauma and its effects on children and youth and support efforts with the community to heal children and youth and to reduce the risk of retraumatizing them (Office of Juvenile Justice and Delinquency Prevention (OJJDP), 2021). Research reported by the Office of Juvenile Justice and Delinquency (OJJDP) (2021) indicates that Native/Indigenous youth experience trauma at higher rates than other youth populations in the United States. This can place them at increased risk for developing trauma-related behaviors like substance abuse and suicidal behaviors; and it can affect school attendance and performance. Trauma-informed schools can contribute to a youth’s chances for healthy development and success at school. With a grant from OJJDP, the Ohkay Owingeh Tribe in New Mexico offered training to school staff at the tribal and public schools in Pueblo that youth attend and to the Tribe’s Health and Human Services Department. The National Native Children’s Trauma Center provided trauma-informed training virtually for staff members at the tribal school and the public school. The training covered the principles of trauma education, childhood



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exposure to trauma, historical trauma, trauma and resilience in tribal communities, and prevention and healing. The Project Lead, Elicka Martinez, reports that the program increased staff’s knowledge and understanding of trauma, noting that previously the staff did not realize the impact that historical trauma could have on children’s and youth behavior and performance in school (OJJDP, 2021). Clearly, there is more emphasis on trauma-informed schools. Teachers are participating in training to identify, address, and treat trauma and to create a trauma-informed milieu. For example, with federal funding, a Delaware Steering Group convened to promote trauma-informed policies. It instituted the “compassionate schools” model that Washington State pioneered in six Delaware school districts. It modifies school environments to enable them to identify and support children and youth who come to school burdened by family and community trauma (Brower, 2016, para. 18). The National Child Traumatic Stress Network has developed a guide for establishing a trauma-informed school that deals with the needs of parents, students, staff, and administrators who might be at risk “…for experiencing the symptoms of traumatic stress” (Foreman et al., 2021, p. 1). It is a comprehensive approach that focuses on the partnership that is essential in addressing trauma, and it outlines six principles that are part of the process. They include: “…Safety, Trustworthiness and Transparency, Peer Support and Mutual Self-Help, Collaboration and Mutuality, Empowerment Voice and Choice, and Cultural, Historical and Gender Issues” (Foreman et al., 2021, p. 2). Similarly, Wiest-Stevenson and Lee (2016) contend that there are important components in creating an effective trauma-informed school. These include a full commitment from all school personnel, but especially from the school administrators, and clearly articulated guidelines on how each set of eminent persons—guidance counselors, principals, support staff—can help those affected by trauma. Further, they recommend that schools disseminate information to all school personnel that could help them identify behaviors that might suggest the child is reacting to trauma, and specific organization and individual contact information to share with children and families who may need assistance (p. 500). POLICY & PRACTICE 10.4 DEVELOPMENTS IN TRAUMA-INFORMED CARE: THE “HANDLE WITH CARE” (HWC) PROGRAM

Contributor: Miriam Therasia van der Spek In 2013, West Virginia implemented the Defending Childhood Initiative. Commonly referred to as “Handle With Care” (HWC), the initiative was designed to prevent childhood trauma and violence and to mitigate the negative efects that such exposure may have on success in school. To

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accomplish these objectives, HWC programming serves to promote schoolcommunity partnerships that facilitate a safe and supportive academic environment. This is achieved through a combination of awareness, information-sharing among agencies/organizations, and training. It includes the following steps. First, police identify a child at the scene of a traumatic event (e.g., domestic violence situation, a shooting, sexual abuse, a home drug raid) and gather information about the child’s school or day-care. Next, the police send a confdential e-mail or fax to the school or agency requesting that the child, who is named in the correspondence, be “handled with care.” No other details are provided. Subsequently, the information is shared with relevant staf and administrators. It is anticipated that any child or youth behavior concerns might be considered reactions to trauma rather than school disciplinary infractions, and then addressed to reduce or eliminate the negative impact. Positive interventions may include educational support, peer mentoring programs, and referrals for mental health counseling, and social services. Additional trauma-informed interventions also have included the use of verbal and non-verbal cues (e.g., a student holding “thumbs-up” or “thumbsdown” to indicate mood/emotions or the utilization of a therapy dog). It is important to reiterate that during this process, the child’s privacy is protected, and details of the trauma are neither disseminated nor discussed with school personnel (or the child). However, police sharing this information with school personnel ensures that the school can ofer appropriate support to students, with both law enforcement and educational providers endeavoring to do what is best for the child (NJ Attorney General’s Ofce, 2020). This collaborative partnership involves multiple systems of care (police, schools, community providers of services). A signifcant part of the HWC program includes training, which is ofered online and in-person to school staf (K-12), frst responders/emergency personnel, school resource ofcers (SROs) and other law enforcement ofcers, school administrators, prevention and treatment providers, counselors, and other interested community or school partners. The training curriculum includes an overview of trauma (direct and community) and an explanation of the HWC system. Currently, there are no published data that have assessed, the efectiveness of HWC. Discuss: What do you think about the HWC program? How might it beneft children in the context of ACEs? Could this type of program be detrimental to children sufering from adverse experiences? If so, how? Are there ethical considerations that should be considered during its implementation? If so, how might you suggest these be addressed? Sources: 1. NJ Attorney General’s Ofce. (2020). Just Announced: Statewide “Handle with Care” Program to Protect Children Who Experience Traumatic Events. TAPinto. Retrieved December 2, 2021, from https://www.



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2. van der Spek. (2021). Law Enforcement Technology: The Handle with Care Program Initiative [Unpublished manuscript]. West Chester University. 3. Virginia Department of Criminal Justice Services: Improving and promoting public safety in the Commonwealth. (2022). Handle With Care Law Enforcement Schools with Trauma Informed Communication System: An Overview of Childhood Trauma and Implementation of Handle With Care. [Webpage]. Retrieved December 13, 2021, from handle-care-law-enforcement%E2%80%93schools-trauma-informed.

Despite the early support that school districts have offered for traumainformed care, there is a dearth of research on its effectiveness. In a systematic review, Maynard et al. (2019) found no rigorous systematic review of this approach. Clearly, their findings illustrate how schools are in the early stages of this process. Maynard et al. (2019) report that it is unclear what school systems are doing, and they advocate for more research on schoolbased trauma-informed care (p. 3). Foreman et al. (2021), quote one of the school educators involved in a TIC approach, who observed, This work is journey, not a destination. A marathon not a sprint. Our lesson learned is to celebrate the smallest accomplishments while working toward larger change. (p. 9)

TAKE-HOME MESSAGE This chapter was intended to provide a foundation on the role of trauma as it relates to mental health and co-occurring substance abuse disorders and, ultimately, justice involvement for many individuals. The evidence for promoting and providing trauma-informed juvenile justice and child welfare services has been well documented (Dierkhising & Branson, 2016; Dierkhising & Kerig, 2017). From law enforcement officers to teachers, training on how to recognize and respond to children with trauma suggests that a model of trauma-informed juvenile justice has emerged (Dierkhising & Branson, 2016). While “barriers to systemic change” persist, the potential for more effective and justice-related outcomes in juvenile justice is more widely accepted (Dierkhising & Branson, 2016, p. 23). As van der Kolk (2014) noted, “Trauma is now our most urgent public health issue, and we have the knowledge necessary to respond effectively” (p. 358). More research on trauma-informed practices must be conducted. However, the existing evidence on effective approaches can be instrumental in realizing a more informed juvenile justice system and a school environment that enable children and youth to learn and thrive. Preventing and treating trauma requires a commitment from justice system leaders, administrators, practitioners, and line staff, schools, counselors and mental health treatment staff, and the community. It is recommended that the future use of the SIM as a conceptual guide to forensic mental health

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be expanded to incorporate trauma-informed approaches for the apprehension, care, and treatment of PwMI who enter the criminal or juvenile justice systems. It seems that positive change can be made once the root causes of behavior are addressed. The research on the extent of trauma and its effects attest to the urgency to act.

Questions for Classroom Discussion 1. What does trauma-informed care refer to? Why is it important? Consider an example of what you learned related to this topic. How significant is this topic for you and your future career goals? 2. Explain PTSD. Does everyone who has been diagnosed with PTSD require psychological treatment? Why? 3. What can be done to help service providers deliver trauma-informed care to children and youth? 4. How does the juvenile justice system address trauma? Is the approach implemented widely? Explain. KEY TERMS AND ACRONYMS • • • • • • • • • • • • • • • • •

Acute vs. Complex Trauma Acute stress disorder (ASD) Adverse Childhood Experiences (ACEs) Annie E. Casey Foundation’s Juvenile Detention Alternatives Dual diagnosis Eye movement desensitization and reprocessing (EMDR) Individual vs. Group Trauma Interpersonal Trauma Juvenile Justice Reform Act in 2018 Post-traumatic stress disorder (PTSD) Prolonged exposure therapy (PE) Sanctuary Model® The National Child Traumatic Stress Network (NCTSN) Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) Trauma-Informed Care Trauma-Informed Education Vagus nerve

NOTES 1 Source: Adapted from Annales d’hygi`ene publique et de m ́edecine l ́egale, “ ́Etude m ́edico-l ́egale sur les s ́evices et mauvais traitements exerc ́es sur des enfants.” (Roche, A. J., Fortin, G., Labbé, J., Brown, J., & Chadwick D., Trans.). Child Abuse & Neglect, 29(4), 325–334. DOI: 10.1016/j. chiabu.2004.04.007. PMID: 15917075. (Original work published in 1860). 2 The recent coronavirus pandemic can be considered an example of a mass trauma.


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3 4 The Purple Heart medal is presented to service members who have been wounded or killed as a result of enemy action while serving in the U.S. military. A Purple Heart is a solemn distinction and means a service member has greatly sacrificed themselves, or paid the ultimate price, while in the line of duty. 5 6 TEDMED Talk (2014).

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Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. Finkelhor, D., Turner, H., Shattuck, A., Hamby, S., & Kracke, K. (2015). Children’s Exposure to Violence, Crime, and Abuse: An Update. Washington, DC: U.S. Department of Justice. pubs/248547.pdf Ford, J. (June 20, 2016). What Is a ‘Trauma-Informed’ Juvenile Justice System? A TARGETed Approach. Juvenile Justice Information Exchange. Retrieved from Ford, J. D., & Blaustein, M. E. (2013). Systemic Self-regulation: A Framework for Trauma-Informed Services in Residential Juvenile Justice Programs. Journal of Family Violence, 28, 665–677. s10896-013-9538-5 Foreman, C., Grossman, H., Graham, M., & Seymour, M. (2021). A Trauma-Informed Resource for Strengthening School Family Partnerships. Los Angeles, CA and Durham, NC: National Center for Child Traumatic Stress. Geoffrion, S., Goncalves, J., Robichaud, I., Sader, J., Giguère, C. É., Fortin, M., ... & Guay, S. (2022). Systematic Review and Meta-Analysis on Acute Stress Disorder: Rates Following Different Types of Traumatic Events. Trauma, Violence, & Abuse, 23(1), 213–223. Goldsmith, R. E., Gamache, C., & Smith, C. P. (2014). Systemic Trauma. Journal of Trauma and Dissociation, 15(2), 117–132. 5299732.2014.871666 Greene, S., Haney, C., & Hurtado, A. (2000). Cycles of Pain: Risk Factors in the Lives of Incarcerated Mothers and Their Children. The Prison Journal, 80(1), 3–23. Kerig, P. K., & Becker, S. P. (2015). Early Abuse and Neglect as Risk Factors for the Development of Criminal and Antisocial Behavior. In J. Morizot & L. Kazemian (Eds.), The Development of Criminal and Antisocial Behavior (pp. 181–199). Cham: Springer International Publishing. https://doi. org/10.1007/978-3-319-08720-7_12 Kessler, R. C., Aguilar-Gaxiola, S., Alonso, J., Benjet, C., Bromet, E. J., Cardoso, G., … & Koenen, K. C. (2017). Trauma and PTSD in the WHO World Mental Health Surveys. European Journal of Psychotraumatology, 8(sup5), 1353383. Khan, A. M., Dar, S., Ahmed, R., Bachu, R., Adnan, M., & Kotapati, V. P. (2018). Cognitive Behavioral Therapy versus Eye Movement Desensitization and Reprocessing in Patients with Post-traumatic Stress Disorder: Systematic Review and Meta-analysis of Randomized Clinical Trials. Cureus, 10(9), e3250. Levenson, J. S., & Willis, G. M. (2019). Implementing Trauma-Informed Care in Correctional Treatment and Supervision. Journal of Aggression, Maltreatment & Trauma, 28(4), 481–501. Levenson, J. S., Willis, G. M., & Prescott, D. S. (2014). Adverse Childhood Experiences in the Lives of Male Sex Offenders: Implications for Trauma-Informed Care. Sexual Abuse: A Journal of Research and Treatment, 28(4), 340–359. Listenbee, R. L. (2014, June 9). The Juvenile Justice and Delinquency Prevention Act: Preserving Potential, Protecting Communities. Testimony before the Committee on the Judiciary. U.S. Senate. Field Hearing, Pawtucket, RI. Retrieved from doc/06-09-14ListenbeeTestimony.pdf

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CHAPTER 10 Approaches to Trauma-Informed Care

Phipps, R., & Thorne, S. (2019). Utilizing Trauma-Focused Cognitive Behavioral Therapy as a Framework for Addressing Cultural Trauma in African American Children and Adolescents: A Proposal. Professional Counselor, 9(1), 35–50. Pickens, I. B., Siegfried, C. B., Surko, M., & Dierkhising, C. B. (2016). Victimization and Juvenile Offending. Los Angeles, CA and Durham, NC: National Center for Child Traumatic Stress. Read, J., Van Os, J., Morrison, A. P., & Ross, C. A. (2005). Childhood Trauma, Psychosis, and Schizophrenia: A Literature Review with Theoretical and Clinical Implications. Acta Psychiatra Scandinavia, 112, 330–350. https:// Rosenberg, L. (2011). Addressing Trauma in Mental Health and Substance Use Treatment. The Journal of Behavioral Health Services & Research, 38(4), 428–431. S.E.L.F. (n.d.). A Trauma-Informed Psychoeducational Group Curriculum. The Sanctuary Model. Retrieved from Other%20PDFs/Outline%20of%20S.E.L.F.%20Psychoeducational%20 Curriculum.pdf Sharma, M., & Bennett, R. (2015). Substance Abuse and Mental Illness: Challenges for Interventions. Journal of Alcohol & Drug Education, 59(2), 3–6. Smith, M., Robinson, L., & Segal, J. (2020). Child Abuse and Neglect. HelpGuide. Retrieved from Substance Abuse and Mental Health Services Administration. (2014a). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) 14–4884. Rockville, MD: Substance Abuse and Mental Health Services Administration. Substance Abuse and Mental Health Services Administration. (2014b). Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13–4801. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from Substance Abuse and Mental Health Services Administration [SAMSHA]. (2021). Understanding Child Trauma [Webpage]. Retrieved January 1, 2022, from The Center for Child Counseling. (n.d.). Retrieved from The Justice for Victims of Trafficking Act of 2015, S.178, 114th Congress (2015–2016). (2015). Public Law No: 114-2, 29 May, 2015. Retrieved from Thurau, L., & Mendel, R. A. (2017). Forging Partnerships with Law Enforcement. A Guide to Juvenile Detention Reform. Baltimore, MD: Anne E. Casey Foundation. Turnball, G. J. (1998). A Review of Post-traumatic Stress Disorder. Part I: Historical Development and Classification. Injury, 29(2), 87–91. https://doi. org/10.1016/s0020-1383(97)00131-9 and https://pubmed.ncbi.nlm.nih. gov/10721399/ U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2021). Child Maltreatment 2019. Retrieved from https://www.acf.

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Conclusions and Future Directions I don’t wish to be seen as regretting the life I could have had if I’d not been mentally ill, nor am I asking anyone for their pity. What I rather wish to say is that the humanity we all share is more important than the mental illness we may not. What those of us who suffer with mental illness want is what everybody wants: in the words of Sigmund Freud, ‘to work and to love.’ —Elyn Saks, Distinguished Professor, Mental Health Law, USC Gould School of Law1

INTRODUCTION This textbook was structured as a presentation of diversion opportunities along the six distinct intercept points in the Sequential Intercept Model ([SIM] Munetz & Griffin, 2006). In the preceding chapters, three key implications were established. First, there is an overrepresentation of persons with lived experience of mental illness (MI) and co-occurring substance use disorders (CODs) who are involved in the justice system. Second, the criminal (or juvenile) justice system has historically been ill-equipped to respond to the needs of justice-involved persons with behavioral health needs—in particular, the complex needs of individuals with serious mental illness (SMI). Third, to make positive changes, responses require administrative buy-in, trauma-informed cross-systems training, creativity, and most importantly, the development of unique partnerships between multiple agencies and systems of care (Figure 11.1; The PA Forensic Inter-Agency Task Force is instructive as to this point). Because the primary undercurrent of this text has been cross-systems collaboration and information sharing, recommendations for practitioners revolve around this theme and include the creation of a community stakeholder group that consists of individuals from varied disciplines and agencies who can effectuate change (Chapter 4). An essential next step would be to conduct ongoing trainings that include programmatic needs, many of which are discussed in more detail throughout this text. These include systems mapping (Chapter 3), knowledge of signs and symptoms related to serious psychiatric and substance use disorders (Chapters 1, 4, and 5), additional knowledge-building programs that reduce stigma and teach valuable de-escalation techniques (e.g., LGBTQ+ Communities, Chapter 4; Crisis Intervention Teams [CIT], Chapter 5), and an array of services that are grounded in trauma-informed care (TIC), a subject visited throughout the text but discussed in more detail in Chapter 10.

DOI: 10.4324/9781003120186-11



CHAPTER 11 Conclusions and Future Directions

Figure 11.1 Collaborative Partnerships

Source: “Collaboration” by Venessa Miemis is licensed under CC BY-NC-SA 2.0;

The remainder of this chapter is intended to highlight important points made in the previous ten chapters and to present suggestions related to systems integration for further reflection and evaluation. Developments in terms of policy and/or research are incorporated in spotlight features throughout the chapter.

REVIEW OF THE ISSUES AND SUGGESTIONS FOR CHANGE On any given day, roughly 17,000 youth (18 years of age or younger) are committed to and confined in juvenile detention facilities throughout the United States (Campaign for Youth Justice; “Key Facts: Youth in the Justice System,” 2012), most for nonviolent offenses (Wagner & Rabuy, 2016). Among adults, approximately 2.3 million persons are confined to adult correctional facilities (jails and prisons, state and federal) (Wagner & Rabuy, 2016) at any point in recent history. Research has clearly indicated that many of these individuals have been affected by trauma, poverty, violence, educational disadvantage, and substance use. As stated early in the text, some estimates have indicated that anywhere between 20 percent and 50 percent of adults and over 70 percent of juveniles in detention have at least one serious psychological disorder and the majority are diagnosed with a co-occurring SUD (see Ditton, 1999; Hayes, 2012; James & Glaze, 2006; NAMI, 2013; Shufelt & Cocozza, 2006; Teplin et al., 2006).

Issues Presented Some of the primary issues in forensic mental health include an underfunded and overwhelmed mental health system; chronic housing displacement; an

Review of the Issues and Suggestions for Change 331

overreliance on the justice system to control and treat individuals with SMI; compromised public safety; increased arrest; isolation, criminalization, and mistreatment of people with mental illness (PwMI) in correctional settings; stigma; and a lack of training for criminal justice actors who work in policing and corrections. Some have argued that these problems can be traced to the declining use of commitment to state-run inpatient hospitals and the subsequent displacement of persons with chronic mental illnesses into poorly developed community-based mental health systems that are unprepared, and sometimes unwilling, to meet their needs (Griffin et al., 2015; Slate et al., 2013). One prevailing issue is the lack of public psychiatric beds for those needing a more restrictive level of treatment in a short term or other residential placement facilities, which unfortunately, increases the risk for justice involvement for many people with serious mental illness (PwSMI) in the community. As illustrated in the “Thinking Critically” segment below, there have been recent developments to address this concern. THINKING CRITICALLY 11.1 RESPONDING TO THE LACK OF TREATMENT BEDS A report from the Treatment Advocacy Center (TAC)2 found that the minimum number of public psychiatric (hospital) beds is 50 per every 100,000 persons (Torrey et al., 2008). As of the time of that report’s release, 42 of the 50 states did not meet the bed minimum requirement. The number of beds available per 100,000 persons is often an indicator of the state of mental health in that country. Too few beds may indicate that individual states and the country cannot aford to keep up with the minimum standards, or that it does not prioritize mental health (Samartzis & Talias, 2019). Repercussions of the lack of psychiatric beds include increased homelessness, and risk for incarceration of PWMI, an increase in psychiatric patients in emergency rooms, and an increase in violent behavior (Torrey et al., 2008). As discussed in Chapter 4, a proper crisis system must be able to provide care and services to all persons requiring them—despite specifc population needs (that is, the services must be available for any population). SAMHSA has created a Crisis Need Calculator (Figure 11.2) to help communities assess what they need to implement or achieve a well-functioning and prepared crisis system of care. Designed to act as both informant and guide, the calculator analyses a multitude of factors throughout the community, including population size and density, average lengths of stay for patients in various system beds or chairs, escalation rates into higher levels of care, readmission rates, bed occupancy rates, and local costs for those resources (SAMHSA, 2020). Should the community not yet have a system of care from which to draw data, use of this calculator can provide examples from similar communities to aid in building better systems of care. Below is a sample of the Crisis Need Calculator, displaying the cost-savings by implementing mental health community services, such as the proper amount of treatment beds.


CHAPTER 11 Conclusions and Future Directions

Crisis Now Crisis System Calculator Projections - Pop. 1,000,000 No Crisis Care # of Crisis Episodes Annually (200/100,000 Monthly) # Initially Served by Acute Inpatient # Referred to Acute Inpatient From Crisis Facility Total # of Episodes in Acute Inpatient # of Acute Inpatient Beds Needed Total Cost of Acute Inpatient Beds # Referred to Short-Term Bed From Stabilization Chair # of Crisis Beds Needed Total Cost of Short-Term Sub-Acute Beds # Initially Served by Crisis Stabilization Facility # Referred to Crisis Facility by Mobile Team Total # of Episodes in Crisis Facility # of Crisis Stabilization Chairs Needed Total Cost of Crisis Stabilizartion Chairs # Served Per Mobile Team Daily # of Mobile Teams Needed Total # of Episodes with Mobile Team Total Cost of Mobile Teams # of Unique Individuals Served TOTAL Inpatient and Crisis Cost ED Costs ($1,233 Per Acute Admit) TOTAL Cost TOTAL Change in Cost




$ $ $ $

24,000 16,320 16,320 500 164,179,200 4 16,320 164,179,200 20,122,560 184,301,760

Crisis Now




$ $ $ $

24,000 3,360 1,336 4,696 144 47,237,736 5,342 41 13,356,000 12,960 2,304 15,264 48 18,840,137 4 7 7,680 2,761,644 24,000 82,195,517 5,789,675 87,985,192 -52%

Figure 11.2 Crisis Now: Crisis System Calculator Projections – Pop 1,000,000

Source: National Guidelines for Behavioural Health Crisis Care. A Best Practice Toolkit. Knowledge Informing Transformation. Rockville, MD: Substance Abuse and Mental Health. Services Administration (SAMHSA),3 2020;

Communities can also implement a Crisis Bed Registry program/database (SAMHSA, 2020). This real-time system can inform service providers how many beds are empty, and where these beds are located. That way, if a certain location does not have any beds available, it would only take a simple search to determine where a patient could be placed or transported, as opposed to having patients wait in crowded emergency rooms or jails, and which suspends them from receiving the treatment and services they need and may lead to further decompensation of symptoms. Sources: 1. National Guidelines for Behavioural Health Crisis Care. A Best Practice Toolkit. Knowledge Informing Transformation. Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA), 2020. 2. Samartzis, L., & Talias, M. A. (2020). Assessing and Improving the Quality in Mental Health Services. International Journal of Environmental Research and Public Health, 17(1), 249. 3. Torrey EF, Entsminger K, Geller J, et al. The Shortage of Public Hospital Beds for Mentally Ill Persons; 2008. The Treatment Advocacy Center. Arlington, VA.

Review of the Issues and Suggestions for Change 333

The Importance of Systems Integration Although diversion options in the justice system are available and have been discussed, significant gaps still affect treatment outcomes and the rates of recidivism; these gaps exist across multiple systems of care. Ultimately, the most comprehensive system of care would incorporate the collaboration between stakeholders from multiple agencies, and an array of treatment programs and services would be accessible, recovery oriented, evidence based, and driven by the needs of consumers (Council of State Governments, 2002; Griffin et al., 2015). This idea of community collaboration is depicted in Figure 11.3.

Needs Assessment Once community linkages have been established and collaborative teams developed, an informal needs assessment should be conducted with constant communication with providers, varied human services-related committees in the community, case management, consumers, and representatives from any managed behavioral care networks in the service area. Needs would then be addressed through consumer and provider surveys. Relevant stakeholders from the locale should be asked to participate in a systems integration survey designed to determine accomplishments, gaps, and solutions to effective integration across systems working with the target populations.

Figure 11.3 Helping Hand

Source: “Silhouette of helping hand and hope concept and international day of peace. how can i help you” by LittlePerfectStock is licensed under CC BY-NC-SA 2.0;


CHAPTER 11 Conclusions and Future Directions

Information Sharing of Identifed Service Needs Public stakeholder meetings could be held at a single location to review and discuss the results from the survey, followed by suggestions for future endeavors. Aside from these meetings, areas of need will be identified through previous advisory board meetings, current discussions, and review of the data provided by provider annual reports. Many gaps in services and needs for funding/development have been identified throughout this text— several of which include: •

Budget concerns that may lead to cuts in services, less spending on medications (e.g., formularies), or more lengthy waiting lists for services/inpatient beds. Integrated training for mental health (MH), public welfare, substance abuse (SA), and justice workers that includes more in-depth information pertaining to SA/MH issues and services available in the locale and the use of de-escalation techniques in MH crisis situations.


Contributors: Jim Fouts, Forensic Systems Solutions and David A. Dinich, M.Ed. The Forensic Inter-agency Task Force started as a result of a tragedy. In early 1989, Fred Pisano, who sufered from a mental illness, killed his mother, Jean. The husband and father, Charlie, was the president of the newly formed Alliance for the Mentally Ill (AMI) of PA. Fred was sentenced to the Camp Hill SCI, located near Harrisburg, PA. Charlie became concerned about the mental health care Fred was receiving. Discussions with the Department of Corrections (DOC) medical director showed a complete lack of communication between the DOC and families, and, perhaps more so, among the DOC, State Probation and Parole, Ofce of Mental Health & Substance Abuse Services, and community providers. As a result, the National Alliance on Mental Illness (NAMI), then AMI, started monthly meetings in early 1991. Eventually this group became known as the Forensic Inter-agency Task Force (FITF). Membership began dwindling as NAMI leadership changed and facilitation of the FITF was then moved to Forensic System Solutions, (FSS), at the end of 2006. The Pennsylvania Forensic Inter-Agency Task Force provides a crosssystems forum for representatives of the behavioral health, criminal justice, social services, and advocacy systems to work together to improve access to and quality of services for persons with severe mental illness and often co-occurring substance use disorders involved or at risk of involvement in the criminal justice system. The FITF meetings garner about 40 to 50 members meeting on a bi-monthly basis. It provides forums for networking, information sharing, collaboration, advocacy and problem solving across all six Intercepts throughout Pennsylvania. The FITF utilizes sub-committees to work on specifc issues and has been instrumental in advocating for change in issues from accessing benefts, competency restoration changes, and housing options for those preparing to reenter the community from jails, prisons, or state hospitals.

Review of the Issues and Suggestions for Change 335

• • • • •

Advocacy and creative solutions designed to keep children with MH/SA issues in school and out of juvenile justice facilities (school-to-prison pipeline). Successful integration of juveniles and adult forensic populations as they transition back into the community. Successful integration of persons committed to state hospitals as they transition back into the community. Improve the data system to have better information on service utilization. Housing available for all individuals with mental health and substance abuse disabilities. Employment programs designed to assist PwMI in entering the competitive work environment and to build tenure in a meaningful position. Increase in effective communication across systems—particularly between law enforcement, consumers, and service providers (including educators) (see “Policy & Practice” 11.1 for an example of information-sharing in Pennsylvania). Training and support for workgroups formed to address the gaps in services.

In terms of an effective system of care, the justice system is not and should not become the lead agency charged with most of these functions. Rather, jurisdictions/locales/communities across the nation must utilize a systems of care (SOC) approach to addressing forensic mental health needs of its consumers of related services. In brief, this relates to a cross-systems approach to recovery in which an array of services will be accessible to all partner agencies. In an SOC model, partnering agencies may include public welfare and children and youth services, aging, Medicaid, juvenile justice, education, agencies for mental health and disability, substance use, emergency medical services, and veterans’ affairs. Depending on their presence in any given community, other agencies may become part of the SOC—in particular, those agencies that provide services related to housing, transportation, and employment.

Policy Matters/Recommendations Based on gaps and identified needs in the overall SOC as listed earlier, the following matrix outlines four specific policy goals that should be incorporated into the development of a comprehensive system of care (Table 11.1). This information, as presented, can be used to more effectively identify persistent goals, objectives, and strategies that are reflective of the prioritized needs of the community. These suggestions are presented to encourage the commitment to positive changes in forensic mental health. Although the effects of deinstitutionalization had started to present themselves decades ago, policy changes to improve the system have not been particularly forthcoming (Compton & Kotwicki, 2007; Slate et al., 2013). Rather, funding for mental health and substance abuse


CHAPTER 11 Conclusions and Future Directions

Table 11.1 Integrative Solutions for a Comprehensive System of Care (SOC)



Suggested Actions

Integration of services

Communities should identify strategies to enhance community-based resources and multiagency collaboration to improve outcomes for children and adults with mental health/ substance use disorders.

Hold a series of meetings and trainings to enhance collaboration with the judiciary, child welfare, providers, school districts, law enforcement, and other state agencies who encounter MH/SA populations. - Develop workgroups, committees, and subcommittees who are charged with the identifcation of strategies to enhance services and motivation for children and families involved in the system of care. - Research and distribute best evidence-based practices for treatment and recovery. - Develop improved data collection procedures and utilize multiple methodologies for data analysis with regard to measuring outcomes. - Track results.

Early intervention and delinquency/ crime prevention

County-specifc children in crisis workgroups composed of multiagency personnel (e.g., DJJ, child welfare, MH/SA providers, law enforcement, school district, county commissioners) shall be developed and charged to work with K–12 exceptional student education (ESE) and mainstream personnel. Such groups will identify estimates of the number of children who will qualify for services and develop strategies for them to access the appropriate services when needed—particularly during periods of crisis and transition between behavioral health and community settings.

Distribute county-wide MH/SA services lists to local schools, law enforcement agencies, and state public health and human services agencies for widespread dissemination. - Meet with school administrators and other personnel responsible for intervention at each of the schools in a region or locale to discuss the referral process. - Meet with student resource ofcers to discuss community-based services and referrals and to advise them about training opportunities. - Meet with families/parents to discuss community-based services and referrals and to advise them about the importance of early intervention, prevention, and treatment. - Participate in Department of Juvenile Justice (DJJ) multidisciplinary staf meetings and local child welfare review teams and initiatives. - Identify areas of need regarding children’s mental health (CMH) and substance abuse (SA) services and transition from intensive services/inpatient/residential to community-based settings (school). - Identify sound data collection methodologies to assess outcomes.

Review of the Issues and Suggestions for Change 337



Suggested Actions

Promote cross-training opportunities

A multiagency steering committee should be developed to work with individuals to identify training interests and needs and assist them in accessing training opportunities, with the goal in mind of a more efective system-wide model of referrals and services.

Promote training opportunities in the community to specifcally target: • Children and adults with disabilities currently receiving services. • Children and adults with disabilities not currently receiving services. • Judicial agents who order clients to seek/ receive mental health and substance abuse services in the community or while detained in a facility. • Legal aid staf, public defenders, and state attorneys who advocate for outcomes related to civil liberties and public safety. • Public health personnel who provide medical services to at-risk children and adults. • Agents in the criminal justice system, particularly jail personnel and those responsible for law enforcement. • Child welfare personnel. • School personnel. - Continue to support and forge relationships with persons leading existing training programs. The core group in any community is usually the Crisis Intervention Team (local or regional). - Utilize agency staf and providers who have personal and professional skills related to best practices by allowing them the opportunities to design and facilitate evidence-based training programs. - Continue to work with outside agencies at the local, state, and federal levels who specialize in training in several of the key areas related to MH and SA. - Always consider cultural competency when developing training programs and/ or assessing existing ones. - Implement brief evaluations after training to assess motivation and positive and negative outcomes.


CHAPTER 11 Conclusions and Future Directions



Suggested Actions

Reform and transform forensic mental health services

To keep people with serious mental illness who do not need to be in the criminal justice system in the community.

Contract with community-based care agencies to perform forensic oversight; includes hiring (at least) one person who will monitor forensic services for the region. - Ensure that there are enough full-time forensic specialists/case managers employed in each region, along with peer-support staf in the community and correctional settings. - Implement policy that mandates specialized probation and parole staf who are trained in best or evidence-based practices, and who, as mandated by law or policy, maintain a specialized case load of no more than 30 to 40 clients (fewer for juvenile probation ofcers). - Develop a center of innovation for promising and evidence-based practices. - Support community reintegration for forensic clients who have been in the state hospital. - Implement an integrated system of services and supports for co-occurring mental health/drug and alcohol recovery. - Implement housing and forensic workgroups to address the following: o Develop employment opportunities. o Structured housing options. o Access to Medicaid, medical services, and SSI/Disability. o Access to medication without breaks in treatment. - Provide recommendations for educating judges and other professionals in the courts regarding competency, insanity, and commitment evaluations and requirements.

Source: Author

services is the first to be cut when states are seeking to minimize spending. What is often left are ineffective public policies which make life more difficult for PwMI and, at the same time, cause an increasing amount of stigma (Compton & Kotwicki, 2007). Taken together, such circumstances prevent PwMI from seeking and utilizing the necessary services to help address underlying trauma and a plethora of human service needs that place them at risk for repeat offending. Thus, as stated several times earlier in the text, the nature of serious mental illness makes it likely that people with a multitude of symptoms will have contact with law enforcement and the courts, often resulting in unnecessary arrest or incarceration/detention (Griffin et al., 2015).

Review of the Issues and Suggestions for Change 339

POLICY & PRACTICE 11.2 DEVELOPING A MORE EFFECTIVE CRISIS CONTINUUM: THE NATIONAL “ROLLOUT” OF 9-8-8 On July 16, 2020, the Federal Communications Commission (FCC) formally designated 988 as the nationwide number for psychiatric crisis and suicide prevention services (NAMI, 2022). As described in Chapter 4, the implementation plan aims to have this number known and instated nationwide by July 16, 2022. While this is a great start, the services must also be available for 988 to succeed. “It will take federal, state and local action to implement the crisis standard of care in every community to ensure everyone in crisis gets the help they need, when they need it” (NAMI, 2022, para. 6). In its report, “National Guidelines for Behavioral Health Crisis Care,” SAMHSA (2020) outlined a comprehensive crisis system, which would include the following three essential elements: (1) Someone to talk to; (2) Someone to respond; and (3) Somewhere to go. • •

Someone to Talk to • Regional crisis call services ofer real-time access to a live person every moment of every day for individuals in crisis. Someone to Respond • Mobile crisis team services ofering community-based intervention to individuals in need wherever they are; including at home, work, or anywhere else in the community where the person is experiencing a crisis. Somewhere to Go • Crisis receiving and stabilization services ofer the community a no-wrong-door access to mental health and substance use care; operating much like a hospital emergency department that accepts all walk-ins, ambulance, fre and police drop-ofs

On a positive note, practitioners who work with justice-involved PwSMI have noticed high levels of resilience among them, in spite of having untreated symptoms which may include the presence of hallucinations (e.g., hearing voices) and delusions (e.g., being convinced that the U.S. president is plotting to kill you). In fact, for many PwSMI, maladaptive behaviors such as panhandling or self-medicating with illicit substances make perfect sense as practical adaptations to daunting environments (e.g., jail or prison) or as solutions to dealing with untreated trauma and symptoms that impair their ability to function in daily life (Compton & Kotwicki, 2007). After entering the justice system, those who never had the opportunity to address the underlying trauma that led them to their present circumstances may be exposed to frequent re-traumatization through violence and victimization as they cycle in and out of the system (Courtney & Maschi, 2013; Miller & Najavits, 2012; Weeks & Widom, 1998). Although gaps in service provisions have existed for decades, it has been especially felt during the coronavirus pandemic due to social distancing restrictions and disruptions to critical mental health services for vulnerable persons (e.g., children and adolescents, older adults, individuals recently released from jails and prisons) despite an increased demand (Barrenger & Bond, 2021; World Health Organization [WHO], 2020). In fact, a WHO


CHAPTER 11 Conclusions and Future Directions

survey of 130 countries revealed the need for further developments in technology to overcome the disruptions to in-person services, including increased use of telehealth options. The following “Practitioner’s Corner” segment provides some guidance in this regard.


Contributor: Craig A. DeLarge, MBA, Digital Healthcare Strategist and Mental Health Advocate & Educator, Digital Mental Health Project; Philadelphia, PA The COVID-19 pandemic has exacerbated insecurity, inequality, and inequity. Being humans, this exasperation too often, by cause of fear, distress, desperation, or otherwise, may result in dysfunctional and violent reactions and responses. It is no surprise that as we have responded to the pandemic less well, we have also seen an increase in crime. This exasperation and its results are, in part, addressed by mental, behavioral, and social care interventions, to which there is too little citizen access. Moreover, this lack of access extends across a range of individuals and communities whose mental health status falls along a continuum, ranging from excelling to a crisis. Used ethically, digital technology is capable of positively impacting the growing burden of crime that is related to mental, behavioral, and social risk factors. The most common or familiar form of technology has been videoconference, which allows family, peer, and professional contact across space and time, bringing protective and recovery resources to many who are not physically close to them. Additionally, there are mobile apps, which have made access to education, practice, social support, and behavior tracking more accessible. Beyond these two most popular technology classes, there are additional options available to support wellness and reduce crime, including wearable sensors, virtual and augmented reality, and the use of artifcial intelligence and big data. Examples of forensic applications include: •

Use of videoconferencing to allow professionals the ability to assess a greater number of incarcerated persons than would be possible without it. Additionally, such technology allows a greater volume of follow ups to keep track of progress. Use of monitors, in the form of ambient technologies like cameras and biosensors, which enable remote and continuous monitoring of an incarcerated individual’s propensity for suicide, with an eye to preventing a greater number of suicides.

In addressing future mental health needs, society must use these technologies with an assertive ethical sense that guards against their abuses related to stigma and discrimination, inefectiveness, unethical privacy invasion, and the digital divide.

Take-Home Message 341

Sources: Videoconferencing in forensic assessment: 1. 2. Detecting prisoner suicidality: 1. Resource_Guide_2.pdf 2. 3.

TAKE-HOME MESSAGE Subjects reviewed and presented in this book have indicated the increasing need for juvenile and criminal justice officials (police/first responders, court personnel, and correctional staff) who are trained specifically in crisis intervention and various mental health-related issues. Training that is occurring in the United States and internationally has shown to be effective in terms of increasing awareness and knowledge pertaining to mental health and co-occurring substance use disorders. Notwithstanding positive feedback from both empirical and anecdotal observations, there is a need for further evaluation so that more of the progressive training programs, some of which were introduced in this text, can be categorized as evidence-based. The overarching goals of programs such as MHFA, ACT or FACT, CIT, systems mapping, and trauma-informed care are public safety and the diversion of people with serious mental illness who do not need to be in the criminal justice system. Although there are multiple needs to consider when designing an effective system of care, the criminal justice system should not be the lead agency in meeting these needs. Instilling a vision of hope beyond a history of trauma and illness is vital to successful recovery (Figure 11.4).

Figure 11.4 Hope Source: Leka Sergeeva/Shutterstock;


CHAPTER 11 Conclusions and Future Directions

FAST FACT 11.1 THE 21ST CENTURY CURES ACT On December 13, 2016, President Obama signed into law HR 34, the 21st Century Cures Act. Among other reforms, the Act incorporated the following changes to the system of care: Increased funding support and expansion of CIT, MHFA, ACT and FACT, and AOT; mandates related to data collection as it pertains to police encounters with PwMI and the incarceration of forensic populations; clarifcation of informationsharing as it pertains to HIPAA restrictions; and the expansion of eforts to decriminalize mental illness (Treatment Advocacy Center, 2017). The extent to which these provisions have beneftted individuals needing MH/SA services must continue to be monitored over time.

The SIM was used as a guide to illustrate each potential diversion point in the traditional criminal justice funnel. Thus, chapter by chapter, the text focused on ways to potentially funnel PwMI out of the juvenile and criminal justice systems. Points of interception are important, but despite the best of intentions, poor symptom control and a fragmented network of care in the community frequently result in the criminalization and unnecessary arrest of PwMI. Too often, PwMI have restricted access to medical care, yet experience increased rates of housing displacement, exposure to trauma, and substance use, which presents challenges to the criminal justice professionals who encounter them. Unfortunately, this interface of criminal justice and mental health is consistent from the cradle to the grave (Bloom, 2016; Courtney & Maschi, 2013). PwMI have the burden of navigating through a seemingly fragmented system of care in search of services related to their overall well-being (Bloom, 2016). Various agencies who are sought out for assistance often have conflicting philosophies regarding treatment and recovery. Consequently, in their struggle to get help, PWLE may show a lack of follow-through or compliance with programmatic requirements. Service utilization is even more difficult once justice involvement is part of the equation (Slate et al., 2013). The message is clear: when we criminalize mental illness and resist the effects of traumatization, we dismiss violence as normal and minimize the impact of violence on victims. In short, we prioritize offending over victimization! Rather than blaming such individuals as being “treatment resistant,” we must evaluate the true issues and collaborate across systems to create a more seamless path to obtaining the needed supports and services.

Questions for Classroom Discussion 1. Of all five intercept points on the original SIM, which do you believe is the most important? How might you propose to fix any issues at your chosen intercept point? 2. What does systems integration refer to? Why is it important? Consider an example of what you learned related to this topic. What value does this topic have for you?

Take-Home Message 343

3. By now, you have read multiple times about the gaps in services related to mental health in community and correctional settings. You have also been informed that PwMI without access to treatment (medication, in particular) and other primary needs such as housing and employment do not fare well and often end up in the criminal justice system. Over the past five to ten years, however, the media has broadcast stories of PwMI who had violently attacked innocent persons in a movie theater, a navy yard, at schools, at concert venues and in grocery stores, and at other random and seemingly safe locations. Sometimes, the perpetrators have often been portrayed as educated, gainfully employed individuals who resided in regular housing, often with family members who appear to be relatively stable and concerned about their well-being. At other times, the public has learned that the perpetrator had a history of mental health issues and failed attempts at service engagement/utilization. What does the research say about the relationship between mental illness and violent offending? Consider the legislative response presented in the following “Policy & Practice” segment and discuss the implications and challenges of enforcement. POLICY & PRACTICE 11.3 EXTREME RISK PROTECTION ORDERS (ERPO) (“RED FLAG LAWS”) With a rise in the number of mass shootings in the United States, there has been an increase in bipartisan support for the adoption and enforcement of Extreme Risk Protection Order (ERPO) legislation, commonly referred to as “red fag” laws. ERPOs allow a court to temporarily seize frearms accessible to individuals who manifest behaviors that signal a risk of harm to self or others. Gun rights advocates have challenged these laws, asserting potential due process and 2nd Amendment violations. Since the 2018 shooting at Stoneman Douglas High School in Parkland, Florida, 19 states and D.C. have enacted red fag legislation, though it is not quite clear as to the efectiveness of these measures without a comprehensive system of gun regulation. Reports indicate that ERPOs are not being enforced by police to the extent possible—a fnding that has been attributed to a relative lack of knowledge as to their authority under the law and a potential lack of motivation for enforcement. While research has indicated that enforcement does reduce gun-related suicides, the evidence is limited and inconclusive, and further study is needed in this area. Sources: 1. Asmelash, L. (2021, April 21). Indiana’s ‘Red Flag’ Law Should Have Prevented the FedEx Shooting. Here’s What Else You Should Know about These Laws. Retrieved from CNN. red-fag-laws-explainer-trnd/index.html 2. Trovato, M. (2019, August 20). ‘Red Flags’ and Guns. The Crime Report. Retrieved from red-fags-and-guns/


CHAPTER 11 Conclusions and Future Directions


Buy-in Public psychiatric beds System of care (SOC)

NOTES 1 Adapted from A tale of mental illness—from the inside [TEDGlobal2012], by M. Bast, 2012, Copyright status. Permission Statement. 2 The TAC is a national nonprofit organization whose primary role is the dissemination of information pertaining to policy and practice related to effective treatment and recovery of PwMI. Their website can be accessed here: 3 Inclusion of SAMHSA content does not constitute or imply endorsement or recommendation by the Substance Abuse and Mental Health Services Administration, the U.S. Department of Health and Human Services, or the U.S. Government.

BIBLIOGRAPHY Barrenger, S. L., & Bond, L. (2021). Mental Health and Service Impacts During COVID-19 for Individuals with Serious Mental Illnesses Recently Released from Prison and Jail. The Journal of Behavioral Health Services & Research, 48(4), 610–616. Bloom, S. L. (2016). Advancing a National Cradle-to-Grave-to-Cradle Public Health Agenda. Journal of Trauma & Dissociation, 17(4), 383–396. Campaign for Youth Justice. (April, 2012). Key Facts: Youth in the Justice System. Washington, DC: Campaign for Youth Justice. Compton, M. T., & Kotwicki, R. J. (2007). Responding to Individuals with Mental Illnesses. Sudbury, MA: Jones & Bartlett Publishers. Council of State Governments. (2002). Criminal Justice/Mental Health Consensus Project (Doc. No 197103). Washington, DC: U.S. Department of Justice. Courtney, D., & Maschi, T. (2013). Trauma and Stress among Older Adults in Prison: Breaking the Cycle of Silence. Traumatology, 20(10), 1–9. Ditton, P. M. (1999). Special Report: Mental Health and Treatment of Inmates and Probationers. Washington, DC: US Department of Justice, Bureau of Justice Statistics. Griffin, P. A., Heilbrun, K., Mulvey, E. P., DeMatteo, D., & Schubert, C. A. (Eds.). (2015). The Sequential Intercept Model and Criminal Justice: Promoting Community Alternatives for Individuals with Serious Mental Illness. New York, NY: Oxford University Press. Hayes, L. M. (2012). National Study of Jail Suicide 20 Years Later. Journal of Correctional Health Care, 18(3), 233–245.

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James D. J., & Glaze, L. E. (2006). Mental Health Problems of Prison and Jail Inmates (Bureau of Justice Statistics Special Report NCJ 213600). Washington, DC: U.S. Department of Justice, Office of Justice Programs. Miller, N. A., & Najavits, L. M. (2012). Creating Trauma-Informed Correctional Care: A Balance of Goals and Environment. European Journal of Psychotraumatology, 3, 1–8. National Alliance on Mental Illness (NAMI). (2013). Mental Illness Facts and Numbers. Retrieved from factsheet.pdf National Alliance on Mental Illness (NAMI). (2022). 988: Reimagining Crisis Response. [Webpage]. Retrieved from Crisis-Intervention/988-Reimagining-Crisis-Response Shufelt, J. L., & Cocozza, J. J. (2006). Youth with Mental Health Disorders in the Juvenile Justice System: Results from a Multi-state Prevalence Study (pp. 1–6). Delmar, NY: National Center for Mental Health and Juvenile Justice. Slate, R. N., Buffington-Vollum, J. K., & Johnson, W. W. (2013). The Criminalization of Mental Illness: Crisis and Opportunity for the Justice System. Durham, NC: Carolina Academic Press. Substance Abuse and Mental Health Service Administration [SAMHSA]. (2016). SAMHSA’s Efforts to Address Trauma and Violence [Webpage]. Retrieved January 6, 2017, from trauma-violence/samhsas-trauma-informed-approach Substance Abuse and Mental Health Service Administration [SAMHSA]. (2020). National Guidelines for Behavioral Crisis Care: Best Practice Toolkit [Online Report]. Retrieved January 6, 2022, from Teplin, L., Abram, K., McClelland, G., Mericle, A., Dulcan, M., & Washburn, D. (April, 2006). Psychiatric Disorders of Youth in Detention. Washington, DC: Office of Juvenile Justice and Delinquency Prevention. Juvenile Justice Bulletin, Office of Justice Programs. Treatment Advocacy Center [TAC]. (2017). 21st Century Cures Act [Webpage]. Retrieved January 13, 2017, from component/content/article/3715 Wagner, P., & Rabuy, B. (2016). Mass Incarceration: The Whole Pie 2016. Northampton, MA: Prison Policy Initiative. Weeks, R., & Widom, C. S. (1998). Self-Reports of Early Childhood Victimization among Incarcerated Adult Male Felons. Journal of Interpersonal Violence, 13, 346–361. World Health Organization (WHO). (October 5, 2020). COVID-19 Disrupting Mental Health Services in Most Countries, WHO Survey. [Online News Release]. Retrieved from

Index Note: Bold page numbers refer to tables; italic page numbers refer to figures, and page numbers followed by “n” denote endnotes.


Act 106 (U.S. Public Law: the “Child Abuse Prevention and Enforcement Act”) 177–178 Acute Stress Disorder (ASD) 297 acute trauma 293; see also trauma administrative segregation 203–204, 206, 208 adverse childhood experiences (ACEs) 100, 299–301, 300, 312, 315 advocacy movement: crusaders for moral treatment 51; Dorothea Dix 50–52; for mentally ill people 50–52 advocacy organizations 89, 199, 256 aftercare, for detained persons 77 alcohol abuse 11, 13, 15, 66, 153, 159, 179, 273–274, 300 Alexis, Aaron 2 ALGEE (five-step action plan) 91 American Law Institute (ALI) 227 American Psychiatric Association (APA) 88, 296 American Psychological Association (APA) 139 Anda, R. 299 anhedonia 13, 14 anosognosia 14, 65 antipsychiatry 55–56 antipsychotic drugs 54, 56, 213; see also medications antisocial associates 245 antisocial behavior 41, 245 antisocial cognition 245, 272 antisocial personality: patterns 245; traits 272 anxiety disorders 9; justice-involved persons with mental illness 11; medications 20; symptomology 12 any mental illness (AMI) 8–9; and ethnicity 10; prevalence rates 10 APIC Model for Transition Planning 77 Arutt, C. 295 assertive community treatment (ACT) 77, 177, 190, 257–258; in Pennsylvania 177–178; PwMI 191; teams 261 assess, plan, identify, and coordinate (APIC) model 247–250 assessment: needs of 333; of people with mental illness (PwMI)

180–181; suicide 182–184; timeliness and frequency of 184–188 assisted outpatient treatment (AOT) 178, 281–284, 285; pros and cons of 282; research highlights 283 asylums: conditions and treatment methods at 46–48; early 45; and moral treatment philosophy 49; PwMI at 46, 50; referred as hospitals 52; superintendents 49; see also mental institutions Asylums (Goffman) 55 Ativan 20 attention deficit-hyperactivity disorder (ADHD) 20 Australia: co-responder team 145; MHFA adoption in 91; reducing emergency commitments in 145 avolition 14 awareness education, and stigma 93–94


Balyakina, E. 274 Barnett, E. R. 306 “Bedlam” 49; see also Saint Mary of Bethlehem Beers, Clifford: A Mind that Found Itself 53 behavioral health: issues and juveniles 18; treatment 19 behavioral health services: community-based 100–102; in a pandemic digital technology to 340–341 behavioral observation 185 Behavioral Risk Factor Surveillance System (BRFSS) 300 best practices: defined 243; in forensic mental health 242 Betts, Connor 2 bilateral prefrontal lobotomy 39, 40 bipolar disorders: risk for justiceinvolvement 12; symptomology 12; see also mental disorders; mental health Birmingham, L. 180 bloodletting 48 Bloom, S. 309 boundary spanners 77, 189, 192, 261 Brad H. vs. City of New York 259–260

Bradley, K. 253 Brooks, Ford 27–30 Buffington, K. 308, 313, 315 “Bummer Squad” 103 burnout 153, 189 Buspar 20 buy-in 329


carceral 58, 87 case management/study: APIC model in action 249–250; bipolar disorder patient 195–196; drug court 314; incompetent defendant allowed to stand trial 229–230; jails/courts 214–215; of Max 316–317; mental health patient 173; transition planning teams/ACT and FACT 257–260; use of force 204–205 Center for Problem-Oriented Policing 149 certified peer support specialists (CPS) 211 Chiarini, G. 230–231 childhood trauma 310; see also trauma child maltreatment 303–304 Children in Crisis (CIC) 150 Children’s Crisis Intervention Training (CCIT) 150 chlorpromazine (Thorazine) 54 chronic psychological disorders 53 chronic psychological symptoms 54 chronic trauma 293 citizens in crisis, and police 127–129 Civil Citation Program (CCP) 151 civil citations 151 clinical needs 186; see also need Cognitive Behavioral Intervention for Trauma in Schools (CBITS) 308 cognitive behavioral therapy (CBT) 233n7 collaborative partnerships 330 commitment statutes and role of police 142–145 communication: and capacity 275; and interaction 186 community: -based behavioral health services 100–102; -based therapy 76; corrections 78–79; police encounters in 174




community-based care: and psychological disorders 54–55; public support for 56 community corrections 269–285; assisted outpatient treatment 281–284, 282; communication and capacity 275; interagency cooperation 277–278; intra-agency collaboration 277–278; MedicationAssisted Therapy 279–280; mental health and 271–272; mental illness 273–274; overview 270–271; post-commitment needs 276–277; recidivism 272; resistance to treatment 280–281; specialized probation 278–279; substance use disorder 273–274; systems integration 277–278; technology 274–275 community mental health centers (CMHCs) 57 Community Mental Health Centers Construction Act 56 community services (crisis aversion) 72–73, 87–109 comorbidities 18 compassion fatigue 152 competency 76; and insanity 223–224; to stand trial 215, 224–226 complex trauma 293; attachment and relationships 311; behavior 312; cognition 312; dissociation 312; economic impact 312–313; effects of 311–313; emotional response 312; long-term health consequences 312; physical health 312; selfconcept and future orientation 312; see also trauma Compton, Leah Vail 26–27, 133 conditional release 76 conditional release order (CRO) 200, 213, 217–220 conditional release plan (CRP) 218–219 continuity of care (COC) 75, 192–193, 251, 272–273 continuum of care 99–102 “conversion disorder” 43 co-occurring disorders (COD) 4, 6, 58; and jail bookings 67; substance use disorders 17 co-occurring substance use disorders (CODs) 17, 190–191, 329, 334, 341 co-responder teams/co-responder model 74, 136–137 correctional facilities 292; data and mental illness 25; mental health

understaffing 58; mental illness in 180; suicide prevention in 208; youths in 18; see also prison settings correctional suicide risk factors 183; see also suicide correctional supervision 65 counseling 19, 210, 221; and correctional facilities 25; family/ group 54; and mental health 20–21; outpatient 177 county diversion strategies 175 county jails 184; see also courts; prison settings courts 199–232; case management 214–215; challenges 229–231; competency and insanity 223–224; competency to stand trial 224–226; conditional release 217–220; county 184; disciplinary issues 203; diversion strategies 209–231; drug treatment court 221; forensic hospitals 215–217; forensic services 213–214; initial detention 201–209; insanity as defense 226–229; jailbased treatment 209–210; mental health treatment court 221–223; peer-based services 211; right to treatment 211–212; segregation 203; self-harm 207; services 220; solitary confinement 204, 206–207; suicide 207–208; therapeutic jurisprudence 220; use of force 204–205; veterans’ treatment courts 223; victimization 202 COVID-19 pandemic 90, 93, 100, 147, 151; and mental health 10; negative effects of 10; risk of mortality and SMI 15; and stressors 100; virtual mental health services 24, 24 criminalization of mental illness 2, 57–58, 58 criminal justice system 11, 25; flowchart 69; and LGBTQ+ people 97; and mental illness 68–70; and PwMI 67–68, 159–160, 180; reforms needed for 108; and systematic suicide risk assessment for individuals 182 criminal profiling, vs. forensic mental health 4 criminogenic risk factors 244–245 crisis: aversion (see community services (crisis aversion)); citizens in, and police 127–129; encounter, and police discretion 142; role of police in mediating 130; specialized

police responses to 129–145; stabilization centers 103 Crisis Assistance Helping Out On The Streets (CAHOOTS) 103–104 crisis care continuum 102–108 crisis hotline 95 Crisis Intervention Team (CIT) 27, 74; curricula 123; model 130–132 Crisis Intervention Training for Youth (CIT-Y) 150 crisis media 94–99; Crisis Text Line (CTL) 95–96 Crisis Need Calculator 331, 332 crisis stabilization unit (CSU) 26–27, 142, 144, 200 Crisis Text Line (CTL) 95–96 critical-incident stress management (CISM) 158 critical time intervention (CTI) 247–248, 258–259 Crumbley, Ethan 2 Cruz, Nikolas 2 cultural relativism 41 Cylert 20


Damian, A. J. 316 dangerousness standard 56 decompensation 25, 73 deinstitutionalization 17, 54–55; and chronic mental illness 65; movement 102 Delaware Department of Correction 185 delusions 14 dementia 106–108 demonology 45 demons, and mental illness 42–43 Department of Corrections (DOC) 334 Department of Veteran Affairs (VA) 259 depression 6, 8, 13, 20, 91; major 9; and suicidal ideation 15 destigmatization efforts: combatting stigma through awareness education 93–94; empirical evidence 92–93; as international agenda 89–94; Mental Health First Aid (MHFA) 91–92 detention alternatives 313–316 determinism 48 developmental traumas 299–304; see also trauma Diagnostic and Statistical Manual of Mental Disorders (DSM-III) 296 Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) 5

Index 349

dialectical behavior therapy (DBT) 210, 233n7 Dickens, Charles 51 digital technology, and behavioral health services 340–341 disability: benefits 25, 147, 256; developmental 216; and people with mental illness 15 discharge determination 187 disciplinary issues 203 disorganized speech 14 Ditton, P. M. 18 diversion 67–68, 71–79, 177–179, 209–231; and behavioral health 67; and criminal justice officials 67; crisis aversion 72–73; effectiveness 179–180; post-arrest 75–76; postconviction 76; post-release 78–79; pre-booking 73–75; preparing for release 76–77 Dix, Dorothea 39, 50–52 drug court case study 314 drugs, and mental illness 54–55 drug treatment courts (DTCs) 221 dual diagnosis clients 302 Durham v. U.S. 227 Dusky v. U.S. 224–225 dynamic risk factors 244, 247


early medical model 44–45 Egyptians, and mental illness 43 elderly correctional populations 193–194 electroconvulsive/shock therapy (ECT) 39, 50 emergency evaluation commitment laws in United States 142–144 employment 253–254 Enlightenment 45 Estelle v. Gamble 212–213 ethnicity: and any mental illness 10; and mental health 59; and mental illness 16; and serious mental illness 10 eugenics 50 Europe: and mental disorders 46–48; mental health treatment 48 evidence-based practices (EBPs) 178 evidence-based treatment approaches 307–309 extreme risk protection orders (ERPO) (“red flag laws”) 343 eye movement desensitization and reprocessing (EMDR) 297


false positives/malingering 220, 228 Federal Communications Commission (FCC) 339 Felitti, V. 299–300 Finkelhor, D. 301–302 flat affect 13 Florida Department of Juvenile Justice (DJJ) 151 Foderaro, J. 309 follow-up teams 74 Food and Drug Administration (FDA) 39 Ford, J. D. 297 Foreman, C. 320 Forensic Assertive Community Treatment (FACT) 190–191, 257–260 forensic commitment 200, 217 forensic hospitals 215–217 Forensic Interagency Task Force (FITF) 334 forensic liaison 192, 214, 219, 262; see also boundary spanner forensic mental health: vs. criminal profiling 4; defined 3; overview 3–4 forensic services 213–214 forensic specialist 26, 200, 214, 218–219 forensic suicide assessments 182 Forensic System Solutions, (FSS) 334 Foucault, Michel 55 Freeman, Walter 53 “Freeze” response 295 frequent flyers 11, 65, 75 Freud, Sigmund 52


GAINS Center for Behavioral Health and Justice Transformation 70 gay-straight alliances (GSAs) 23 gender: in mental health courts 222; and mental illness 16 genetics, and mental illness 50 Glaze, L. E. 16 Goffman, Erving: Asylums 55 Goldsmith, R. E. 306 Gonzalez, C. 313 grandiosity 13 Griffin, P. A. 68 Grimm, Holly A. 297–298 Grimm, Todd L. 297–298 group trauma 294; see also trauma

guilty but mentally ill (GBMI) 229 gyrating chair 47


Halladay, J. 313 hallucination 9, 10, 14, 51, 202, 204, 216, 241 Handle With Care (HWC) 318–320 Haneberg, R. 179 Harris, N. B. 303 Hayes, L. M. 184 health supports for LGBTQ+ community members 96–99 Heinmiller, B. 281 Hinckley, J. 227, 233n11 Hippocrates 44 The History of Mental Retardation (Dix) 50 Holder, E. 301–302 Holmes, J. 282 Holmes, James Egan 1, 2 homelessness 18, 30, 56, 257, 331, 342; chronic 330; and LGBTQ+ people 99; and veterans 66 housing 254–256; see also specific types humoral theory/humorism 44–45


incarcerated persons 181, 184–186, 207, 212, 213, 220, 233n8; PwMI 16–17; PwSMI 58, 67; and substance use disorders 17; suicide prevention for 186 incompetent to proceed (ITP) 215–217, 219, 225, 262 incompetent to stand trial 215–217, 219, 229 indirect traumatization 153 individual placement and support (IPS) 254 individual trauma 294; see also trauma initial detention/initial court hearings 75–76, 201–209 inmates 201–202; see also incarcerated persons Inquirer 188 insanity as a defense 226–229 Insanity Defense Reform Act (IDRA) 227 INSPIRE (violence against children) 305 integration, system 247–248 integrative solutions for system of care (SOC) 336–338



intellectual/developmental disabilities (I/DDs) 75 intellectual disabilities (ID) 184 interaction and communication 186 inter-agency collaboration 99 interagency cooperation 277–278 intercept 0 87–109; accessible social services 99–102; components of 88–102; continuum of care 99–102; crisis media 94–99; destigmatization efforts 89–94; prevention 89–102; response 88–108; take-home message 109; ultimate diversion 88–102 Intercept Five 78–79 Intercept Four 76–77 Intercept One 73–75, 119–161; additional complexities of leo– citizen encounters 145–151; mental health and well-being of police 151–159; police as first responders to citizens in crisis 127–129; responding to special populations 145–151; specialized police responses to crisis events 129–145; take-home message 159–160 Intercept Three 76 Intercept Two 75–76, 193 Intercept Zero 68, 72–73 International Association of Chiefs of Police (IACP) 123 interpersonal traumas 294–295; see also trauma intra-agency collaboration 277–278 involuntary commitment 56, 142 isolation in prison 182 isolation of confinement 201


jail see prison settings James, D. J. 16 James, Frank 2 judges, and juvenile justice system 313–316 Jung, Carl 52 Justice for Victims of Trafficking Act of 2015 304 justice-involved people with mental illness (PwMI) 16–18; challenges in managing 25–30; in the community 17–18; PwMI incarcerated persons 16–17; and substance abuse 65 juvenile justice system 18, 311 juvenile mental health courts (JMHCs) 76 juvenile probation officers (JPO) 285 juveniles 3; and behavioral health issues 18; and MCUs 140; with

mental and BH disorders 150; police encounters with 149; and self-injurious behavior (SIB) 207


Kennedy, John F. 56 Kesey, Ken: One Flew over the Cuckoo’s Nest 55 Klonopin 20


lack of treatment beds 331–332 Laing, R.D. 55 Lane, Charlene 59 Lanza, Adam 2, 282 Latin America and the Caribbean (LAC) 305–306 law enforcement 119–161; agencies 73–75; mental health in 153–157; officers 187; wellness in 153–157 Law Enforcement Assisted Diversion (LEAD) 105–108 LEAD National Support Bureau 105–106 Lee, C. 318 Lensbower, Justin M. 79–80 leo–citizen encounters 145–151 leucotomy 39, 40 LGBTQ+ persons 193–194; bullying of 23; mental health of 23; and mental health struggles 122; “safe spaces” in schools 23; U.S. map of laws protecting 24; wellness and health supports for 96–99 Lifton, R. 296 linkage blindness 252 “The Lobotomist” 53 lobotomy 53; see also prefrontal lobotomy Long, Robert Aaron 2 Loughner, Jared 2


major depression 9; see also depression major depressive disorder (MDD): risk for justice-involvement 13; symptomology 13 malingering 220, 228 maltreatment on victims, effects of 304–305 mania: risk for justice-involvement 13; symptomology 13; see also mental disorders; mental illness; psychotic disorders Martinez, E. 318 mass shootings, in United States 343

mass trauma 294; see also trauma Maynard, B. R. 320 McCollister, C. 314–315 McEnaney, J. 229 measuring risk for violence 246 Medication-Assisted Therapy (MAT) 279–280 medication management 66 medications: prescription psychotropic 210; psychotropic 19–20, 39, 66; see also antipsychotic drugs memorandum of understanding (MOU) 77, 252 Memphis model 74, 131 mental disorders: and Enlightenment era 46; and Europe 46–48; treatment 65; see also mental illness; psychotic disorders mental health (MH): barriers to treatment of 188; caseload 187; community corrections and 271–272; and ethnicity 59; hygiene movement 53; integrated training for 334; in law enforcement 153–157; and race 59; triage 209–210; and well-being of police 151–159 Mental Health Act in 1963 137 Mental Health America (MHA) 256 mental health courts (MHCs) 221–222 Mental Health First Aid (MHFA) 91–92, 123; adoption, in Australia 91; in Australia 91; subsequent adaptation 91 mental health professional (MHP) 187 Mental Health Programs 176 mental health services: barriers to 8; counseling 21; virtual 24, 24; utilization 20–21, 22 mental health treatment: approaches 41; court 221–223; in early nineteenth-century America 48; Europe 48; moral treatment 48; philosophy on 56; psychogenic approach 41; somatogenic approach 41; supernatural approach 41; see also treatment mental hygiene 89 mental illness (MI) 329; any mental illness 8–9; categorizing 8–15; common types in the United States 9; community corrections 273–274; and correctional facilities data 25; criminalization of 57–58, 58; and criminal justice system 68–70; defined 5–6, 8; dual diagnosis of 274; and genetics 50; historical responses to 39–61; people, as immoral creatures 42; prevalence

Index 351

of 6–7; psychogenic theories for 52–53; reported in correctional facilities 180; serious mental illness 9–10; severe and persistent mental illness 11–15; societal responses to 42–59; suicide as consequence of 15; see also mania; mental disorders; psychotic disorders mental institutions: dehumanizing experiences 53; state 254; see also asylums mental status at the time of the offense (MSO) evaluation 226–228 mercy booking 159 Merrick, M. T. 301 Mesmer, Franz Anton 48 mesmerism 48 Mesopotamian civilizations, and mental illness 42 military personnel 187 military veterans see veterans A Mind that Found Itself (Beers) 53 mixed program 176 mobile crisis response 103–105 mobile crisis response teams (MCRTs) 104, 137–139 mobile crisis units (MCUs) 137–139 mood disorders 9 mood stabilizers 20 Morabito, M. S. 134 moral treatment 48; and asylums 49; crusaders for 51 multiple systems of care 251 Munetz, M. R. 68 Muñoz shooting, Lancaster, Pennsylvania 122 Murdough, Jerome 66, 78 The Myth of Mental Illness (Szasz) 55

National Health Service (NHS) (UK) 252–253 National Institute of Mental Health 53 National Mental Health Act 53 National Mental Health Association (MHA) 53 National Research Council (NRC) 180 National Suicide Hotline Designation Act 95 National Suicide Prevention Lifeline 95 National Survey of Children Exposed to Violence (NatSCEV) 301 National Survey on Drug Use and Health (NSDUH) 21, 32n4 Natural Traumas and Human-Caused Traumas 293–294; see also trauma need: assessment 333; case management 257–260; clinical 186; disability benefits 256; employment 253–254; housing 254–256; information sharing of identified service 334–335; post-commitment 276–277; principle 247; supportive employment (SE) 254; transition planning teams/ACT and FACT 257–260 negative symptoms 14 Neolithic civilizations, and mental illness 42 neurofeedback (NF) for PTSD 298 NIMBY (not-in-my-backyard) 255 not guilty by reason of insanity (NGRI/NGI) 1, 200, 215, 217, 226–227, 229, 233 not in my backyard (NIMBY) mentality 56



National Academies of Sciences, Engineering, and Medicine (NASEM) 90 National Alliance on Mental Illness (NAMI) 56, 256; creating change through 93–94; peer support prevention programs 93–94 National Centers of Excellence in Youth Violence Prevention (YVPC) 305 National Child Traumatic Stress Network (NCTSN) 309–311, 318 National Committee for Mental Hygiene 53 National Council for Behavioral Health 146 national data on child maltreatment 303–304

Obama, Barack 147 obsessive-compulsive behaviors 9 Office of Juvenile Justice and Delinquency (OJJDP) 317 Olafson, E. 313 One Flew over the Cuckoo’s Nest (Kesey) 55 “One Mind Campaign” 123 operational stress 153 organizational stress 153 outpatient commitment 281; see also assisted outpatient treatment (AOT)


Pacific County Jail, Washington 191 Paddock, Stephen 2 Padilla, J. 204–205

Pan American Health Organization (PAHO) 305 parens patriae 142, 214 parent of the people 233n9 Path to Incarceration, Eastern State Penitentiary, Philadelphia 174 peer-based services 211; see also peer support programs (PSPs) peer support prevention programs 93–94 peer support programs (PSPs) 211; see also peer-based services Pennsylvania Department of Corrections (PA DOC) 184, 188 Pennsylvania Forensic Interagency Task Force 334 people of color (POC) 122; with dual diagnoses 59; and mental illness 16; police interactions with 122 people with dementia, and police 106–108 people with lived experience (PWLE) of mental illness 4, 50, 103, 174, 199, 253, 261, 285, 342; “pains of imprisonment” experienced by 67; and police 73–75 people with mental illness (PwMI) 87–88, 175, 177, 270, 275, 331, 338–339, 342; ACT 191; at asylums 46, 50; boundary spanners 192; constitutional protections 212; in correctional setting 206; custody and treatment strategies 223; and disability 15; drugs and community-based care 54–55; in early nineteenthcentury America 48; in Eastern societies 45; electroconvulsive/ shock therapy used on 50; general population data 20–24; incarcerated persons with 16–17; incarceration 200, 201, 203–204, 208–210; in jails and prisons 208; justice-involved 16–18, 25–30, 65; and justice system 3; legal mandate 217; police response to 128–129; post-conviction 76; processing and disposition of 180; reentry for 243, 253–260; screening and assessment of 180–181; self-injurious behavior 207; as stigmatized groups 41; stigmatizing 56; suicidal ideation 231; use-of-force 205 people with serious mental illness (PwSMI) 4, 191; incarcerated in jails 58, 67; in public psychiatric hospitals 58



people with serious psychological disturbances/disorders (PwSPD) 4 person-first language 5 phlebotomy 45 phrenology 46, 47 physiognomy 46 Pickens, I. B. 313 Pinel, Phillippe 48 police: -based crisis intervention teams 74; -citizen relations 121; –clinician follow-up 139–140; commitment statutes and role of 142–145; and crisis situations 74; discretion during a crisis encounter 142; encounters 124–127, 149, 174; as first responders to citizens in crisis 127–129; local 29–30; maximizing officer wellness and safety 157; mental health and well-being of 151–159; people with dementia and their interaction with 106–108; -provoked shootings 135, 136; and PWLE 73–75; recruit training 313–316; regional 29–30; role in mediating crisis 130; training programs 121, 173 Police Executive Research Forum (PERF) 121 police response: to people with mental illness 128–129; specialized, to crisis events 129–145 police stress 152–153 police suicide 158–159 policy matters/recommendations 335–340 Policy Research Associates (PRA) 68, 70 political terror and war 296 polyvictimization 301 possession, and mental illness 42–43 post-arraignment programs 176 post-booking diversion 174–175; overview 175–176; participants 176 post-commitment needs 276–277 post-traumatic stress disorder (PTSD) 9, 223, 296–297, 297; justiceinvolved persons with mental illness 11; and law enforcement officers 187; and military personnel 187; risk for justice-involvement 12; symptomology 12 pre-arraignment programs 175 pre-booking diversion 73–75, 173 prefrontal lobotomy 53; see also lobotomy prison settings 199–232; case management 214–215; challenges 229–231; competen