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Linda Rosenberg

Former President and CEO, National Council for Behavioral Health

And Justice for All: What Works at the Interface of Mental Health and Criminal Justice

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I wish I had a penny for every time I’ve said, “We know what to do; now we just have to do it.” Nowhere is this truer than in the treatment of people with mental illnesses and substance use disorders in the criminal justice system.

“We have good science,” Fred Osher, M.D., told us. “We have policies that are associated with a reduction of people with mental illnesses in the justice system. But we haven’t put it together and sustained it over time.” Fred, a psychiatrist at the Charleston Dorchester Mental Health Center in Charleston, South Carolina, is the retired health systems and services policy director for the Council of State Governments (CSG) Justice Center.

We recently spoke to Fred and to Chan Noether, director of the GAINS Center for Behavioral Health and Justice Transformation. We wanted to know why people with mental and substance use disorders are overrepresented in the criminal justice system, what we’re doing right, and what we need to be doing better. First, some key facts:

How did we get here? The reasons are as simple as they are tragic. We arrest people with mental illnesses more often that those without these conditions, typically for nonviolent crimes or low-level offenses. They stay in jail longer, where they are more likely to be placed in solitary confinement than other inmates and to decompensate. And they return more frequently, often because they have violated conditions of their release, which might include paying a fine or keeping medical appointments. They get stuck in the system, Fred pointed out.

How do we break this cycle? First and foremost, we must prevent people with mental and substance use disorders from encountering the criminal justice system in the first place. That demands a robust crisis care continuum that includes mobile crisis teams, short-term crisis stabilization, peer crisis services and 24/7 hotlines and warm lines. For those familiar with the Sequential Intercept Model, developed to inform community-based responses to the involvement of people with mental and substance use disorders in the criminal justice system, a crisis system is part of Intercept O.

A comprehensive crisis continuum requires collaboration and coordination between mental health providers and first responders, including local law enforcement. Too often, these systems are siloed and compete for resources, Chan said. To be effective in responding to mental health crises, law enforcement officers need adequate training. To date, more than 400 law enforcement agencies across the country have taken the One Mind Pledge, which includes a commitment to train and certify 100 percent of their agency’s sworn officers in Mental Health First Aid for Public Safety and at least 20 percent of the force in Crisis Intervention Team training. Police also need a place to take someone in need of treatment, and one Certified Community Behavioral Health Clinic (CCBHC) is providing just that.

Cascadia Behavioral Healthcare, a CCBHC in Oregon, developed an urgent walk-in clinic as a place for police officers to bring individuals who are in crisis and need behavioral health treatment, rather than booking them in jail. The clinic provides assessment and coordination to decrease an individual’s further engagement with the justice system.

Second, when someone is booked into jail, we must screen and assess everyone for the presence of mental and substance use disorders. The GAINS Center developed an eight-question Brief Jail Mental Health Screen that can be administered by any corrections staff. Universal screening and assessment is a key component of the Stepping Up Initiative – a program of the CSG Justice Center, the National Association of Counties and the American Psychiatric Association Foundation – to help counties reduce the number of jail inmates with mental illnesses. To date, more than 450 counties have joined the effort, and eight innovator counties are making substantial progress in identifying people with mental illnesses in their custody.

Third, once we identify people with mental and substance use disorders who don’t need to be in jail, we must divert them to treatment and services. Over the past decade, the Miami-Dade County, Florida, Criminal Mental Health Project – begun by pioneering Judge Steven Leifman – has diverted some 4,000 individuals with mental illness from the country jail into community treatment. The recidivism rate among participants who committed a misdemeanor is about 20 percent, compared to 75 percent among defendants not in the program.

Fourth, we must provide services for those who need to remain in jail. As Fred noted, inmates have a constitutional right to receive health care services, but some jails do a better job than others. Despite the prevalence of substance use disorders among those in jail, only 19 percent of inmates receive any kind of treatment. They are at high risk for relapse and death when they are released. Recently, Rhode Island became one of the first states in the nation to offer its jail inmates all three approved medications for opioid addiction.

Fifth, we must connect former inmates to treatment and services when they reenter the community. Once again, CCBHCs are stepping up to the plate. The Family Guidance Center in Missouri created a fulltime law enforcement center liaison to work as a discharge planner in the local jail. The liaison completes assessments, provides crisis services at the correctional facility and connects individuals to needed treatment, including assessment and management of risk and evidence-based cognitive interventions.

Ultimately, we must support well-funded, comprehensive systems of care in the community for everyone with or at risk of having a mental illness or substance use disorder. That’s why the National Council is a proud supporter of CCBHCs and of the Excellence in Mental Health and Addiction Treatment Expansion Act. This bill would fund all current CCBHCs for another year and expand the program to 11 more states that already applied to participate. CCBHCs are helping transform the system of care for mental illnesses and addictions, from a patchwork of underfunded, overburdened organizations struggling to meet their communities’ needs to a thriving array of clinics that meet standards for comprehensive, high-quality treatment.

We know what to do. Now we need the resources and the political will to do it. Won’t you join us? And be sure to register now for NatCon19 – the National Council conference – where we’ll have a comprehensive criminal justice track to explore these issues in more depth. You won’t want to miss it!