Stepping Up to Address a National Crisis: Too Many People with Mental Illnesses in our Jails

Transcription

1 Stepping Up to Address a National Crisis: Too Many People with Mental Illnesses in our Jails Fred C. Osher, M.D. May 9, 2017 Stepping Up in North Carolina Raleigh, North Carolina

2 Stepping Up: A National Initiative to Reduce the Number of People with Mental Illnesses in Jails Released in January 2017 To read the full report, please visit:

3 There will be fewer people with mental illnesses in our jails tomorrow than there are today.

4 National Partners Rally Around a Common Goal Partners and Steering Committee Members Federal Partners

5 Number of Counties Continues to Grow, Reaching Critical Mass Approximately 130 million people reside in Stepping Up counties

6 39 North Carolina Counties Have Stepped Up Alamance Buncombe Burke Cabarrus Camden Catawba Columbus Craven Cumberland Dare Davidson Durham Forsyth Graham Granville Guilford Halifax Harnett Hoke Lee Macon Mecklenburg New Hanover Northampton Orange Pasquotank Pender Perquimans Person Pitt Rockingham Scotland Surry Tyrrell Vance Wake Warren Washington Wayne Stepping Up counties represent 58% of the state s average daily jail population.

7 About CSG Justice Center National non-profit, non-partisan membership association of state government officials that engages members of all three branches of state government. Justice Center provides practical, nonpartisan advice informed by the best available evidence.

8 Overview Scope of the issue: How did we get here? Key challenges counties face: Why is it so hard to fix? Effective Strategic Plans: How do we move forward?

9 01. Mental Illnesses in the Criminal Justice System: How did we get here?

10 Millions of Adults Now Under Correctional Supervision Bureau of Justice Statistics ,000,000 7,000,000 6,000,000 Total Probation Prison Parole Jail 5,000,000 4,000,000 3,000,000 2,000,000 1,000,

11 Recent Decline in State Prison Population First decline in state prison populations in 38 years Pew Center on the States (2009)

12 Jails are Where the Volume is Number of Admissions to Jail and Prison Weekly and Annually, ,605,175 Annually Weekly 553, ,565 10,621 Jail Admissions Prison Admissions

13 While Jail Populations Have Declined in Some Counties Inmates Confined in Local Jails at Midyear and Percent Change in the Jail Population, Number of Inmates at Midyear 900, , , , , , , , ,000 Annual Percent Change Year -3.0

14 Jails Report Increases in the Numbers of People Mental with Illnesses NYC Jail Population ( ) Average Daily Jail Population (ADP) and ADP with Mental Health Diagnoses 13,576 Total 10,257 76% 11,948 Total 7,557 63% 3,319 24% 4,391 37% M Group Non-M Group

15 Mental Illnesses: Overrepresented in Our Jails General Population Jail Population 5% Serious Mental Illness 17% Serious Mental Illness 72% Co-Occurring Substance Use Disorder

16 Rising Number of People in Jails and Prisons for Drug Offenses

17 Percent of Population Alcohol and Drug Use Disorders: Household vs. Jail vs. State Prison % 53 % % 44 % Alcohol use disorder (Includes alcohol abuse and dependence) Drug use disorder (Includes drug abuse and dependence) 10 8 % 2 % 0 Household Jail State Prison Abrams & Teplin (2010)

18 Substantial Increase in the Number of Women: Federal and State Prisons ( )

19 Substantially Higher Rates across Demographic Lines Source: The Growth of Incarceration in the United States: Exploring Causes and Consequences, (Washington, DC: National Academies Press, 2014), 63.

20 Factors Driving the Crisis Disproportionately higher rates of arrest Longer stays in jail and prison Limited access to health care Higher recidivism rates Low utilization of EBPs More criminogenic risk factors

21 What Factors are Driving the Crisis? Disproportionately higher rates of arrest

22 Homelessness and the Enforcement of Quality-of-Life Violations Laws: 187 Cities

23 What Factors are Driving the Crisis? Longer stays in jail and prison

24 Longer Lengths of Stay in Jail Portion of M Group Meeting Criteria for Serious Mental Illness (SMI) Non- M Group 79% M Group 21% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 43% 57% M Group, SMI M Group, Non-SMI Average Length of Stay by Mental Health Status Non-M Group 61 M Group (Overall) 112 M Group, Non- 128 M Group, SMI 91 Source: The City of New York Department of Correction & New York City Department of Health and Mental Hygiene 2008 Department of Correction Admission Cohort with Length of Stay > 3 Days (First 2008 Admission)

25 Factors Driving the Crisis Limited access to healthcare

26 Limited Access to Health Care Poor health status Hispanic Uninsured Rate for Hispanic, Black, and White Populations (2013) 33% Poor health access Black 22% White 14% Source: The Commonwealth Fund, Closing the Gap: Past Performance of Health Insurance in Reducing Racial and Ethnic Disparities in Access to Care Could Be an Indication of Future Results, March 2015.

27 Factors Driving the Crisis Low utilizations of evidence-based practices (EBPs)

28 Low Utilization of EBPs: Filling the Science to Service Gaps Past Year Mental Health Care and Treatment for Adults 18 or Older with Both SMI and Substance Use Disorder NSDUH (2008)

29 Factors Driving the Crisis Higher rates of recidivism

30 What Accounts for the Problem? High Recidivism Rates on Reentry Screened 2,934 probationers for mental illness: 13% identified as mentally ill Followed for average of two years No more likely to be arrested but 1.38 times more likely to be revoked Source: Vidal, Manchak, et al. (2009); see also: Eno Louden & Skeem (2009); Porporino & Motiuk (1995)

31 Factors Driving the Crisis More criminogenic risk factors

32 Number of Crimes Yet, Incarceration Is Not Always Directly Related to the Individuals Mental Illness % % 10.7% 17.2% Continuum of Mental Illness Relationship to Crime Completely Direct Mostly Direct Mostly Independent Completely Independent Source: Peterson, Skeem, Kennealy, Bray, and Zvonkovic (2014)

33 What Accounts for the Problem? Those with Mental Illnesses Have More Criminogenic Risk Factors ** LS/CMI Tot Persons with mental illnesses Persons without mental illnesses.and these predict recidivism more strongly than mental illness Skeem, Nicholson, & Kregg (2008)

34 Predicting Future CJ contact: Criminogenic Risk Risk Crime type Dangerousness or violence Failure to appear Sentence or disposition Custody or security classification level Risk = How likely is a person to commit a crime or violate the conditions of supervision?

35 Criminogenic Risk Factors Static Criminal History - Number of arrests - Number of convictions - Type of Offenses Current Charges Age at first arrest Current age Gender Dynamic (the Central 8 ) 1. Substance abuse 2. History of antisocial behavior 3. Antisocial personality pattern 4. Antisocial cognition 5. Antisocial associates 6. Family and/or marital discord 7. Poor school and/or work output 8. Few leisure/recreation outlets

36 Risk-Need-Responsivity (RNR) Model Principle Risk Principle Implications for Supervision and Treatment Focus resources on higher RISK individuals; limited supervision of lower RISK individuals Needs Principle Target the NEEDS associated with recidivism such as antisocial attitudes, antisocial associates, unemployment, substance abuse Responsivity Principle General and specific factors impact the effectiveness of treatment. Be RESPONSIVE to learning style, motivation, culture, demographics, and abilities of the offender

37 The Importance of the Risk Principle Failing to adhere to the risk principle can increase recidivism Average Difference in Recidivism by Risk for Individuals in Ohio Halfway House LOW RISK + 3% Moderate Risk - 6% High Risk - 14% Source: Presentation by Dr. Edward Latessa, What Works and What Doesn t in Reducing Recidivism: Applying the Principles of Effective Intervention to Offender Reentry

38 The Needs Principle: Addressing Criminogenic Needs Can Reduce Future Criminal Behavior Employment/ Education The Big Four Housing Past Criminality* Criminal Behavior Thinking Peers Family Higher-risk offenders are likely to have more of the Big Four. Substance Use Personality Programs targeting these needs can significantly lower recidivism rates Leisure * Past criminality cannot be changed.

39 The Responsivity Principle and Mental Illnesses Poor Employment History Lack of Education Lack of Prosocial Leisure Activities Antisocial Attitudes Mental Illness Family and/or Marital Factors Antisocial Personality Pattern Substance Abuse Antisocial Friends and Peers Use methods, which are effective for justice involved individuals. Adapt treatment to individual limits (length of service, intensity). Consider those factors that may serve as barriers to program or supervision compliance (language barrier, illiteracy, etc.).

40 Knitting Together Available Research

41 To Create A Framework for Prioritizing Target Population Low Criminogenic Risk (low) Medium to High Criminogenic Risk (med/high) Low Severity of Substance Abuse (low) Substance Dependence (med/high) Low Severity of Substance Abuse (low) Substance Dependence (med/high) Low Severity of Mental Illness (low) Serious Mental Illness (med/high) Low Severity of Mental Illness (low) Serious Mental Illness (med/high) Low Severity of Mental Illsness (low) Serious Mental Illness (med/high) Low Severity of Mental Illness (low) Serious Mental Illness (med/high) Group 1 I-L CR: low SA: low MI:lo Group 2 II-L CR: low SA: low MI: med/high Group 3 III-L CR: low SA: med/high MI: low Group 4 IV-L CR: low SA: med/high MI: med/high Group 5 I-H CR: med/high SA: low MI: low Group 6 II-H CR: med/high SA: low MI: med/high Group 7: III-H CR: med/high SA: med/high MI: low Group 8 IV-H CR: med/high SA: med/high MI: med/high

42 02. Counties Step Up but Face Key Challenges: Why is it so hard to fix?

43 Key Challenges Counties Face: Observations from the Field Being data driven Using best practices Continuity of care Measuring results

44 Challenge 1 - Being data driven: Policymakers Face Complex Systems with Limited Information

45 Challenge 1 - Being data driven: Inconsistent Definitions; Not All Mental Illnesses are Alike Portion of M Group Meeting Criteria for Serious Mental Illness (SMI) Non- M Group 79% M Group 21% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 43% 57% M Group, SMI M Group, Non-SMI Average Length of Stay by Mental Health Status Non-M Group 61 M Group (Overall) 112 M Group, Non- 128 M Group, SMI 91 Source: The City of New York Department of Correction & New York City Department of Health and Mental Hygiene 2008 Department of Correction Admission Cohort with Length of Stay > 3 Days (First 2008 Admission) 45

46 Challenge 1 - Being Data Driven: Not Knowing the Target Population County A County B County C County D Mental Health - Assessment Substance Abuse Assessment - Risk Assessment -

47 Challenge 2 Using Best Practices: Addressing Dynamic Needs Dynamic Risk Factor History of antisocial behavior Antisocial personality pattern Antisocial cognition Antisocial associates Family and/or marital discord Poor school and/or work performance Few leisure or recreation activities Substance abuse Need Build alternative behaviors Problem solving skills, anger management Develop less risky thinking Reduce association with criminal others Reduce conflict, build positive relationships Enhance performance, rewards Enhance outside involvement Reduce use through integrated treatment Andrews (2006)

48 Challenge 2 Using Best Practices: Applying Results of Screening and Assessment: Without Risk Assessment With Risk Assessment Risk of Re-offending LOW 10% re-arrested MODERATE 35% re-arrested HIGH 70% re-arrested

49 Challenge 3 Continuity of Care Existing Services Only Reach a Small Fraction of Those in Need 10,523 Bookings 969 People with serious mental illness 2,315 People with serious mental illness based on national estimates 609 Received treatment in the community Example from Franklin County, OH 1,706 Did NOT receive treatment in the Community 926 LOW RISK 1,389 HIGH/ MOD RISK

50 Challenge 4 Tracking Progress: Focusing County Leaders on Key Outcomes Measures Outcome measures needed to evaluate impact and prioritize scare resources 1. Reduce the number of people with mental illness booked into jail 2. Shorten the length of stay for people with mental illnesses in jails 3. Increase the percentage of people with mental illnesses in jail connected to the right services and supports 4. Lower rates of recidivism

51 03. Effective Strategic Plans: How do we move forward?

52 How do We Know if a County is Positioned to Reduce the Number of People with Mental Illness in Jail? Six Key Questions 1. Is your leadership committed? 2. Do you have timely screening and assessment? 3. Do you have baseline data? 4. Have you conducted a comprehensive process analysis and service inventory? 5. Have you prioritized policy, practice, and funding? 6. Do you track progress?

53 Is your Leadership Committed? Mandate from county elected officials Representative planning team Commitment to vision, mission, and guiding principles Designated project coordinator and organized planning process Accountability for results

54 Mental Illnesses: Overrepresented in Our Jails December 9, 2014 federal, state and local leaders, such as Commissioner Brown, discussed their support for reducing the number of people with mental illnesses in jails. Commissioner Brown at National Stepping Up Summit Mentally ill inmates at Franklin County Jail stay longer Franklin County Jail adding 27 employees to assess new inmates System would help Franklin County jail better track inmates

55 Do You have Timely Screening and Assessment? Is there are system-wide definition of: Mental illness Substance use disorders Recidivism Screening and assessment: Validated screening & assessment tools Efficient screening & assessment processes Electronically collected data

56 Selecting Tools to Screen and Assess for MH, SU, and CR Multiple screening instruments to consider, for example: Brief Jail Mental Health Screen Correctional Mental Health Screen Mental Health Screening Form Texas Christian University Drug Screen V

57 Information Sharing Agreements between Agencies is Recommended Screening & Assessment: Salt Lake County, UT Screenings Administered at Jail Booking and Follow Up Assessments in Salt Lake County, UT Recommended Uses for Informing Decision-Making Correctional Mental Health Screen Jail Management Level of Service Inventory: Screening Version Texas Christian University Drug Screen V Salt Lake Pretrial Risk Instrument Assessments Based on Screening Results in Jail or In the Community Pretrial Release Diversion Connection to Care at Discharge Community Supervision

58 Screening & Assessment: Bexar County, TX BEXAR COUNTY PRETRIAL FACILITY & JAIL Check Continuity of Care State to see whether accessed state public mental health system Screening Form for Suicide and Medical/Mental/Developmental Impairments IF EITHER IS A POSITIVE MH SCREEN: MH ASSESSMENT IS REQUIRED BY LAW INFORMATION MUST BE AVAILABLE TO THE PRETRIAL JUDICIAL OFFICER FOR A MH PERSONAL RECOGNIZANCE BOND

59 Do You have Baseline Data? Ability to measure: Prevalence rate of mental illnesses in jail population Length of time people with mental illness stay in jail Successful connection to community-based treatment, services, and supports Recidivism rates Electronically collected and recorded data

60 Baseline Data: New York City M Group, SMI M Group, Non-SMI New York City: Portion Of M Group Meeting Criteria For Serious Mental Illness (Smi) Non- M Group 79% M Group 21% 43% 57% Non-M Group 61 Average Length of Stay by Mental Health Status M Group (Overall) M Group, Non-SMI M Group, SMI 91 Source: The City of New York Department of Correction & New York City Department of Health and Mental Hygiene 2008 Department of Correction Admission Cohort with Length of Stay > 3 Days (First 2008 Admission)

61 Have You Conducted a Comprehensive Process Analysis and Service Inventory? System-wide process review Inventory of services and programming Identified system gaps and challenges Process problems Population projections Capacity needs Evidence Based Practices Identified

62 Arrest and Booking Comprehensive Process Analysis: TX Warning 1: CIT training of law enforcement is not comprehensive; protocols vary by agency. Arrested Person (AP) taken into custody YES ARREST Police respond to call Make an arrest? If in crisis and no offense or Misd C or lower, AO may take individual to hospital or psychiatric facility NO Warning 2: Can law enforcement locate a facility with capacity for APs with acute MH needs? Hospital/psychiatric facility is not appropriate, AO may take individual to shelter FOR SPECIFIED JURISDICTIONS Individuals brought to County Jail for booking AP can be diverted to services with referral, with AO supervisor s approval (misd. only); or, AP can be released out of psych facility EXIT OUT OF CRIMINAL JUSTICE SYSTEM IF MUNICIPAL POLICE APs with Misd. B and higher brought to Dallas County Jail for booking 23 municipalities AP brought to city jail if Misd. C or lower; AP can bond out or be released from city detention center Arresting Officer verifies ID of Arrested Person Shakedown process by Booking Officer; personal information entered into AIS by DMU Nurse screens for medical or mental health issue; can refer for special services Nurse assessment becomes part of DPD report Booking information is completed and entered electronically/manually as IT capacity allows Detention officer completes case routing form ; Central Intake screen for Suicide, Medical, and Mental Impairments Case routing form ; Central Intake Assessment and Housing Recommendation Warning 3: Lack of standardized policies at the various detention facilities across the county Warning 4:. Automated information system data entry happens at various times Warning 5: Medical staff cross check jail booking info with local hospital(s) system to check MH history; info is not shared with County Jail staff

63 Have You Prioritized Policy, Practice and Funding? Consider a full spectrum of strategies Strategies clearly focus on the four key measures 4 Costs and funding identified $ County investments

64 Prioritized Policy, Practice, & Funding: Santa Clara County, CA Jail Diversion Subcommittee develops 35 recommendations Recommendations touch all parts of system plus administrative costs Recommendations prioritized as High, Medium or Other Time frames identified for recommendations Costs estimated and funding sources identified Agency lead identified Presentation to Board of Supervisors focuses on 10 recs Identifies existing resources to be leveraged Recommendations for Screening & Assessment, Treatment, Housing, Supervision, and Administrative Support/Data/Evaluation are pegged to funding from MHSA, AB 109, Medi-Cal, and county General Funds Subcommittee recs that can be started immediately without additional money- such as team-building and a cross-systems work group- are started immediately Large investments- such as BH Urgent Care Centers and Permanent Supportive Housing Units- are staged over time Considerations for booking environment focus on pre- and post- new jail construction Approved unanimously by BOS on Aug. 31, 2016 Implementation plans and initial appropriations on Sept. 13, 2016 First monthly progress report to BOS on implementation Nov. 1, 2016

65 Do You Track Progress? Reporting timeline of four key measures 4 Process for progress reporting Ongoing evaluation of program implementation Ongoing evaluation of program impact

66 Tracking Progress: Franklin County, OH

67 Phases of Stepping Up Phase 1: Build coalition, recruit counties, convene summit Phase 2: Develop/refine framework for action, increase knowledge, support county-level planning Phase 3: Help all county to have real-time data on the number of people with mental illnesses in their jails Phase 4 : Help counties set reduction targets, pursue and improve strategies, highlight successes

68 Federal Opportunities: The 21 st Century Cures Act Reauthorizes the Mentally Ill Offender Treatment and Crime Reduction Act Expands diversion opportunities for people with mental health and substance use disorders Expands uses of Second Chance Act grant funds for mental health treatment and supports and housing Funds mental health training for law enforcement departments Prioritizes federal grant funding for evidencebased programs, use of risk assessment, and focus on data-informed decision-making

69 What can you do??

70 THANK YOU For more information, contact: Fred Osher The American Psychiatric Association Foundation: americanpsychiatricfoundation.org The National Association of Counties: naco.org The Council of State Governments Justice Center: csgjusticecenter.org