The State of the Justice-involved Seriously Mentally Ill

The State of The JusticeInvolved Seriously Mentally Ill

What are best practices correctional departments are engaging to address this crisis?

According to the American Psychological Association nearly 4% of all inmates are schizoid; 18% suffer major depression. It is also reported the 2%-4% are bipolar and 72% of inmates have multiple disorders. It has often been said that correctional facilities serve as today’s mental health institutions—with disastrous effect on those they are meant to treat.

To better understand this crisis in correctional facilities nationwide, Corrections Forum asked sev

eral medical directors, mental health providers and prison advocates how they best address this medically challenged population.

“Sixty years of failed mental health policies and misplaced incentives have forced law enforcement onto the front lines of mental illness crisis response. Jails and prisons are now our de facto mental health institutions, as psychiatric bed capacity has reached its lowest point in our nation’s history,” states John Snook, executive director, Treatment Advocacy Center, in testimony before the President’s law enforcement commission this past spring.

Law enforcement officers do not sign up to be mental health practitioners and using them as such wastes precious resources, damages law enforcement-community relationships, unnecessarily criminalizes a medical issue and ultimately ill serves both the person in need and the system attempting to provide care, he furthers.

Snook points out that an estimated 8.3 million adults in the United States live with a severe mental illness (SMI). Approximately half go untreated

every year (Treatment Advocacy Center, 2017). The consequences of failing to care for the most severely ill are devastating and have significant implications for law enforcement and the effective administration of justice, he says. As a result of limited community treatment options and a dire shortage of psychiatric treatment beds, those in need of mental illness care frequently only receive care once a crisis occurs that necessitates law enforcement involvement. He points out that, though numbering somewhat fewer than 4 in every 100 adults in America, individuals with SMI generate no less than 1 in 10 calls for police service (Chappell, D., Editor, 2013).

The National Alliance on Mental Illness, or NAMI, the nation’s largest grassroots mental health organization dedicated to building better lives for the millions of Americans affected by mental illness, points to similar sobering statistics. It is estimated that nearly 11.2 million adults (NIMH, Feb. 2019) in the U.S. have a SMI yet only 64% received treatment in 2018 (Substance Abuse and Mental Health Administration, Aug. 2019).

“There are many reasons why people don’t receive treatment, but one is that there is an absence of a community-based mental health system that can meet the needs of people with mental illness. Without a robust mental health system, we are forced to place an overreliance on the criminal justice system to address the mental health crisis,” according to Daniel H. Gillison, Jr., CEO of NAMI.

“Mental illness is not a crime,” he furthers, “we should not treat it as one. When someone is experiencing a medical emergency, such as a heart attack or a stroke, it is almost guaranteed that if they call for help, they will be provided with the medical care they need. However, when someone is in a mental health crisis, they often get a cop, not a doctor.”

We know that when people with serious mental illness don’t get adequate treatment they can end up in hospital emergency rooms, in jail, or on the streets with worse long-term outcomes. “People with mental illness in a crisis need help, not handcuffs.

“Jails and prisons are expected to provide treatment in a system that is not structured to provide the therapeutic environment necessary to treat mental illness, and we turn to the courts to connect the most seriously ill with the services and supports they need.

“NAMI is fighting to ensure that people with serious mental illness can access the treatment they need and deserve so they do not end up in hospital emergency rooms, in jails, and homeless on the streets. Creating an effective mental health system that has the services and supports to help anyone with a mental health condition is the number one thing we can do to reduce our reliance on the criminal justice system,” asserts Gillison.

High Cost of Lack Of Treatment

As a result of the lack of public health treatment for those with SMIs the high cost of treatment falls to public safety and corrections. According to Snook, a 2019 survey done by Treatment Advocacy Center in conjunction with the National Sheriffs Association on the role and impact on law enforcement of transporting individuals with SMI found that at least one-fifth of total law enforcement staff time was used to respond to and transport individuals with mental illness, at an estimated cost of $918 million. Another survey by the Treatment Advocacy center showed that law enforcement officers nationwide drove a total of 5,424,212 miles to transporting individuals with serious mental illness in 2017 (Sinclair, E., et al., 2019).

“This poses a significant financial burden on law enforcement and county budgets,” Snook underscores. Mentally ill inmates cost more than other prisoners for a variety of reasons, including increased staffing needs. “In Broward County, Fla., in 2007, it cost $80 a day to house a regular inmate but $130 a day for an inmate with mental illness. In Texas prisons in 2003, the average prisoner costs the state about $22,000 a year, but prisoners with mental illness range from $30,000 to $50,000 a year.” Psychiatric medications are a significant part of the increased costs. The cost of settling or losing lawsuits stemming from the treatment of mentally ill inmates also adds considerable costs. (Treatment Advocacy Center, 2016, Serious Mental Illness Prevalence in Jails and Prisons.)

Current Prison Strategies

How are health care providers inside prisons and jails addressing these individuals with SMIs within their populations?

Wellpath says its focus in responding to its large population of patients diagnosed with serious mental illness is grounded in a model of proactive care, from identification, to provision of evidence-based treatment, to planning for release back to the community. Charlene Donovan, Ph.D., RN, MSN, PMHNP-BC, vice president, Behavioral Health Services, says that a solid intake process is necessary to start each patient on a trajectory of proactive care, and including behavioral health professionals in the intake process can be particularly valuable. Identifying mental and behavioral health issues, along with recognizing the need for a more thorough assessment of clinical need as quickly as possible starts a thorough treatment process, she adds.

In order to quickly triage, “The Wellpath Receiving Screen provides guidance for users in terms of determining the urgency status of the referral. Our team members receive training in issue-spot

ting more time sensitive clinical presentations and are encouraged to use their clinical judgment when the status of a referral needs to be escalated in terms of urgency of response.”

Assuring patients that we are aware of their health care needs and are working to initiate services for them can go a long way to addressing any anxieties they may have about whether their needs will be met while incarcerated, she furthers. “Engaging in these initial visits as soon as clinically indicated sets the tone for the patient that he or she is working with a health care team who cares about patients.”

Collaboration between health care team members is another essential feature of a health care program that successfully manages a large and clinically challenging population, according to Donovan. “Daily meetings to review high-risk patients should include all health care stakeholders. Specialized units should also utilize a team meeting approach, and when appropriate, custody staff should be involved as well.” Donovan says that the opioid crisis and the suicide crisis has been a particular challenge for our patient population and for correctional health care providers. “Effective treatments for both of these issues require additional resources and the need to ramp those resources up very quickly.” Utilizing technology such as tablets, computerized psychoeducation applications, and virtual interventions, can also increase the efficiency of mental and behavioral health care efforts in correctional settings. “Notably, telehealth has been increasingly implemented in rural settings in the free world with success,” she says. “Its use in the correctional setting allows for expeditious mental health care by allowing highly qualified professionals provide service at facilities in rural and hard-to-service areas.”

Finally, Donovan tells of how her perspective has shifted on the subject of medication assisted treatments (MAT). “For those of us who have been involved in correctional health care for many years, it seems like we may be seeing indications of a paradigm change in the approach to care behind

It is widely accepted that telepyschiatry has the same benefits as face-to-face visits, and can guarantee continuity of care even from the most remote locations.

the walls. The introduction and gaining acceptance of [MAT] in our facilities offers our patients opportunities at approaches to care that can be life-changing for them, reducing the risk of relapse and recidivism significantly. In behavioral health, the changing focus to the risk-needs-responsivity model of care encourages our providers to focus on several fronts of treatment, including reducing risk of recidivism.”

The dual challenges of the opioid and suicide crises will likely change the approach of correctional care for years to come with even greater focus on evidencebased treatments and clinical programming at higher levels than seen previously, believes Donovan. “These are exciting times to be involved as a correctional health care provider, and our challenge is clear—to continually evolve to meet the clinical needs of our patients as their needs change over time.”

There has been a paradigm change in how behavioral staff conducts their work, concurs Ronald J. Smith, PsyD, CCHP-MH, corporate vice president,

Behavioral Health Clinical Services of Wexford Health Sources, Inc. Over the last 10 years, he says, it has become necessary for behavioral health staff to not just respond to the needs of inmates, but to become proactive in the development of services and activities that meet the needs of the inmates and keep everyone safe and secure. “Wexford Health’s behavioral health staff has become a vital front line team in the life of the correctional setting,” he notes. “Our behavioral health programming is a robust set of services and protocols that allows for maximization of resources and enhanced quality clinical services across all facilities and all levels of care.”

3 Keys to Quality

Training is a key in Wexford’s overall plan, details Smith. “It is essential that all correctional facilities and systems develop and implement an ongoing comprehensive behavioral health training program, focusing on all facility staff, including custody and administration,” he says. “Such training should be geared toward the specific duties of the attendees. It is vital that trainings be conducted routinely and that there be an experiential ‘handson’ component involved. Wexford Health has established an in-depth training library utilizing various modalities of learning-classroom, practical firsthand, online, and self-guided. It is also critical that behavioral trainings be ‘frontloaded’ and provided to all in employees during orientation or while attending Academy,” he emphasizes.

Tele-psychiatry is another area that holds promise. “Wexford Health has found that tele-psychiatry and tele-psychology can increase the quality, communication, and consistency of behavioral health care in correctional facilities,” says Smith. “In our experience we have found that the quality of psychiatric services in tele-health visits is at least as good as face-to-face. Our experience is consistent with research that indicates that some patients speak more freely (and disclose much sooner) when using telepsychiatry than they do in faceto-face encounters.

Pharmocology should be part of an overall plan, Smith continues. “Years of evidence-based, best practice standards lead Wexford Health’s strong advocacy for the prudent use of psychotropic medications in correctional facilities.” When coupled with provider evaluations and appropriate patient inmate review, behavioral health pharmacotherapy is an extremely effective way to help inmates with serious mental illness. However, he cautions: “While medication can provide immediate and life-changing results, we recognize that pharmacotherapy is only one aspect of the continuum of necessary services, so we couple them with cognitivebehavioral therapies, support services and case management.”

Community Strategies

NAMI provides advocacy, education, support and public awareness for those with mental illness in communities across the U.S. Its initiatives seek to reduce the number of justice-involved persons before they enter the system. NAMI maintains that estimates reflect that 6%-10% of all calls to law enforcement involve someone with an SMI, according to a 2016 study “Contact Between Police and People with Mental Disorders: A Review of Rates,” in Psychiatry Online.

“Many of these calls are for someone in crisis who needs mental health care, not jail,” says Gillison, NAMI’s CEO. By bolstering crisis services in every community, it creates an alternative to calling police and allows the mental health system to intervene and provides law enforcement with an alternative to taking someone to jail, he continues.

Gillison explains that core components of any crisis system include 24/7 crisis hotlines, warm lines, mobile crisis services, crisis stabilization programs and peer support services. All these services are resources for law enforcement and other first responders. They can be used as referrals to address situations that do not require a police response. They also shift responsibility from law enforcement back to the mental health system. “Simply put, robust crisis response systems can mean the difference between receiving help or handcuffs during a mental health crisis,” he says.

Many of the more than 640 NAMI state and affiliate organizations are involved with Crisis Intervention Team Programs in their communities, helping expand CIT programs to over 2,700 communities. CIT programs throughout the U.S. and worldwide are implemented in order to promote and support collaborative efforts to create and sustain more effective interactions among law enforcement, mental health care providers, individuals with mental illnesses, their families, and communities.

In addition, Gillison furthers, one of the cornerstones of NAMI’s work is providing support and educational programming. Many NAMI organizations are involved in providing peer support programs directly in jails and prisons. These support groups are led by someone with a mental illness and provide information about mental illness and training in skills to cope with certain mental health symptoms.

NAMI Western Nevada, for example, has seen “great success” with the program they operate out of the Northern Nevada Correctional Center, Gillison says. “Because of the support being provided through the program, the prison psychiatrists have seen a decrease in requests for appointments, which has freed up their resources to focus on those who have more serious mental health conditions.” ✪

immediate release of inmates who are detained solely on the basis of their inability to satisfy a financial condition of pretrial release, or solely on the basis of a technical violation of probation or parole; and inspection of the jail by a qualified public health expert to document the actions needed to prevent the spread of COVID-19 in the jail, including to enable social distancing among those living and working in the jail. Pulse Continued from page 8

WEBINAR ON REOPENING READINESS

The American Jail Association partnered with jail administrators across the country to hold a webinar on May 20 that tackled reopening readiness. During the hourlong webinar, corrections leaders shared their plans for reopening their facilities during the pandemic, and discussed the steps their agencies are taking to make staff care a priority. The recording is available through the AJA home page.

‘WE NEED TO STEM THE SPREAD OF COVID-19 AMONG INMATES’

Hillsborough’s former jail director wrote an opinion piece in a Florida newspaper on how to cool down the hot spots in correctional facilities. In the May 11 edition of the Tampa Bay Times Col. David Parrish (Ret.) wrote: “During this global pandemic, we must do all we can to slow the spread of COVID-19 and flatten the curve. Unfortunately, Florida’s prisons and jails are poised to incubate and spread the virus. Fifty-four prisons already have positive cases, including 180 just discovered at Liberty Correctional Institution. Gov. Ron DeSantis can assist in slowing the spread by taking executive action to (1) remove prisoners who pose little threat to public safety, (2) encourage local authorities to do the same thing for people held pre-trial in county jails and (3) direct that all inmates and staff in correctional facilities be tested.”

Wexford Health uses electronic Medication Administration Reports (eMARs) to help streamline the organization and administration of the medication pass. “EMARs are a safer, more reliable, and accurate form of documenting medication administration,” Ingram notes. For clients who do not have an eMAR, she says they use standard paper MARs, doing things manually, which is also a viable option. “The bottom line is to ensure the continuity of an inmate’s medication upon his/her arrival at a facility acMEDS: Continued from page 26

In order to prevent the cases in our prisons and jails from spreading like wildfire behind bars and out into the surrounding community, we need to know who has the virus. When testing was mandated at the Marion Correctional Institution in Ohio, approximately 2,000 out of 2,400 inmates, and almost 200 staff, tested positive, he pointed out. Tennessee Gov. Bill Lee just announced that every corrections officer and incarcerated person in his state will be tested. Florida should follow suit. The governor needs to ensure that correctional administrators can conduct universal testing. The staff, incarcerated people, and general public deserve no less, he opined.

Florida should also reduce the prison population, as other states have done. North Dakota granted early parole to 50 people and Ohio’s governor released 100 individuals

cording to ACA and NCCHC standards; to provide uninterrupted medication throughout the inmate’s incarceration; and to confirm proper documentation of medication administration in the inmate’s medical record.”

An eMAR provides high security and protection for patient information while ensuring compliance to HIPAA regulations. Nurses can set up multiple med-passes by unit, wing, room, and bed with eMARs through interfaces with many different offender management systems. With the use of currently who pose little threat to society. Attorney General William Barr has directed the Bureau of Prisons to make significant releases. I applaud these leaders for acting quickly to diminish the risk of transmission.

Finally, across the state, counties can greatly reduce the chance of an epidemic in local jails by removing people who pose no real public safety risk. About two thirds of the people in a typical jail are being held pretrial, many because they cannot afford a few hundred dollars. Some local leaders have already reduced their jail populations by removing people held for low bail amounts. They are not releasing people held for serious offenses, just those who would already be out on bond if they had the cash. The governor should encourage each county to follow suit, he said.

AJA ESTABLISHES COVID-19 RELIEF FUND

The American Jail Association, in conjunction with its generous business partners, has established a Corrections Officer Relief Fund to assist those affected by the pandemic. To be considered for assistance, complete and submit an application form (americanjail.org), along with a letter from your jail administrator or sheriff confirming your eligibility. All applicants will be evaluated by the AJA Corrections Officer Relief Fund committee to determine eligibility and award amount. There is also a place on the site to donate to the fund. ✪

available barcode technology, nurses can identify patients and their medication blister cards to ensure the “eight rights of medication administration.” (See box page 20.)

During this unprecedented time, when Covid-19 is adversely impacting prisons and jails, all these tools can offer relief. They help to reduce the labor intensive process of passing out medications, get meds to those who need them quickly and lower the financial burdens of providing the necessary drugs to those in your custody. ✪