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SAKS Institute for Mental health law SAKS Institute for Mental health law

SAKS Institute for Mental health law - PowerPoint Presentation

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SAKS Institute for Mental health law - PPT Presentation

Spring symposium criminalization of the mentally ill Stephen mayberg P h D April 11 2013 Policy Practice and Perception Implications in the Criminalization of the Mentally Ill Criminalization of the Mentally Ill ID: 340943

health mental treatment programs mental health programs treatment state policy jail community mentally care substance county perception responsibility abuse

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Slide1

SAKS Institute for Mental health lawSpring symposium: criminalization of the mentally illStephen mayberg, PhDApril 11, 2013

Policy, Practice and Perception: Implications in the Criminalization of the Mentally IllSlide2

Criminalization of the Mentally IllNew trends or long term problemContributory factorsPerceptions/Public Policy

Promising alternativesSlide3

Policy IssuesRealignment CA Mental Health 1991Funding/Responsibility shiftState to county responsibility/authority

Civil Commitments/LPS

Forensic

Commitments

1991

3300

60020125506000

State Hospital PopulationSlide4

Policy Impact: RealignmentFinancial IncentivesCounty choice/flexibilityState pays for forensic care

State hospital beds

County pays LPS

State pays – NGI, IST, MDO, SVP

IST Costs

Counties – Misdemeanors

State - FelonySlide5

Resource IssuesCounty mental health allocation insufficient for all servicesLimited long term care availableDeclining state hospital beds

24 hour acute care

Short term – Crisis use

Average stay less than 7 days

Follow up capabilities inconsistent

Responsibility and resourcesSlide6

National Policy TrendsCommunity Care vs. Institutional CareDeclining state hospital bedsState hospitals/ IMD’s – no 3

rd

party payment

Court decisions stressing communities instead and community programsSlide7

Policy Decisions - FundingMediCal (Medi-Caid) not available for single adults (forensic population)State hospitals, IMDs, jails, prisons mental health services not reimbursable

Loss of MediCal eligibility in jail and juvenile hall

100% county (or state) cost for forensic services

No federal participationSlide8

Program Development Practice/PolicyIncentive to develop programs is in areas where monies can be leveragedLaw enforcement more likely to be funded at local level with county dollars

Public Safety

Politically more acceptableSlide9

Liability/Public PerceptionLocal mental health programs concerns about responsibility for forensic patientsADVERSE EVENTSMedia coverage – “Blame”

Torts/liability

Local political pressures

Accountability/responsibilitySlide10

Liability Perception ImpactConditional Release from Parole for Mentally Ill Inmates (CONREP)Extensive Service/Treatment Array – 100% state fundedCounties have right at first refusal

Very few counties participate

Consequence: lack of coordination with local programsSlide11

Conflict About Responsibility for CareParole outpatient versus county mental healthScreening, evaluation, and recommendationsProbation vs. County Mental Health

Who should provide/pay for serviceSlide12

ConflictVoluntary vs. Involuntary treatmentLPS Law variably implemented“Fungible” definition of WI 5150

Police vs. First Responders

Jail vs. hospitals

Can reflect lack of clarity

Impact training, resources, responsibilities

Laura’s Law – Outpatient commitment

Only 1 county has implementedSlide13

AccountabilityWho is accountable/responsibleLack of clarity“fall between cracks”

Conflicting laws/standards

Welfare and institution code vs. penal codeSlide14

Court Decisions ImpactSell – U.S. Supreme court rules IST’s cannot be involuntarily medicated without criteria/hearingJameson vs. Farabee – California Courts – inmates cannot be forcibly medicated without hearing

Consequence –

decompensation

Barriers complicate ability to treatSlide15

IST ProcessIncentives for state hospital treatment vs. jailReduces jail census, jail treatment cost, court time Incentive – Defense attorneys/inmates: hospital better than jail environment

Credit time served – hospital in lieu of jail

Medication in jail usually cannot be involuntary

Consequence: Disconnected system

Revolving doorSlide16

ImpactInadequate or insufficient treatment resources available in 24 hour institutionsMentally ill in jail/prison opt to not get treatmentRecidivism common

Mentally ill parolees most likely to be revoked/reoffendSlide17

Other Contributory FactorsSubstance Abuse70% SI Adults have substance abuse issues9

0% forensic mentally ill have co occurring diagnosis

Drug Use/Possession

Illegal – Criminal Justice Contact

Substance Abuse Behavior

Impulsive, lower frustration tolerance, aggression

Consequence: Untreated Substance AbuseMore likely to become part of systemSlide18

Contributory FactorsVacaville Mental Health StudyEvaluations on consecutive admissions over two time periodsFindings

Average IQ - low to low average

Education – 8

th

grade

Social Economic Status (SES) -low

Brain Injuries – 65%Fighting, Falls, Drug UseSlide19

Vacaville ContinuedEmployment marginalFamily History– more apt to be single, disengaged from familyHistory of violence

Consequence: Complex factors must be addressed to prevent criminal behaviorSlide20

Policy Implications for TreatmentCognitive/Outpatient treatment may not be effectiveStructured environment may be requiredCoordination of substance abuse/mental health treatment essential

Educational/Vocational programs integral part of approachSlide21

Contributory Factors: HomelessnessSubstance use/Mental illnessHostile living environmentCrimes of opportunity/Quality of life crimes

High visibility

Lack of coordinated resources or responsibilitySlide22

Contributory Factors: StigmaFailure to access treatment because of stigma Perception of nexus of violence and mental illnessMedia sensationalism

Blame

NRA - MonstersSlide23

Contributory Factors: Public PerceptionPerception: community safer with individuals locked up rather than treated in outpatient or in the communityNIMBY issues for community program placement

Elected officials tend to fund programs that lock up or promise “public safety” before funding community programsSlide24

Public Perception ContinuedTolerance/ExpectationsParolee “Acting out” vs. Mentally IllDifferential response from press, media, community

Funding for Control Agencies (Law Enforcement) rather than treatment programs

Prison realignment experience -AB 109Slide25

Summary of Issues - ResponsibilityState vs. Local Law Enforcement vs. Mental HealthMental health vs. Substance Abuse

“No One”Slide26

Summary of Issues - FinanceInsufficient funds for mental health/substance abuse treatmentNo Federal dollars (MediCal) available for treatment of most forensic populations

Incentive in construction of laws/regulations for state to pay rather than counties for forensic populations

Paradox: Counties responsible and funded for rest of MH system a disconnect

Priority funding for Law Enforcement vs. Mental Health when monies are availableSlide27

Summary of Issues – StigmaPerception: individual concerns inhibits treatment seeking behaviorPerception: public concerns of stereotypes of mentally ill

Mental illness and violence

Perception: community concerns, 24 hour care is “safer” than community treatment

Fear of Violence/unpredictability consistent and reinforced by mediaSlide28

Summary – Lack of ResourcesLimited long term or structured careLack of specialty trained professionalsLack of specific programs addressing unique needs of this population

Lack of 3

rd

party participation

CONSEQUENCE

Jails/Prisons have become our defacto mental health treatment programsSlide29

Summary – Legal SystemInvoluntary medication difficultInvoluntary commitments difficultLegal system may encourage accepting charges rather than treatment

Criminal Justice system not always well informed about mental illness and options

Administrative Office of Court FindingsSlide30

Promising Practices/OpportunitiesPolicies that workPrograms that workPotential opportunitiesSlide31

Programs that WorkAB 34/2034 SteinbergHomeless Mental Health ServicesSignificant reduction in hospital days

Significant reduction in jail days, arrests

Cost effective – 50% reduction in costs

Defined responsibility, broad based approachSlide32

Promising Programs (Con’t)Law Enforcement Training/PartnershipCIT (Crisis Intervention Training) for Law EnforcementSmart/PET teams

Mobile CrisisSlide33

Promising Program (con’t)Court/Criminal Justice InvolvementMental health/behavioral health courtDrug courts

Diversion

MIOCR programsSlide34

Policy that Works24/7 Mental Health availability in crisisPoint of contact responsibilityCrisis training/consultation

Co-Occurring programs

Violence programs

Bullying

Domestic violence

Anger management

Trauma based approachesSlide35

Policy that Works (Con’t)Mental Health Services in Jails/PrisonsConnected with community programsScreening/case management

Dedicated trained staffSlide36

Policy that Works (Con’t)Stigma ReductionMedia educationCourt/Law enforcement education

Public education/awarenessSlide37

Advocacy InvolvementNAMIStrong advocacy for recognition/treatment alternativesClient Groups

Peer Support/Self help

Promoting less stigmatizing alternativesSlide38

Best Practices/OpportunitiesProposition 63/Mental Health Service ActTarget At-Risk PopulationsLos Angeles County Mental Health examples

Cultural Competence Outreach

Urgent Care

24/7 Full Service Partnership (FSP)

Homeless programsSlide39

Los Angeles Mental HealthCommunity PartnershipsEarly Intervention programs/PreventionStigma reduction programs

Jail programsSlide40

Best Practice/OpportunitiesCo-Occurring ProgramsSpecific programs designed for mentally ill/substance abuse forensic patients

PROTOTYPES as example

Target population

Broad array services

CONREP

Recidivism less than 10%Slide41

OpportuniesHealth Care ReformParity for Mental Health/Substance Abuse now requiredReduces Stigma

Expands access

Expanded eligibility

3

rd

party payment for uninsured population

Incentives for treatmentSlide42

Opportunities (Con’t)Prison Realignment AB 109New dollars for criminal justice system approachesLocal decision making

Role of prevention, diversion, and treatmentSlide43

Opportunities (Con’t)Utilization of Research findingProgram success ratesCost Reduction Data

Return on Investment (ROI)