Jails and prisons are well aware that their systems have had to pick up the slack left by under-funded community mental health systems. It's no joke to corrections administrators that their facilities have become the nation's largest mental health treatment centers.

Estimates indicate that the number of mentally ill offenders is rising to near the 20 percent mark and most agree that the majority of those individuals have some sort of substance abuse problems as well.

 "The problem with the mentally ill chemical abuse (MICA) client is they place an exceptional demand on the criminal justice system and treatment systems. We are confronted with patients who don't fit into neat boxes," said Stanley Sacks of the Co-Occurring Center for Excellence at the recent Behavioral Health in Corrections Conference in Rhode Island.

The difficulty for many is exactly how to go about managing this population.

According to Oscar Morgan, NMHA chief operating officer and former Commissioner of Mental Health for the state of Maryland, the best possible option is to prevent this group of individuals from going into an incarcerated setting in the first place.

"Many of them are in for minor offenses and are put into the criminal justice system and are languishing there, awaiting disposition. What our agency proposes is diversion programs where individuals who have committed minor offenses such as loitering or  shoplifting are screened and if they are found to be in need of medical care, they can be diverted to treatment as opposed to incarceration," Morgan said.

In this scenario, a minor offender could be screened, intervention started, support services provided, housing assistance and job placement activated and the individual would be well on the road to recovery.

Although this alternative approach to incarceration is becoming more accepted and used by jurisdictions, it does not cover the additional group of offenders with co-occurring disorders whose crimes are more serious.

In cases where offenders are locked up and still need all the services mentioned above, corrections agencies must be ready to collaborate with multiple agencies and organizations to effectively serve this group. And, if they do this, they very well may see recidivism rates drop right along with the challenges that this population poses.

Solutions for Corrections

According to Morgan, it is important from the start for corrections officials to consider the offender with co-occurring disorders as a person in need of treatment.

"The assumption is that if they have a presenting problem of substance abuse there is likely an underlying mental health problem. If someone comes in with a mental health problem, there may have been, or still is, substance abuse activity," said Morgan.

These offenders still need to be screened and given the right type of treatment and care and staff need to understand how incarceration may affect them.

"Professionals need to be trained to recognize a mental illness and substance abuse problems and to differentiate between the stigma of an individual behaving inappropriately and an individual [acting out]," said Morgan. "The correctional system needs to recognize that individuals, because they are separated from their family, may behave in certain ways."

Finally, Morgan suggests, if a correctional institution has the means, it should create some form of collaboration with the local health department so that assistance can be provided to this population after release.

 "The point is, we need to recognize there is a high co-morbidity, which means health care professionals [also] need to be cross-trained or at least have enough information to refer and then work in collaboration with the referring agency," he added.

It is crucial to treat these individuals swiftly so that they do not deteriorate further while incarcerated.

Sacks suggests that therapeutic community interventions in the correctional setting combined with community aftercare efforts are the way to go.

In his presentation at the Behavioral Health in Corrections Conference in Rhode Island, Sacks said that studies show that therapeutic communities for these offenders (where they function in the facility within a pod or wing with other similar offenders, receive psycho-educational and cognitive-behavioral instruction and receive therapy) can reduce recidivism.

The downside is that these effects seem to diminish over a three-year period after release. However, when therapeutic community treatment is linked with community aftercare, the effectiveness is much greater.

According to Sacks, one study in Delaware showed that, after 18 months, post-release offenders who only had TC or had no treatment at all had a 49 percent re-arrest rate, but those with TC and aftercare had rates of 21 percent. Similarly, a study of offenders in California after three years post-release showed offenders with TC and aftercare had a 22 percent recidivism rate versus 76 percent for those with only TC.

Sacks own research of offenders 12 months post-release showed that re-incarceration rates for those receiving TC and aftercare were five percent versus 16 percent for TC only.

"The idea is better linkages would mean better access [to services and treatment] and better functioning," he said.

So, the challenge, then, is to share information about the best approaches, the programs that have the greatest success and the elements to include in them so that these successes can be attained elsewhere.

Sharing Evidence-Based Practices

Since 1995, the GAINS Center for Co-Occurring Disorders has brought attention to the prevalence of offenders in the criminal justice system with these issues. After years of education, then years of technical assistance to criminal justice agencies, the GAINS Center is now focusing on highlighting evidence-based practices that are working in the criminal justice system.

"A lot of attention we have been paying is on 'how'," said Susan Davidson, Division Manager, Criminal Justice Division and Associate Director, National GAINS Center. "[Now] people are blending their funds and treating co-occurring disorders with the attention that it should be afforded."

With a new mission and a federal grant to run the Center for Evidence-based Programs for People in the Justice System, the hope is that model programs will be highlighted and replicated in jurisdictions across the country.

"It doesn't lose the co-occurring focus because we believe you can't talk about mental health without talking about co-occurring disorders," said Davidson.

What is new in the field, Davidson said, is the focus on recovery and re-entry and helping offenders stay out in the community.

First, under this new focus, the GAINS Center will create a program database of successful programs targeting offenders with mental health problems, then personnel will conduct site visits and evaluate the programs for model status and replication.

"One of the challenges for us is there are pockets of innovation and the people who are reaching out to us have neighboring counties doing the same thing [they are, but they don't know it]. The more activity that is going on and the more you can see people buying into the notion [of treatment], the more it will snowball," she said.

One the staff finds the programs worth touting, then it is up to GAINS to, again, get the word out.

Davidson said the plan is for GAINS to push for these programs at the state corrections level and, to assist with this, create mini GAINS Centers that would provide technical assistance across the country.

"The idea is that the state centers would become a locus of information about co-occurring disorders," said Davidson.

Once people buy into the idea of a continuum of treatment for this population, then GAINS wants people to be able to implement programs they know will work.

"People are looking more and more at effectiveness issues. You have people staying in jails longer and they are an expensive population.  Ultimately, you are going to save money and more people are buying into the notion that treatment is an option," said Davidson.

One state that has bought into the treatment of mentally ill offenders is Maryland and many consider the program to be an existing model for diversion, community collaboration and treatment inside the criminal justice system.

Maryland Stands Out

In the early 1990's in Maryland, a combination of concern from local jail officials and  support from state mental health officials brought about the creation of a jail mental health program to help identify offenders with mental health issues, increase communication between corrections and mental health staff and address the needs of these offenders in the community.

Today that program provides $2 million annually to local detention centers and has built a bridge between two separate systems to help offenders with mental health and other trauma-related issues get back on their feet again.

"Part of it was just saying we are not talking about different people [in two different systems]; they are the same people. It really took the acknowledgment that we needed to stop pointing the finger and start addressing the problem," said Morgan, who was Maryland's Commissioner for Mental Health at the time.

One aspect of Maryland's approach that makes it unique is it serves offenders in local detention statewide. In many other jurisdictions, these programs are instituted on a county or citybasis and never have the chance to make a statewide impact.

Also, the engine behind the program, the state Department of Health and Mental Hygiene/Mental Hygiene Administration, clearly saw the problem and was committed to improving the situation.

"It wasn't just putting money in the jail. There was the feeling that folks coming out to the community should have the same accessibility [to services] as anyone else," said Joan Gillece of the Mental Hygiene Administration's Special Populations Unit, which runs the program. "The case manager in the jail works with our clients, calls the jails and gets immediate approval for services in the community. There's none of the 'You're our last priority' attitude."

The program has also been able to expand to offer housing assistance through a Housing and Urban Development grant and to provide specialized treatment such as trauma counseling and assistance for pregnant incarcerated women.

"We now have made it work in this division to unravel these complicated systems that drove people into the criminal justice systems in the first place and provide the proper support and allow them to stay out," said Gillece.

And, from the corrections side, administrators agree.

Steve Williams, Warden of the Dorchester County, Md., Detention Center is thrilled with the result of the partnership between corrections and mental health.

"It works because we have open communication and openness to change and willingness to learn other persons' responsibilities. It has made many of us very proud of what we have accomplished," said Williams, who says he underwent a transformation from a lockem'-up mentality to a warden who understands the obligation to treat those with mental health problems.

Williams has seen the programs grow from part-time case management to full-time psychiatric services to trauma treatment and diversion programs and specialized areas of treatment.

"We realize we are doing a lot of good for the people we come in contact with, but also for the community," said Williams.

And, with a jail currently at 50 percent capacity, Williams also feels that he and his staff are experiencing the benefits directly.

"A lot of it has to do with the programs because we have not seen a lot of the old faces.
We shouldn't be incarcerating people who could be handled in a better way," he said.

While the jails in Maryland are feeling the positive effects of almost a decade of work, Maryland is now setting its sights on state corrections - much like other organizations such as the Council of State Governments, which is bringing reentry to the forefront of state policy.

"You have to be so holistic. There's so many different needs; it's about jobs, education, housing.
What starts as a small project becomes a change-the-world-project; it's like peeling an onion," said Gillece, who is encouraged that the issue is gaining prominence in policy discussions.

Gillece and others firmly believe that if the right services are provided to this ever-growing population of offenders with multiple needs from mental health counseling, to substance abuse treatment to housing to childcare, then they may finally have the support to live crime-free lives.

"We see our clients as the most wounded spirits. It's not easy to put folks back together who have been down and out for so long. [But] the more you can instill in someone the feelings that they are a valued human being, the more you will turn a corner," she said. It's a collaborative effort."

Resources:

National GAINS Center - http://www.gainsctr.com/b/Default.asp

National Mental Health Association - www.nmha.org

National Mental Health Information Center -
http://www.mentalhealth.org/cmhs/communitysupport/toolkits/
cooccurring/competence.asp

Council of State Governments - www.csg.org