2 0 1 0 , Issu e 1

Published by the National Council for Community Behavioral Healthcare

NationalCouncil
magazine Sharing Best Practices in Mental Health & Addictions TREATMENT www.TheNationalCouncil.org

Beyond Bars
Mental Health-Addictions and
Criminal Justice Collaborations
Improving Public Safety and Maximizing Taxpayer Dollars
Neal Cash

Ending an American Tragedy

National Leadership Forum for Behavioral Health/Criminal
Justice Services

Human Rights at Home:

Mental Illness in U.S. Prisons and Jails
David Fuller

Where Does the Buck Stop?

Linda Rosenberg

Decriminalizing Mental Illness:

Miami Dade County Tackles a Crisis at the Roots
Judge Steven Leifman, Tim Coffey

Mental Health First Aid Equips Police Officers

to De-escalate Crises
Richard Leclerc
 PDF available at www.TheNationalCouncil.org

NationalCouncil
M A G A Z I N E

2 What Happened to Me, Not What Was Wrong With Me

Tonier Cain
4 Editorial Improving Public Safety and Maximizing Taxpayer Dollars National Council Magazine, 2010, Issue 1
Neal Cash
6 Human Rights at Home: Mental Illness in U.S. Prisons and Jails Beyond Bars
David Fuller
Mental Health-Addictions and
8 Ending an American Tragedy: Addressing the Needs of Justice-Involved People
with Mental Illnesses and Co-Occurring Disorders
Criminal Justice Collaborations
National Leadership Forum for Behavioral Health/Criminal Justice Services
14 Behavioral Health and Criminal Justice Collaboration:
Where Does the Buck Stop?
Interview with Linda Rosenberg
18 Decriminalizing Mental Illness: Miami Dade County Tackles a Crisis at the Roots
Steven Leifman, Tim Coffey p.34 From the Field
24 Jails and Prisons, Our New Mental Asylums
Interview with Pete Earley
26 Reducing Justice Involvement for People with Mental Illness: Strategies that Work
Interview with Fred Osher
28 Funding for Behavioral Health and Criminal Justice Programs
Henry J. Steadman, Samantha Califano
30 Back to Basics: Evaluating Opportunities to Serve the Justice-Involved
Population in Community Behavioral Health
John Petrila
32 Advocate to Give Youth a Second Chance: Juvenile Justice and Delinquency
Prevention Reauthorization Act
Mohini Venkatesh
34 FROM THE FIELD
Center for Health Care Services, Centerstone, Citrus Health Network,
Community Partnership of Southern Arizona, Community Psychiatric Clinic,
Chrysalis, Hands Across Long Island, John Eachon Re-entry Program,
The Kent Center, Mental Health Center of Denver, MHMR Tarrant County,
River Edge Behavioral Health Center, River Oak Center for Children,
Seacoast Mental Health Center, Spanish Peaks Mental Health Center,
Wayne State University Project CARE
52 Double Tragedies: Speaking Out Against the Death Penalty for People
with Mental Illness
Ron Honberg National Council Magazine is published quarterly by the
54 Reinstating Medicaid Benefits: Life in the Community after Incarceration National Council for Community Behavioral Healthcare,
Alex Blandford 1701 K Street, Suite 400, Washington, DC 20006.

56 Incarceration and Homelessness: Breaking the Tragic and Costly Cycle www.TheNationalCouncil.org
Andy McMahon Editor-in-Chief: Meena Dayak

58 Mental Health First Aid Equips Police Officers to De-escalate Crises Specialty Editor, Mental Health-Addictions and
Richard Leclerc Criminal Justice Collaborations: Mohini Venkatesh

62 E-learning in Corrections: Viable Training Option in a Tough Economy Editorial Associate: Nathan Sprenger
Diane Geiman Editorial and advertising queries to
Communications@thenationalcouncil.org or
64 Member Spotlight
202.684.7457, ext. 240.
National Council 2010 Awards of Excellence Honorees
 Beyond Bars
What Happened to Me,
“I am a 41-year-old African American woman who
Tonier Cain, Consumer Advocate
Tonier Cain has spoken nationally on trauma, incarceration,
and recovery. She has served as a member of the
Protection and Advocacy for Individuals with a Mental
Illness Council. She has also worked as a case manager
and director of advocacy services for a private nonprofit
in Annapolis, Maryland. She is the team leader for the
National Center for Trauma Informed Care, which provides
consultation, technical assistance, and training to
revolutionize the way in which mental health and human
services are organized, delivered, and managed while
furthering the understanding of trauma-informed practices
through education and outreach. Ms. Cain is the subject
of “Healing Neen,” a documentary based on her life as
she moved through multiple systems of care.
Tonier Cain is a featured
“In My Own Words” speaker at
the 2010 National Council Conference,
March 15-17, Disney World, Florida.
www.TheNationalCouncil.org/Conference
4 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
Not What Was Wrong With Me
has been in and out of prison multiple times; I
am a mental health consumer who’s been hospi-
talized many times; and I have been in so many
substance abuse programs, I can’t even name
them all. Most important, I am a trauma survivor.
During every incarceration, every institutionaliza-
tion, every court-ordered drug treatment program,
it was always the same: I was always treated like a
hopeless case. All people could see was the way I
looked or the way I smelled. It wasn’t until I finally
entered a recovery-oriented, trauma-informed
treatment program a little more than four years
ago, where I felt safe and respected, that I could
begin to heal.
As a young child, I had a belief system that I was
nothing and that I would never amount to anything.
I thought that the men whom my mother enter-
tained, who touched and hurt me, did it because
something was wrong with me and I deserved it.
I thought that my mother abused me and didn’t
love me because I was a bad child. My eight broth-
ers and sisters needed me to protect them. I had
to keep the men from hurting them, like they hurt
me; I only wished my mother loved me enough to
protect me.
I spent a long time living with no hope and finding
no help in the different systems I entered. Every
time I went into jail or prison, I asked for help, but
I was told that it was a jail, not rehab. When I was
leaving, they said, “See you when you come back,
we’ll hold your cell for you.” No one ever said, “I
hope you make it this time.”
When I was admitted to mental health units, I was
told that I had several diagnoses, and I always
asked, “How do you know? I’ve been up smoking
crack for 7 days.” They never allowed the street
drugs to get out of my system before they evalu-
ated me. I also went to many substance abuse
programs — at one, I was raped by a counselor;
others used a “tear you down and build you back
up” model, but I was broken down enough already.
Even in school, where I was teased because of the
way I smelled, no one asked about what was hap-
pening to me.
I have also been secluded and restrained several
times. I am a victim of neglect and abandonment,
and one of the worst things that you can do to
someone with this type of history is to put them
into a seclusion room. When that door was shut,
the flashbacks of my mother’s abuse and aban-
donment began. When they’d come later with a
tray of food, I had been triggered, and so I pushed
the tray away from me, but then they restrained
me. I was a rape victim, and this restraint triggered
me even more. I was also always overmedicated.
It’s hard not to lose hope under those circum-
stances.
Then, after 19 years of drug addiction, alcohol-
ism, homelessness, going in and out of prison (83
arrests and 66 convictions), mental health insti-
tutions, and substance abuse programs, I finally
found the help that I needed to heal. Someone
finally asked me “What happened to you?” instead
of “What’s wrong with you?”
I was in prison and pregnant, and I was terrified
that I was about to lose another child: I had al-
ready had four kids taken from me, and I could not
survive losing another. I was told about a program
that would help me heal from my trauma, recover
from my addictions, treat my mental illness, and
let me keep my baby with me. Well, I didn’t know
how they were going to manage all that, but I knew
I had to give it a try. What did I have to lose?
The first thing my therapist said to me was
“Everything that happened to you as a child, hap-
pened to you; you didn’t do it to yourself,” and
I believed her because her tone was gentle and
not judgmental. Then we began the work, and I
had to remember and talk about every time I was
touched and assaulted as a child. I talked about
my issues with my mother, how she never loved me
and never protected me. I began to heal because I
started to understand that I am an adult now, and my
mother’s lack of love for me, and men’s abuse of me,
is a reflection of who they are; it’s not about who I am.
Then my therapist told me that we had to start talking
about my children, and I shut down. I asked her how
I could talk about something that gives me so much
pain and suffering every day of my life: How do you
heal from having four kids walking the earth when you
don’t know how they’re doing, what they look like, or
who they are? She said, “You do; you just don’t do it
by yourself,” and she was there with me, for weeks of
crying and rocking, as I allowed myself to remember
them and grieve them.
In that program, I felt safe for the first time. The walls
had pictures and positive quotes on them. We had our
own rooms with nice colors. No one was screaming
“medication time” at us or secluding or restraining us.
I was asked every day, “How are you feeling today?”
Everybody there was trained in trauma, which meant I
Every time I went into jail or prison, I asked for help, but I was
told that it was a jail, not rehab. When I was leaving, they said,
“See you when you come back, we’ll hold your cell for you.”
could talk to any staff member at any time, and they sions. I have a healthy, beautiful child whom I simply
would listen. For the first time in my life, I felt like a adore and who is securely attached to me. I do not
person, a human being, and not like the monster I have the desire to use drugs or alcohol. I am no longer
had been treated as in the past. I felt hope. Oh, what on medication. I am now an advocate in the streets
a difference it makes when someone asks, “What hap- where I once lived, used drugs, and was raped and
pened to you?” instead of “What’s wrong with you?” beaten. I am now a national spokesperson on trauma,
Once I was able to start healing from the trauma in I am a homeowner, and I sit on several boards.
my life, my belief system changed from “I am nothing” Five years ago, I was taking hits of crack, in a mental
to “I am somebody, and I can be anything I want in institution, and in and out of prison. Everyone then
this world.” All of the earlier treatment and informa- thought that I would spend the rest of my life going
tion that people had tried to give me for years had in and out of prisons and mental institutions or that I
only reached the surface; it didn’t get down to the was going to die in the streets. They were wrong.
foundation of my problems and needs. Since getting Where there’s breath, there’s hope, and for me it be-
trauma treatment in a safe, trauma-informed setting, gan with respectful, individualized trauma treatment.”
however, I have been able to heal. I make better deci-

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 Editorial
Improving Public Safety and Maximizing Taxpayer Dollars
Community Behavioral Healthcare’s Best-kept Secret
Neal Cash, President and CEO, Community Partnership of Southern Arizona, and Member, Board of Directors, National Council for Commu-
nity Behavioral Healthcare
Neal Cash is president and
CEO of the Community Part-
nership of Southern Arizona,
the regional behavioral health
authority contracted by the
state of Arizona for funding
and oversight of the public
behavioral health system in
five counties. He has a bach-
elor’s degree in psychology
from Syracuse University and a master’s degree in rehabilitation
counseling from the University of Arizona. He is a member of
the National Leadership Forum on Behavioral Health/Criminal
Justice Services of the National GAINS Center.
C ommunity behavioral healthcare’s role in pre-
venting crime and increasing public safety is
one of our country’s best-kept secrets. And that’s a
shame.
A few months ago, news reports focused on a third
straight year of decreased crime rates across the
United States, surprising law enforcement officials
and other experts who predicted just the opposite,
given the high rate of unemployment and the eco-
nomic recession. In previous periods of economic
stress, crime rates increased. Yet preliminary statis-
tics for 2009, released by the FBI in late December,
showed that rates for all types of crime had again
decreased from the year before.
As analysts struggled to explain this anomaly, few to
none mentioned the role of community behavioral
health services. Yet many of us in the field know how
important our efforts have been in this regard — and
how much more we can accomplish.
Community behavioral healthcare serves as an
important partner for the criminal justice system,
whether by providing treatment which prevents be-
haviors that could bring people into contact with
law enforcement; training officers in how to deal
with people with mental illness who are in crisis;
or preventing recidivism by ensuring continued and
coordinated treatment for people involved with the
justice system, leaving the justice system, or both.
6 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
In these difficult financial times, it is especially
important that our systems recognize and embrace
their interrelatedness and work together to maxi-
mize public resources. At the same time, we must
educate the public about how effective behavioral
health treatment reduces crime, avoids expensive
incarceration, helps people remain in or re-enter the
community as contributing citizens, and enhances
the quality of life of everyone in the community.
As reported in the National Leadership Forum on
Behavioral Health/Criminal Justice Services Report
featured in this issue, the interface between our
systems often is frayed, if it exists at all. Yet there
are pockets of excellence around the country that
provide models for collaboration and cooperation,
with promising results in both individual outcomes
and taxpayer savings — examples are featured in
the From the Field section of this issue. Representa-
tives of the Center for Mental Health Services’ Na-
tional GAINS Center visited some of these pockets
of excellence in fall 2009, including those operated
by the Community Partnership of Southern Arizona.
Participants in the mental health court
experienced a 50 percent overall reduction in subsequent
criminal charges in the 2 years after being in the program.
Collaboration Is Key
As a community-based nonprofit organization, CPSA
has a large stake in the quality of life and public
safety of the communities it serves — more than 1
million people across five counties. Our work helps
prevent crime, reduce recidivism, and divert people
with mental illness and substance use issues from
incarceration into less expensive, and more effec-
tive, community-based treatment.
CPSA, the regional behavioral health authority over-
seeing publicly funded care in southern Arizona, has
sought creative ways to collaborate with the crimi-
nal justice system. We’ve learned that:
>> Any cross-system program or strategy must be
built on a firm foundation of mutual respect and
understanding and on relationships that both
grow out of and are nurtured by the collaboration.
>> Planning needs to be deliberate and incremental,
with both short- and long-term common goals.
>> Processes, strategies, and results should be
monitored and evaluated, and improvements
should be made on the basis of findings.
>> Communication, including sharing and celebrat-
ing results, should be structured and ongoing.
>> Collaborations must be cost effective and sus-
tainable, even in tough times. This is supported
by the mutual advocacy and identification of
new opportunities that evolve out of collabora-
tive relationships, further strengthening commit-
ment, and magnifying the impact of strategies
and programs.
This is basic community development. It can be slow
and at times frustrating, but CPSA’s experience has
demonstrated that it is worth it — and that no sub-
stantive and lasting change can happen without it.
CPSA began this journey in the late 1990s by form-
ing a work group of behavioral health and criminal
justice stakeholders in Tucson/Pima County that
sought to identify systemic strategies to decrease
the time people with a mental illness were inap-
propriately incarcerated. This group evolved into the
current Forensic Task Force, which meets quarterly
and includes representatives of the court system,
law enforcement, jails and corrections, local behav-
ioral health providers, crisis services, attorneys, the
veterans’ hospital, and other community stakehold-
ers. The task force, along with collocated behavioral
health and criminal justice staff, provides the founda-
tion and framework for all strategies and programs.
Most of CPSA’s efforts in this collaboration have fallen
into two areas: diversion programs and service coordi-
nation via information sharing (see article, p. 37).
CPSA also helped to establish Arizona’s first mental
health court in 1999 in Tucson and has founded ad-
ditional mental health courts in the Pima County Su-
perior Court and Consolidated Justice Court. It also
developed a formal mental health collaboration with
every other limited-jurisdiction court in Pima County
(six in total). CPSA has developed relationships and
tools to allow swift identification of members who
have been arrested and appropriate, real-time shar-
ing of information while protecting confidentiality.
These relationships and tools expedite communica-
tion between the community behavioral health treat-
ment provider and the jail’s treatment provider, ensur-
ing that members receive support in navigating the
criminal justice system while maintaining coordina-
tion of care.
Most recently, CPSA has established an Initial Appear-
ance program, which involves community behavioral
healthcare staff participation. This program has signif-
icantly decreased the likelihood that a CPSA member
will be detained in the jail system. CPSA has also be-
gun training forensic peer mentors to provide support
and advocate for members involved with the criminal
justice system and is again offering crisis intervention
training to law enforcement in southern Arizona.
Participants in the mental health court experienced a
50 percent overall reduction in subsequent criminal
charges in the 2 years after being in the program. The
most recent annual figures for CPSA’s diversion pro-
grams in Tucson City Court and Pima County Justice
Court show graduation rates of 97 percent and 92
percent, respectively — a total of 627 CPSA members
who avoided incarceration and had charges dropped.
“Many people were skeptical about mental health
court,” noted the Hon. Nanette Warner, Judge of Supe-
rior Court, Division 20, in a recent letter, “but with the
leadership and the commitment from CPSA, it became
a reality and allayed all concerns...The result has been
fewer people with mental illnesses falling through the
cracks. They have escaped the revolving door of the
criminal justice system and are now experiencing
meaningful recovery and success for the first time in
their lives. There are innumerable people who have
graduated from mental health court, even people the use of dwindling dollars but to create stronger, more
professionals thought would not be successful.” efficient, more effective, and more humane systems
in the long run.
Current Conditions Demand Creativity
Collaborations are especially critical now. Federal and The status quo is being shattered by fiscal realities.
state governments face historic budget shortfalls, just We can seize this opportunity to create partnerships
as expenditures on corrections across the country are with criminal justice and to educate decision makers
nearing a staggering $70 billion annually, according and the public about community behavioral health-
to the Bureau of Justice Statistics. Some states are care’s critical role in the safe diversion and release of
releasing inmates early, and many are increasingly people with substance use issues and mental illness.
relying on community supervision as an alternative to We can make real connections between community
expensive incarceration. behavioral healthcare and criminal justice. And by
promoting our accomplishments to the larger com-
At the same time, publicly funded behavioral health
munity, we can emphasize our contribution to public
services — the very resources that can help ensure the
safety.
success of these alternative justice approaches — are
in grave danger of being cut.
With states struggling to cut costs and few lawmak-
ers willing to consider new revenue sources, the result
could be a mad, self-defeating scramble for funding
among different systems and stakeholders. Alter-
natively, our industry’s proactive engagement with
criminal justice could create collaboration instead of
chaos and lead to thoughtful changes and strategies
that result in real improvements at both the systems
and individual levels — not only to make the best
Expenditures on corrections
across the country are nearing a staggering
$70 billion annually. Some states are
releasing inmates early, and many are
increasingly relying on community
supervision as an alternative
to expensive incarceration. At
the same time, publicly funded
behavioral health services —
the very resources that can
help ensure the success of
these alternative justice
approaches — are in grave
danger of being cut.
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 7
 Beyond Bars
Human Rights at Home:
Mental Illness in
U.S. Prisons and Jails
Testimony of David Fuller, Certified Psychiatric Rehabilitation Practitioner and Forensic Peer Specialist; a Person with a History of Incarcer-
ation and Psychiatric Disability, before the United States Senate Committee on the Judiciary, Subcommittee on Human Rights and the Law,
Hearing on “Human Rights at Home: Mental Illness in US Prisons and Jails,” September 15, 2009.
“Mr. Chairman, Ranking Member Coburn, and dis-
tinguished members of this Subcommittee, it is an
honor to provide testimony before this body. My
purpose in testifying is to bring to light some of the
experiences people with mental illness encounter
when they enter the criminal justice system and to
expose the inhumane treatment they receive. I have
also included information on how this travesty in
human rights can start to be corrected.
With the ability of hindsight, I can say I started
to experience depression at an early age. The first
twinge of it was in elementary school at the time
of Martin Luther King, Jr.’s assassination. I can re-
member thinking, “The people in this country will
never change. If they could kill a man as good as
him what chance do I have?” These thoughts were in
the context of experiencing racism through my en-
tire life, from times visiting family in the rural south
as a young child to going to a majority white school
in my native New York from elementary through high
school. I think now, and feel seven years old is too
young to feel hopelessness, especially in a country
that has as much as this country.
When I was seventeen I experienced my first arrest.
New York City’s Rikers Island at that time was called
the “gladiator school” by local youth. I was arrested
for illegal gambling because I had betted a few
dollars on some numbers and was caught near the
“number spot.” Honestly, I used to bet to get a thrill
because even at that age, it was hard for me to feel
joy or happiness like other young men, so I used to
fill that void with thrill seeking and other non goal-
producing behaviors like drugs and alcohol use. This
charge was considered a misdemeanor in New York
City [and] State.
8 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
In the few days it took for me to post bail I experi-
enced suicidal thoughts and was actually stabbed
by another inmate for the jacket I was wearing. I
was afraid to go to the clinic because I knew they
would put me in isolation on suicide watch and I felt
punished enough.
When I became eighteen years old, things were
not getting better for me. I was abusing drugs like
heroin and crack cocaine. My family did not know
what to do. I was trying to outrun someone I could
never outrun, myself. By the time I was twenty-one
years old, I had been arrested several times for drug
possession/sale and gambling. I was using a large
amount of drugs and got caught in a drug den dur-
ing a police raid. I was facing a lot of time and was
scared to death. My family found me a good attor-
ney who eventually got the charges dismissed and
suggested that I seek drug treatment. I went to a
long-term drug treatment facility in New York State. I
did not like being there, but I thought maybe I could
get help with the problems I had been experiencing.
I told my counselor I thought I had more than just
a drug problem — that I felt sad and lonely pretty
much all the time no matter what I did. I also told
him I thought about ending my life quite a bit. When
he heard this, he warned me that if I mentioned
that again I would be discharged from the program
and sent to a mental hospital. I never mentioned it
again. I graduated from the program after a year,
went back home, picked up drugs again in less than
two weeks, and was back in the street like nothing
ever changed.
Through the next twenty years, I went back and
forth to jail. My ability to function was slowly, but
steadily, declining. I was arrested at least twenty or
Printed with permission
of David Fuller
This cycle would
repeat itself many more
times: get out, no place to live,
stop taking my medication,
use drugs, become suicidal,
then go back to jail.
thirty times in that time period. I served sentences
from ten days to one year. The first six to ten times I
would ask my lawyer or the staff in the jail for help
with the issues I had, I got the same answer every
time — that is if they bothered to answer; that either
I went to drug treatment or the mental hospital. I
knew one or the other by itself would not work, so I
gave up asking for help from the system.
Towards the last few years of my suffering, I ex-
perienced my first hospitalization for psychiatric
reasons; it was after my first suicide attempt. I was
there for a couple of months. I went to therapy, and
I was put on medication. It helped; I became stable
and was discharged from the hospital. I did not
have stable housing when I was discharged. I was
referred to a “¾ house” to live and it was worse than
living on the streets, so that is what I did. I ended
up not taking my medication, not participating in
therapy, and quickly re-offended.
When I went to jail the next time I didn’t stand up
for the count. I was written up and put into punitive
segregation (“the box”). In segregation, I was put in
a cold, dark, barren cell — no TV, no books — where
the environment exaggerated my symptoms and I
even experienced some new ones like audio hal-
lucinations. The officers were verbally and physically
abusive. There was no point in making an official com-
plaint because the officers would just abuse you more
and nothing would ever be done about it.
This cycle would repeat itself many more times: get
out, no place to live, stop taking my medication, use
drugs, become suicidal, then go back to jail. I remem-
ber I “caught a ticket” in jail one time and before they
could send me to the box I tried to hang myself in my
cell, my cellmate found me before the officers did and
untied the sheet. He did not tell the officers because
he knew what would happen. I wept in my cell the rest
of the night; I was discharged after two days.
There were fights with other inmates almost every
time I went to jail. Because of my depression, I would
appear to be an easy victim and some of the other
inmates would try to steal my food. Most of the time
I would win the fight, but lose the battle for my self-
esteem and self-respect — fighting for food like a
common animal.
“There is no HIPAA in jail” because there is really no
privacy in regards to your psychiatric care. Either you
are on the “Mental Observation Unit” with all the stig-
ma and dangers that implies, or you are living in gen-
eral population where every time you go for medica-
tion or need to see the doctor it is announced through
the cell block. When you are getting your medication
you are on a line with a hundred other inmates and
inmates going back and forth on the other side of the
hall. People are buying and selling medication and
other illicit drugs. Everybody pretty much knows what
the other person is getting. When you go to the “clinic”
to see the doctor you have to wait for hours on end
and once again, everybody knows what you are there
for. You can hear staff talking about other patients
when you are meeting someone about yourself, so
you think about whether they talk about you when you
leave, so you do not share much and do not get the
help you need.
For 28 years of my life, I struggled with depression
and then later [posttraumatic stress disorder]. I used
hard drugs most of this period and it seemed like I
was always going in and out of jail. Violence was al-
ways around me. Through my periods in jail and being
homeless I have been stabbed and shot. I was abused
by the very people and system that were supposed to
be helping me, and keeping me safe. I did not have
access to the services I needed; I was alienated from
friends and family. I felt isolated and alone. I dwelled
in hopelessness, shame, guilt, and fear of the future.
I believed God had abandoned me and things would
never change.
I turned down treatment a few times in the past when
I was in jail before because I was never offered a
place [where] I could address my psychiatric disabil-
ity and my drug addiction at the same time, in the
same place. I had been through treatment many times
for one or the other at different times and it seemed
to never work for me.
I am happy to say things did change. The last time I
was incarcerated I was offered an opportunity to par-
ticipate in a Mentally Ill/Chemically Addicted — resi-
dential treatment rather than stay in jail. It turned my
life around. I was able to be around people who had
Psychiatric disability
and substance abuse
are chronic illnesses similar to
hypertension or diabetes. The last
time I checked, people with those
illnesses were not being put in jail
and shunned by society.
similar experiences and I did not feel so alone. I talk-
ed to people like me who had recovered and [were]
on their way to happy, productive lives. For the first
time in a long time, I had real hope for the future.
I learned I had to be honest, open-minded, and willing
to do the footwork in order to recover. I had to take
responsibility for my life. I gained a relationship with
a higher power that I choose to call God. I confronted
my fears and insecurities and made friends with other
people, some like me and some that did not have
the same experiences as me. I did not use my past
as an excuse to fail; I used it as a source of strength
and truth to move me forward. I learned to love again;
first myself and then others. I learned to forgive. It
set me free.
I went back to work with the help of my peers at the
Howie T. Harp Advocacy Center, a supportive employ-
ment/training center for people with histories similar
to my own, got a place to live, and found someone
special to share my life with. I learned to be a father,
a husband, a citizen — a man!
Eight years ago I never thought I would be able to say
this, but I am happy, joyous, and free. Today, all things
are possible!
Through my years of suffering, the government has
probably spent about one million dollars (not includ-
ing court and law enforcement costs) on incarceration
and treatments that just made my life worse and were
ineffective in diminishing or eliminating the problem.
All my drug use was a desperate attempt to medicate
symptoms that I did not understand and that society
had made me ashamed and fearful to get help for.
All of my arrests were due to my drug use. Why did I
have to be punished so severely, for so long, for be-
ing sick?
Psychiatric disability and substance abuse are chronic
illnesses similar to hypertension or diabetes. The last
time I checked, people with those illnesses were not
being put in jail and shunned by society. People can
live with all of these disorders with proper treatment
and support.
In closing, I encourage everyone to read Ending an
American Tragedy: Addressing the Needs of Justice-In-
volved People with Mental Illnesses and Co-Occurring
Disorders, which I have attached.
I believe this document can point this committee in
the right direction in changing the way services are
given; in a cost-effective and humane way that ben-
efits the community as a whole”
Sincerely,
David L. Fuller
David Fuller, CPRP, a consumer in recovery from psychiatric
disability, substance abuse, and the criminal justice system, is
employed at Kings County Hospital Center in Brooklyn as a peer
counselor who coordinates the Adult Outpatient Walk-In Clinic and
a group facilitator with its Continuing Day Treatment Program. He
is also an outreach and housing coordinator for the Manhattan
Outreach Consortium. As an administrator, service provider, and
independent consultant, Fuller draws on his personal experiences
as a consumer — and his opportunity to overcome many chal-
lenges — to fuel his mission to improve access to services for
people who have been affected by psychiatric diagnoses and who
use the public mental health system. Fuller is also a member of
the National Leadership Forum on Behavioral Health/Criminal
Justice with the National GAINS Center; an advisory board
member of the Peer Integration Project through the Columbia
School of Social Work’s Workplace Center; a guest lecturer at the
Columbia, Adelphi, and New York Universities Schools of Social
Work on trauma and mental health recovery models.
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 9
 Beyond Bars

Ending an American Tragedy:

Addressing the Needs of Justice-Involved
People with Mental Illnesses and
Co-Occurring Disorders

A Report of the National Leadership Forum for Behavioral Health/Criminal Justice Services, Co-chaired by Linda Rosenberg, MSW, President
and CEO, National Council for Community Behavioral Healthcare and Henry J. Steadman, PhD, President, Policy Research Associates; CMHS
National GAINS Center

It is my privilege to co-chair the National

Leadership Forum for Behavioral Health/Criminal
Justice Services. Ending an American Tragedy:
Addressing the Needs of Justice-Involved People
With Mental Illnesses and Co-Occurring Disorders
is a working document of the NLF. The report is
designed as both a call to action, focusing on the
crisis in our nation’s jails and prisons — men and
women with mental illnesses and addictions
incarcerated because they didn’t get the treat-
ments they desperately need — and an inspiration
— highlighting the possibilities of effective
services. We are asking leaders in all communities
to come together, pool resources, and work as
one. I’m proud of member organizations that are
already providing such leadership and you’ll find
a small sample of member programs in the “From
the Field” section of this issue. National Council
members are endlessly creative in overcoming
financial, bureaucratic, and cultural barriers and
establishing collaborations that solve community
problems. And we look forward to the growth and
spread of programs and services that offer
productive lives to people with mental illnesses
and addictions as the alternative to incarceration.”
— Linda Rosenberg
I n 1841, Dorothea Dix was appalled by the conditions she observed in Massachusetts jails and
crusaded for more humane responses to the needs of those inmates with mental illnesses. Within
a decade her work was translated into therapeutic state run institutions that traded punishment for
care. Over the next century, without sustained commitment to Dix’s vision for recovery, these facilities
fell into disrepair to the point that today, hundreds of thousands of people with mental illnesses crowd
our county jails and state prisons.
In 1946, Life Magazine published an exposé detailing cruel and inhumane conditions in State psychi-
atric hospitals across the United States.1 The article described widespread abuse of patients resulting,
in part, from “public neglect and legislative penny pinching;” and was punctuated by a series of
haunting photographs depicting desolate and shameful conditions under which people with mental
illnesses were being confined, often for years or even decades on end. The author referenced grand
jury reports as well as State and Federal investigations documenting widespread abuses and hazard-
ous living conditions in State institutions. Citing severely inadequate staffing, substandard treatment,
inappropriate use of restraints, and provision of little more than custodial care, the institutions were
described as, “…costly monuments to the States’ betrayal of the duty they have assumed to their
most helpless wards”
Although the population of State psychiatric hospitals continued to grow over the next decade, the
publication of this article, along with similar accounts from other media sources, began to expose
a crisis that had existed largely hidden from public view for far too long. As more light was shed on
the horrific treatment people received in State psychiatric hospitals, along with the hope offered by
the availability of new medications, a flurry of federal lawsuits resulted in court decisions leading to
substantial reductions in the numbers of people housed in State psychiatric hospitals.
Unfortunately, while State hospital beds were shut down by the thousands, the types of comprehensive
community-based services and supports promised as a condition of their closing were never developed.
Combined with changes in sentencing practices, evolution of quality of life ordinances, and restricted
definitions of eligibility for public sector behavioral health services, this has resulted in many individu-

10 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1

als with mental illnesses and co-occurring substance
use disorders repeatedly coming into contact with
the criminal justice system. Our Nation is once again
in the midst of another shameful and costly mental
health crisis that has been allowed to fester and grow,
largely out of public sight. It is a secret of stunning
proportions; in numbers and in harm.
Everyday, in every community in the United States,
our law enforcement officers, courts, and correctional
institutions are witness to a parade of misery brought
on by an inadequately funded, antiquated, and frag-
mented community mental health system that is un-
able to respond to the needs of people with serious
mental illnesses. Each year, more than 1.1 million
people diagnosed with mental illnesses are arrested
and booked into jails in the United States. Roughly
three-quarters of these individuals also experience
co-occurring substance use disorders, which increase
their likelihood of becoming involved in the justice
system. On any given day, between 300,000 and
400,000 people with mental illnesses are incarcer-
ated in jails and prisons across the United States, and
more than 500,000 people with mental illnesses are
under correctional control in the community.
Over the past 50 years we have gone from institutional-
izing people with mental illnesses, often in subhuman
conditions, to incarcerating them at unprecedented
and appalling rates — putting recovery out of reach
for millions of Americans.
These people are not all the same. They are a hetero-
geneous group.
>> A small subgroup does resemble the State hos-
pital patients of yesteryear, and their presence in
our jails/prisons is one of the most egregious and
disturbing images related to our failed systems of
care. The availability of intensive care models, in-
cluding hospital care for some, is critical.
>> Many other citizens with mental illnesses in our
jails have less disabling conditions and with ac-
cess to appropriate community treatment and
support, will do quite well.
>> A third subgroup includes people with mental ill-
nesses who have traits that are associated with
high arrest and recidivism rates. These individuals
would be best served with good treatment and
supports, which include interventions targeted to
their dynamic risk factors for arrest.
As we attempt to respond to the needs of these peo-
ple and respect the legitimate public safety concerns
of all community members, conditions in these cor-
rectional settings, which are designed for detention
and not therapeutic purposes, are often far worse
than conditions described in the State hospitals of
the 1940s. Moreover, when justice-involved persons
with co-occurring disorders leave correctional institu-
tions, they repeatedly are left adrift only to recycle
through the criminal justice system. Furthermore,
individuals who become involved in the justice sys-
tem often must contend with the additional stigma of
criminal records, which make access to basic needs
in the community, such as housing, education, and
employment, even more difficult to obtain.
This national disgrace, kept hidden for too long,
represents one area in civil rights where we have
actually lost ground. This failed policy has resulted in
a terrible misuse of law enforcement, court, and jail
resources, reduced public safety, and compromised
public health.
These conditions have recently resulted in investiga-
tions into the treatment of people with mental illnesses
in institutional settings, only this time the institutions
are correctional facilities that were never intended to
serve as de facto psychiatric hospitals. Over the past
decade alone, the U.S. Department of Justice has
issued findings from investigations of mental health
conditions in more than 20 jail and prison systems
across the United States, with additional investiga-
tions currently ongoing. Equally reminiscent of the
past, among the more pervasive findings from these
investigations are severely inadequate staffing, sub-
standard treatment, inappropriate use of restraints,
and provision of little more than custodial care.
The following excerpts are taken from recent grand
jury and Department of Justice reports:
>> During our tour, we observed inmate JM hitting her
head on the window of her cell and talking with
slurred speech. She was housed in a hospital cell
under suicide watch. She spoke of seeing angels
and said that she was afraid of her cellmate (who
was in the advanced stages of pregnancy) was
trying to harm her. She had been at [the jail] for
approximately one month prior to our visit. JM
stated on her intake form that she had previously
been treated at a mental hospital in Little Rock
and that she had been seen at a local hospital in
January 2005 for seeing ‘spiritual things.’ Shortly
after her admission to [the jail], she was placed
on suicide watch for making statements about
going to sleep and not getting up and ‘not caring
if she was alive or not.’ Her medical record notes
numerous instances of ‘talking wildly’ and ‘talking
to herself.’ She told us that she had a history of
hypothyroidism and told us the names of various
psychiatric medications that she had been taking
before being admitted to [the jail]. Throughout our
tour, we could hear JM moaning and crying and at
times screaming. In spite of all this, this inmate
was never evaluated by a mental health care pro-
vider. We were told that she was not started on any
psychiatric medications or sent to the local hos-
pital because she did not have the ability to pay.
>> Inmate M.K. hung herself on January 5, 2003 af-
ter having been admitted on December 4, 2002.
Her record contained the following inmate request
form dated two days before her death on January
3, 2003. The note indicated the following.
‘I need to see the doctor to get my medicine
straightened out. I am not getting my meds
that my doctor faxed prior orders for me, and
I brought in the medication myself and paid
for it. I cannot afford to be treated this way!
Please help me! I need my medicine.’
There is no indication that M.K. received her medi-
cation before her death.
There are no comparable Department of Justice inves-
tigations into a lack of community services, because
there is no constitutional right to community-based
services as there is for persons who are incarcerated.
However, by contrast, there are success stories in the
community. A recent report by the Health Foundation
of Greater Cincinnati offers a number of compelling
personal stories from four Forensic Assertive Commu-
nity Treatment (FACT) Teams they fund.
Clearly, jails and prisons were
never intended as a community’s
primary setting to provide acute
care services to individuals
experiencing serious mental
illnesses. In most cases they
are ill equipped to do so.
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 11
 Beyond Bars
In the absence of what are now seen as essential services
for people with mental illnesses living in the community,
people will continue to be forced into more costly, deep-end
services in hospitals, crisis centers, emergency rooms, and
the justice system.
>> “My housing is a lot better. My Social Security
just got approved today, so I start receiving that
again. They cut it off while I was in prison. I did
18 months in prison. I got [Social Security] back
with the help of [the FACT team]. And they’ve
been helping me with my housing. And that’s a
lot better ‘cause now I can get adjusted to a cer-
tain environment. And I don’t have to worry about
where I’m going to live, one week to the next for
whatever reason.”
>> “Well, I was really in bad shape. I didn’t know
how to go about getting help. The only thing that
I really knew that I had to do was try to care
for myself and my habit. And that’s what leads
to criminal behavior, which limited me on jobs.
I felt like I couldn’t work because of my record.
So, I had to keep being a criminal to support my-
self and my habit. I didn’t know where to go for
help. I didn’t know who to talk to. I was suicidal
all the time. And I really hated myself for all the
feelings and things that I was doing. I had an
apartment but I was evicted because I couldn’t
pay the rent. And then, I was just, like, going from
place to place and sometimes in homeless shel-
ters and sometimes with friends or just wherever.
I was in jail all the time. I just spent two years
in the penitentiary. I’ve been in the penitentiary
3 times and I’ve been in jail probably 30 to 40
times.” The same consumer, when asked about
life after receiving FACT services, reported: “Yeah,
I haven’t had any problems. I work at McDonalds
full-time.”
Clearly, jails and prisons were never intended as a
community’s primary setting to provide acute care
services to individuals experiencing serious mental
illnesses. In most cases they are ill equipped to do so.
When we look at community-based services, we find
current policies governing the funding and organiza-
tion of community mental health care have resulted
in people with more intensive and chronic treat-
ment needs being underserved or unserved in typi-
12 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
cal community-based settings. This is due in large
part to rules and regulations that limit flexibility
in designing service and reimbursement strategies
targeting the specific needs of people with serious
mental illnesses. For example, the Substance Abuse
and Mental Health Services Administration (SAMH-
SA) and the Centers for Medicare and Medicaid Ser-
vices (CMS) are two agencies housed within the U.S.
Department of Health and Human Services (DHHS).
SAMHSA has identified intensive case management,
psychosocial rehabilitation, supported employment,
and supported housing as evidence-based inter-
ventions, consistently yielding positive outcomes for
persons with serious mental illnesses.
However there are several obstacles to using Medic-
aid to pay for these effective services. These include
categorical restrictions on eligibility, which exclude
many people with serious mental illnesses and co-
occurring substance use disorders who have been
involved in the criminal justice system, as well as
fragmentation in coverage for treatment of medical,
mental health, and substance abuse problems. Nar-
row criteria for “medical necessity” and definitions
of covered services that are often not aligned with
what we know about evidence-based practices cre-
ate barriers to more effective service delivery and
recovery outcomes. As a result, there is an increased
demand for services provided in hospitals, emer-
gency settings, and the justice system, contributing
to extraordinarily high costs for local communities,
states, and the Federal government.
Furthermore, new practices have been slow to be
made available to justice-involved persons with
co-occurring disorders. For example, it has now be-
come widely accepted that all services for people
with serious mental illnesses, particularly those with
criminal justice involvement, be trauma-informed.
Among both women and men with criminal justice
involvement, histories of trauma are nearly univer-
sal. Ninety-three percent of 2,000 women and men
in federally funded jail diversion programs between
2002 and 2008 reported at least one incident of
physical or sexual abuse in their lifetime. Sixty-
one percent reported physical or sexual abuse in
the last 12 months. Yet few programs, institutional
or community-based, offer environments that are
trauma informed or trauma specific.
Moreover, a recent study found 31 percent of
women being booked into local jails with current
symptoms of serious mental illness.2 This compares
with 14 percent of men. These rates exacerbate the
issues of providing adequate services for women in
predominantly male facilities whose physical plants
and staffing are geared to men. Gender-specific ser-
vices that reflect a trauma-informed culture must
be developed in all institutional and community
settings to respond to the frighteningly high rates
of mental illness among women in contact with the
criminal justice system.
In addition, we know that individuals using mental
health services — often referred to as “consumers”—
have a significant impact on creating recovery-ori-
ented mental health and substance abuse services.
For people involved in the criminal justice system,
forensic peer specialists — those with histories of
mental illness and criminal justice system involve-
ment — can help pave the way for a successful re-
turn to the community.
The ability to effectively design, implement, and
reimburse treatment providers for delivering high
quality services targeting specialized treatment
needs is critical to establishing an effective com-
munity-based system of care for people who expe-
rience serious mental illnesses. In the absence of
what are now seen as essential services for peo-
ple with mental illnesses living in the community,
people will continue to be forced into more costly,
deep-end services in hospitals, crisis centers, emer-
gency rooms, and the justice system.
The result is a recycling of individuals between jails,
prisons, shelters, short-term hospitalizations, and
homelessness — with public health, public safety,
and public administration implications that are
staggering. Now more than ever, as we strive to
provide health care to our most vulnerable citizens,
we must address this serious public health and
public safety crisis. It is high time to be open and
honest about the deplorable conditions that ex-
ist and take steps to address them. We offer four
recommendations for immediate action.
 Beyond Bars
Recommendations
for Immediate Action
u The President should appoint a Special
Advisor for Mental Health/Criminal Justice
Collaboration.
Currently, there is no fixed responsibility within the
Federal government to promote effective mental
health/criminal justice activities and ensure ac-
countability for the use of public dollars. The Special
Advisor will serve as an advocate and ombudsman
across the wide array of Federal agencies that serve
the multiple needs of justice-involved people with
mental and substance use disorders. One of his or
her tasks will be to implement an immediate re-
view of all CMS and SAMHSA regulations to identify
conflicts and inconsistencies for people with mental
illnesses and co-occurring substance use disorders
— particularly those involved in the justice system.
u Federal Medicaid policies that limit or
discourage access to more effective and
cost-efficient health care services for indi-
viduals with serious mental illnesses and
co-occurring substance use disorders should
be reviewed and action taken to create more
efficient programs.
Congress is encouraged to review Medicaid policies
and take action that will enable states to create
more effective and appropriate programs target-
ing eligible beneficiaries most likely to experience
avoidable admissions to acute care settings. Such
programs should allow states flexibility in designing
and implementing targeted outreach and engage-
ment services, coordinated care management,
and community support services that are likely to
reduce expenditures on deep-end services, and en-
gage people in prevention, early intervention, and
wellness care in the community. Services provided
should reflect evidence-based and promising prac-
tices and should be designed around principles of
recovery, person-centered planning, and consumer
choice. Because of the high rates of co-morbid
health care needs among people with serious men-
14 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
tal illnesses and co-occurring substance use disor-
ders, programs should seek to establish more ef-
fective integration of primary and behavioral health
care service delivery system as well.
u All States should create cross-system
agencies, commissions, or positions charged
with removing barriers and creating incen-
tives for cross-agency activity at the State
and local level.
No one system can solve this problem alone. These
cross-system groups or individuals will play a key
role in spanning the different administrative struc-
tures, funding mechanisms, and treatment philoso-
phies of the mental health, substance abuse, and
criminal justice systems. States must make clear
that collaboration is not only possible but expected.
In Montana, for example, the State Department of
Corrections and Department of Public Health and
Human Services jointly fund a boundary spanner
position that facilitates shared planning, communi-
cation, resources, and treatment methods between
the mental health and criminal justice systems.
u Localities must develop and implement
core services that comprise an Essential Sys-
tem of Care:
Recognizing the limited resources often available
and the complexities of the cross-system collabora-
tions required, the eight components of an Essential
System of Care are best approached in two phases.
Phase 1 includes less expensive, easier to mount
services. Phase 2 includes essential evidence-
based practices that are more expensive and more
challenging to implement, but are critical to actu-
ally increasing positive public safety and public
health outcomes.
Phase 1
>> Forensic Intensive Case Management
>> Supportive Housing
>> Peer Support
>> Accessible and Appropriate Medication
These four services are the ones we believe are
minimally necessary to break the cycle of illness,
arrest and incarceration, and recidivism. We believe
these services — described in brief below — can
be implemented quickly, cost-effectively, and with
positive results. However, these services can only
be effective if the programs that provide them are
structured and staffed by people who understand
and are prepared to address trauma as a risk fac-
tor for both mental health problems and criminal
justice involvement. A trauma-informed system that
features trauma-specific interventions can help en-
sure public health and public safety and transform
individuals’ lives.
Forensic Intensive Case Management (FICM) is
designed for justice-involved people with multiple
and complex needs and features services provided
when and where they are needed. FICM focuses on
brokering rather than providing services directly,
making it less expensive than ACT. For a brokered
service model to be effective, communities must
have adequate and accessible services to which in-
dividuals can be linked. What makes these services
“forensic” is “criminal justice savvy,”3 that is, pro-
viders understand the criminal justice system and
the predicaments of their clients involvement in it.
Supportive Housing is permanent, affordable hous-
ing linked to a broad range of supportive services,
including treatment for mental and substance use
disorders. Supportive housing can significantly de-
crease the chance of recidivism to jails and prisons
and is less costly on a daily basis than jail or prison.
Unfortunately, affordable housing is in short supply
in many communities, and ex-offenders with drugre-
lated offenses often have trouble securing public
housing assistance. Housing for ex-offenders must
balance the needs for supervision and the provision
of social services.
Peer Support services can expand the continuum
of services available to people with mental and
substance use disorders and may help them engage
in treatment. Forensic peer specialists bring real-
world experience with multiple service systems and
an ability to relate one-on-one to people struggling
to reclaim their lives. The practice of consumer-
driven care — as exemplified by the involvement of
mental health consumers in service design, delivery,
and evaluation — is at the heart of a transformed
mental health system.
Accessible and Appropriate Medication supports
continuity of care for individuals with mental ill-
nesses whose treatment often is disrupted when
they become involved in the criminal justice system.
They may not receive appropriate medication in
jail or prison or adequate follow-up when they return
to the community. It is imperative that people with
mental illnesses and co-occurring substance use
disorders have access to the right medication at the
right dosage for their condition, as determined by the
individual together with his or her clinician.
Phase 2
Clearly, the Phase 1 services are necessary, but not
sufficient. Services that support the Essential System
of Care include several evidence-based practices for
people with serious mental illnesses. These services
may be more expensive or difficult to implement than
the four listed above, but we encourage States and
communities to move toward development of these
services by codifying them in policy, supporting them
in practice, and rewarding their implementation.
Phase 2 services include:
>> Integrated Dual Diagnosis Treatment, which
provides treatment for mental and substance use dis-
orders simultaneously and in the same setting
>> Supported Employment, which is an evidence-
based practice that helps individuals with mental ill-
nesses find, get, and keep competitive work
>> Assertive Community Treatment (ACT)/ Foren-
sic Assertive Community Treatment (FACT), which
is a service delivery model in which treatment is pro-
vided by a team of professionals, with services deter-
mined by an individual’s needs for as long as required,
and
>> Cognitive Behavioral Interventions Targeted to
Risk Factors specific to offending, are a set of in-
terventions, well researched within both institutional
settings and community settings, that have a utility
when extended to community treatment programs.
This list of evidence-based and promising practices is
illustrative but not exhaustive. Clearly, however, there
is much that can be done to help people with mental
and substance use disorders avoid arrest and incar-
ceration and return successfully to their communities
after jail or prison. We acknowledge that in difficult
financial times, new dollars may not be available.
However, though new money is not always required for
systems change, new ways of thinking are.
To meet the public health and public safety needs
of our communities demands a fully collaborative
campaign involving both the behavioral health and
criminal justice systems. Neither system can continue
To meet the public health and public safety needs
of our communities demands a fully collaborative
campaign involving both the behavioral health
and criminal justice systems. Neither system can
continue business as usual.
National Leadership Forum Members
business as usual. The criminal justice system needs Thomas Berger
to do an adequate job of screening, assessing, and Vietnam Veterans of America
individualizing responses to detainees and inmates Sandra Cannon
Ohio Department of Mental Health
identified with mental illness. The behavioral health Neal Cash
system needs to refine and deliver evidence-based Community Partnership of Southern Arizona
practices with an awareness of its responsibility to not David Fuller
Manhattan Outreach Consortium
only improve the quality of life of its clients, but to ad-
Robert Glover
dress interventions to factors associated with criminal National Association of State Mental Health Program
recidivism in these clients and to more directly involve Directors
clients as partners in a recovery process that recog- Gilbert Gonzales
Bexar County Mental Health Authority Center for Health
nizes the community’s public safety concerns. Care Services
Prime examples of this Essential System of Care have Richard Gowdy
Missouri Department of Mental Health
been developed within the CMHS TCE Jail Diversion
Jennifer Johnson
program since 2002. San Antonio, TX, has become a San Francisco Office of the Public Defender
national model with a highly integrated system of care Hon. Steve Leifman
Special Advisor on Criminal Justice and Mental Health to
that reflects strong behavioral health and criminal
Florida Supreme Court
justice partnerships that have resulted in a central- Stephanie LeMelle
ized police drop-off that directly links persons to case New York State Psychiatric Institute, Columbia University
Department of Psychiatry
management, medications, housing, and peer sup-
port. A medium-size city that has built a comprehen-
Ginger Martin
Oregon Department of Corrections Transitional Services
sive, integrated system around an existing community Division
mental health center is Lincoln, NB. These are but two John Morris
examples of successfully moving entire communities
The Technical Assistance Collaborative
Fred Osher
forward via a jail diversion program to achieve Phase Council of State Governments Justice Center
1 services and move towards Phase 2 implementa- Linda Rosenberg*
tion. These goals are achievable even in today’s eco- National Council for Community Behavioral Healthcare
nomic tough times. David Shern
Mental Health America
We must move toward a day when people with men- Henry J. Steadman*
tal and substance use disorders receive the effec- Policy Research Associates, CMHS National GAINS Center
tive community-based interventions they need and
Carol Wilkins
Corporation for Supportive Housing
deserve, and jails and prisons no longer are forced B. Diane Williams
to serve as primary, de facto treatment facilities. We Safer Foundation
know what works to address successfully the needs Dee Wilson
Texas Department of Criminal Justice
of people with mental and substance use disorders
Sharon Wise
who come in contact with the criminal justice system; The Gregory Project of Washington D.C.
now we have to DO what works. The time for action *Co-chair of National Leadership Forum
is now!
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 15
 Interview
Behavioral Health and Criminal Justice Collaboration:
Linda Rosenberg, MSW, President & CEO, National Council for Community Behavioral Healthcare, Interviewed by Mohini Venkatesh,
Director, Federal and State Policy and Nathan Sprenger, Marketing and Communications Associate — National Council for Community
Behavioral Healthcare
Linda Rosenberg, MSW, President & CEO, National
Council for Community Behavioral Healthcare, shares
her thoughts about the current status of treatment for
justice-involved individuals with mental illness and ad-
diction. Committed to supporting the efforts of member
organizations to address the problems of their communi-
ties, Rosenberg has positioned the National Council to
promote the expansion of community based alternatives
to incarceration. Prior to her position at the National
Council, she served as the Senior Deputy Commissioner
for the New York State Office of Mental Health, during
which time she oversaw the state’s services for justice-in-
volved individuals, implementing a network of jail diversion
programs including New York’s first mental health court.
National Council: What challenges exist in serving
justice-involved people with mental illness and addic-
tions?
Linda: There are many challenges in connecting jus-
tice involved consumers with services. We’re talking
primarily about people with little money or power and
they may have little or no interest in mental health or
addictions treatment services. They’ve not found ser-
vices useful or relevant and often dislike programs that
are highly structured. Our job at the National Council
is to identify member organizations that have devel-
oped successful services for this population and then
to facilitate the member to member spread of these
programs.
National Council: New York has an assisted outpa-
tient treatment law — what is the controversy behind
such laws?
Linda: Some view these laws as victimizing — blaming
— people with mental illness. In a perfect world, court
ordered treatment would be unnecessary but in our
world the combined power of the court and treatment
can mean successful community living for consumers
that would otherwise be in and out of hospital or jail.
Assisted Outpatient Treatment must be carefully used
but when all else fails it can connect people to vital
services. But AOT alone isn’t enough — a full array of
community services including housing, effective treat-
ments, work supports, and general medical care must
be available and accessible. Unfortunately passage of
AOT is often a political reaction to an unfortunate inci-
dent — a law is passed with no financing of the services
that are critical if we’re going to keep both individuals
with mental illnesses and our communities safe.
16 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
Where Does the Buck Stop?
National Council: As a state official in New York,
you were a strong supporter of the state’s first mental
health court. What benefits do such courts bring to
providers and the individuals they serve?
Linda: I’ve seen mental health courts and to an even
greater extent, drug courts, emerge as a powerful
means through which people access care. In many
places the court begins with a judge who has personal
and/or professional interest in behavioral health is-
sues. Mental health and drug courts aren’t meant to
be applied broadly — these courts are alternatives for
people with serious mental illnesses and addictions
that are on the way to jail or prison. And like AOT, there
must be seamless connections to the full continuum of
treatment and support services. These problem-solving
courts give individuals with serious behavioral health
disorders a unique opportunity to engage with a judge
around their needs. The courts provide alternatives to
people with mental illnesses and addiction — offering
services instead of time behind bars.
National Council: How can states move forward in
creating programs for justice-involved persons in this
era of budget cuts? What role do community providers
play?
Linda: Change is often incremental in our very complex
world but it looks like we’ve reached a tipping point in
regard to diversion and re-entry. Policy change is often
driven by a convergence of ideas and money. States
are in tremendous economic distress and can’t con-
tinue to build new jails and prisons or support grow-
ing numbers of incarcerated individuals. At the same
time it’s becoming clear that treatment and services
works and are less expensive alternatives. Look at the
President’s budget proposal – growth in financing of
alternatives to criminal justice involvement. This is an
area where there is both new money and potential for
re-investment of dollars currently directed to incarcer-
ation. And as always leadership is essential — excited
by the possibilities, local leaders emerge, enlist others
in their vision, and the money follows.
National Council: How does the justice-involved
population “fall through the cracks?”
Linda: The falling through the cracks problem is not
unique to justice-involved individuals. Every time we
create a new program or service to keep people from
falling through the cracks, we are creating another
There must be a single point of
accountability. If everyone is respon-
sible, then no one is responsible.”
crack for someone to fall through. The system has got-
ten so rich and so complicated — multiple programs
and services, most under different corporate auspices
and each with its unique rules and operating practices
— that it’s difficult to navigate it. A person’s treatment
is run by one organization, their housing by another,
their employment supports by another — and getting
all these organizations on the same page and at the
same table becomes nearly impossible. It is very, very
difficult to coordinate services.
National Council: What can be done to support co-
ordinated treatment?
Linda: I think in the end we need a system where one
organization/person is responsible. If everyone is re-
sponsible, then no one is responsible. The buck has
to stop somewhere and I think it needs to stop with
an organization that gets an adequate pot of money
and ensures that the consumer gets the services they
need and want. With adequate financing, clarity as to
what treatments and services are effective and the de-
livery of those interventions, use of health information
technology, and the ongoing measurement of simple
outcomes — hospitalization, incarceration and home-
lessness — we can coordinate care and go a long way
toward supporting successful community tenure. That
doesn’t mean that all justice-involved people will have
a straight trajectory to recovery. Some people will be
hospitalized and some might be incarcerated or be-
come homeless. We can do better but challenges will
remain. Our jobs are to address the challenges, always
exploring new approaches and refining our efforts to
improve lives.
Mohini Venkatesh serves as the staff policy liaison to the
National Council for Community Behavioral Healthcare’s
network of associations throughout the states, conducts federal
legislative and policy analysis on an array of issues, and man-
ages political engagement activities including an annual Hill
Day in Washington, DC. She received a masters in public health
from Yale University and a BA in psychology from the University
of Massachusetts-Amherst.
Nathan Sprenger supports the National Council’s public rela-
tions and marketing efforts, leads the social media activities,
maintains the website, and serves as editorial assistant for
National Council Magazine. He has a masters degree in public
communication from American University in Washington DC.

* Eligibility for co-pay assistance: Offer not valid for prescriptions purchased under Medicaid, Medicare, or any federal
or state healthcare programs, including any state medical or pharmaceutical assistance program. Offer not valid
in Massachusetts. Void where prohibited by law, taxed or restricted. Alkermes, Inc. reserves the right to rescind,
revoke or amend these offers without notice.
indicaTion1
VIVITROL is indicated for the treatment of alcohol dependence in patients who are able to abstain
® hepatic injury appears to be only five-fold or less. VIVITROL does not appear to be a hepatotoxin at the
from alcohol in an outpatient setting prior to initiation of treatment with VIVITROL.
Patients should not be actively drinking at the time of initial VIVITROL administration.
Treatment with VIVITROL should be part of a comprehensive management program that includes
psychosocial support.
imPorTanT safeTy informaTion for ViViTrol1
VIVITROL is contraindicated in patients receiving opioid analgesics or with current physiologic
opioid dependence, patients in acute opiate withdrawal, any individual who has failed the naloxone
challenge test or has a positive urine screen for opioids, or in patients who have previously exhibited
hypersensitivity to naltrexone, PLG, carboxymethylcellulose or any other components of the diluent.
VIVITROL patients must be opioid free for a minimum of 7-10 days before treatment. Attempts to overcome
opioid blockade due to VIVITROL may result in a fatal overdose. In prior opioid users, use of opioids after
discontinuing VIVITROL may result in a fatal overdose because patients may be more sensitive to lower
doses of opioids. Patients requiring reversal of the VIVITROL blockade for pain management should be
monitored by appropriately trained personnel in a setting equipped for cardiopulmonary resuscitation.
Please see brief summary of ViViTrol Prescribing informaTion,
including boxed warning, on The nexT Page.
VIVITROL is a registered trademark of Alkermes, Inc.
©2010 Alkermes, Inc.
All rights reserved VIV 981 B January 2010 Printed in U.S.A.
www.vivitrol.com
For the treatment of alcohol dependence
VIVITROL...
there when they need it.
Tell Your Patients About Our
Co-Pay Assistance Program
Up to 6 months of medication with
potentially no out-of-pocket costs*
For more information, call toll-free
1-800-VIVITROL (1-800-848-4876, ext. 2).
Naltrexone has the capacity to cause hepatocellular injury when given in excessive doses.
Naltrexone is contraindicated in acute hepatitis or liver failure, and its use in patients with active liver
disease must be carefully considered in light of its hepatotoxic effects.
The margin of separation between the apparently safe dose of naltrexone and the dose causing
recommended doses.
Patients should be warned of the risk of hepatic injury and advised to seek medical attention if they
experience symptoms of acute hepatitis. Use of VIVITROL should be discontinued in the event of symptoms
and/or signs of acute hepatitis.
VIVITROL is administered as a gluteal intramuscular injection. Inadvertent subcutaneous injection of
VIVITROL may increase the likelihood of severe injection site reactions. VIVITROL must be injected using
the customized needle provided in the carton. Because needle length may not be adequate due to body
habitus, each patient should be assessed prior to each injection to assure that needle length is adequate
for intramuscular administration. VIVITROL injection site reactions may be followed by pain, tenderness,
induration, swelling, erythema, bruising or pruritus; however, in some cases injection site reactions may be
very severe. Injection site reactions not improving may require prompt medical attention, including in some
cases surgical intervention.
Consider the diagnosis of eosinophilic pneumonia if patients develop progressive dyspnea and hypoxemia.
In an emergency situation in patients receiving VIVITROL, suggestions for pain management include regional
analgesia or use of non-opioid analgesics. Alcohol dependent patients, including those taking VIVITROL,
should be monitored for the development of depression or suicidal thoughts. Caution is recommended in
administering VIVITROL to patients with moderate to severe renal impairment.
The most common adverse events associated with VIVITROL in clinical trials were nausea, vomiting,
headache, dizziness, asthenic conditions and injection site reactions.
1. VIVITROL [full prescribing information]. Waltham, MA: Alkermes, Inc; May 2009.
BRIEF SUMMARY See package insert for full Prescribing Information. intramuscular injection with the provided needle. Patients should be informed that any injection site
INDICATIONS AND USAGE: VIVITROL is indicated for the treatment of alcohol dependence in patients reactions should be brought to the attention of the healthcare provider (see INFORMATION FOR PATIENTS).
who are able to abstain from alcohol in an outpatient setting prior to initiation of treatment with Patients exhibiting signs of abscess, cellulitis, necrosis or extensive swelling should be evaluated by a
VIVITROL. Patients should not be actively drinking at the time of initial VIVITROL administration. physician. Renal Impairment VIVITROL pharmacokinetics have not been evaluated in subjects with
Treatment with VIVITROL should be part of a comprehensive management program that includes moderate and severe renal insufficiency. Because naltrexone and its primary metabolite are excreted
psychosocial support. CONTRAINDICATIONS: VIVITROL is contraindicated in: • Patients receiving primarily in the urine, caution is recommended in administering VIVITROL to patients with moderate to
opioid analgesics (see PRECAUTIONS). • Patients with current physiologic opioid dependence (see severe renal impairment. Alcohol Withdrawal Use of VIVITROL does not eliminate nor diminish alcohol
WARNINGS). • Patients in acute opiate withdrawal (see WARNINGS). • Any individual who has failed withdrawal symptoms. Intramuscular injections As with any intramuscular injection, VIVITROL should
the naloxone challenge test or has a positive urine screen for opioids. • Patients who have previously be administered with caution to patients with thrombocytopenia or any coagulation disorder (e.g.,
exhibited hypersensitivity to naltrexone, PLG, carboxymethylcellulose, or any other components of the hemophilia and severe hepatic failure). Information for Patients Physicians are advised to consult Full
diluent. Prescribing Information for information to be discussed with patients for whom they have prescribed
VIVITROL. Drug Interactions Patients taking VIVITROL may not benefit from opioid-containing medicines
(see PRECAUTIONS, Pain Management). Because naltrexone is not a substrate for CYP drug metabolizing
WARNINGS: Hepatotoxicity
enzymes, inducers or inhibitors of these enzymes are unlikely to change the clearance of VIVITROL.
No clinical drug interaction studies have been performed with VIVITROL to evaluate drug interactions,
Naltrexone has the capacity to cause hepatocellular injury when given in excessive doses. therefore prescribers should weigh the risks and benefits of concomitant drug use. The safety profile
of patients treated with VIVITROL concomitantly with antidepressants was similar to that of patients
Naltrexone is contraindicated in acute hepatitis or liver failure, and its use in patients with active liver taking VIVITROL without antidepressants. Carcinogenesis, Mutagenesis, Impairment of Fertility
disease must be carefully considered in light of its hepatotoxic effects. Carcinogenicity studies have not been conducted with VIVITROL. Carcinogenicity studies of oral naltrexone
The margin of separation between the apparently safe dose of naltrexone and the dose causing hydrochloride (administered via the diet) have been conducted in rats and mice. In rats, there were small
hepatic injury appears to be only five-fold or less. VIVITROL does not appear to be a hepatotoxin at the increases in the numbers of testicular mesotheliomas in males and tumors of vascular origin in males and
recommended doses. females. The clinical significance of these findings is not known. Naltrexone was negative in the following
Patients should be warned of the risk of hepatic injury and advised to seek medical attention if they in vitro genotoxicity studies: bacterial reverse mutation assay (Ames test), the heritable translocation
experience symptoms of acute hepatitis. Use of VIVITROL should be discontinued in the event of symptoms assay, CHO cell sister chromatid exchange assay, and the mouse lymphoma gene mutation assay.
and/or signs of acute hepatitis. Naltrexone was also negative in an in vivo mouse micronucleus assay. In contrast, naltrexone tested
positive in the following assays: Drosophila recessive lethal frequency assay, non-specific DNA damage in
repair tests with E. coli and WI-38 cells, and urinalysis for methylated histidine residues. Naltrexone given
orally caused a significant increase in pseudopregnancy and a decrease in pregnancy rates in rats at 100
Eosinophilic pneumonia In clinical trials with VIVITROL, there was one diagnosed case and one
mg/kg/day (600 mg/m2/day). There was no effect on male fertility at this dose level. The relevance of these
suspected case of eosinophilic pneumonia. Both cases required hospitalization, and resolved after
observations to human fertility is not known. Pregnancy Category C Reproduction and developmental
treatment with antibiotics and corticosteroids. Should a person receiving VIVITROL develop progressive
studies have not been conducted for VIVITROL. Studies with naltrexone administered via the oral route
dyspnea and hypoxemia, the diagnosis of eosinophilic pneumonia should be considered (see ADVERSE
have been conducted in pregnant rats and rabbits. Teratogenic Effects Oral naltrexone has been shown
REACTIONS). Patients should be warned of the risk of eosinophilic pneumonia, and advised to seek
to increase the incidence of early fetal loss in rats administered ≥30 mg/kg/day (180 mg/m2/day) and
medical attention should they develop symptoms of pneumonia. Clinicians should consider the possibility
rabbits administered ≥60 mg/kg/day (720 mg/m2/day). There are no adequate and well-controlled studies
of eosinophilic pneumonia in patients who do not respond to antibiotics. Unintended Precipitation of
of either naltrexone or VIVITROL in pregnant women. VIVITROL should be used during pregnancy only if
Opioid Withdrawal—To prevent occurrence of an acute abstinence syndrome (withdrawal) in
the potential benefit justifies the potential risk to the fetus. Labor and Delivery The potential effect of
patients dependent on opioids, or exacerbation of a pre-existing subclinical abstinence syndrome,
VIVITROL on duration of labor and delivery in humans is unknown. Nursing Mothers Transfer of naltrexone
patients must be opioid-free for a minimum of 7-10 days before starting VIVITROL treatment. Since
and 6β-naltrexol into human milk has been reported with oral naltrexone. Because of the potential for
the absence of an opioid drug in the urine is often not sufficient proof that a patient is opioid-free,
tumorigenicity shown for naltrexone in animal studies, and because of the potential for serious adverse
a naloxone challenge test should be employed if the prescribing physician feels there is a risk
reactions in nursing infants from VIVITROL, a decision should be made whether to discontinue nursing or
of precipitating a withdrawal reaction following administration of VIVITROL. Opioid Overdose
to discontinue the drug, taking into account the importance of the drug to the mother. Pediatric Use The
Following an Attempt to Overcome Opiate Blockade VIVITROL is not indicated for the purpose of
safety and efficacy of VIVITROL have not been established in the pediatric population. Geriatric Use In
opioid blockade or the treatment of opiate dependence. Although VIVITROL is a potent antagonist with
trials of alcohol dependent subjects, 2.6% (n=26) of subjects were >65 years of age, and one patient was
a prolonged pharmacological effect, the blockade produced by VIVITROL is surmountable. This poses
>75 years of age. Clinical studies of VIVITROL did not include sufficient numbers of subjects age 65 and
a potential risk to individuals who attempt, on their own, to overcome the blockade by administering
over to determine whether they respond differently from younger subjects. ADVERSE REACTIONS: In all
large amounts of exogenous opioids. Indeed, any attempt by a patient to overcome the antagonism by
controlled and uncontrolled trials during the premarketing development of VIVITROL, more than 900 patients
taking opioids is very dangerous and may lead to fatal overdose. Injury may arise because the plasma
with alcohol and/or opioid dependence have been treated with VIVITROL. Approximately 400 patients
concentration of exogenous opioids attained immediately following their acute administration may be
have been treated for 6 months or more, and 230 for 1 year or longer. Adverse Events Leading to
sufficient to overcome the competitive receptor blockade. As a consequence, the patient may be in
Discontinuation of Treatment In controlled trials of 6 months or less, 9% of patients treated with VIVITROL
immediate danger of suffering life-endangering opioid intoxication (e.g., respiratory arrest, circulatory
discontinued treatment due to an adverse event, as compared to 7% of the patients treated with placebo.
collapse). Patients should be told of the serious consequences of trying to overcome the opioid blockade
Adverse events in the VIVITROL 380-mg group that led to more dropouts were injection site reactions (3%),
(see INFORMATION FOR PATIENTS).There is also the possibility that a patient who had been treated with
nausea (2%), pregnancy (1%), headache (1%), and suicide-related events (0.3%). In the placebo group, 1%
VIVITROL will respond to lower doses of opioids than previously used. This could result in potentially
of patients withdrew due to injection site reactions, and 0% of patients withdrew due to the other adverse
life-threatening opioid intoxication (respiratory compromise or arrest, circulatory collapse, etc.). Patients
events. Common Adverse Events The most common adverse events associated with VIVITROL in clinical
should be aware that they may be more sensitive to lower doses of opioids after VIVITROL treatment is
trials were nausea, vomiting, headache, dizziness, fatigue, and injection site reactions. For a complete list
discontinued (see INFORMATION FOR PATIENTS). PRECAUTIONS: General—When Reversal of VIVITROL
of adverse events, please refer to the VIVITROL package insert for full Prescribing Information. A majority of
Blockade is Required for Pain Management In an emergency situation in patients receiving VIVITROL,
patients treated with VIVITROL in clinical studies had adverse events with a maximum intensity of “mild”
suggestions for pain management include regional analgesia or use of non-opioid analgesics. If opioid
or “moderate.” Post-marketing Reports—Reports From Other Intramuscular Drug Products
therapy is required as part of anesthesia or analgesia, patients should be continuously monitored in an
Containing Polylactide-co-glycolide (PLG) Microspheres – Not With VIVITROL. Retinal Artery
anesthesia care setting, by a person not involved in the conduct of the surgical or diagnostic procedure.
Occlusion Retinal artery occlusion after injection with another drug product containing polylactide-
The opioid therapy must be provided by an individual specifically trained in the use of anesthetic drugs
co-glycolide (PLG) microspheres has been reported very rarely during post-marketing surveillance.
and the management of the respiratory effects of potent opioids, specifically the establishment and
This event has been reported in the presence of abnormal arteriovenous anastomosis. No cases
maintenance of a patent airway and assisted ventilator. Depression and Suicidality In controlled clinical
of retinal artery occlusion have been reported during VIVITROL clinical trials or post-marketing
trials of VIVITROL, adverse events of a suicidal nature (suicidal ideation, suicide attempts, completed
surveillance. VIVITROL should be administered by intramuscular (IM) injection into the gluteal
suicides) were infrequent overall, but were more common in patients treated with VIVITROL than in
muscle, and care must be taken to avoid inadvertent injection into a blood vessel (see DOSAGE
patients treated with placebo (1% vs. 0). In some cases, the suicidal thoughts or behavior occurred after
AND ADMINISTRATION). OVERDOSAGE: There is limited experience with overdose of VIVITROL. Single
study discontinuation, but were in the context of an episode of depression which began while the patient
doses up to 784 mg were administered to 5 healthy subjects. There were no serious or severe adverse
was on study drug. Two completed suicides occurred, both involving patients treated with VIVITROL.
events. The most common effects were injection site reactions, nausea, abdominal pain, somnolence, and
Depression-related events associated with premature discontinuation of study drug were also more
dizziness. There were no significant increases in hepatic enzymes. In the event of an overdose, appropriate
common in patients treated with VIVITROL (~1%) than in placebo-treated patients (0). In the 24-week,
supportive treatment should be initiated. This brief summary is based on VIVITROL Prescribing Information
placebo-controlled pivotal trial, adverse events involving depressed mood were reported by 10% of
(VIV 566C May 2009).
patients treated with VIVITROL 380 mg, as compared to 5% of patients treated with placebo injections.
Alcohol dependent patients, including those taking VIVITROL, should be monitored for the development of
depression or suicidal thinking. Families and caregivers of patients being treated with VIVITROL should be
alerted to the need to monitor patients for the emergence of symptoms of depression or suicidality, and to
report such symptoms to the patient’s healthcare provider. Injection Site Reactions VIVITROL injections
may be followed by pain, tenderness, induration, swelling, erythema, bruising or pruritus; however in
some cases injection site reactions may be very severe. In the clinical trials, one patient developed an
area of induration that continued to enlarge after 4 weeks with subsequent development of necrotic tissue
that required surgical excision. In the postmarketing period, additional cases of injection site reaction
with features including induration, cellulitis, hematoma, abscess, sterile abscess and necrosis have been
reported. Some cases required surgical intervention. VIVITROL is administered as a gluteal intramuscular
injection. An inadvertent subcutaneous injection of VIVITROL may increase likelihood of severe injection Alkermes® and VIVITROL® are registered trademarks of Alkermes, Inc.
site reactions. VIVITROL must be injected by the customized needle provided in the carton. Alternate Manufactured and marketed by Alkermes, Inc.
treatment should be considered for those patients whose body habitus precludes a gluteal ©2009 Alkermes, Inc. VIV 107C July 2009 Printed in U.S.A. All rights reserved.
 Beyond Bars
Decriminalizing Mental Illness:
Miami Dade County Tackles a Crisis at the Roots
Judge Steven Leifman, Special Advisor on Criminal Justice and Mental Health, Supreme Court of Florida, and Associate Administrative
Judge, County Court, Criminal Division, 11th Judicial Circuit of Florida; Tim Coffey, Coordinator, 11th Judicial Circuit, Criminal Mental Health
Project
Miami-Dade County, Florida houses the largest percentage of people
with serious mental illness (e.g., schizophrenia, bipolar disorder, major
depression) of any urban community in the United States. Roughly
9.1 percent of the population (170,000 adults) experiences serious
mental illness, yet only 1 percent (24,000 adults) receives treatment
in the public mental health system. By contrast, the number of people
accessing mental health services through the Miami-Dade County jail
is staggering. Of the roughly 114,000 bookings into the jail this past
year, it is estimated that as many as 20,000 people with mental
illness required psychiatric treatment during incarceration.
On any given day, the county jail houses approximately 1,200 people
with mental illness receiving psychotherapeutic medications. This
number represents 17 percent of the total inmate population and
costs taxpayers more than $50 million annually. The Miami-Dade
County jail serves as the largest psychiatric institution in the state
of Florida, housing more beds serving people with mental illness
than any inpatient hospital in the state and nearly half as many beds
as there are in all state civil and forensic mental health hospitals
combined.
Sadly, these statistics are not unique to south Florida. Findings from
a recent study suggest that people with serious mental illness are
arrested and booked into jails in the United States more than two
million times annually. Roughly three-quarters of these people also
have co-occurring substance use disorders that increase their
likelihood of becoming involved in the justice system. On the basis
of the most recent population data reported by the Department of
Justice, it is estimated that currently 400,000 people with mental
illnesses are incarcerated in jails and prisons across the country,
and nearly 900,000 are on probation or parole in the community.
20 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
Judge Leifman Encounters the Challenge
“When I first became a judge, I discovered a situation familiar
to many of my colleagues but seldom discussed outside the
courtroom — a situation that my legal and judicial training
had not prepared me for. Day after day, defendants stood be-
fore me, disheveled and distraught. Most were charged with
relatively minor offenses such as loitering or panhandling.
Some exhibited impulsive behaviors, speaking in pressured,
incoherent sentences. Others were guarded and withdrawn,
appearing to have little understanding of the circumstances
in which they found themselves. Homelessness, substance
abuse, and trauma were symptoms of a larger set of personal
and social factors contributing to their unfortunate and often
repeated involvement in the criminal justice system. These
people of many backgrounds shared one thing in common —
serious and persistent mental illness.
When I first came across defendants experiencing acute men-
tal illness, I followed the lead of my fellow judges by appoint-
ing experts and ordering psychiatric evaluations to determine
their competence to proceed with their court cases. Although
these evaluations tended to be very costly and meant that
defendants would remain in jail for weeks or possibly even
months, the idea of releasing a person in acute psychiatric
distress to the streets with nowhere to live and no supports
seemed a far more cruel response to the situation. I assumed
that once evaluations by mental health experts were complet-
ed and the need for treatment was documented, the mental
health treatment system would step in, if not voluntarily, then
by court order.
Before long, I realized my assumptions were wrong. Even
though I had expert opinions indicating that people were
indeed experiencing severe psychiatric symptoms — and in
many cases requiring immediate hospitalization — state law
prohibited judges presiding over misdemeanor cases from
ordering treatment in the forensic mental health system. In-
stead, the law required people to be released to the commu-
nity on the condition that they participate in treatment, but
there was no mechanism to ensure that treatment, housing, or
any other type of support was actually provided.
Most people released under these circumstances
never received any type of services on re-entering
the community and were quickly rearrested and
reappeared in my courtroom, often over and over
again. These people accrued lengthy criminal re-
cords for offenses that were all too obviously the
result of untreated mental illness. This contributed
to a revolving door of neglect and despair; caused
a huge backlog of cases in the justice system; placed
enormous burden on the courts, jails, and law enforce-
ment agencies; and left taxpayers to foot the bill.
Not wanting to continue to be a witness to the parade
of misery passing through my courtroom, I was deter-
mined to figure out why and where the system was
failing. With the help of many dedicated stakeholders
from the community mental health, criminal justice,
and social services systems, I set out to learn as much
as I could about the community mental health sys-
tem and how it intersected with the criminal justice
system.”
Identifying the Root Cause
A 2-day summit was convened in 2000 to review the
ways in which the community collectively responded
to people with mental illness before and after they
became involved in the justice system. What we dis-
covered were embarrassingly dysfunctional and frag-
mented systems.
Before the summit, it was apparent that people with
mental illness were over-represented in the justice
system. What was not so apparent, however, was
the degree to which stakeholders were unwittingly
contributing to and perpetuating the problem. Many
participants were shocked to find that a single per-
son with mental illness was accessing the services
and resources of almost every other stakeholder in
the room, including law enforcement agencies, emer-
gency medical services, mental health crisis units,
emergency rooms, hospitals, homeless shelters, jails,
and the courts. This happened repeatedly as people
revolved through a criminal justice system that was
never intended to handle overwhelming numbers of
people with serious mental illness and a community
mental health system that was ill equipped to provide
the level and capacity of care necessary for those ex-
periencing the most acute forms of mental illness.
Stakeholders were largely disconnected from one an-
other and no mechanisms were in place to coordinate
resources or services. Everyone was so busy doing his
or her job that no one was looking at the bigger pic-
ture to see what the impact was on the welfare of the
system as a whole or of the people it served. The po-
lice were policing, the lawyers were lawyering, and the
judges were judging. Treatment providers knew little
about what went on when their clients were arrested
and had little incentive to learn, because of barriers
to accessing information and laws that prohibit reim-
bursement for services provided to people who are
incarcerated.
For people who had no resources to pay for services,
crisis units, hospitals, and the jail were often the only
options to receive care. Ironically, although many
people could not access the most basic prevention
and treatment services in the community, they were
readily provided some of the most costly levels of
institutional care over and over again. The degree of
fragmentation in the community not only prevented
the mental health and criminal justice systems from
responding more effectively to people with mental ill-
ness but actually created increased opportunities for
people to fall through the cracks. By the conclusion
of the summit, we began to realize that people with
untreated serious mental illness may be among the
most expensive populations in the community, not
because of their diagnoses but because of the way
they are treated.
As we’ve come to better understand the problems and
context of people with mental illness involved in the
justice system, we learned three critical lessons:
>> First, our criminal and juvenile justice systems are
in the midst of mental health crises at the local,
state, and national levels. The current level of de-
mand for deep-end services in settings such as
emergency rooms, crisis units, state hospitals, and
ultimately jails and prisons is inappropriate and
unsustainable and contributes to enormous social,
fiscal, and personal tragedies. The backlog of cases
in the justice system involving people with mental
illness impedes the administration of justice and
contributes to needless pain and suffering.
>> Second, the problems facing the mental health
and, consequently, criminal justice systems in the
United States today relate to the fact that the cur-
rent community mental health system was devel-
oped at a time when most people with severe and
disabling forms of mental illness resided in state
hospitals. Most community mental health systems
were designed around people with more moderate
treatment needs, not around the needs of people
We began to realize that
people with untreated serious
mental illness may be among
the most expensive popula-
tions in the community, not
because of their diagnoses
but because of the way they
are treated.
who experience highly acute and chronic mental
illness. Intensive supports necessary to live suc-
cessfully in the community are many times in short
supply or altogether unavailable.
>> Third, state expenditures on mental health services
have become disproportionately skewed toward
providing expensive, acute-care services such as
crisis stabilization and hospitalization in state-
funded facilities, not to mention services pro-
vided in jails and prisons. Such heavy investment
in these kinds of back-end services has come at
the cost of being able to adequately invest in a
responsive and comprehensive continuum of pri-
mary and preventive care in the community.
Criminal Mental Health Project
Provides Solutions
The 11th Judicial Circuit Criminal Mental Health
Project was established 10 years ago in an effort to
better respond to the needs of people with serious
mental illness and co-occurring substance use dis-
orders involved in or at risk of becoming involved in
the justice system. Initially, the CMHP worked to di-
vert misdemeanor offenders from the criminal justice
system into community-based treatment and support
services. Today, the CMHP has expanded to serve de-
fendants arrested for lower level felony offenses and
other charges as are determined appropriate. It has
developed collaborations with other local problem-
solving courts including domestic violence court
and drug court and has developed partnerships with
community mental health and substance abuse treat-
ment providers, housing providers and other social
services agencies, consumer and family advocacy
groups, countywide criminal justice and law enforce-
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 21
 Beyond Bars
ment agencies, and state and federal social welfare
agencies.
Funding
Initial support for the development of the CMHP was
provided through a grant from the National GAINS
Center that enabled the courts to host the summit
meeting in 2000. The GAINS Center provided tech-
nical assistance and helped the community map
existing resources, identify gaps in services and
service delivery, and develop a more integrated ap-
proach to coordinating care. Stakeholders included
judges and court staff, law enforcement agencies
and first responders, attorneys, mental health and
substance abuse treatment providers, state and
local social service agencies, consumers of mental
health and substance abuse treatment services,
and family members.
Using information generated from the summit, pro-
gram operations were initiated on a limited basis.
Additional funding was secured from a local phil-
anthropic foundation to conduct a planning study
of the mental health status and needs of people
arrested and booked into the county jail, as well as
the processes in place to link people to community-
based services and supports. Information from this
planning study was used to develop a more formal
program design and to secure a 3-year federal tar-
geted capacity expansion grant from the Substance
Abuse and Mental Health Services Administration,
which enabled the CMHP to significantly expand
its staffing and operations. At the conclusion of the
federal grant period, the county assumed continua-
tion of funding for all positions. Because of the pro-
gram’s early success and demonstrated outcomes
at the misdemeanor level, in 2008 the CMHP was
awarded a 3-year grant by the state of Florida to
further expand postbooking diversion operations
to serve people charged with less serious felonies.
Efforts are currently underway to secure long-term
sustainability for felony operations and to develop
strategies to increase program capacity.
Since its inception, the CMHP has received ongo-
ing support from the Florida Department of Children
and Families. This support has included funding case
management positions as well as providing resourc-
es to secure housing, medications, and transporta-
tion for program participants. Early in its develop-
ment, the CMHP also benefited from a partnership
established with faculty from Florida International
22 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
University. This partnership facilitated activities
around program planning and evaluation and the
preparation and submission of funding proposals.
Jail and Forensic Hospital
Diversion Programs
Today, the CMHP operates a total of four different
diversion programs and is working with the county
to develop of a first-of-its-kind mental health diver-
sion complex. All programs are complemented by
support components designed to improve access to
basic needs and economic self-sufficiency.
Diversion programs and support components in-
clude the following elements:
Prebooking jail diversion program targeting crisis
intervention team training for law enforcement
officers
Crisis Intervention Team training is designed to
educate and prepare law enforcement officers to
recognize the signs and symptoms of mental illness
and to respond more effectively and appropriately
to people in crisis. When appropriate, people are
assisted in accessing treatment in lieu of being ar-
rested and taken to jail. To date, CIT training has
been provided to more than 2,500 officers from
36 law enforcement agencies across the county.
Additional CIT-related training courses have been
developed or adapted to target emergency dispatch
(e.g., 911) call takers, law enforcement crisis ne-
gotiators, correctional officers, other nonpolice law
enforcement agencies, and executive management
of CIT programs.
Since the implementation of CIT, significantly fewer
people in psychiatric crisis are being arrested and
booked into jail, law enforcement agencies are ex-
periencing fewer injuries to officers and civilians,
fewer instances of use of force involving officers and
people with mental illness have occurred, and more
people are being linked to appropriate care in the
community.
Postbooking jail diversion program targeting
people arrested for misdemeanor offenses
All defendants booked into the jail are screened
for signs and symptoms of mental illness by correc-
tional officers using an evidence-based screening
tool known as the Brief Jail Mental Health Screen.
People charged with misdemeanors who meet pro-
gram admission criteria are transferred from the
jail to a community-based crisis stabilization unit
within 24–48 hours of booking. On stabilization,
legal charges may be dismissed or modified in ac-
cordance with treatment engagement. People who
agree to services are linked to a comprehensive
array of community-based treatment, support, and
housing services that are essential for successful
community re-entry and recovery outcomes. Pro-
gram participants are monitored by CMHP for up to
1 year after community re-entry to ensure ongoing
linkage to necessary supports and services. Most
participants (75-80 percent) in the misdemeanor
diversion program are homeless at the time of ar-
rest and tend to be among the most severely psychi-
atrically impaired people served by the CMHP. The
misdemeanor diversion program receives around
300 referrals annually, with program recidivism
rates of just 22 percent, far below most other re-
cidivism estimates.
Postbooking jail diversion program targeting
people arrested for felony offenses
Participants in the felony jail diversion program are
referred to the CMHP through a number of sources
including the public defender’s office, the state
attorney’s office, private attorneys, judges, correc-
tions health services, and family members. All par-
ticipants must meet diagnostic and legal criteria as
well as be eligible to apply for entitlement benefits
such as Supplemental Security Income, Social Se-
curity Disability Insurance, and Medicaid. At the
time a person is accepted into the felony jail di-
version program, the state attorney’s office informs
the court of the plea the defendant will be offered
contingent on successful program completion. Simi-
lar to the misdemeanor program, legal charges may
be dismissed or modified on the basis of treatment
engagement. All program participants are assisted
in accessing community-based services and sup-
ports, and their progress is monitored and reported
back to the court by CMHP staff. To date, the felony
diversion program has served roughly 150 people,
and participants have demonstrated reductions of
roughly 75 percent in both numbers of arrests and
days incarcerated after program enrollment.
Postbooking forensic hospital diversion program
targeting people arrested for felony offenses and
adjudicated incompetent to proceed to trial
The forensic hospital diversion program was recently
implemented as a state-sponsored pilot project
to serve people in Florida’s forensic mental health
 Do you need capital to buy, build or
renovate a facility, update your IT systems, or
Since the implementation of Crisis Intervention refinance existing debt?
Team training, significantly fewer people in psy-
chiatric crisis are being arrested and booked
into jail, law enforcement agencies are experi-
CHFF Can Help!
encing fewer injuries to officers and civilians,
We are a non-profit loan fund that
fewer instances of use of force involving officers provides capital to non-profit behavioral healthcare
and people with mental illness have occurred, organizations nationwide.
and more people are being linked to appropri-
o Aggressive interest rates
ate care in the community.
o Flexible terms and structures
system and to control growth in demand for services provided in state hos- o Gap and subordinate financing
pitals. People served are charged with third-degree and nonviolent second-
o Loans from $150,000
degree felonies, have been found incompetent to proceed to trial, and
require placement in a state hospital in the absence of a less restrictive al- o Participation with other lenders
ternative. The program seeks to provide a more cost-effective alternative to o Strategic financial planning services
forensic hospitalization, while providing enhanced interventions targeting
long-term recovery, reduced recidivism, and successful community living. The Community Health Facilities Fund is pleased to
Admissions for competency restoration in state hospitals in Florida typically have provided financial advisory services and/or direct
result in a length of stay of around 6 months at a cost of $60,000 per indi- loans to the following organizations in 2009:
vidual. It is estimated that the forensic hospital diversion program can pro-
Ability Beyond Disability
vide a full year of services to program participants — including competency
Bethel, CT
restoration services, recovery services, and community re-entry services —
for $32,000 per individual. At current capacity, the program is projected Alternatives Unlimited
to divert 40 people per year from admission to state hospitals, which is Whitinsville, MA
projected to result in a savings to the state of $1.1 million while funding an
additional 7,200 days of new community-based treatment services. Cache Employment and Training Center
Logan, UT
Mental Health Diversion Complex
In support of all diversion programs, Miami-Dade County and the CMHP Community Housing Associates
have been actively working to develop a first-of-its-kind comprehensive Baltimore, MD
mental health diversion, treatment, and community re-entry complex near
downtown Miami. Development of this project, which is funded in part
through a general obligation bond issue approved by voters, will involve
renovating and expanding a former state forensic hospital that has been
leased to the county.
The complex will consist of programs operated by community-based treat-
ment and social services providers to create a full continuum of care and
support, including a crisis stabilization unit, a short-term residential treat-
For more information contact,
ment program, a transitional housing program, day treatment and day ac-
Chris Conley Dean Adams
tivity programs, intensive case management, specialized services address-
203-273-4200 812-273-5198
ing the unique needs of people with mental illness involved in the justice
cconley@chffloan.org dadams@chffloan.org
system (e.g., trauma treatment and treatment for co-occurring disorders),
outpatient services, and job training and employment services. All programs www.chffloan.org u info@chffloan.org
will incorporate peer support and peer leadership components. Space will
Community Health Facilities Fund
also be provided for agencies and programs that address the comprehen-
6 Landmark Square, 4th Floor, Stamford, CT 06901
sive social needs of people served, such as legal services, public welfare
and entitlement programs, and immigration services.
Meet us at the National Council Conference Expo Hall, Booth #421
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 23
 Beyond Bars
In addition to community-based treatment and
support services, the complex will house a secure
medical unit serving inmates in the custody of the
county’s corrections and rehabilitation department
who are being evaluated to determine eligibility for
diversion. The complex will also include a courtroom
to expedite and facilitate legal hearings.
The vision for the mental health diversion complex is
to create a centralized, coordinated, and seamless
continuum of care for people who are diverted from
the criminal justice system either before or after
booking. By housing a comprehensive array of ser-
vices and supports in one location, it is anticipated
that many of the barriers and obstacles to navigat-
ing traditional community mental health and social
services will be removed, and people will be more
likely to engage treatment and recovery services.
Social Security Benefits
All CMHP participants are assisted with individual-
ized transition planning and linked to community-
based treatment and supports as appropriate.
Services provided include supportive housing,
supported employment, assertive community treat-
ment, illness self-management and recovery (Well-
ness Recovery Action Planning), trauma services,
and integrated treatment for co-occurring mental
illness and substance use disorders.
Most people served by the CMHP are indigent and
are not receiving entitlement benefits at the time
of program entry. As a result, many do not have the
necessary resources to access adequate housing,
treatment, or support services in the community.
To address this barrier and maximize resources, the
CMHP developed an innovative plan to improve the
ability to transition people from the criminal justice
system to the community.
On the basis of an agreement established between
Miami-Dade County and the Social Security Admin-
istration, a gap-funding program was developed to
provide assistance for people applying for federal
entitlement benefits such as Supplemental Security
Income or Social Security Disability Insurance dur-
ing the period between application for and approval
of benefits. If approved for benefits, people applying
for Social Security are compensated retroactively to
the date of initial application. Participants applying
for benefits and receiving assistance from the CMHP
sign an interim assistance reimbursement agree-
24 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
ment, which allows the county to be reimbursed for
housing costs when an individual is approved for
Social Security benefits and receives a retroactive
payment.
In an effort to ensure that program participants who
are eligible for entitlement benefits receive them as
quickly and efficiently as possible, the CHMP uses a
best practice model referred to as SOAR (SSI/SSDI,
Outreach, Access and Recovery). This approach was
developed as a federal technical assistance initia-
tive to expedite access to Social Security entitle-
ment benefits for people with mental illness who
are homeless. All CMHP participants are screened
for eligibility for federal entitlement benefits, with
staff initiating applications as early as possible
using the SOAR model. Program data demonstrate
that 88 percent of the CMHP participants who ap-
ply for benefits using SOAR are approved on the
initial application. By contrast, the national average
across all disability groups for approval on initial
application is 37 percent. In addition, the average
time to approval for CMHP participants is 62 days.
This achievement is remarkable compared with the
ordinary approval process, which typically takes
9–12 months or longer.
Lessons Learned: Collaboration
is Key
The CMHP’s success and effectiveness depends on
the commitment, consensus, and ongoing efforts of
traditional and nontraditional stakeholders through-
out the community. In the past, treatment providers
regularly talked with other treatment providers and
criminal justice agencies regularly talked with other
criminal justice agencies; however, treatment pro-
viders and criminal justice agencies rarely bridged
the gap between their respective systems. In estab-
lishing the CMHP, a mental health committee was
established within the courts and a local chapter of
a statewide advocacy organization known as Florida
Partners in Crisis was formed. The purpose of these
bodies was to facilitate and encourage communica-
tion and information exchange.
As a representative of the courts, the CMHP is in a
unique position to bring together stakeholders who
may otherwise not have opportunities to engage in
such problem-solving collaborations. By working
together across systems and communities to craft
more appropriate, responsive, and coordinated pro-
grams and services, it is possible to prevent people
from unnecessarily entering the criminal justice sys-
tem and to increase opportunities for recovery.
The justice system was never intended to serve as
the safety net for the public mental health system
and is ill equipped to do so. The current shortcom-
ings of the community mental health and criminal
justice systems did not arise recently. No one cre-
ated these problems alone, and no one will be able
to solve these problems alone.
The forensic hospital diversion
program is projected to divert
40 people per year from
admission to state hospitals,
which is projected to result
in a savings to the state
of $1.1 million while
funding an additional
7,200 days of new
community-based
treatment services.
Miami-Dade County Judge Steven Leifman has served as
Special Advisor on Criminal Justice and Mental Health for the
Supreme Court of Florida since April 2007. In this capacity,
Judge Leifman is responsible for chairing the Court’s Mental
Health Subcommittee which authored a ground-breaking report
entitled, Transforming Florida’s Mental Health System. Judge
Leifman also serves as Chair of the Eleventh Judicial Circuit
of Florida’s Mental Health Committee, and is responsible for
creating the Eleventh Judicial Circuit Criminal Mental Health
Project. Judge Leifman is a former Assistant Public Defender for
Miami-Dade County, Florida.
Tim Coffey has nearly 20 years of experience in the fields of
behavioral health, public health, and social science research
and evaluation. Having worked in a variety of healthcare,
academic, and government settings, he has been involved
in basic and applied research activities addressing mental
and behavioral health issues. As coordinator for the Eleventh
Judicial Circuit Criminal Mental Health Project, Coffey is respon-
sible for the development, implementation, and evaluation of a
variety of court-based projects and programs designed around
the needs of people with mental illnesses involved in the
criminal justice system
 www.jjnegley.com
www.MHRRG.com 1.800.845.1209 Fax:973.830.8585

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 Interview
Pete Earley on Jails and Prisons,
Our “New Mental Asylums”
Pete Earley, Journalist and Author Interviewed by Meena Dayak, Vice President, Marketing
and Communications; Mohini Venkatesh, Director, Federal and State Policy; and Nathan
Sprenger, Marketing and Communications Associate — National Council for Community
Behavioral Healthcare
Why did National Council Magazine interview Pete
Earley, author of Crazy: A Father’s Search Through
America’s Mental Health Madness for a criminal-
justice focused issue? Pete describes it best in
his own words — in his introduction to Crazy at
www.peteearley.com.
“I had no idea. I’d been a journalist for thirty
years and written extensively about crime and
punishment and society. But I’d always been on
the outside looking in. I had no idea what it was
like to be on the inside looking out – until my son,
Mike, was declared mentally ill. Suddenly the
two of us were thrown headlong into the maze
of contradictions, disparities and Catch-22s that
make up America’s mental health system. Crazy: A
Father’s Search Through America’s Mental Health
Madness is a nonfiction book that tells two stories.
The first is my son’s. The second describes what
I observed during a year-long investigation inside
the Miami-Dade County jail, where I was given
unrestricted access. I feel more passionately
about this book than any I have every written. Our
nation’s jails and prisons have become our new
mental asylums. I wrote this book as a wake-up
call to expose how persons with mental illness are
ending up behind bars when what they need is
help, not punishment.”
We know how to help people —
we just aren’t doing it. We just
won’t put the necessary funds
into community mental health
in order to save people.
26 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
National Council Magazine talked to Pete about
both the stories he tells in Crazy.
National Council: Pete, why did you choose to tell National Council: What effect did Crazy have on
the two stories?
Pete: I was outraged that my son got arrested. I was Pete: Not enough since this book was read very
frustrated that imminent danger laws in Virginia,
where I live, kept me from getting my son help and
treatment. Then the legal system wanted to punish
my son when he wasn’t thinking clearly. It was a ter-
rible Catch-22 situation. As a father I couldn’t do
much but as a reporter I could. So I wanted to tell
two stories. One about the struggles I had in help-
ing my son and the other about the state of mental
health treatment in this country and I was shocked
at what I found in the criminal justice system.
National Council: In Crazy, you tell stories of some
persons with mental illness other than your son. Any
idea how they’re all doing now?
Pete: Sadly, none of them got any better. In fact,
their stories have gotten more tragic. The only per-
son I profile in my book who ever got better was
my son.
National Council: What made the difference with
your son?
Pete: Good case management and good people in
the community mental health system that treated
him. I had no option but to call the cops when Mike
was threatening me one night — my son was shot
twice with a Taser and taken away. After that, he was
assigned a case manager who was a saint — I give
her full credit. She worked with him for three years
and he got better. Now Mike is getting trained to go
and work in jails, providing peer support. As a parent
you are limited — the system doesn’t want to listen
Pete Earley with two oil paintings by his son, Mike (the faceless
chess player is a self portrait)
to you but you are the one that has to pick up the
pieces. This social worker literally saved his life!
people’s attitudes about mental health?
little outside the mental health community. It was
very well received by those who work in behavioral
health, but it didn’t educate many people who like
most of us, are ignorant about mental health. The
strongest supporters of this book are the parents
of those who have mental illness. I was lucky as my
son was able to get treatment. I hear from people all
the time whose children are dead, in prison, or even
on death row because they had a mental illness
and committed crimes while suffering from bipolar
disorder or schizophrenia. This includes judges and
psychiatrists.
National Council: What advice would you give to
other parents trying to get help for their kids with
mental illness?
Pete: First, you can’t give up. You have to be a
squeaky wheel. You also have to be an advocate for
someone who often doesn’t want you involved and
in a system that doesn’t want you involved. You have
to be willing to have your child hate you at times in
order to get them proper treatment.
National Council: How did you get into Miami
Dade County Jail — the setting for the other story
you tell in Crazy?
Pete: The only reason I got into the Miami-Dade
County Jail was because of Judge Steven Leifman. I
found the officers were very frustrated with the con-
ditions in the jail. Most of them wanted to do the
right thing. They wanted to do their job and their
job was not to take care of people with severe mental
illness. The leading advocates for change in how we
incarcerate those with mental illness have not been
mental health advocates but correctional officers,
judges, and those in law enforcement who see how
horrible this is.
National Council: Did you visit other jails and
prisons?
Pete: The LA County Jail has been described as the
largest public mental health facility and that’s where
it started. I was invited to observe the LA County Jail
but was asked to leave after three days as they cited
legal concerns about the privacy rights of inmates
under HIPAA. I then tried Cook County Jail in Chicago
and they said no. Then I tried Rikers Island in New York
and Baltimore and they said no. I tried DC and they
said, “Hell, no.”
In LA, the corrections officers wanted me out and the
mental health staff wanted me in. In Rikers, it was the
opposite. In LA, I think it was because the corrections
officers knew how deplorable the conditions were and
didn’t have the proper training to deal with inmates
who had mental illness and in cases where the mental
health staff didn’t want me in, I think it was because
they weren’t doing much for a variety of reasons. I
think fear was the motivating factor behind their op-
position to me getting inside these jails.
National Council: How did you feel when you first
entered the psychiatric unit at the Miami Dade
County Jail?
Pete: It was barbaric! Nothing prepared me for what
I saw. There was severe overcrowding. You had naked
people in cells that had nothing in them. Because it
was an old system, you had days when the water didn’t
work. You had people drinking out of toilets because
they couldn’t get anything to drink otherwise. You had
people yelling and screaming.
The officers at that time had received zero training for
dealing with those who had mental illness. Because
of a history of abuse by the correctional officers and
many lawsuits, all forms of restraint were taken away
from the officers — the cells were sealed shut to pre-
vent things from being thrown at the officers, and they
had no way of controlling the inmates except to beat
them or isolate them. Now the officers do receive
more training on how to deal with those who have
mental illness.
National Council: Community mental health orga-
nizations often partner with their local corrections
systems to address the needs of incarcerated popula-
tions. How best can they help?
Pete: We are mistakenly putting too much money into
corrections instead of into treatment. Without enough
funding for community mental health, it doesn’t mat-
ter how good your Crisis Intervention Teams training
program is. You are going to fail!
Real partnerships between corrections and community
mental health providers are key, since correctional
professionals don’t know how to handle persons with
mental illness without the help from those in com-
munity mental health, who are on the outside. A prime
example of community partnerships is San Antonio,
where police are trained to recognize those with seri-
ous mental illness — if they arrest such persons, they
take them to the local drop off center instead of jail.
They’ve convinced their local and state government
that it’s much more cost effective to put those with
mental illness into the community mental health
network — this saves more money than it costs by
preventing incarceration and repeat arrests.
This is not a case of us not knowing what to do. It’s a
case of us not wanting to do it. We know that assertive
community treatment works. We know that Sam Tsem-
beris’s Housing First program had an 86% success
rate in getting persons with mental illness and addic-
tions off the street. We know that peer outreach works
and that good case management can help people
recover their lives. We know how to help people — we
just aren’t doing it. We just won’t put the necessary
funds into community mental health in order to save
people. You can’t expect case managers with 50 – 60
clients or community mental health centers without
temporary hospital beds for those with severe schizo-
phrenia to do a good job.
National Council: What barriers do you see to better
funding to treat the incarcerated?
Pete: We tend to look for short-term solutions. Then
there is the issue of civil commitment laws — we have
a system now where one has to be an imminent dan-
ger before they can be hospitalized. Many states are
using the civil rights issue as a sham to not fund good
community mental health services. The civil rights is-
sue is being twisted to justify denying treatment to
those who could benefit from it. I wish there were
someone in the mental health community who would
try to show that persons with mental illness have a
constitutional right to good treatment. I think until we
get lawsuits going, we will never have the leverage to
get politicians and others to really do what needs to
be done to help people!
National Council: Given the magnitude of mental
health budget cuts that state after state is facing, do
you really think criminal justice populations have any
hope?
Pete: Housing First and good community mental
health treatment programs will ultimately save money,
but you have to hang in there for the long term.
A great way to pay for mental health services would
be the cigarette tax, if politicians had enough guts to
raise it. Some states have increased it but in Virginia
we charge a ridiculously low 30 cents per pack. If we
raised that a dime, that would raise $100 million. Why
the cigarette tax? A UCLA study showed that 40% of all
cigarette sales go to those who have been diagnosed
with a mental illness.
I think law enforcement and corrections people should
be the first ones to step forward and say that jails are
not an appropriate place for those with mental illness.
Jails are straining to pay for medications for inmates
in these times of budget cuts. Behavioral health peo-
ple need to make it clear that they can help people
with mental illness and addictions if they are given
the resources to do so. It needs to be emphasized
that incarcerated persons can be helped and that
their mental illnesses aren’t their fault.
Meena Dayak has more than 15 years of experience in marketing
and media relations for nonprofit healthcare organizations. She
spearheads branding, PR, social media, member communica-
tion, and public education initiatives at the National Council for
Community Behavioral Healthcare. Her mission is to help member
organizations tell a compelling story so the world will recognize
that mental illnesses and addictions are treatable health condi-
tions from which persons can recover and lead full lives.
Mohini Venkatesh serves as the staff policy liaison to the National
Council for Community Behavioral Healthcare’s network of
associations throughout the states, conducts federal legislative
and policy analysis on an array of issues, and manages political
engagement activities including an annual Hill Day in Washington,
DC. She received a masters in public health from Yale University
and a BA in psychology from the University of Massachusetts-
Amherst.
Nathan Sprenger supports the National Council’s public relations
and marketing efforts, leads the social media activities, maintains
the website, and serves as editorial assistant for National Council
Magazine. He has a masters degree in public communication
from American University in Washington DC.
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 27
 Interview
Reducing Justice Involvement for People with
Mental Illness: Strategies
Fred Osher, MD, Director of Health Systems and Services Policy, The Council of State Governments Justice Center, Interviewed by Mohini
Venkatesh, Director, Federal and State Policy; Meena Dayak, Vice President, Marketing and Communications; and Nathan Sprenger, Market-
ing and Communications Associate — National Council for Community Behavioral Healthcare
National Council: What does the latest research
show regarding the prevalence of mental illness and
addictions among the justice-involved population?
Fred: It is important to be aware of the overrepre-
sentation of people with behavioral health disorders
in the criminal justice system. Recent research has
found that about 14.5 percent of men and 31 per-
cent of women booked into jails have serious men-
tal illnesses. These rates are about three to six times
the prevalence rates for the general population.
About 70 percent of people admitted into prison
meet the criteria for a substance use disorder; and
most have co-occurring disorders. The majority have
not committed violent crimes and do not pose a
threat to public safety. These facts beg for creative
responses to prevent those who are unnecessarily
in custody from being there, and to link those com-
ing out of jails and prisons to effective behavioral
health interventions.
National Council: What type of interventions can
limit the criminal justice involvement of individuals
with mental illnesses and addiction disorders?
Fred: There are now a number of initiatives that
hold a lot of promise in supporting recovery with
these populations. For those individuals who are
not a public safety risk, we want to divert them to
treatment. There are specialized responses geared
toward police officers and other first responders in
how to deal with those who have serious mental ill-
nesses. One of the most common is called Crisis
Intervention Teams training, which teaches police
officers how to be aware of those with mental ill-
nesses and to de-escalate potentially dangerous
situations when they encounter someone with a
serious behavioral problem on the street. Those are
widespread and growing in popularity.
Another point of intervention is at jails and other
post booking sites where we can appropriately
28 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
screen for mental illness and drug addiction and
work with judges and defense and prosecuting at-
torneys to find appropriate treatment options. One
of the most likely post booking options is the ap-
pearance at specialty courts, such as drug and
mental health courts. These courts are becoming
more common and are often options that defense
attorneys advise their clients to pursue. These courts
require treatment as a condition of release and
monitor progress with more frequent appearances
before the bench. These courts have been shown to
be effective in engaging those with mental and ad-
diction disorders, and are cost effective.
We also have programs for those who are reenter-
ing the community after being in jail and prison
settings. This has gotten a lot of attention recently
with the passage of the Second Chance Act, which
focuses on the needs of individuals leaving custody
and returning to their home communities. All are
concerned that these programs protect public safe-
ty while advancing public health outcomes through
the integration of best practices in supervision and
treatment. We have specialized probation and pa-
role initiatives that train community corrections of-
ficers about mental health and addiction disorders,
and treatment providers about supervision strate-
gies and objectives.
National Council: What can be done to reduce
recidivism?
Fred: The factors that influence criminal activity
among those with mental illnesses and addiction
disorders aren’t that different from the factors that
influence those who commit crime in the general
population. These criminogenic factors include stat-
ic factors such as age at one’s first arrest and basic
demographic information. Additionally, there are dy-
namic factors that are subject to change over time,
such as antisocial patterns of thinking that have
that Work
been identified as increasing risk of crime; antiso-
cial peers that can influence the likelihood of recidi-
vism; and mental health and addictions issues that
influence one’s decision-making processes. Many
justice-involved individuals with mental illness may
also have a co-occurring substance use problem.
These dynamic factors suggest that the application
of evidence-based treatment practices, such as
cognitive behavioral therapy, can assist people to
make better choices when confronted with certain
situations that lead to criminal behavior.
One cannot overlook the importance of other envi-
ronmental factors that reduce recidivism, such as
stable housing and access to meaningful employ-
ment and/or education. I haven’t met anyone with
mental illness or addictions who wants to be in cus-
tody. They key to reducing recidivism is to match
effective treatment with essential supportive pro-
grams that allow these people to realize their goals.
National Council: What cognitive behavioral treat-
ments are known to be effective for justice-involved
persons with mental illness?
Fred: There are several models that are known
to work for those involved in the criminal justice
system, such as Thinking for a Change and Moral
Reconation Therapy. The key is to utilize models
that put people in a well documented and strategic
program that provides treatment sessions and gives
people the tools and skills they need to advance in
their recovery. In New York, there is a program called
SPECTRM (Sensitizing Providers to the Effects of In-
carceration on Treatment and Risk Management)
that helps to change the types of behaviors that
led inmates into criminal behavior and to prevent
recidivism once they are released from prison. While
we are starting to see more innovative programs be-
ing initiated by community mental health providers,
more work needs to be done here.
National Council: What are the major barriers that
limit collaboration between the criminal justice and
treatment systems?
Fred: Traditionally, community behavioral health sys-
tems have not had a primary focus on public safety is-
sues; however, we are now seeing these organizations
playing a larger role in this arena. Unfortunately, there
are financial barriers that limit the ability of commu-
nity behavioral health to be responsive to this need.
Many of those in the criminal justice system don’t
qualify for the various state mental health funded
programs because of their eligibility criteria. While ac-
tuarial models that have been developed by the crimi-
nal justice field help us to determine who might be
more at risk of committing a crime, this information is
not frequently used to identify priority populations.
National Council: Are there federal initiatives that
support behavioral health and criminal justice col-
laborations?
Fred: Absolutely. The passage of the Mentally Ill Of-
fender Treatment Crime Reduction Act (MIOTCRA) pro-
vided funding for the Bureau of Justice Assistance to
develop the Justice Mental Health Collaboration pro-
gram. Grants under this program require the partner-
ship of the community mental health and criminal jus-
tice systems. We’ve seen the creation of a specialized
law enforcement initiative in Philadelphia, a mental
health court in Kalamazoo, MI, and specialized com-
munity corrections strategies in Portland, ME, with
this funding. There are about six dozen grantees that
are implementing these types of programs across the
country.
The Second Chance Act provides a new source of
funding for criminal justice and treatment collabo-
rations with several grant programs that focus on
justice-involved individuals with substance use and
co-occurring disorders.
Additionally, we’ve seen growing support for justice re-
investment work in the states. [Justice Reinvestment
is an approach that uses data-driven, fiscally respon-
sible policies and practices to increase public safety
and reduce recidivism and corrections spending.] This
approach gives policymakers options to reduce cor-
rections expenditures while enhancing public safety.
Justice reinvestment projects stimulate collabora-
tion between criminal justice, community behavioral
health, and other key partners. On the federal level,
the Justice Center has been working with our advo-
Community behavioral health providers are an
absolutely critical component to the success of justice reinvestment
strategies; we need their expertise in providing effective community
behavioral health treatments. Their involvement in these initiatives
gives them a mechanism to access additional resources and to
focus their staff on the needs of justice involved persons.
cacy partners to develop further support for these
initiatives.
National Council: Why do we need justice reinvest-
ment projects?
Fred: State spending on corrections has risen faster
than any other item in state budgets over the last 20
years. It has increased from $10 billion in 1990 to
over $45 billion today. This is occurring in the con-
text of significant budgetary pressures related to this
recession. Justice reinvestment is an approach that
starts with an analysis of the drivers of jail and prison
growth in communities and states. One of the more
common findings is that the growth is not about new
crimes or new arrests; it’s being driven by high rates
of revocation of people on probation or parole — peo-
ple coming out of prison have a two-third chance of
being sent back to prison within three years of their
release and most of them return within the first eight
months. Often, they are having their parole or proba-
tion revoked not for new crimes but for technical vio-
lations of their release. The majority of these technical
violations are related to behavioral problems such as
failure to appear or keep appointments, or continued
substance abuse. This has created an opportunity for
those in behavioral health to partner with the criminal
justice system to slow down this revolving door.
National Council: What role do you see for community
behavioral health providers in justice reinvestment?
Fred: Community behavioral health providers are an
absolutely critical component to the success of jus-
tice reinvestment strategies; we need their expertise
in providing effective community behavioral health
treatments. Their involvement in these initiatives gives
them a mechanism to access additional resources
and to focus their staff on the needs of justice in-
volved persons. For example, we are seeing the be-
havioral health community coming to the table and
saying, “We can provide the integrated treatment for
co-occurring disorders that these people coming out
of prison need.”
National Council: What advice would you give to
states that want to start getting involved in justice
reinvestment work?
Fred: The first step is to understand what comes
from collaboration. One system on its own can’t do
everything; all branches of government and all stake-
holders — the criminal justice field, community be-
havioral health providers, victims’ advocates, families
and consumers, and others — need to use the power
of collaboration to access different funding streams
and more importantly, to be responsive to the needs
of persons with mental illness and addictions in the
criminal justice system and to the need to create
safer communities.
Fred Osher, MD, oversees the health components of the Council of
State Governments Justice Center’s initiatives. He also provides
technical assistance to state and local governments across the
country seeking to improve their response to people who have
mental health and/or substance use disorders and are involved
in the criminal justice system. Before joining the CSG Justice
Center, Fred served as the Director of the Center for Behavioral
Health, Justice, and Public Policy and as an Associate Professor
of Psychiatry at the University of Maryland School of Medicine.
He has published extensively in the areas of homelessness, com-
munity psychiatry, co-occurring mental and addictive disorders,
and effective approaches to persons with behavioral disorders
within criminal justice settings. He received his BA from Harvard
University and his MD from Wayne State University.
Mohini Venkatesh serves as the staff policy liaison to the National
Council for Community Behavioral Healthcare’s network of
associations throughout the states, conducts federal legislative
and policy analysis on an array of issues, and manages several
political engagement activities including an annual Hill Day in
Washington, DC. She received a masters in public health from
Yale University and a BA in psychology from the University of
Massachusetts-Amherst.
Meena Dayak has more than 15 years of experience in marketing
and media relations for nonprofit healthcare organizations. She
spearheads branding, PR, social media, member communica-
tion, and public education initiatives at the National Council for
Community Behavioral Healthcare. Her mission is to help member
organizations tell a compelling story so the world will recognize
that mental illnesses and addictions are treatable health condi-
tions from which persons can recover and lead full lives.
Nathan Sprenger supports the National Council’s public relations
and marketing efforts, leads the social media activities, maintains
the website, and serves as editorial assistant for National Council
Magazine. He has a masters degree in public communication
from American University in Washington DC.
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 29
 Beyond Bars
Funding for Behavioral Health and
Criminal Justice Programs
Henry J. Steadman, PhD, President, Policy Research Associates;
Samantha Califano, MS, Project Assistant, CMHS National GAINS Center
A ll is not bleak for finding resources for innovative
programs. In both the public and private sectors
and at the local, state, and federal levels, there are
opportunities worth exploring. Two major federal
sources of funding are the Bureau of Justice Assis-
tance (www.ojp.usdoj.gov/BJA/) and the Substance
Abuse and Mental Health Services Administration
(www.samhsa.gov/Grants/). On the private side,
many local foundations fund innovative programs
at the interface of behavioral health and criminal
justice.
Through BJA, behavioral health organizations that
partner with local justice agencies on grants to
service justice-involved people in their communities
can use grant funding to provide services. BJA offers
an array of grants to partnerships between justice
and mental health agencies. Two grant programs
are currently seeking applications for funding, the
Justice and Mental Health Collaboration Program,
created by the Mentally Ill Offender Treatment
and Crime Reduction Act of 2004 and the Second
Chance Act of 2007. The third grant program, for
which the application deadline has passed, is the
Byrne Justice Grant (JAG).
Since fiscal year 2006, the BJA has granted joint
justice and mental health partnerships funding
under the Justice and Mental Health Collaboration
Program to plan, implement, or expand a justice and
mental health collaboration program. This program’s
goal is to increase public safety through mental
health and criminal justice collaboration for justice-
involved people with mental illness or co-occurring
mental health and substance abuse disorders. In FY
2009, BJA received 246 applications seeking a total
of $43,401,754 in funding and awarded 43 site-
based applicants a total of $7,874,824 in funding.
In FY 2010, the Justice and Mental Health Collabo-
ration Program will receive an increase of $2 million
over FY 2009, for a total of $12 million.
The Second Chance Act of 2007 was signed in 2008
to ensure safe and successful transitions for people
30 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
In FY 2010, SAMHSA and the Center
for Substance Abuse Treatment, in
collaboration with the Bureau of
Justice Assistance, are offering a
unique opportunity that blends
funding sources. Grantees will receive
two separate awards totaling $20 million
to enhance the court services, coordination,
and substance abuse treatment capacity of adult drug courts. This
program allows applicants to submit one application to receive
blended criminal justice and substance abuse treatment funding.
from prison, jail, or juvenile residential facilities into
the community. The Second Chance Act Adult and
Juvenile Offender Reentry Initiative FY 2010 grant
is seeking applications from state, local, and tribal
governments who have developed a strategic re-
entry plan with extensive evidence of partnership
and collaboration and have created a Reentry Task
Force that includes both justice system and com-
munity representatives. Under the FY 2010 spend-
ing package, the Second Chance Act will receive
$100 million, which is $75 million more than in FY
2009. Applications are due by March 4, 2010, 8:00
p.m. eastern time.
Although the deadline for the JAG program passed in
January 2010, this program is the primary provider
of federal criminal justice funding to state and local
jurisdictions. All areas of the criminal justice system,
including drug and task forces, crime prevention,
courts, treatment programs, and sharing justice
information, are supported by this program. In FY
2010, the JAG program will receive $511 million.
In addition to BJA, SAMHSA funds grant opportuni-
ties for states and local government. In September
2009, SAMHSA awarded a second round of Jail Di-
version Trauma Recovery Grantees to support local
and statewide expansion of jail diversion programs
for people with posttraumatic stress disorder and
other trauma-related disorders. A priority for this
program is to provide needed services to veterans
returning from Iraq and Afghanistan. Awards were
given to the states of Florida, North Carolina, New
Mexico, Ohio, Rhode Island, and Texas. The first six
states to be funded under this grant in 2008 were
Colorado, Connecticut, Georgia, Illinois, Massachu-
setts, and Vermont.
In FY 2010, SAMHSA and the Center for Substance
Abuse Treatment, in collaboration with BJA, are of-
fering a unique opportunity that blends funding
sources. Grantees will receive two separate awards
totaling $20 million to enhance the court services,
coordination, and substance abuse treatment ca-
pacity of adult drug courts. BJA will fund the drug
court component, and CSAT will fund the substance
abuse treatment component. Up to a total of 31
grants will be awarded. This program allows appli-
cants to submit one application to receive blended
criminal justice and substance abuse treatment
funding.
Local health foundations are also available to pro-
vide funding to local organizations and government
 agencies in their states. Two local health foundations,
for example, are Staunton Farm Foundation in Penn-
sylvania and The Health Foundation of Greater Cin-
cinnati. These foundations award grants to nonprofit
organizations and government agencies in their sur-
rounding areas.
The Staunton Farm Foundation was founded approxi-
mately 70 years ago and focuses on the behavioral
health of children, youths, and adults. Rural behav-
ioral health and access to behavioral health and
criminal justice diversion are the three areas funded
by foundation funds. The Staunton Farm Foundation
provides grants to organizations in 10 counties in
southwestern Pennsylvania. It has provided grants
to mental health courts, drug courts, dual-diagnosis
treatment programs, and agencies to create new
websites and much more with the goal of improving
behavioral health treatment.
Another local health foundation active in behavioral
health services for justice-involved people with mental
illness is the Health Foundation of Greater Cincinnati,
a social welfare organization whose focus is enhanc-
ing community health. In 1997, the foundation refined
its focus after conducting an extensive assessment of
health issues within its region. The Health Foundation
of Greater Cincinnati provides grant funding in Cincin-
nati and 20 counties in Indiana, Kentucky, and Ohio.
The four areas of focus are community primary care,
school-age children’s healthcare, substance use dis-
orders, and severe mental illness. Annually, the Health
Foundation of Greater Cincinnati awards about $9
million in grants. Seventy-four grants were awarded
between 1999 and 2007, focusing on substance use
disorders and severe mental illness in the criminal
justice system.
The Staunton Farm Foundation and the Health Foun-
dation of Greater Cincinnati are just two examples of
local entities not often thought of in the context of
behavioral health–criminal justice issues that are, in
fact, very active throughout the United States. So, do
not overlook these options in your community.
With opportunities available on local, state, federal,
and private levels, it is important to think creatively
about funding. Many opportunities are available to
blend multiple local, state, federal, and private fund-
ing sources.
Henry J. Steadman is internationally known for his research on
interfacing criminal justice and mental health systems. He has
been President of Policy Research Associates since he founded it
in 1987. Previously, he ran a nationally known research bureau
for 17 years for the New York State Office of Mental Health. Dr.
Steadman’s major current projects are the National GAINS Center
for Evidence-Based Practices in the Justice System; the John
D. and Catherine T. MacArthur Foundation Mental Health Court
Study; the CMHS Transformation Center; and SAMHSA’s Technical
Assistance and Policy Analysis Center for Jail Diversion.
Samantha Califano is a project assistant for the CMHS National
GAINS Center, which is operated by Policy Research Associates,
Inc., in Delmar, NY. She graduate Cum Laude with a bachelor of
science in Criminology/Criminal Justice from Keuka College in
2008 and was awarded a master of science in Forensic Mental
Health in December 2009 from Sage Graduate School.

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NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 31

 Beyond Bars

Back to Basics:
Evaluating Opportunities to Serve the Justice-Involved
Population in Community Behavioral Health
John Petrila, JD, LLM, Director, Florida Mental Health Institute Criminal Justice, Mental Health,
and Substance Abuse Technical Assistance Center

W hat are some of the major issues a community behavioral health provider should consider before
investing resources in the treatment of people who have entered or may be at risk of entering
the criminal justice system?

Defining the Population

People with mental disorders in the criminal justice system have diverse patterns of offending, di-
verse clinical profiles, and diverse needs. Many have co-occurring disorders, others are homeless, and
some may have had prior contact with the treatment system. For example, in Florida, 190,000 (or
nearly 30%) of the 638,000 people arrested in 2006 had used a behavioral health service paid for by
Medicaid or provided in a state licensed facility in the five years prior to arrest. While the fact that a
person charged with a crime does not mean that mental illness caused the crime, people with mental
illnesses and substance abuse problems often engage in behavior that results in misdemeanor
arrests because the behavior is a public nuisance.
At the Florida Mental Health Institute we examined four years of crimi-
nal justice and treatment involvement for 3,769 people with a
serious mental illness arrested in Pinellas County, Florida
between July 2003 and June 2004. For a 4-year period, this
group generated 17,663 arrests with a mean arrest rate
per person of 4.6 arrests over the four years. However, a
group of 210 individuals averaged more than 16 arrests,
or 4 arrests per year, for the 4-year period, with
nearly all arrests for misdemeanors. What
was distinctive about this group? In con-
trast to other arrestees with serious mental
illnesses that we examined, this group was
much more likely to be male, have a psy-
chotic disorder, and have the lowest rate of
outpatient treatment contacts. In addition,
44% had been homeless at some point dur-
ing the four years. Policymakers might focus
on the group averaging 16 arrests over 4
years; however a treatment provider might
or might not consider this an appro-
priate group for a treatment
intervention.

32 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1

An intervention with empirical support for its effect
on treatment should not be applied indiscriminately with the
assumption that it will have an impact on recidivism.
Defining the Treatment
What is treatment supposed to accomplish? Is it focused primarily on behavioral
health issues, unrelated to the person’s criminal involvement? Or is it designed to
ameliorate risk? And if so, risk to the public, a specific person, or the individual
receiving treatment? There is little evidence that most types of treatment have a
direct impact on criminal recidivism, even if they relieve symptoms or improve
mental status or functioning. Treatments with empirical footing, such as dialectical
behavioral therapy for borderline personality disorders, or multisystemic therapy
for youth, require significant investments in resources and fidelity to the particular
model.
Interventions that have proved successful in other contexts, such as assertive com-
munity treatment may not have a similar effect with a justice-involved population.
An intervention with empirical support for its effect on treatment should not be
applied indiscriminately with the assumption that it will have an impact on re-
cidivism. A study of North Carolina’s outpatient civil commitment law found that
a court order of at least six months duration, combined with treatment of the
same duration, had an impact on recidivism and rehospitalization of people with
psychotic disorders. However, one without the other did not have this effect, nor did
the combination of long-term court order and long-term treatment have the same
effect on people with affective disorders.
Paying for the Treatment
Most people with mental illnesses involved in the criminal justice system are poor.
People with Medicaid are less likely to be re-arrested than those without. However,
given Medicaid eligibility rules, obtaining and retaining Medicaid eligibility can be
difficult. Of 689,000 individuals arrested in Florida during 2006, 66,679 (or 9.7%)
had been enrolled in Medicaid at some point during the 365 days prior to arrest.
However, only 48,342 (or 7.0%) were still enrolled at the time of arrest. Loss of eli-
gibility may occur for a variety of reasons. However, the lack of entitlements creates
difficulties in making even the smallest co-pay for medications and other services.
In addition, Medicaid is a minor payer for substance abuse services. More than
90% of Florida arrestees who had used a Medicaid reimbursed behavioral health
service in the 365 days prior to their arrest used a mental health service, with fewer
than 10% using a substance use service. This means that Medicaid is often of little
utility in paying for substance use services that may be clinically essential.
Public Safety
No issue is more important to law enforcement, judges, and prosecutors than
public safety. Any provider that works with people referred by the criminal justice
system must understand this, and must consider how risk will be assessed and
managed. Today, we know a great deal about the relationship between mental ill-
ness, substance abuse, and violence. Good instruments also are available to struc-
ture the assessment of risk
to third parties — some
developed for institutional
populations, others for com-
munity use. However, our knowledge of
risk management is more limited. Good treat-
ment alone is not enough unless it is targeted to those dynamic factors that re-
search has shown are most related to future risk. In addition, providers need to
develop and implement clear policies that describe the factors that should be
considered if a person misses appointments, stops taking medication, or exhibits
other behaviors that conceivably could foreshadow future risk. Such policies are
good risk management tools in any practice, but are essential in working with the
criminal justice system.
Political Alliances
One of the most important developments in public mental health in the last de-
cade has been the emergence of judges and law enforcement officials as leaders
in addressing the needs of people with mental illnesses and substance abuse
disorders. This can be uncomfortable for treatment providers, because of some-
times quite different perspectives on identifying and solving problems. However,
the interest of other leaders provides an opportunity to create local and statewide
political alliances that would have been unheard of several years ago. Any provider
working with justice-involved people needs to know the local sheriff, the relevant
police departments, the state attorney (the prosecutor), and the public defender.
These relationships will lead to increased trust between the parties as well as alli-
ances that may result in increased investment for services.
Many behavioral health providers may be offered or will seek out opportunities
to work with people entering services through the criminal justice system. Such
work can be rewarding and can place the provider in a larger set of community
relationships. However, recognizing the diversity of the population, and the limited
impact of most treatments on criminal recidivism and understanding the impor-
tance of public safety are essential for any provider to succeed in this rapidly
growing market.
John Petrila is a professor in the Department of Mental Health Law & Policy and in the USF College
of Public Health. He is also the Director of the Florida Mental Health Institute Criminal Justice,
Mental Health, and Substance Abuse Technical Assistance Center. Petrila was General Counsel to
the New York State Office of Mental Health and the first Director of Forensic Services in the Missouri
Department of Mental Hygiene. He has published frequently on mental health law and policy issues,
and authored the chapter on confidentiality in the Surgeon General’s Report on Mental Health.
He is a member of the MacArthur Foundation Research Network on Mandated Community Care,
Past-President of the International Association of Forensic Mental Health Services, and co-editor of
Behavioral Sciences and the Law.
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 33
 Beyond Bars
Advocate to Give Youth
a Second Chance
Juvenile Justice and Delinquency
Prevention Reauthorization Act
Mohini Venkatesh, Director, Federal and State Policy, National Council for Community Behavioral Healthcare
W hat is the underlying rationale of state juvenile justice systems? Is it to
punish youths who commit crimes or to rehabilitate youths to give them a
second chance? Although this perpetual debate plays out similarly for incarcer-
ated adults, what is unique to the juvenile justice discussion is the people who
are most affected: youths. Yes, they are supposed to be corrected when they do
something wrong but, isn’t it also important to invest in them and give them the
opportunity to mature and grow into adulthood? When considering factors that
contribute to juvenile delinquency, such as mental health and substance use
problems, negative environmental influences, or complicated family situations,
the role of state juvenile justice systems and community providers becomes
clear — to prevent juvenile delinquency whenever possible and to rehabilitate
youths who are in the system to give them the best chance to succeed.
Studies have indicated that 70 percent or more of youths who are securely
detained in a juvenile justice facility have a mental health or related disorder;
in contrast, approximately 20 percent of the general youth population have such
a disorder. According to a public opinion poll commissioned by the Center for
Children’s Law as part of the John D. and Catherine T. MacArthur Foundation’s
Model for Change juvenile justice reform initiative, a majority of people polled
viewed alternatives to incarceration — such as community mental health treat-
ment, mentoring, and vocational training — as effective ways to rehabilitate
youths. In addition, 8 out of 10 polled strongly favored taking away some of the
money states spend on incarcerating youth offenders and using that funding to
pay for counseling, education, and job training.
Juvenile Justice and Delinquency
Prevention Act
In response to widespread abuses in state and local juvenile justice facilities,
Congress passed the Juvenile Justice and Delinquency Prevention Act in 1974.
The JJDPA serves as the primary federal funding stream for juvenile justice ser-
34 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
vices to states and territories that voluntarily ascribe to its core requirements.
Among other requirements, the JJDPA established rules to ensure that juveniles
who commit minor or “status offenses” are not held in secure confinement,
protect juveniles from being incarcerated in adult jails or lock-ups for extended
periods of time, address the disproportionate contact youths of color have with
the juvenile justice continuum, and other protections. Through these core re-
quirements, the JJDPA is meant to foster services and supports to prevent juve-
nile delinquency and, in cases in which youths enter the juvenile justice system,
protections to ensure that they are not unduly exposed to harm or trauma while
incarcerated.
According to a 2008 survey of the states conducted by the Coalition for Juvenile
Justice, 55 of 56 states and territories voluntarily participate in the JJDPA and
85 percent are compliant with all JJDPA core requirements. One of the true
benefits of the JJDPA is the federal–state partnership it creates via the U.S.
Office of Juvenile Justice and Delinquency Prevention; as a result, states and ter-
ritories greatly value the opportunity to receive technical assistance and share
successful practices with each other and the OJJDP. Through small investments
in successful programs, the federal government is able to offer the opportunity
for states and territories to replicate successful programs, the result of which is
hoped to be an overall improvement in the way juvenile justice systems respond
to youths’ unique needs.
Although the principles of the JJDPA are laudable and have created key protec-
tions for youths, implementation challenges persist — funding limitations, lack
of appropriate staffing and training, and other challenges prevent the realiza-
tion of the original vision of the JJDPA.
Reauthorization
Advocates, including the National Council for Community Behavioral Healthcare,
view reauthorization of the JJDPA as an opportunity to address these challenges.
A majority of people polled viewed
alternatives to incarceration —
such as community mental health
treatment, mentoring, and vocational
training — as
effective ways to
rehabilitate youths.
The JJDPA was most recently reauthorized in 2004, and efforts are underway to Preview of FY 2011
reauthorize the act in the 111th Congress. After being introduced in the Senate,
the Juvenile Justice and Delinquency Prevention Reauthorization Act (S. 678) was
Federal Budget Appropriations
approved by the Senate Judiciary Committee, thus sending the bill to the Senate for Criminal Justice
floor for consideration. Although a companion bill has yet to be introduced in the
>> On February 1, 2010, President Obama released his requests for the
House of Representatives, efforts are underway to push for Senate passage in
Fiscal Year (FY) 2011 federal budget. The release of the President’s
2010 to bolster efforts in the House.
budget signifies the official initiation of the Congressional appropria-
Among several improvements, S. 678 takes important steps to strengthen the tions process; both the House and Senate appropriations commit-
ability of state and territorial juvenile justice systems to meet the substance use
tees will hold hearings, amend the budget over several months, and
and mental health needs of youths by incorporating
approve a final FY 2011 budget.
>> New incentives for improving mental health and substance use screenings,
>> Details of the president’s budget help us understand what the Presi-
treatment, diversion, and re-entry services.
dent’s priorities are and give us a foundation from which to advocate.
>> An increase of federal authorizations for core juvenile justice programs.
The following is a snapshot of the President’s FY 2011 budget requests
>> Reinforcements of the relationship between OJJDP and participating states and for key criminal justice programs compared with previous fiscal years:
territories to facilitate increased compliance with the core requirements of the
>> Treatment drug courts: $56 million, including $5 million for family
JJDPA.
dependency, treatment drug courts. Increase of $12 million from FY
To achieve reauthorization of the JJDPA in 2010, the National Council, along with 2010.
an array of advocacy organizations, participates in a national coalition effort:
Act4JJ (www.act4jj.org). Through this coalition, the National Council joins juvenile >> Ex-offender re-entry: $23 million. Increase of $5 million
justice, child welfare, and youth development organizations with a unified message from FY 2010.
in support of enhancing the JJDPA. Readers who want to be involved in advocacy >> Drug courts: $57 million. Level-funded from FY 2010.
for the Justice and Delinquency Prevention Reauthorization Act on a national level
are encouraged to sign on to the Act4JJ Statement of Principles and monitor the >> Second chance re-entry: $100 million. Level-funded from
National Council’s Public Policy Update for notices of our activity on the JJDP FY 2010.
Reauthorization Act in 2010. >> Mentally Ill Offender Treatment Crime Reduction Act: None. Although
Youths who commit crimes often face an uphill battle to improve their lives, and it this amount represents a $12 million decrease in funding, it is
is our job as community providers, advocates, and members of our communities suspected that the President is attempting to combine MIOTCRA
to guide them in a manner that protects them from danger and gives them the op- funding into the funding provided for drug and mental health courts.
portunity to achieve more. Although reauthorization of the JJDPA won’t resolve all The President’s FY 2009 budget also requested this change, but it was
challenges in serving justice-involved youths, it will certainly get us closer. denied by Congress.
A detailed budget chart for these and other substance use and mental
Mohini Venkatesh serves as the staff policy liaison to the National Council for Community Behavioral
Healthcare’s network of associations throughout the states, conducts federal legislative and policy
health-related federal programs is available
analysis on an array of issues, and manages political engagement activities including an annual Hill at www.TheNationalCouncil.org (click on Public Policy/Issues and
Day in Washington, DC. She received a masters in public health from Yale University and a BA in Resources/Federal Budget) to learn more.
psychology from the University of Massachusetts-Amherst.

NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 35

 From The Field

From The Field

National Council member organizations across America share stories of collaboration with
criminal justice and law enforcement systems to strengthen communities,
save taxpayer dollars, and give persons with mental illness and
addiction disorders a new life, beyond prison bars.

36 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1

Bexar County’s Restoration Center Offers Alternatives
to Jail and the Streets
Gilberto Rendon Gonzales, Director, Communications and Diversion Initiatives, The Center for Health Care Services, Bexar County Mental Health
Authority, San Antonio, TX / ggonzales@chcsbc.org
1,158
individuals admitted to the
Restoration Center instead
of the municipal court
detention area saved
taxpayers $2,657,610.
469 people taken to the
Restoration Center instead of
to a hospital emergency room
before incarceration saved an
additional $703,500.
A ddressing the silos dividing substance abuse treat-
ment and mental health services is a monumental
task. The Restoration Center, started in 2007 by The
Center for Healthcare Services, Bexar County’s Mental
Health and Mental Retardation Authority, seeks to ad-
dress this problem by providing integrated substance
abuse services. In combination with its sister Crisis
Care Center, a 24-hour psychiatric emergency unit, the
Restoration Center sees 900–1,000 people a month.
Working closely with the Crisis Care Center, the Res-
toration Center provides law enforcement with quick
access to treatment for nonviolent misdemeanor of-
fenders with substance abuse problems and also of-
fers substance abuse services to homeless persons in
the community.
In establishing the Restoration Center, CHCS worked
closely with local government and public and private
stakeholders and drew upon lessons learned from the
nationally recognized, award-winning Bexar County
Jail Diversion Program, started in 2003. Earlier, stake-
holders had sought to address the community’s pub-
lic safety needs by developing the Crisis Care Center
with medical clearance for law enforcement officers
so that drop-offs take about 15 minutes, compared
to an 8-14 hour wait in emergency rooms earlier. The
Crisis Care Center’s success in returning officers to
service prompted community stakeholders to address
the gaps in substance abuse treatment through the
Restoration Center.
The Restoration Center includes a substance abuse
court and features three distinct programs:
>> The public safety unit, which provides injured
prisoner medical clearance and treatment and a
sobering unit (40+ person capacity) that enables
safe sobering of persons brought in by law enforce-
ment for public inebriation.
>> The medical detox unit, which provides 27-bed
capacity with a 3- to 5-day stay.
>> Intensive outpatient substance abuse services —
specialized day care treatment with intensive and
supportive counseling programs.
County Judge Nelson Wolff and business leaders such
as Bill Greehey won the support of the Bexar County,
Texas, legislative delegation for a special funding ap-
propriation to establish the Restoration Center.
The Restoration Center is proving to be cost-effective.
In its first 180 days of operation, it served 395 home-
less people who were diverted from jail, saving tax-
payers $766,530. The sobering unit admitted 1,627
individuals in 162 days — 1,158 of them would oth-
erwise have been admitted into the municipal court
detention area at a cost of $2,657,610. An additional
$703,500 was saved when law enforcement officers
took 469 people to the Restoration Center instead of
to a hospital emergency room before incarceration.
Officers are spending less time in emergency room
waiting rooms, which allows them to return to com-
munity policing.
Admissions to the Restoration Center’s detox unit
stem from multiple referral sources such as courts,
the sobering unit, the crisis care unit, Haven for Hope
partners, and walk-ins by people who are homeless.
The Restoration Center is a stakeholder partner in
the $100 million, 37-acre, 962-bed Haven for Hope
homeless facility. Located just across the street from
the Restoration Center, Haven for Hope is scheduled
to be fully operational in June 2010. The ability to pro-
vide 24-hour access to psychiatric crisis assessment,
sobering services, minor medical clearance services,
pre-employment services, and housing — all in one
area — exponentially enhances the possibility of treat-
ment success.
CHCS President and Chief Executive Officer Leon
Evans attributes the Restoration Center’s success to
community collaboration. “We were able to accom-
plish this because we addressed a compelling need,”
he explains.
Catherine Jones, director of Addiction Recovery Ser-
vices at CHCS says, “We made it a point to provide
information to each of our stakeholders, we moni-
tored outcomes, we showed our collaborative pro-
gram partners what was working and what wasn’t, we
showed that we were saving money, and we showed
that this approach was a good doorway into treatment
as well.”
Melanie Lane, director of the Restoration Center, at-
tributes success to persistence and staff serving as ef-
fective role models. She explains that they were able
to introduce real change — in the past, persons could
not access substance abuse services unless they were
sober but the Center knows you can’t get sober until
you get services.
Lane, having once been homeless herself, says, “I’m
glad someone was willing to take one more chance
on me.”
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 37
 From The Field
New Centerstone Initiative Heralds Promise of Work with Justice System
As reported in Mental Health Weekly, Volume 20, Number 6, February 8, 2010
L inda Grove-Paul, M.S.W., believes that a newly
launched re-entry initiative for criminal offenders
with addictions and co-occurring mental health prob-
lems in Indiana can help erase unproductive mis-
conceptions about working with the justice system.
“Mental health clinicians don’t realize how well-in-
formed the judicial system is, in terms of evidence-
based practices and outcomes,” said Grove-Paul,
director of addiction and forensic services at the
nationally prominent behavioral health services
organization Centerstone. “Corrections ‘gets it’ that
prison is not a place for the seriously mentally ill.”
Centerstone of Indiana last week began overseeing
the first participants in the Project CARE (Commu-
nity and Re-entry Enhancement) initiative. The effort
is bound to be watched nationally for several rea-
sons. Centerstone is the contractor for a $1.2 mil-
lion Substance Abuse and Mental Health Services
Administration (SAMHSA) grant for the initiative, a
grant awarded to the Indiana Division of Mental
Health and Addictions in a highly competitive en-
vironment.
As a large behavioral health organization formed
out of three entities, Centerstone is consistently
being looked at as a model for innovative program-
ming (see MHW, Dec. 24, 2007). And perhaps most
importantly, Project CARE will serve as a significant
test case for successful integration, between addic-
tion and mental health services as well as between
the behavioral health and justice systems.
“This initiative really is about breaking down service
silos,” Grove-Paul said.
38 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
For each individual potentially eligible for participa-
tion, a case manager will complete a comprehensive
assessment within the correctional facility, usually
This initiative really several months prior to the offender’s scheduled
release date. This process will assist in identifying
is about breaking a wraparound team for each individual, taking into
account that person’s potential support system in
down service silos.” the with the case manager, a formalized treatment
plan will be drawn up within 14 days.
The initiative then will emphasize nearly immediate
contact with program workers and treatment provid-
Details of initiative
A collaboration among SAMHSA, the state behav-
ers upon an offender’s release. Within one to two
business days after release, an individual will be re-
ioral health division and the state Department of quired to attend an appointment with a community
provider as well as with a case manager, community
Corrections, Project CARE will involve pre- and post-
corrections officer or parole officer. The individual’s
release planning for offenders in order to support
the provision of behavioral health services and wraparound team will have its first meeting within a
other supports to ease community reintegration and week of the offender’s return to the community.
reduce recidivism. The initiative’s reach covers six Grove-Paul said Project CARE will be needs-driven,
southern Indiana counties (Bartholomew, Crawford, emphasizing individualized services in the realms
Harrison, Monroe, Orange and Washington), a region of behavioral health treatment, general health as-
that does not have a re-entry court system. sistance, vocational support, housing support and
other key areas. There may be times when either the
Grove-Paul said that while most of the offenders
to be served under the initiative will have a co- community corrections officer or the offender might
occurring mental health issue such as depression deter- mine that the program is not a fit, and there
or bipolar disorder, all will have a substance depen- will be an opt-out provision.
dence diagnosis.
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 From The Field
Citrus Jail Diversion Program Provides
Integrated Care in a Relationship-Based Care Model
Rafael A. Rivas-Vazquez, PsyD, Director, Assessment and Emergency Service, and Manual Sarria, LCSW, Administrator, Adult Homeless
Programs — Citrus Health Network, Inc., Miami, FL / rrv@citrushealth.com
C itrus Health Network is a federally qualified
health center located in Miami-Dade County,
Florida and specializing in the integration of primary
care and behavioral health services. In 2008, we
aggregated and analyzed 4 years of data from our
jail diversion program. The results were reported in
Psychiatric Services in June 2009. Here, we provide
an overview of our treatment model and a summary
of results from that data review.
Concern regarding the prevalence and inadequate
management of people with mental illness within
the criminal justice system has generated interest
in developing effective diversion programs. In 2000,
CHN received funding from the state to develop a
jail diversion program, in keeping with a countywide
initiative prompted by Judge Steve Leifman, Associ-
ate Administrative Judge of the 11th Judicial Circuit
in Miami-Dade County.
CHN’s jail diversion program is based on two princi-
ples geared toward enhancing psychosocial stability
and reducing criminal recidivism:
a) Facilitating access to integrated medical and
psychiatric care.
b) Delivering all interventions within the framework
of our relationship-based care model, which we
developed as a result of our experience in treat-
ing people with pronounced difficulty in engage-
ment and sustained interpersonal contact. In
addition to specific interventional techniques,
the RBC model reflects a philosophical approach
that pervades all interactions with participants.
The model assumes that the empathy, respect,
and connectedness inherent in healthy relation-
ships can be instrumental in engaging people in
therapeutic activities and empowering them to
take responsibility for their lives.
RBC incorporates elements from other philosophi-
cally compatible approaches, such as the low-de-
mand model and motivational enhancement thera-
py. For example, the principle of “express empathy”
directs us to communicate respect and encourage
collaboration with staff, who come to be viewed as a
40 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
The Relationship-Based Care model assumes that
healthy relationships can be instrumental in engaging
people in therapeutic activities and empowering them
to take responsibility for their lives.
blend of supportive companions and knowledgeable
consultants. The concept of “rolling with resistance,”
from the low-demand model, discourages staff from
meeting resistance head on; rather, they try to facili-
tate a discrepancy between a person’s perception of
the current situation and future aspirations. An end-
point objective of RBC is establishing self-efficacy
and self-agency, in which people develop a sense
that they can change specific behaviors, act on their
own behalf, and take responsibility and be account-
able for their decisions.
To operationalize RBC and facilitate its implemen-
tation, we conceptualized the following stages: (a)
engagement, (b) stability and commitment, (c)
awakening, and (d) growth and differentiation.
During engagement, the initial foundation of a re-
lationship is established; motivational interviewing
techniques are used to mobilize self-interest and
encourage the client to choose care.
Stability and commitment marks a period of rest
and quiescence in which participants begin to feel
safe and secure. This second stage consolidates the
client’s relationship with staff as evidenced by their
accepting physical and mental healthcare, develop-
ing trust to rely on others for basic needs, and col-
laborating with others to obtain day-to-day stability.
We note that although some clients did not progress
past this phase, they were nonetheless able to suc-
cessfully remain out of jail. Probability for long-term
change, however, increases if a person progresses
through the next stages.
The third stage, awakening, refers to a phenomenon
in which clients begin to manifest a desire for more
than a day-to-day existence and meeting basic
needs. This stage is marked by clients taking in-
creased advantage of the therapeutic, educational,
and rehabilitation opportunities offered to them
through our program.
The final stage, growth and differentiation, begins
when participants manifest stability, demonstrate
new adaptive behaviors, exhibit signs of psychoso-
cial flourishing, and ultimately transition into inde-
pendent living.
For this study, we analyzed data from the Criminal
Justice Information System in Miami-Dade County
for 151 people consecutively referred to our RBC
program and compared them with data for 78
people diverted to other programs in the commu-
nity. Number of arrests for each participant was
determined during the 1-year period preceding
date of diversion, followed by a review of arrests
during the year after diversion. Results indicated
that the RBC group demonstrated a statistically sig-
nificant reduction in postdiversion arrest rates (p
< .0001), whereas the rearrest rate for the control
group remained nearly identical (p = .398). For both
groups, postdiversion arrest rates were significantly
correlated with number of arrests before diversion
(p < .001). For the RBC group, regression analysis
revealed that when number of prior arrests was ex-
cluded from the equation, length of participation in
the program (p < .045) and number of psychiatric
contacts (p < .043) accounted for a significant por-
tion of the variance in postadmission arrest rates.
The RBC model appears to be effective in reduc-
ing criminal recidivism. Length of participation in
program and involvement in psychiatric treatment
correlates with reduced arrest rates.
CPSA’s Criminal Justice Team Stay in Touch to Reduce Incarceration
Neal Cash, MS, President and CEO, and Kate K.V. Lawson, MPA, Criminal Justice Manager — Community Partnership of Southern Arizona,
Tucson, AZ / kate.lawson@cpsa-rbha.org
C ommunity Partnership of Southern Arizona has
taken a creative, strategic approach to collabo-
rating with the criminal justice system — from the
establishment of Arizona’s first mental health court
10 years ago to new initiatives that quickly identify
and mobilize therapeutic and peer support for CPSA
members who have been arrested. CPSA works closely
with both the adult and the juvenile justice systems
to ensure appropriate diversion, coordinate treatment
during incarceration, and plan for continued services
after release.
Collaboration with criminal justice and other govern-
ment systems is built into CPSA’s structure and op-
erations. CPSA is a nonprofit, community-based man-
aged care organization created 15 years ago by local
stakeholders to administer public behavioral health
services in five southern Arizona counties. CPSA now
oversees these services for more than 1.2 million
people. CPSA’s community roots and ability to rein-
vest cost savings into services allow it to respond to
emerging needs, including the creation of teams that
focus on support services such as housing, employ-
ment, and wellness.
The seven-person criminal justice team is an im-
portant part of CPSA’s holistic effort to reintegrate
members into the community, maintaining a collabo-
ration with law enforcement and courts that benefits
all partners. The CJT will be presented with the 2010
SAMHSA’s Center for Mental Health Services National
GAINS Center Impact Award at the GAINS national
conference in March 2010. This award recognizes
programs doing outstanding work in criminal justice
and mental health services for adults.
CPSA formed the CJT in 1999 as a result of a work-
group of behavioral health and criminal justice staff in
Tucson/Pima County that sought to identify systemic
strategies to decrease the time that a person with
mental illness is inappropriately incarcerated. CPSA
began mandating that its contracted Comprehensive
Service Providers, which coordinate care and provide
direct behavioral health services, hire criminal justice
specialists to help resolve system-wide and member-
specific issues. An ongoing forensic task force also
grew out of the workgroup. This collaboration resulted
in the development of relationships, processes, and
tools that allow timely identification of CPSA members
who have been arrested and appropriate, real-time
The initial appearance component has resulted in an
approximately 60 percent decrease in the likelihood
that a CPSA member will be detained in custody. The
information sharing that protects member confiden- approximate number of members remanded for jail
tiality. time in the component’s first year dropped from 40
CPSA’s CJT staff check county booking lists against per month to 24 per month. This trend has continued
membership information twice a day. Staff alert the in subsequent months.
member’s assigned CSP of an arrest and ensure that In 2009, CPSA began a peer mentor program in Pima
treatment is coordinated with the jail’s behavioral County. In this program, members who graduate from
health treatment provider. Staff from the CSP visit the superior mental health court receive extensive train-
member in jail within 72 hours of arrest notification, ing and coaching so they can help incarcerated mem-
7 days before the member’s adjudication or hear- bers navigate the behavioral health and criminal jus-
ing, and every 30 days thereafter. CPSA, the CSP, and tice systems. CPSA’s CJT has also provided technical
medical personnel from the jail hold staff meetings on assistance to and become a stakeholder in the newly
select cases each week. implemented Veterans Court in Tucson City Court.
On any given day, the CJT monitors 250–300 mem- Success in Tucson/Pima County has led CPSA to
bers detained in jail and as many as 800 members establish six more mental health court collaborations
throughout the criminal justice system. Approximately across its region. The initial appearance component
65 members are diverted from jail each month as the will be expanded as funding is available.
result of the CJT program, via mental health court or
other means, resulting in approximately 17 fewer days
of incarceration per member — a savings of more than
$84,000 each month. The Criminal Justice
In December 2008, CPSA initiated an effort to ensure Team diverts approximately
CJT representation at its members’ initial court ap-
pearances, to help divert these members before jail 65 members from jail and
detention and quickly connect them with community
results in approximately 17
treatment services. This initial appearance compo-
nent has significantly decreased the likelihood of fewer days of incarceration
incarceration for CPSA members.
per member — a savings of
At initial appearances, the judge informs the member
of the charges and determines conditions of release. more than $84,000 each
CJT staff are prepared to obtain the member’s signa-
ture on a universal consent form for information shar-
month.
ing, assess the member’s ability to transport him- or
herself home and to treatment, and share informa-
tion with pretrial services and the presiding judge. For
people who are eligible but not yet enrolled in the
public behavioral health system, CJT staff facilitate
enrollment and oversee timely contact with a treat-
ment provider. When the member is too unstable to
safely leave the jail on his or her own, staff coordinate
pickup by a treatment provider or shelter.
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 41
 From The Field
At Community Psychiatric Clinic, Integrated Funding Stream
Facilitates Comprehensive Care
Shirley Havenga, MA, MPA, CEO, Community Psychiatric Clinic, Seattle, WA / shavenga@cpcwa.org
I n 2003, Community Psychiatry Clinic developed its
IMPACT program, one of the first co-occurring dis-
order programs in the region, providing integrated
mental health and chemical dependency services
using a single funding source. IMPACT was one of
the first programs funded by King County’s Criminal
Justice Initiative, which created multiple programs
focused on developing alternatives to incarceration
and is funded through both the county and state.
IMPACT provides services to people referred by sev-
eral local mental health and drug diversion court
programs. Clients are enrolled in IMPACT for up to
12 months before transitioning to the regular men-
tal health treatment provider network for ongoing
services. IMPACT serves approximately 100 people
annually.
The IMPACT program provides evidence-based in-
tegrated treatment services, including Integrated
Dual-Disorder Treatment and Moral Reconation
Therapy for adults with co-occurring mental health
and chemical dependency disorders and a history
of incarceration. IDDT has been shown to reduce
hospitalization, homelessness, and incarceration
and improve employment outcomes over time. MRT
focuses on changing behavior and personality with
a systematic, 12-step treatment approach aimed at
re-educating clients socially, morally, and behavior-
ally and assisting them in developing appropriate
values, goals, and motivation. An intensive case
management model is strengthened by small case-
Chrysalis’ Employment Support Network Improves
Job Prospects for Ex-Offenders
Tanya Howard, Services Director, Chrysalis Center, Hartford, CT / thoward@chrysaliscenterct.org
C hrysalis Center has provided employment servic-
es since the mid-1980s. The State of Connecticut
Department of Mental Health and Addiction Services
has funded Chrysalis Center to provide the Employ-
ment and Recovery Network, an outcomes-driven
employment support service for people with mental
42 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
load size, team-based services, and assertive out-
reach to promote client engagement. Program staff
include chemical dependency professionals and
mental health professionals. Beginning in 2010,
the IMPACT program will also include a boundary
spanner position to serve as the liaison between the
criminal justice system and the treatment team.
Coordination with the criminal justice system, com-
munity providers, landlords, and family members
is a key program component that aids clients in
achieving treatment recovery goals and avoiding
further incarceration. Staff have developed solid
relationships with local resources — housing agents
to assist in securing housing for clients who may
have significant difficulty with this because of their
criminal history; jail health services staff to promote
continuity of care for inmates preparing for release,
particularly for medication maintenance; court staff
to help clients remain in compliance with court
orders, and others. In addition, IMPACT staff col-
laborate with the State of Washington Department
of Corrections in cases in which the client is adju-
dicated on a felony and is now on DOC community
supervision (state form of probation) for ongoing
compliance with DOC sanctions.
“One of the most effective components of the IM-
PACT program has been the ability to operate with
a single funding stream, rather than the traditional
siloed mental health and chemical dependency
funding sources,” says Shirley Havenga, CPC’s CEO.
illness, substance abuse history, or both. The new
Employment Support Network began operations in
summer 2009, providing a full range of employment
services for parolees, many of whom struggle with
mental illness, substance abuse, or both.
ESN staff include a services director, three employ-
Coordination with the criminal
justice system, community
providers, landlords, and family
members aids clients in achiev-
ing treatment recovery goals and
avoiding further incarceration.
Other helpful program components have included
access to CPC’s extensive housing resources for
people with mental illness and funds to assist cli-
ents with securing housing; offering intensive treat-
ment groups, peer support services, involvement
with AA meetings, and individual sessions to help
gear clients toward success; and close coordination
of treatment with courts and probation.
Data from the first 4 years of the program demon-
strate that clients have significant reductions in
substance abuse when discharged from the pro-
gram. Clients showed this reduction irrespective of
the referral source. In years 1, 2, 3, and 4 regarding
specialty court–referred clients 47 percent, 34 per-
cent, 44 percent, and 44 percent, respectively, of
clients reduced to ≤1 use per week; in years 1 and
2 regarding King County Jail referrals, 29 percent
and 47 percent, respectively, of clients reduced to
≤1 use per week).
ment specialists, and two job developers. Staff have
diverse prior work experience, representing criminal
justice, behavioral health, employment, and educa-
tion. Employment specialists work with participants
to assess strengths and deficits, determine career
interests, and help develop individual service plans
 to help participants work toward their goals. Staff link
participants to additional training and education and
to appropriate community supports. Staff focus on
addressing the needs of the whole person, not just
the employment component. They help participants
gain access to housing, behavioral health treatment,
support groups, legal assistance, driver’s license or
identification, child care, and more to help them suc-
ceed. Staff counsel people that despite their illness,
disability, or life circumstance, each brings with them
a host of strengths, experiences, and skills to build on.
Job developers work in the community to introduce
Chrysalis Center and its services to potential employ-
ers and educate them about hiring ex-offenders. Staff
work to persuade employers to give an opportunity
to ex-offenders and assure employers that partici-
pants will continue to receive the supports they need
to maintain employment. Job developers make their
case by informing employers about tax credits avail-
able to businesses that hire people with a criminal
background. In addition, they cite research demon-
strating that employment is a key factor in reducing
Mental illnesses are
To learn more visit
www.MentalWellnessToday.com
Your Partners In Mental Wellness
recidivism. They emphasize that ex-offenders being
employed and paying taxes is of greater benefit to the
local economy and to society.
Job developers and employment specialists conduct
intensive counseling with clients so they are confident
when they interview with a potential employer. Staff
conduct mock interviews, set up appointments for
clients, and drive them to interviews as needed. They
assist each person with developing an explanation
letter for potential employers, addressing the person’s
felony and his or her subsequent remorse and reha-
bilitation. Staff provide supports for a maximum of
120 days while participants are on parole.
“Some clients walk through the door ready for em-
ployment, while others are in need of training, motiva-
tion, and other supports,” says Tanna Howard, services
director for the project. “We arm clients with the tools
they need for success by providing a number of train-
ing programs in-house, and linking clients to other
services that meet their needs. We make sure par-
ticipants understand that gaining employment is their
complicated
You probably know
someone who has one
responsibility, and that we are here to support them.”
Although ESN is designed to serve 300 participants
each year, the project has served more than 200 ex-
offenders in its first 4 months of operation. Staff work
closely with both parole officers and participants to
ensure a successful outcome for each person served.
To date, 50 participants have gained employment.
Because of their own life experiences, many partici-
pants have a strong desire to work with people in
recovery from mental illness or substance abuse. Two
have completed the Recovery Coach Academy with the
Connecticut Community for Addiction Recovery. One
has graduated from the Connecticut Department of
Mental Health and Addiction Service’s Recovery Uni-
versity, and two are working toward degrees in drug
and alcohol counseling.
Howard attributes the project’s early success to four
factors: employer education, a strong relationship
with parole officers, the diversity of experience and
passion of ESN staff, and ongoing collaboration with
other community providers and stakeholders.
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 43
 From The Field
At Hands Across Long Island, Peers Follow People
from Prison to the Community
Ellen M. Healion, MA, Executive Director, Hands Across Long Island, Inc., Central Islip, NY / ellen@hali88.org
H ands Across Long Island, a peer-run organization
that has been operating for more than 21 years,
supports people with severe and persistent mental
illness in the criminal justice system.
It is not easy for mental health providers to gain ac-
cess to the criminal justice system, given safety con-
cerns. New York State has led the way to a solution
by providing mental health services in a separate
unit of Sing Sing Prison in Ossining. HALI has been
part of this program since 2002, in addition to work-
ing in the county jail. The goals of this program are
to prepare inmates for the changes that have taken
place in the community since their incarceration;
develop their interview skills with respect to parole,
housing, and other practitioners; and develop new
coping skills to help them remain in the community.
It is imperative that inmates understand that the
coping skills they’ve acquired in prison or jail will
not be an asset to them in the community.
Because HALI staff have “been there, done that” and
work with inmates for 3 months, they develop posi-
tive, trusting relationships. Next, staff help to bridge
inmates from prison to the community. Staff meet
inmates at the gate on the day of release and ac-
company them to parole and a meeting with their
case manager and then to a shelter for the evening.
To date, no housing programs have been developed
to accept inmates on release; therefore, shelters are
necessary for approximately 2 weeks to verify home-
lessness. To facilitate the transition to the commu-
nity, staff continue working with a participant for
another three months.
A drop-in center was developed to offer support
to those people who have completed the program
and want continued support. The center is open on
“reporting day,” just around the corner from parole.
If someone has dropped off the radar, chances are
that they can be found at parole on their reporting
day. The center also provides a place where people
can touch base with the staff who worked with them
in prison and with whom they have a relationship.
This center required permission of the Parole De-
partment to allow felons to congregate as most fel-
44 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
ons are prohibited from being with other felons.
The New York State Office of Mental Health has re-
ported that since the inception of these services,
the recidivism rate has dropped significantly.
On Long Island, HALI recognized the needs of peo-
ple being released to the county from prison and
from the local jail. In collaboration with the Suffolk
County Re-Entry Task Force, HALI developed a Re-
Entry House Pilot project to fill a major gap in the
recovery process — housing.
With a grant from the Department of Criminal Jus-
tice and HALI funds, we were able to create an in-
tensive program and establish housing. We can ac-
commodate four people at any given time. Attached
to the house is a studio apartment in which a staff
person resides and provides emergency response
for the residents. We help people develop routines
and attitudes helpful for community integration.
The program initially provides intensive supervision
and then lifts restrictions as appropriate. Staff ar-
rive at the house every morning, inspect the house,
and make sure residents are ready before they are
transported to their program or appointments. By
3:30 pm, residents are picked up from their work
and brought back to the house where they have
time for dinner and chores before they head out for
a community-based 12-step program (AA or NA).
Staff stay with them through the meeting to coach
them to participate, meet people, and integrate into
the community. They typically return to the house
around 10:00 pm. On weekends, staff accompany
residents to the grocery store and other errands,
and residents participate in some form of exercise
and recreation. The goal is to teach the residents
how to live a full life in recovery. For many, this is an
exhausting process — life in jail or prison is certainly
not filled with activity.
When the staff and the resident together feel that he
or she is ready to have more responsibility, unsuper-
vised activities are planned that also take into con-
sideration conditions of parole or probation. During
this phase, the resident is given more and more
Staff help inmates
understand that the coping
skills they’ve acquired in
prison or jail will not be an
asset to them outside and
work with them after release
to support transition to the
community.
freedoms with frequent drug testing, verification of
planned activities, and so forth. In addition, plan-
ning is done for after the resident graduates from
the program. Applications for housing programs,
employment programs, recovery programs, and the
like are prepared and submitted to the appropri-
ate agencies. Although providers, employers, and
schools may be hesitant to accept a parolee’s ap-
plication, a graduation certificate from the re-entry
program provides supporting documentation that
attests to the person’s efforts to change his or her
life. HALI can also directly communicate with provid-
ers to help with their acceptance of the parolee.
People with mental illness require intense assis-
tance to succeed in returning to the community
from prison. HALI gives them the opportunity to live
on the outside with others who have done the same
and not only survived but created a life worth living.
Twenty-eight people from Sing Sing and Suffolk
County Jail have crossed our threshold. Of these,
22 are employed or going to school, have reunited
with their family, have started a family of their own,
or live independently or in a supported housing
program — their names line the wall at the re-entry
house to give hope to newcomers.
Operating premier mental health crisis
response systems for over a decade

Including:
Mobile crisis teams (both police-based
and clinician-based models)
365/24/7 call centers
Urgent care centers
In-home and family intervention teams
CISM
Hospital and jail diversion

Assisting over 3 million residents during times of crisis

www.thesantegroup.org
For more information about our services and capacities please contact
Fred Chanteau at fchanteau@santegroup.org
 From The Field
John Eachon Re-Entry Program Focuses on Intensive Therapeutic Services
Elaine Cooper, MEd, LPC, NCC, Mental Health Therapist, John Eachon Re-Entry Program, Lakewood, CO / ElaineC@jcmh.org
T he John Eachon Re-Entry Program serves offend-
ers who are eligible for community placement
or parole. JERP offers intensive residential and
nonresidential treatment for offenders with serious
mental illnesses and substance abuse disorders.
JERP is a collaboration between four major entities:
the Colorado Department of Corrections, Jefferson
Center for Mental Health (serving Jefferson, Gilpin,
and Clear Creek Counties), Intervention Community
Correction Services, and Jefferson County Justice
Services Division of Criminal Justice Department
of Public Safety. Early planning and collaboration
began in September 2003, and with a grant from
the Bureau of Justice Assistance, doors opened in
November 2005. On July 1, 2005, JERP began re-
ceiving state funding.
The goals and objectives of JERP are to:
>> Integrate correctional supervision with
community re-entry, mental health treatment,
substance abuse treatment, vocational rehabili-
tation (education and employment), and social
services (housing, benefits, family resources).
>> Increase mental health functioning and
prosocial behavior.
>> Decrease psychiatric hospitalizations (or
returns to DOC resulting from psychiatric
emergencies or decompensation).
>> Increase medication compliance.
>> Reduce technical violations and new criminal
offenses.
>> Reduce community corrections placement
failures.
Our mission is to offer intensive therapeutic servic-
es (individual and group therapy, psychiatric care,
medication monitoring) to meet program goals for
offenders with co-occurring disorders. Typical diag-
noses treated include major depression, bipolar
disorder, schizophrenia, schizoaffective disorder,
substance abuse disorders, personality disorders,
attention deficit hyperactivity disorder, and post-
traumatic stress disorder. Much-needed mental
health treatment helps to reduce recidivism.
46 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
While in the JERP program, the clients are able to
take part in many Jefferson Center services and
programs, including additional group therapy; a
Criminogenic Factors
wellness program; assistance with transition to The JERP program has identified
other housing; benefits application assistance; specific criminogenic factors of
peer mentoring and counseling; and case manage-
severe and persistently mentally
ment to assist in obtaining employment, education,
transportation, and other services. ill substance-abusing offenders —
A JERP participants remains in the residential pro- focusing on these factors supports
gram at ICCS until he or she is deemed ready for recovery and lowers recidivism.
nonresidential placement — transition to Jefferson
Center housing or other community living. To ensure Criminogenic factors include
community readiness, the decision to transition
from community corrections to the community is l Mental health
made by an interdisciplinary team of JERP clini-
l Criminal thinking
cians, nurse, and supervisor, as well as the ICCS
clinical director and staff and the offender’s parole l Antisocial companions
officer. Jefferson Center offers a continuum of hous-
l Antisocial
personality or
ing options to serve as transitional living opportuni-
ties for clients who are working to eventually obtain temperament
independent living within the community. l Substance
abuse
After completing services at JERP’s inpatient site,
l Family and marital conflict
clients are offered housing through other Jefferson
Center programs or within the community. Clients (social supports)
continue attending weekly individual and group
l Employment (social supports)
therapy, as well as other therapeutic services. Also,
offenders may be able to move from the residen- l School (social supports)
tial program site at ICCS to other approved living
arrangements, such as with family or independent l Leisureand recreation
living, with the approval of their parole officer and (social supports)
the JERP team.
Jefferson Center offers mental health treatment ser-
vices that range from intensive residential services
through general outpatient therapy or medication
management, and JERP clients are encouraged to
maintain services with Jefferson Center even after
completion of the JERP program, parole, or both.
Preliminary statistics indicate a significant de-
crease in JERP clients’ recidivism rate (2–3 times
less) compared with that of severe and persistently
mentally ill substance-abusing offenders who re-
ceive no treatment.
Kent Center’s Court Clinic Bridges Behavioral Health and
Criminal Justice Systems
David S. Lauterbach, ACSW, President & CEO, The Kent Center, Warwick, RI / astoltz@thekentcenter.org
R hode Island — the smallest state in the nation — is
not immune to the personal, social, and financial
ramifications of the inappropriate incarceration of
people with behavioral health challenges. Greater
awareness of this issue has slowly come to the fore-
front, and one way in which Rhode Island has success-
fully prevented many inappropriate incarcerations in
favor of treatment is through The Kent Center’s Court
Clinic Program.
In 1999, the Rhode Island Department of Mental
Health, Retardation and Hospitals provided funding
to The Kent Center to establish the first court clinic in
Rhode Island at the Kent County District Court. Since
the program’s inception, we have assisted nearly
2,500 people with outcomes that include diversion
from jail, placement in treatment, dropped or reduced
charges, and reduced court fees. We have also as-
sisted family members by educating them about what
happens in court and by referring them to community
resources.
The Kent Center employs a full-time master’s-level cli-
nician whose primary work site is the courthouse. The
clinician is present during court hours and is imme-
diately available to the judges should they request an
assessment of a person who comes before the court.
The clinician assesses the person’s behavioral health
needs, makes treatment recommendations, and pro-
vides follow-up information regarding the person’s
compliance with court orders. The prosecuting and
defense attorneys, police, family members, or defen-
dants themselves may also request an assessment.
Mental Health Center of Denver’s Court to Community Program Gets Results
Kristi Mock, MSW, LCSW, Adult Recovery Services Director, and Jay Flynn, JD, Deputy Director of Adult Recovery Services — Mental Health
Center of Denver, Denver, CO / kaylynn.dougall@MHCD.org
B efore 2006, a young man like JT might not have
had much of a chance of escaping his revolving
cycle of depression, substance abuse, and repeated
incarcerations for multiple misdemeanor violations
The court clinician’s flexible approach to problem solving
has helped to create an atmosphere of mutual respect between
the behavioral health and criminal justice systems in Kent County.
Our court clinician assesses the person for mental
health issues, substance disorders and a history of
trauma. The clinician uses the guidelines of a trauma-
informed intervention model when making an assess-
ment. The clinician — employed by The Kent Center
and not the court — serves as an independent and ob-
jective advocate. This arrangement fosters significant
trust between the clinician and clients and families.
Equally as important to the program’s success are the
relationships developed over several years between
the Kent Center’s court clinician — and, by extension,
the Kent Center’s Emergency Services team of which
she or he is a member — and all segments of the
criminal justice system. We realized early on that one
key to success would be a receptive judiciary. One
judge in particular, Judge Stephen Erickson, assuaged
all concerns. Judge Erickson has a track record of
working with people struggling with mental illness
and addictive disorders and supported a clinician in
the court from the start. Other judges have quickly
become supportive as well. A strong rapport has also
been established between the court clinician and the
prosecution teams of the towns and cities served at
the Kent County Court, as well as between the court
clinician and police departments. The clinician’s
knowledge of the roles of each segment of the crimi-
in the city and county of Denver. Thanks to Court to
Community (C2C), a collaborative program of Denver’s
criminal justice system and community mental health
and service agencies, JT has made dramatic strides in
nal justice system, appreciation for the unique cul-
tures of all agencies involved, and flexible approach to
problem-solving has helped to create an atmosphere
of mutual respect between the behavioral health and
criminal justice systems in Kent County.
One of the most positive outcomes of the Court Clinic
Program is the impact it has had on the relationship
between the criminal justice system — in particular
police departments — and the Kent Center’s 24/7
Emergency Services Department. The court clinician
acts as a consultant to police in handling emergency
encounters with people in crisis and trains police
officers from across the county and state in how to
handle emergency encounters with people present-
ing with behavioral health symptoms. She is often the
point person for police and is called on at any time
of day to assist with emergency situations. In turn,
she calls in other members of the emergency services
team to assist.
The relationship between the Kent Center and the
criminal justice system continues to grow. Working
together, we will divert many more people struggling
with behavioral health challenges from inappropriate
involvement with the criminal justice system into treat-
ment, in order to provide cost savings and the best
outcomes for individuals, families, and communities.
his recovery and hasn’t had a single legal infraction
since entering the program.
C2C, a jail diversion program, grew out of the vision of
the Denver Crime Prevention and Control Commission,
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 47
 From The Field
Over the C2C program’s first year, an 87 percent drop was seen in the
cumulative arrest rate. It is estimated that 5 years after completion,
the program saves $3.50 for every dollar spent on a consumer.
with the mission of creating a flexible and respon-
sive system to serve and manage municipal ordi-
nance offenders with serious and persistent mental
illness. Now entering its fourth year, C2C has proven
to be an enormous success for Denver, both in out-
comes for its participants and in demonstrating a
successful system of cooperation and collaboration
between mental health providers and the criminal
justice system.
With services provided by the Mental Health Center
of Denver and the Colorado Coalition for the Home-
less, the program serves at least 36 adults at any
given time, connecting consumers to court-ordered
mental health treatment, substance abuse services,
and housing and social support assistance. The pro-
gram is funded by the city and county of Denver and
the Colorado Health Foundation.
C2C’s initial goals included reducing arrests and
incarcerations of people with serious and persistent
mental health issues by 25 percent. Over the pro-
gram’s first year, an 87 percent drop was seen in the
cumulative arrest rate. The cumulative number of
days spent in jail dropped by 80 percent compared
Tarrant County’s Mental Health Law Liaison Project Is On 24/7
Steve Moore, Chief of Police, Hurst Police Department, Fort Worth, TX; Ken Bennett, LCSW, and Courtney Janes, LPC-I, CART — MHMR
Tarrant County, Fort Worth, TX / Ramey.Heddins@mhmrtc.org
M HMR’s Mental Health Law Liaison Project is a
jail diversion program that works with all law
enforcement agencies in Tarrant County. Program
funding is provided by Tarrant County Commission-
ers Court and a federal justice assistance grant. The
goal is to slow down the “reinstitutionalization” of
people with mental illness in prison by diverting
them to services appropriate to their needs.
The project answers officers’ calls 24/7, to help as-
sess the clients’ condition and recommend treat-
ment services. Follow-ups include consultation with
officers on the phone and at the scene to determine
the most appropriate action to take. MHMR also
48 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
with the year before admission. It is estimated that
5 years after completion, the program saves $3.50
for every dollar spent on a consumer. The program
has also shown reductions in psychiatric admis-
sions, the need for detoxification services, and sub-
stance abuse.
C2C uses Assertive Community Treatment in a novel
way by providing a clinically sound process for
graduating consumers to lower service levels while
maintaining their progress in recovery, allowing
the C2C team to serve more consumers than with
a traditional ACT approach. MHCD also provides
integrated dual-disorders treatment and access to
dialectic behavioral therapy and trauma recovery
empowerment model groups when indicated. Pro-
gramming and outcomes are evaluated, monitored,
and improved on using sophisticated measurement
methods developed by MHCD’s Department of Out-
comes and Evaluation.
At first, C2C was met with skepticism. According to
MHCD Deputy Director of Adult Recovery Services
Jay Flynn, the greatest obstacle was the criminal
justice system’s initial lack of trust and reluctance
advocates for clients by training officers at local
police departments, sheriffs’ departments, and po-
lice academies on how to interact with people with
mental illness. These trainings include the Mental
Health Peace Officers Course, crisis intervention
training, and other specialized mental health train-
ings on request.
On April 11, 2003, the Hurst Police Department re-
sponded to a shooting at a condominium complex
in the southeast portion of the city. At the scene,
the witnesses relayed to officers that a 78-year-
old woman, Ms. Locke, had been making threats
against another resident in the complex, Ms. Porter.
to allow consumers to join the program. “It took a
lot of communication and collaboration to help the
city attorney’s office feel comfortable that people
could succeed in the program and not commit fur-
ther crimes,” explains Flynn.
As a result of C2C’s success, Denver now has a
mental health court docket and a judge dedicated
to strict review and oversight of consumer partici-
pation and progress. The program has made sig-
nificant contributions to promoting mental health
literacy within the criminal justice system and has
provided ample evidence that mental health treat-
ment can be cost effective in reducing the use of
public funds. C2C’s demonstrated effectiveness has
led to a collaborative effort to seek funds to sustain
and expand the program. Denver Judge Larry Bohn-
ing, who oversees Denver’s weekly mental health
docket, was an early skeptic. “Now I’m convinced
we’re doing some good,” he says. “We could use 300
more slots.”
C2C has been and continues to be a model for the
development of a number of similar programs and
partnerships targeted at reducing the skyrocketing
number of people with severe mental illness, co-
occurring substance abuse disorders, and trauma
in Denver who are involved in the criminal justice
system.
Ms. Porter died of a single gunshot wound inflicted
by Ms. Locke. It was discovered that Ms. Locke had
been making threats against Ms. Porter because
she believed Ms. Porter was having a relationship
with a man in Virginia who Ms. Locke believed was
her boyfriend. No such relationship actually existed.
During the investigation, the department found that
they had dealt with Ms. Locke on a couple of occa-
sions when she had made threats against city rec-
reation staff. The department also discovered that
Ms. Locke had been arrested in 1982 for attempted
murder and that the case was dismissed for rea-
son of insanity. Subsequently, a Tarrant County jury
found Ms. Locke incompetent to stand trial for the
2003 murder, and she was sent to the Vernon State
Hospital.
The Hurst Police Department comes into contact with
an increasing number of citizens with mental health
issues. Officers often deal with family members who re-
port how well these citizens are when they are on their
medication; however, many stop taking their medicine
when they feel they are doing better. The Hurst Police
Department is unable to solve many of these mental
health issues without the assistance of mental health
professionals. So, the department started looking for
a way to be more proactive and preventive in dealing
with clients with mental illness.
A proactive approach to dealing with people with
mental illness has been partnering with the MHMR
Mental Health Law Liaison Project. The Hurst Police
Department and the Law Liaison Project have been
able to work closely together to identify people in the
community with mental health issues and coordinate
the appropriate treatment services. This partnership
has facilitated effective communication in crisis situ-
ations, which has resulted in better outcomes in the
River Edge Combines Services and Training to Lower Recidivism
Tiffany M. Russell, Community Affairs Manager, and Shannon T. Harvey, LCSW, CEO — River Edge Behavioral Health Center, Macon, GA
sharvey@river-edge.org
I n 1998, in an effort to decriminalize people with
mental illness and move defendants from jail into
treatment, Bibb County law enforcement joined River
Edge Behavioral Health Center and other community
partners to begin a forensic social services program.
In the early days, officers brought inmates of the 930-
bed Bibb Law Enforcement Center with significant is-
sues to a River Edge site for evaluation. Eventually,
River Edge began sending an evaluator to the LEC
for at-risk inmates because bringing the inmates to
the River Edge facility was deemed expensive, time-
consuming, and embarrassing to inmates. River Edge
From FY 2007-2009, the Bibb County jail had no suicides or
referrals for psychiatric hospitalization. Among inmates with ongoing
access to treatment and supportive services on release, the rate of
recidivism is far lower than average.
community. The partnership also has been instru-
mental in reducing calls for services, thus leading
to decreased costs for the department. By working
together to identify people with special needs early
in the process, we’ve been able to decrease the num-
ber of people going to hospital or jail and to increase
public, officer, and client safety.
The Hurst Police Department has created a protocol
within its agency to ensure that the proper documenta-
tion is completed and forwarded to the Mental Health
Law Liaison Project. Once this information is received,
the Law Liaison Project attempts to follow up with the
client to determine the best course of action. The Law
Liaison Project also completes follow-ups by riding
with trained mental health peace officers and has
one designated mental health peace officer who com-
municates regularly with MHMR to discuss the status
of clients with mental illness within the community. A
high percentage of contacts made by the Hurst Police
Department and MHMR are health wellness checks to
reduce emergency detentions.
The Law Liaison Project is also a part of the hostage
negotiation team and provides technical assistance
also began providing licensed staff to be available on
weekends and holidays for emergency evaluations,
along with a psychiatrist who could prescribe medi-
cations.
Through a contract with Bibb County Government, fi-
nancial contribution by River Edge Behavioral Health
Center, and donated office space and computer in
the LEC, River Edge now provides a full-time licensed
clinical social worker, a part-time psychiatrist, and
two (male and female) certified addiction counselors
available 24/7, on call and onsite. Services provided
include case management, psychiatric services, eval-
By identifying people with
special needs early in the
process, we’ve been able to
decrease the number of
people going to hospital or
jail and to increase public,
officer, and client safety.
to negotiators to make a good diagnostic impression
and to determine the best course of action in a cri-
sis situation. As a result of the successful partnership
between MHMR and the Hurst Police Department, the
program has grown exponentially. This proactive ap-
proach has been implemented by five departments in
Northeast Tarrant County, which include Euless, Bed-
ford, Richland Hills, North Richland Hills, and Haltom
City Police Departments.
uations, medication management, brief intervention
groups for addiction, therapy groups, skills training,
parenting classes, and discharge planning.
With the sheriff’s financial and political support, the
Bibb County LEC has significantly decreased inmates’
assaults on other inmates or staff and suicide at-
tempts or referrals for psychiatric hospitalization.
During the past fiscal year, only 1 percent of the jail
population assaulted another inmate and only nine
inmates attempted assaults on staff. In fiscal years
2007, 2008, and 2009, the Bibb County jail had no
suicides or referrals for psychiatric hospitalization.
Among inmates with ongoing access to treatment and
supportive services on release, the rate of recidivism
is far lower than average.
In 2005, River Edge, the National Alliance on Mental
Illness, and the Bibb County sheriff’s office teamed up
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 49
 From The Field
to provide crisis intervention training to teach pub-
lic safety officers and first responders how to more
therapeutically intervene with individuals or families
experiencing a mental health crisis.
In April 2007, a mental health court was initiated
in Bibb Superior Court. Persons charged with either
a misdemeanor or a felony may participate in the
mental health court; however, those charged with
homicide or sex crimes cannot yet be served. After
an initial referral from jail staff, the defense attorney,
LEC medical staff, or the inmate, an assessment for
clinical appropriateness is completed. If a referral
is received pre-adjudication, most charges can be
dropped on graduation from mental health court.
If a referral is received from a probation officer, in-
mates can be sentenced to program participation.
Accordingly, the court can serve both as pretrial di-
version and in lieu of incarceration, saving taxpayer
River Oak Center Helps Youth on Probation through Multisystemic Therapy
Mary Hargrave, PhD, CEO, and Stephanie Parmely, PhD, Director MST, River Oak Center for Children, Carmichael, CA
mhargrave@riveroak.org
R iver Oak Center for Children adopted the Mul-
tisystemic Therapy program in 2003 to address
unmet needs for youths in probation with mental
health and substance abuse issues. MST is an
evidence-based program known to reduce out-of-
home placement, criminal behavior, and substance
abuse among youths ages 10–17 years. MST works
by assessing the multiple systems that contribute
to the client’s behaviors and works through the key
stakeholders within those systems (parents being
the most significant) to increase structure, limit
setting, monitoring, warmth, and prosocial peer
activities.
In Sacramento, CA, MST services are funded through
probation grants and mental health funding. Each
therapist works intensively with four to six families
at a time. Services include 24/7 availability and two
to three sessions weekly provided in the home, com-
munity, school, and neighborhood to make systemic
changes. To ensure quality feedback and maintain
model fidelity, staff are required to submit to super-
vision, weekly case summaries that include clients’
overarching goals, previous weekly goals, advances
50 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
dollars on jail beds — approximately $52.00 per
inmate bed per day.
Referrals are reviewed by the mental health court
team, which includes the assistant district attorney,
representatives from state and federal probation,
the Department of Family and Children Services,
River Edge, and the public defender’s office. Once
a referral is accepted, the participant is assigned a
case manager who works with him or her to deter-
mine treatment and resource support needs. It is
important to note that mental health court partici-
pants receive intensive court supervision, including
reporting their progress to the judge every other
Thursday. People served typically enter services
homeless and quite ill psychiatrically; therefore,
program services and monitoring are usually con-
tinued for 12–16 months before graduation. Gradu-
ates can receive additional services and aftercare.
toward and barriers to those goals, assessments
regarding what has contributed to any problems or
successes that week, and new goals for the week
ahead. In the weekly supervision group, staff are re-
quired to discuss every case. After supervision, there
is a weekly consultation group with an MST consul-
tant. Each client completes a monthly evaluation of
the therapist, and therapists complete evaluations
of their supervisor to ensure fidelity.
MST is rooted in family systems approaches and
cognitive–behavioral, parent management, and
solution-focused theories. No intervention is pro-
vided until a thorough assessment or sequence of
the problem is established with the family, thus en-
suring that the therapist avoids a one-size-fits-all
approach and encouraging family awareness and
participation in the development of interventions.
With substance abuse, the therapist does a func-
tional assessment with the child and family looking
at (a) systemic triggers for the substance use, (b)
positive and negative effects of using, and (c) after-
effects of use. Research indicates common triggers
for youths include parents who use, family conflict,
The Bibb County mental health court has been enor-
mously successful; the number of graduates has
doubled at each graduation. Graduates have only
a 1 percent rate of rearrest. Program success can
be attributed to visionary leadership and consis-
tent, strong collaboration between law enforcement,
health professionals, and other supportive services.
With more than 30 percent of the population in-
carcerated in the Bibb County jail currently entering
the facility with a diagnosable mental illness, the
need for services is huge. Funding for medication,
psychiatric time, and additional supportive services
— especially case management and transitional
housing with watchful oversight — has been the lim-
iting factor in mental health court expansion. It is
projected that with the addition of these services,
hundreds more could be served and recidivism cut
by an additional 20 percent.
Of youth in the multisytemic
therapy program, 93 percent
were in school or working
and 70 percent showed
success in an educational
or vocational setting.
low monitoring, ineffective discipline, peers who
use, lack of prosocial activities, truancy, pleasure or
escape, boredom, low social support, and perceived
benefits of using. With this information, staff work
to help the family reduce these triggers, increase
positive coping skills, and involve youths in proso-
cial activities in which exposure to substance-using
peers decreases.
The June 2007–June 30, 2008, Mentally Ill Offender
Crime Reduction Outcome Report reflected River
Oak client outcomes as follows:
>> 6.6 times fewer petitions filed for new law viola-
tions (111 days for historical group vs. 18 days).
>> 6.9 times fewer sustained new law violations (62
historical vs. 9).
>> 6.5 times fewer commits to juvenile hall, ranch, or
camp (13 historical vs. 2).
>> Fewer days detained in a juvenile hall, ranch, or
camp (323 historical vs. 23).
>> Three out-of-home placements (vs. 8 historical).
>> One admission to an acute psychiatric hospital
(vs. 18 people in the historical group with a total
of 24 admissions).
>> More minors attending school and more days
attended (5 of 71).
>> No petitions filed or sustained for status offenses
Seacoast’s Community Wellness Court Rehabilitates Persons
with Serious Mental Illness
Rob Levey, MA, Development and Communications, Seacoast Mental Health Center, Portsmouth, NH / rlevey@smhc-nh.org
L aunched in May 2008, Seacoast Mental Health
Center’s Community Wellness Court in Portsmouth,
New Hampshire, seeks to rehabilitate people charged
with crimes who have severe and persistent mental
illness.
The result of a year-long coordinated planning pro-
cess, the program, which recently graduated its first
class, involves SMHC, local police departments, the
county jail, prosecutors, public defenders, and the
court system.
According to the director of SMHC’s Community Sup-
port Program, Gretchen Estes, the collaborative na-
ture of the CWC has been critical to its initial success.
“A lot of cross-education has taken place,” says Estes.
“It was important [that] we shared our knowledge —
they have learned a great deal about how we operate
and we have learned how the legal system works. It’s
improved the program.”
Portsmouth District Judge Sawako Gardner agrees
and says the program originated from their initial
effort to deal with crimes perpetrated by the city’s
homeless population. “We realized pretty quickly the
(vs. 14 filed and 0 sustained historical).
>> 6.1 times fewer people made WIC 602 wards of
the juvenile court (43 historical vs. 7).
MST outcome data for the same period showed the
following:
>> 73 percent completed treatment.
>> 88 percent showed parenting skills necessary to
handle future problems.
>> 84 percent showed improved family relations.
>> 80 percent showed improved social support
networks.
>> 93 percent were in school or working.
>> 70 percent showed success in an educational
or vocational setting.
>> 48 percent of youths were involved in prosocial
activity.
The recidivism rate for program participants is below 15 percent,
and the program has reduced crime on an individual basis and
improved overall community safety.
problem was also combined with mental illness so the
idea started from there,” says Judge Gardner, who also
cited the efforts of Al Wright, superintendent of the
Rockingham County House of Corrections, and Mike
Magnant, retired Portsmouth police chief, as crucial
to CWC’s development. “Without that sort of collab-
orative effort, we wouldn’t be in existence,” Judge
Gardner added.
Offering case management, psychiatric, and therapeu-
tic services in addition to vocational and educational
supports, the CWC program is based on evidence-
based practices found in illness management and
recovery and supported employment principles.
SMHC’s Debra Braun, team leader for the Intensive
Treatment Team within CSP, supervises the program
and says its objective is to help participants, more
than half of whom have co-occurring substance abuse
issues, acquire tangible skills they may use to sta-
During the time River Oak has been using MST, we’ve
learned that:
>> With quality supervision, there is high
motivation and competence and prevention of
burnout among quality staff.
>> With quality staff that fit a systemic approach,
there are quality outcomes for families.
>> With quality outcomes for families, there is
support for the program.
>> With support for the program, there is funding.
>> With funding and quality outcomes, there are
fewer clients that fill up our juvenile halls,
ranches, and group homes.
>> With fewer clients in facilities, there is more
money to fund quality programs.
bilize themselves. Responding to critics who suggest
the alternative-sentencing program provides repeat
offenders with a free pass, Braun says that CWC re-
quires each participant to sign a 1-year contract and
actively develop his or her own treatment plan. “It’s a
lot of work,” states Braun, who says participants meet
with their therapist and case manager at least once a
week in addition to seeing a psychiatrist, nurses, and
other appropriate personnel as necessary.
Judge Gardner adds that she and the city’s public
prosecutors and defenders also meet with program
participants on a monthly basis to better understand
their goals, circumstances, and any stressors in their
lives. “The court has to be invested in the process and
needs to connect with each participant,” she says.
Judge Gardner also notes that the program has sig-
nificantly improved the eligibility criteria needed to
enter CWC.
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 51
 From The Field
“You have to be careful who you choose to be in
the program,” said Judge Gardner, who points out
that participants’ diagnosed mental illnesses must
be deemed substantially responsible for causing
the crimes.
“It can’t just be that the person has committed a
crime and they happen to have a mental illness,”
she adds. “That wasn’t on our radar in the beginning
of the program, but it is now.”
As for program outcomes, the recidivism rate for
program participants is below 15 percent, and
Spanish Peaks Offers the Alternative to Incarceration — Treatment
Lisa Rea, MA, LPC, Special Services Program Director, Spanish Peaks Mental Health Center, Pueblo, CO / LisaR@spmhc.org
B eginning in July 2008, Spanish Peaks Mental
Health Center in Pueblo, Colorado, received
funding through Senate Bill 097 to create a multi-
disciplinary community collaboration and to imple-
ment programming to provide mental health and
co-occurring substance abuse treatment to adult
and juvenile offenders in the community. The center
specifically enrolls people who would not otherwise
have the means to access services. Its first goal was
to develop a community collaboration that included
leadership from SPMHC, the court, law enforcement,
and other criminal justice agencies. We wanted to
hear from everyone about how offenders with men-
tal illness affect their agencies and how we might
work together to divert these offenders into effective
treatment rather than incarceration.
The Treatment Alternatives Collaboration Program
was created in October 2008. In partnership with
seven of the area’s law enforcement and judicial
and criminal justice agencies, we worked to develop
our goals, objectives, and outcome measures and
to create a Memorandum of Understanding. The TAC
Program Treatment Team began accepting referrals
in October 2008 and is made up of three full-time
staff — a mental health clinician, a substance abuse
treatment specialist, and a case manager. We re-
ceived more than 225 referrals during fiscal year
2008–2009. The TAC Program is able to serve up to
50 people. We offer outpatient individual and group
mental health and co-occurring substance abuse
treatment.
52 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
Judge Gardner anecdotally notes that she believes
CWC has reduced crime on an individual basis and
has improved overall community safety.
According to Portsmouth Prosecutor Karl Durand,
participants have also been able to take away an
immense amount of pride in themselves. “The court
provides incentives for people to address their men-
tal health problems that have caused them to react
criminally,” he says. “Without this court, they would
not have that opportunity. We need to provide in-
centives for them to get therapy and be medication
compliant.”
The evidence-based practices that are available
to all TAC Program clients, depending on their indi-
vidual treatment needs, include Moral Reconation
Therapy, Integrated Dual-Disorder Treatment /co-
occurring treatment, Dialectical Behavior Therapy,
and Assertive Community Treatment. SPMHC also
provides comprehensive case management ser-
vices that include referrals and linkage to housing
resources, prescription assistance, employment and
educational resources, and referrals to agencies to
apply for any benefits for which clients may qualify.
Once the treatment team and the programming
were in place, our next goal was to identify and in-
tercept offenders with mental illness and increase
their access to community treatment. We used the
sequential intercept model as a guide in developing
our programs and protocols. Initially, it was difficult
to decide at which point(s) in the criminal justice
process we should try to identify and intercept of-
fenders. To really understand our community needs,
we elected to accept referrals from all points in the
criminal justice system — from initial contact with
law enforcement, to diversion in lieu of prosecution,
to diversion at sentencing, to people re-entering
the community from the jail or Department of Cor-
rections. Though ambitious, this has allowed us to
really tailor our interventions to our communities’
specific needs.
Although the TAC Program has only been in existence
for about 18 months, we are already seeing encour-
CWC has also proved to be sustainable; as Estes
says, it “works within established models already
in place,” although she notes it could benefit from
expansion, which would require additional outside
funding sources.
However, Judge Gardner says she believes the
maximum capacity CWC can handle at one time is
between 15 and 20 people and cautions against
allowing the program to get too big. “We need to
connect with participants individually,” she adds. “If
the program was any bigger, I don’t think we could
do that.”
Between April 1, 2009, and
December 1, 2009, the TAC
Program accepted nine clients with
combined sentences of 22.5 years —
the potential cost savings associated
with this is $582,480.
aging outcomes, both clinically and with decreased
recidivism — we define recidivism as any return to
jail or DOC as a result of a new charge or conviction
or revocation of probation or parole. We are also
tracking potential cost savings because clients are
sentenced to the TAC Program in lieu of sentenc-
ing to Colorado DOC. These clients come to the TAC
Program with suspended sentences.
Between July 1, 2008, and June 30, 2009, the TAC
Program served a total of 66 adult clients. In the
12 months preceding their enrollment in the TAC
Program, these clients served a combined total of
5,191 jail or DOC days. During their admission to
the TAC Program, they served a combined total of
only 897 days, a decrease of 4,294 days. This trans-
lates into a cost savings of $38,874 for the Pueblo
County Jail and a savings of more than $300,000
for DOC. Additionally, between April 1, 2009, and
December 1, 2009, the TAC Program accepted nine
clients with combined suspended DOC sentences of
22.5 years. The potential cost savings associated
with this is $582,480.
In Wayne County, Jail and Community-based Services Work in Tandem
Julie Hanna, MSW, Research Assistant, WSU Project CARE, Detroit, MI / jhann@med.wayne.edu
T o address the issue of co-occurring substance use
and mental health disorders in jails, staff from the
Wayne County Jail, Detroit-Wayne County Community
Mental Health Agency, Detroit Recovery Project, and
Wayne State University Project CARE collaborated to
form the Co-Occurring Peer Empowerment program. In
2006, WSU staff began facilitating meetings and dis-
cussions among involved parties, researching existing
models, writing the proposal to obtain block grant
funding for the program, and obtaining Institutional
Review Board approval from the university and from
the jail. On the basis of research on existing models,
the COPE Program was developed with three compo-
nents: the APIC (Assess, Plan, Identify, Coordinate)
model, Dual Recovery Anonymous, and peer support.
COPE was implemented in September 2007 to en-
hance existing jail-based services, with the mission of
“Providing jail and community-based relapse and re-
covery services for inmates with co-occurring disorders
at the Wayne County Jail” and the goal of “Reducing
relapse and the associated behaviors that contribute
to the increase in mental health services, substance
abuse, and the involvement in criminal activity that
lead to recidivism and increased cost.”
COPE provides a range of jail-based and community-
based services. Initially, DRA groups were established
twice a week inside the jail. In 2009, two groups a
week were added at a second facility. Peer support
specialists facilitate groups. The case manager does
intake interviews with new participants, collecting in-
formation for their case files and for program evalua-
tion. In the community-based component, COPE offers
re-entry assistance, DRA groups, participation in peer
activities, case management, and peer mentoring.
WSU staff reviewed participants’ records on a quar-
terly basis to collect relevant information and enter
it into an electronic database. Data were triangulated
with data provided by the jail and data from the coun-
ty’s community mental health database.
In the program’s first 2 years, 218 people participated
in the jail-based DRA groups. The average age was 38
years. Fifty-nine percent were African American, and
32 percent were White. Sixty-four percent reported
being unemployed, and 32 percent reported being
homeless at the time of arrest. Of all participants, 117
were released from jail. Nineteen of those released
subsequently followed up with the COPE program in
of time for community follow-up at this point.
In light of all we have learned, we encourage cre-
ative and assertive methods to ensure higher rates
the community. Those who continued in the COPE of participation in the community, such as providing
program after release, as opposed to those who did transportation on release from jail and engaging in
not continue, tended to be African American, older, un- assertive community outreach.
employed, and homeless, which has implications for
program staff in terms of understanding and engaging
the target population and tailoring services to their
People who followed up with
particular needs.
In comparing the 19 who followed up with COPE with
COPE were more likely to get
the 94 who didn’t, we looked at outcomes related to into community mental health
community mental health appointments, inpatient
psychiatric hospitalizations, and recidivism. The hy-
services sooner and remain in
pothesis was that ongoing contact with COPE would in- the community for a longer period
crease the likelihood of people making and keeping a
of time before being hospitalized
community mental health appointment and decrease
the incidence of psychiatric hospitalization and recid- or reincarcerated.
ivism. People who followed up with COPE were more
likely to have a postrelease community mental health
services claim (90 percent vs. 50 percent), get into
community mental health services sooner (42 days
vs. 74 days from release to first appointment), remain
in the community for a longer period of time before
being hospitalized (221 days vs. 89 days from release
to hospitalization), and remain in the community for a
longer period before being reincarcerated (247 days
vs. 134 days from release to incarceration).
COPE participants reported that they liked the
jail DRA groups because of the educational as-
pect, the facilitation by peer support special-
ists, and the linkages to the community after
release. Interest in the jail-based DRA groups
was surprisingly high, but the rates of community
follow-up were not as high as we had anticipated.
We discovered that this was in part because of
logistics. First, only 54 percent of participants were
actually released. Second, the facilities differ in that
one mainly houses people awaiting sentencing, and
the other houses people who have already been sen-
tenced. Following up with the latter was easier be-
cause they were more likely to know their release date
and less likely to be transported to another facility
outside of the county; however, groups did not begin
at that facility until 2009, thereby limiting the amount
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 53
 Beyond Bars
Double Tragedies: Speaking Out Against the
Death Penalty for People with Mental Illness
Ron Honberg, JD, Director of Policy and Legal Affairs, National Alliance on Mental Illness
Reprinted with permission from the Fall 2009 issue of The NAMI Advocate.
I n 1999, Manny Babbitt, a decorated Vietnam vet-
eran diagnosed with schizophrenia and posttrau-
matic stress disorder, was executed at San Quentin
Prison in California after having been convicted of
murder. Manny’s brother Bill, who turned Manny in
to the authorities after being promised that the state
would not pursue the death penalty, has become a
staunch advocate against the death penalty.
In 1998, Linda Gregory’s husband, Gene, was shot
and killed while responding to a call to assist a man
with paranoid schizophrenia who had barricaded
himself in his residence with an arsenal of weapons.
Since then, Linda has become a leading advocate
for better mental health services in Florida.
These extraordinary individuals joined many others
in San Antonio in October 2008 to begin an unprec-
edented conversation about whether persons with
severe mental illnesses should be exempt from
capital punishment. The participating families dis-
covered that they had much in common. Whether
families of homicide victims or families of people
who had been executed, they all shared common
frustrations about problems in the mental health
system and common beliefs that executing indi-
viduals with severe mental illness only compounded
tragedies. These executions serve no useful purpose
in deterring crimes.
The meeting in San Antonio was organized by Mur-
der Victims’ Families for Human Rights (MVFHR), an
international organization of relatives of homicide
victims and relatives of people who have been ex-
ecuted, all of whom oppose the death penalty. NAMI
has long opposed the execution of people with se-
vere mental illness. Recognizing a commonality of
interests, MVFHR Executive Director Renny Cushing
conceived the idea for this project and approached
NAMI about becoming a partner. “Family opposition
to the death penalty is grounded in personal trag-
edy,” said Cushing. “In the public debate about the
death penalty and how to respond in the aftermath
54 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
of violent crime, these are the voices that need to
be heard.”
MVFHR and NAMI have released a report giving
voice to the shared concerns of the participants in
the San Antonio meeting. Entitled Double Tragedies:
Victims Speak Out against the Death Penalty for
People with Severe Mental Illness, the report calls
the death penalty “inappropriate and unwarranted”
for people with severe mental illnesses and “a dis-
traction from problems within the mental health
system that contributed or even directly led to
tragic violence.”
The report is based on extensive interviews with 21
family members from 10 states: California, Florida,
Georgia, Illinois, Louisiana, Maine, Massachusetts,
North Carolina, Tennessee, and Texas. The families
represented in these interviews fall into one of two
categories: families of victims of homicides at the
hands of a person with a severe mental illness and
families of persons with severe mental illness who
have been convicted of homicides and executed. In
certain cases, the person who committed the homi-
cide and the victim of the homicide were related.
Most state laws list “mental disease and defects”
or some variant of this term as a factor that should
mitigate against the death penalty. However, studies
suggest that defendants with severe mental illness
are more likely to be sentenced to death than those
without mental illness convicted of similar crimes.
At least 100 people with mental illness have been
executed in the United States, and hundreds more
are currently on death row awaiting execution.
In 2002, the U.S. Supreme Court ruled that the ex-
ecution of individuals with intellectual disabilities
(mental retardation) is unconstitutional and in
2005, the Court further ruled that it is unconstitu-
tional to execute people whose crimes were com-
mitted when they were juveniles. The court’s rulings
in both cases were based on its concern that factors
such as impaired judgment, understanding, and im-
How can a modern, civilized
society choose to exterminate its
mentally ill citizens rather than treat
them? I’ve been waiting 25 years…
for people to come together and
say that the death penalty is not the
answer to the problem of untreated
mental illness in our country.
Lois Robinson
pulse control reduce the level of culpability in cases
involving defendants with intellectual disabilities
or juveniles and, therefore, do not justify the most
extreme penalty of death. These factors frequently
apply as well in capital cases involving severe men-
tal illness — raising serious questions about whether
the death penalty should be similarly banned for
defendants with these illnesses.
The Double Tragedies report describes horrendously
violent acts but notes that supportive services are
the best way to avoid risks. “Most people with men-
tal illness are not violent,” said NAMI Executive Di-
rector Michael Fitzpatrick. “When violent tragedies
occur they are exceptional, because something has
gone terribly wrong, usually in the mental health-
care system. Tragedies are compounded and all our
families suffer.”
The report makes four basic recommendations:
1. The death penalty for persons with severe men-
tal illness should be banned.
Currently, legislation is pending in at least four states
to limit or eliminate the execution of people with
severe mental illnesses. However, only Connecticut
has a law on the books limiting capital punishment
for individuals with “significantly impaired mental
capacity” and that law is seldom used.
continued on page 55
 Beyond Bars
Reinstating Medicaid Benefits:
Life in the Community after Incarceration
Alex Blandford, Project Coordinator, Institute for Evaluation Health Science in Community Health, Graduate School of Public Health,
University of Pittsburgh
I t is vital that the significant number of justice-
involved persons with mental illness have con-
sistent access to healthcare and other supports
— both while they are incarcerated and upon re-
lease. Given that many people with mental illness
rely on Medicaid to access services and that those
who are incarcerated likely had their mental illness
before incarceration; it follows that they must rely
on Medicaid to cover services upon their release.
Yet, many offenders with mental illness automati-
cally lose their health and social supports because
of state policies that terminate rather than suspend
benefits on incarceration. A central issue is conflict-
ing guidelines across different levels of government
and agencies that render the system complex and
difficult to navigate. Although federal law prohibits
state Medicaid agencies from using federal funds
to pay for services while a person is incarcerated,
it does not delineate how states should implement
this requirement. Termination of Medicaid eligibility
is not required, and states have the option of sus-
pending eligibility while people are incarcerated.
States face a series of barriers that challenge their
ability to suspend and reinstate Medicaid eligibility.
Suspension or reinstatement of Medicaid require
coordination across multiple systems and agencies
but in many states, data systems cannot commu-
nicate. Other states face restrictions that limit the
degree to which information can be shared between
jail and prison systems and community agencies.
Many states terminate rather than suspend eligibil-
ity to ensure that claims are not inadvertently filed
for people while they are incarcerated.
Another barrier is that the Social Security Adminis-
tration provides financial incentives (up to $400 per
case) for reporting incarcerated people in receipt
of federal benefit payments so that Supplemental
Security Income and Social Security Disability In-
surance benefits can be suspended or terminated.
No incentive is provided to notify SSA when such
people are released so that benefit eligibility can
56 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
be reinstated. This program can be detrimental to
inmates with mental illness because Medicaid ben-
efits are tied to SSI and SSDI.
However, several strategies are being used by states
and localities to facilitate access to federal benefits
for inmates with mental illness and substance use
disorders. Two strategies in particular — legislation
for suspension of eligibility and prerelease plan-
ning as part of re-entry programs — have recently
received attention.
Medicaid Suspension Legislation
Legislation could be introduced at the federal level
to require that states suspend Medicaid eligibil-
ity upon incarceration and reinstate on release to
ensure continuity of care. Released inmates would
then be able to go directly to a Medicaid provider,
demonstrate eligibility, and receive services without
interrupting access to medications and other treat-
ment. Suspension of eligibility is the most desirable
approach because it does not require that a new
application be filed, and benefits can be restored
with minimal delay. In the absence of federal legis-
lation, state Medicaid policy could allow incarcer-
ated people — where applicable by federal law — to
maintain Medicaid eligibility.
The most significant recent development at the
federal level was the introduction of H.R. 2829, the
Recidivism Reduction Act, in June 2009. The bill was
subsequently referred to the House Ways and Means
and Energy and Commerce Committees but has not
been reported on to date. The bill proposes amend-
ments to the Social Security Act
>> Requiring the reinstatement of SSI benefits after
application, during or following incarceration,
and the provision of benefits in the interim, ef-
fective the day of release.
>> Requiring the reinstatement of Medicaid benefits
on release for those with eligibility before incar-
ceration unless there is a determination that the
Many offenders with mental
illness automatically lose
their health and social
supports because of state
policies that terminate rather
than suspend benefits on in-
carceration. A central issue is
conflicting guidelines across
different levels of government
and agencies that render the
system complex and difficult
to navigate.
person is no longer eligible to be so enrolled.
>> Offering financial assistance for states imple-
menting Medicaid suspension systems.
>> Offering case management services to engage in
planning for services after a person’s release.
>> Requiring that to receive the incentive payments
from the SSA described earlier, jails and prisons
must participate in a prerelease agreement with
the SSA.
Another example of federal legislative action is the
inclusion of section 1729 in H.R. 3962, the Afford-
able Health Care for America Act, which requires
states to suspend, rather than terminate, Medic-
aid eligibility for incarcerated people age 18 and
younger.
With regard to state activity, several states have
passed legislation to bridge the gap between fed-
eral and state funding. States with policies and laws
for the suspension of Medicaid include Colorado,
Florida, Indiana, Ohio, Maryland, Maine, Michigan,
North Carolina, New York, and Oregon. The example
of New York State highlights what states can do to
address the barriers they face. New York was one of
the first states to pass legislation requiring that Med-
icaid eligibility for inmates be suspended (April 2008)
and that the effort be a shared responsibility be-
tween state and local departments of social services.
Although the law clearly requires the suspension of
eligibility, the reinstatement process is less explicit
and requires clarification. For people to have their
benefits reinstated on release, the state must be able
to check whose Medicaid eligibility was suspended
against who is released from jail. Although state law
requires coordination between the Department of
Corrections and the Office of Temporary and Disability
Assistance to identify offenders who need Medicaid
suspended on entering correctional facilities, many
states, including New York, do not require that correc-
tional facilities report an inmate’s release to the state,
thus rendering information about incarcerated people
incomplete and hindering reinstatement of Medicaid
coverage. Many state agencies issue a memorandum
of understanding that specifies requirements and re-
sponsibilities for information exchange between the
two entities. This approach, however, is largely rela-
tionship based and can be problematic.
Prerelease Planning for Re-entry
For inmates whose benefits were terminated or who
were not previously enrolled, a desirable option is to
continued from page 52
2. Mental health systems need to be reformed to
more effectively provide treatment and supportive
services to individuals with severe mental illnesses
before they reach the point of crisis.
NAMI’s Grading the States 2009 report contains a
number of recommendations for improving mental
health systems and services, including strategies
for responding effectively to individuals with severe
mental illness who are most at risk and have difficulty
adhering to treatment regimens.
3. Recognize the needs of families of murder victims
through rights to information and participation in
criminal and mental health proceedings.
4. Recognize that families of individuals who are
executed are victims themselves and provide as-
sistance to these families due to any victims of
traumatic loss.
ensure that an application for Medicaid, SSI, and oth-
er benefits is submitted well in advance of release (at
least 1–3 months) so that assistance is available upon
release. A variety of federal, state, and local funds and
grants support enrollment in public programs as part
of the discharge planning process. Prerelease plan-
ning varies by the length of incarceration, the size of
the correctional facility, and the resources available.
Planning programs can include ensuring that the in-
mate has identification cards (for Medicaid), a supply
of medications, and community resource supports
(food stamps, cash assistance, and housing) upon
release. Collocating relevant specialized staff (trained
social workers) or local SSA staff at the institution to
facilitate the process is advisable.
In Allegheny County, Pennsylvania, comprehensive
re-entry planning (including providing access to
benefits) is provided in jail as part of the Allegheny
County Jail Collaborative, a joint effort of the Allegh-
eny County Jail, the Allegheny County Department of
Human Services, and the Allegheny County Health
Department. As part of transition planning, intensive
case management is offered during incarceration and
after release to construct a service plan to coordinate
services and apply for assistance while the offender is
still in jail. Case managers help people connect with
existing supports (e.g., family support) and in devel-
Lois and Ken Robison of Texas became activists
against the death penalty after their son Larry — diag-
nosed with paranoid schizophrenia — was executed
in 2000. The Robisons struggled for years to get help
for their son prior to the crimes that led to his execu-
tion. At the meeting in San Antonio, Lois posed the
question “How can a modern, civilized society choose
to exterminate its mentally ill citizens rather than
treat them? I’ve been waiting 25 years…for people
to come together and say that the death penalty is
not the answer to the problem of untreated mental
illness in our country.”
NAMI hopes The Double Tragedies report is the start
of this process.
Ron Honberg oversees NAMI’s federal advocacy agenda and the
NAMI Law and Criminal Justice Action Center. In recent years,
he has worked on issues affecting people with mental illnesses
oping other supports in the community through peer,
provider, and other community organizations.
The fact that suspension of Medicaid benefits for the
incarcerated has garnered more attention on the lo-
cal and state levels, and more recently on the federal
level, is encouraging but much remains to be done.
In the absence of enacted federal legislation, states
should adopt legislation to suspend, rather than ter-
minate, the Medicaid benefits of eligible people dur-
ing incarceration. They should also seek or continue
to seek funding to create and sustain re-entry initia-
tives. This issue is extremely complex, and federal
benefit enrollment is only one part of the solution.
However, people should not leave jail or prison with-
out immediate access to vital care and support in the
community, which can be achieved in part by access
to Medicaid.
Alex M. Blandford is Project Coordinator for the Institute for
Evaluation Health Science in Community Health, housed in the
Graduate School of Public Health at the University of Pittsburgh,
Pennsylvania. Her areas of research interest include integrated
care and criminal justice issues for justice involved individuals
with mental illness, particularly the effective provision of care
and services across fragmented systems using collaborative ap-
proaches. Blandford received a masters in Public Health from the
University of Pittsburgh and BA in psychology from Pennsylvania
State University. She is a former National Council Public Policy
intern.
Most people with mental
illness are not violent. When
violent tragedies occur they
are exceptional, because
something has gone terribly
wrong, usually in the mental
healthcare system.
Michael Fitzpatrick
involved with criminal justice systems, and more. Before joining
NAMI in 1988, Honberg worked as a Vocational Rehabilitation
Counselor for the State of Maryland and in a variety of direct ser-
vice positions in the mental illness and developmental disabilities
fields. Honberg has a Juris Doctor degree from the University of
Maryland School of Law and master’s degree in education from
the University of Maryland.
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 57
 Beyond Bars
Incarceration and Homelessness:
Breaking the Tragic and Costly Cycle
Andy McMahon, Associate Director for Innovations and Research, Corporation for Supportive Housing
L avelle Conner, 46, estimates he’s been arrested
150 times. While struggling with schizophrenia,
depression, and drug addiction during his 12 years
of homelessness, he slept in abandoned buildings
and ate out of garbage cans. With little, if any, sup-
port from the community, Lavelle faced one dead
end after another. “The drugs helped my pain, so
I kept taking things that weren’t mine, to support
my habit.”
Lavelle’s story is not unusual. Every year, U.S. pris-
ons and jails release almost 10 million people.
Like Lavelle, many return to impoverished neighbor-
hoods and are trapped in a cycle of homelessness,
incarceration, and health and mental health crises.
More often than not, these people find themselves
right back in prison or jail for parole violations and
quality-of-life crimes. Taxpayer dollars are wasted as
the cycle continues and people’s lives spiral of out
control.
In addition to the mind-boggling costs in terms of
lost human potential, productivity, child and fam-
ily stability, and public safety, states and cities
are spending billions as a result of failed policies.
Among the 20,000 parolees with mental illness
exiting California prisons each year, about 3,500
become homeless. Ninety-four percent of those who
are homeless return to prison within 24 months. This
alarming recidivism rate results in an equally shock-
ing expense to the state — the average annual cost
of housing an inmate with mental illness in Califor-
nia is $110,000. Keeping someone incarcerated in
a Chicago jail or at New York’s Rikers Island is simi-
larly expensive and averages more than $47,000 a
year, without considering the added costs of mental
health treatment. The nation’s jails and prisons are
58 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
now de facto mental health institutions — and the
Los Angeles County Jail; Cook County, Illinois, Jail;
and Rikers Island in New York are this country’s
three largest such facilities.
Of all the issues facing parolees re-entering com-
munities, studies suggest that none is more imme-
diate than the need to find a place to live. Without
stable housing, returning to jail or prison is almost
a given in a system in which people find themselves
arrested again and again for violations related to
homelessness, untreated mental illnesses, and ad-
diction.
An Opportunity to Succeed
With the right help, Lavelle was able to turn his
life around. He became a permanent supportive
housing tenant through Thresholds, a Chicago-area
nonprofit. Since obtaining housing, counseling, and
other support services, he has been living success-
fully in the community for almost 4 years. Lavelle
no longer abuses drugs and has remained out of
trouble. He has served as president of the tenant
council and as a consumer advocate for a Thresh-
olds’ jail diversion program, working with judges and
the district attorney. Of his new life, Lavelle says, “I
have three children and six grandchildren. Before
Thresholds, years and years passed before I could
see them — at one point I couldn’t even knock at my
family’s door. Now that they’ve opened up their door
to me, I learned how to be a grandfather.”
Supportive Housing Works
Supportive housing — permanent, affordable hous-
ing linked with services that meet the needs of
individuals and families — has emerged as a real
solution that works. Services are tailored and coordi-
nated and provide health, mental health, substance
use, vocational services and benefits advocacy, and
other supports necessary to help people stabilize
their lives. Successful programs often begin to en-
gage participants and provide services while they
are still incarcerated.
The Corporation for Supportive Housing’s Return-
ing Home Initiative, funded primarily by the Robert
Wood Johnson Foundation and the Open Society
Institute, aims to end the cycle of incarceration
and homelessness. The initiative focuses on engag-
ing criminal justice systems and integrating the ef-
forts of housing, behavioral health, corrections, and
other agencies to better serve people with a history
of homelessness and incarceration by placing them
into supportive housing. Returning Home has ad-
vanced efforts in nearly a dozen jurisdictions across
the country, all focused on reducing the number of
people with histories of homelessness, behavioral
health issues, and incarceration who are inappro-
priately languishing in U.S. jails and prisons.
Jurisdictions Leading the Way
Nationwide, more and more cities, counties, and
states are investing in supportive housing for people
re-entering their communities from jails and pris-
ons. Highlighted next are examples of real work on
the ground that is proving successful in ending the
cycle of homelessness and incarceration for people
with serious behavioral and other health issues.
Frequent Users Service Enhancement Initiative
— New York City
The New York City Department of Correction, Home-
less Services, and CSH, with assistance from the
Human Resources Administration, the Department
of Health and Mental Hygiene, Housing Preserva-
tion and Development, and the New York City Hous-
ing Authority are implementing the FUSE Initiative.
This groundbreaking initiative has placed more than
150 people with long histories of incarceration and
homelessness into permanent supportive housing —
breaking their institutional circuit among jail, shelter,
emergency health, and other public systems.
As the program’s name implies, it is targeted to fre-
quent users of public services. Eligible participants
are identified through an administrative data match
between the Department of Corrections and New York
City Homeless Services, and recruitment and enroll-
ment often begin while people are still incarcerated.
Participants are provided with an initial, intensive
burst of services as outreach is done, housing is se-
cured, and they begin to stabilize in the community.
FUSE is funded with a blend of federal, state, local,
and private philanthropic resources. Housing for the
program is funded using a combination of Section
8 rental subsidies from the NYCHA and funds from
New York City departments, including the DOHMH
and DHS. NYCHA granted a criminal justice waiver for
sponsor-based vouchers that are linked with stabiliza-
tion and support services that promote public safety
and tenant success. Funds for service enhancements
have been provided by the New York DOC and DHS,
CSH, and the Justice, Equality, Human Dignity, and
Tolerance Foundation.
The first round of FUSE has been extremely success-
ful in helping people maintain housing and avoid
returning to homelessness. An evaluation conducted
by John Jay College, of the first year after placement,
demonstrates
>> 91 percent housing retention.
>> 53 percent reduction of jail days used.
New York’s FUSE program, which places people with
a history of incarceration in permanent supportive
housing, has resulted in 91 percent housing retention,
53 percent reduction of jail days used, and 92 percent
reduction of shelter days used.
FUSE participants showed significantly increased
resilience and extended time in the community,
yielding cost offsets of $2,953 per person per year.
health, and other agencies to more effectively and amounts of public resources with little or no ben-
efficiently transition people back into the community efit. This cycle wastes money and lives, but solu-
from prison. tions exist. Efforts like the ones in New York, Ohio,
Priority placement within the program is given to and other communities across the country dem-
people identified as being most likely to require hous- onstrate that we can more efficiently invest our
scarce public resources and more effectively serve
ing linked to support services to maintain housing.
people with histories of homelessness and incar-
Through this pilot, ODRC and CSH are working with
ceration. Some lessons learned and strategies that
select nonprofit organizations to demonstrate how
are working are captured in a systems change re-
supportive housing can reduce an offender’s return to
port the Urban Institute recently completed for CSH
the criminal justice system and prevent homelessness.
(http://documents.csh.org/documents/policy/
Over the course of the pilot, ODRC is providing more
Reentry/UI-RHI-After3Yrs-Nov09.pdf).
than $3.8 million, which will be used for rental sub-
sidies, tenant assistance, case management, program In short, communities need to
evaluation, and project management. Providers use a >> Identify the scale and scope of this problem in
mix of scattered-site and single-site housing and also their own communities.
coordinate with community-based organizations for
>> Develop the interagency collaborations needed
additional behavioral health and other services.
among criminal justice, housing, behavioral health,
CSH, in collaboration with the Ohio Housing Finance and other agencies.
Agency, has also established a rental subsidy program
>> Create in-reach and outreach programs that are
to assist Returning Home tenants who may require
linked to a network of supportive housing providers.
rental subsidy for an indeterminate amount of time
beyond the pilot period. >> Direct housing and support services resources to
effectively serve this population, including rein-
The first of 92 participants was accepted into housing
in March 2007. As of March 2009, 51 people (55%) vestment of criminal justice funds.

>> 92 percent reduction of shelter days used.
When results are viewed next to those of a matched
comparison group, FUSE participants showed signifi-
cantly increased resilience, extended time in the com-
munity, and a reduced rate of cycling between DOC
and DHS, showing cost offsets to those systems of
$2,953 per person per year.
Returning Home — Ohio
The Ohio Department of Rehabilitation and Correc-
tions has invested in a supportive housing program
targeted to parolees at risk of homelessness. The
program links and integrates the efforts of the cor-
rections system with housing, mental and behavioral
were in housing, 20 (22%) had exited with posi-
tive outcomes, 11 (12%) had been terminated with
negative outcomes, and 5 (5%) had exited for other
reasons (e.g., death, to participate in a treatment
program, placement in a nursing home).
The Returning Home pilot includes an evaluation
component, which is being conducted by the Urban
Institute’s Justice Policy Center in Washington, DC.
An interim report can be viewed at www.urban.org/
publications/411869.html.
The Way Forward
Too many people like LaVelle languish in a cycle of
homelessness and incarceration, using immense
>> Support data-driven evaluation that documents the
costs and impacts on individuals and the community.
We can do better — and cities and states across the
country are proving it.
Andy McMahon leads Returning Home, the Corporation for
Supportive Housing’s national initiative focused on engaging cor-
rections and criminal justice systems to create supportive housing
and end the cycle of homelessness and incarceration that so
many people face. He also is responsible for providing strategic
direction for Returning Home in its three primary sites — Los
Angeles, New York City, and Chicago — and leads CSH’s national
efforts to increase investment in re-entry supportive housing and
change public policy to better integrate efforts among corrections,
human service, and housing agencies at all levels of government.
NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 59
 Beyond Bars
Mental Health First Aid USA
Equips Police Officers to
De-escalate Crises
G ateway Healthcare in Pawtucket, Rhode Island
was a pilot site for the rollout of Mental Health
First Aid USA training. As Gateway staff were trained
and certified to offer the 12-hour Mental Health
First Aid program to the public, local police depart-
ments in Rhode Island were seeking to broaden of-
ficers’ response options during incidents involving
citizens with serious mental illness. This fostered a
strong partnership that now has mental health pro-
fessionals and law enforcement officers speaking a
common language.
Police officers have become priority recipients of
Mental Health First Aid training in Rhode Island,
with eight training courses having been offered at
the state’s Municipal Police Academy since spring
2008. Representatives from both Gateway and the
law enforcement community say the effort has suc-
ceeded largely because the course offers much
practical information on mental illness and a police
lieutenant helps officers figure out how to apply this
new knowledge on their beat.
“Law enforcement is a pretty tight-knit group, and
bringing in an outsider to do this training alone
would be kind of tough,” says Carole Bernardo, a
certified Mental Health First Aid instructor at Gate-
60 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
Richard H. Leclerc, President, Gateway Healthcare
way who serves as training coordinator for the
community mental health organization’s LifeWatch
Employee Assistance Program. “I co-train with an of-
ficer, Lt. Joe Coffey of the Warwick police. I basically
present the mental health information, and Joe puts
it in their world.”
“Carole covers the signs and symptoms of mental
illness, and I interject examples of scenarios and
engagements that the officers might see,” says Cof-
fey. “Then I talk about the response side. We talk
about giving the officer discretion in what to do, and
offering ideas that are outside the box.”
Bernardo recalls that she was observing another
training at the Municipal Police Academy when she
informed the training coordinator, Captain David
Ricciarelli, that she was becoming certified as a
trainer for the innovative 12-hour Mental Health
First Aid course. They agreed to follow up later and
came up with plans for a jointly taught class that
has become one of the academy’s most popular of-
ferings.
“Officers certainly need to know about the signs and
symptoms and the definitions of what constitutes a
mental illness,” Coffey says. “As first line responders,
this is key for them.”
It has become clear to Bernardo from the first
course she facilitated at the academy that officers
prefer a practical learning approach that empha-
sizes examples of options for defusing potentially
harmful situations involving people with mental ill-
ness. Both Bernardo and Coffey emphasize that they
do not ask participating officers to change the way
they do their jobs; officers are simply acquiring new
tools with which to respond to potential crises.
Just as police departments have acquired new
methods for applying non-deadly force in danger-
ous situations, the knowledge acquired in Mental
Health First Aid training gives officers strategies for
trying to prevent a situation on the street from es-
calating, Coffey says. The training became available
to municipal departments shortly after a number of
highly publicized incidents in the state that ended
tragically with an officer’s use of deadly force on a
suspect with mental illness.
“The officers have seen these behaviors, and now
they can understand people with mental illness, and
they can respond without compromising safety,” he
continued on page 60
About Mental Health First Aid USA

Mental Health First Aid is the initial help given to a person showing symptoms of mental illness or in a
mental health crisis (severe depression, psychosis, panic attack, suicidal thoughts and behaviors…)
until appropriate professional or other help, including peer and family support, can be engaged.

Mental Health First Aid is delivered to members of
By the Numbers the public through an interactive 12-hour course,
which introduces participants to risk factors and
> 6,000+ warning signs of mental health problems, builds
Mental Health First Aiders trained understanding of their impact, and overviews
common treatments. Participants learn a 5-step
> 700 action plan encompassing the skills, resources
instructors certified
and knowledge to help an individual in crisis
connect with appropriate professional, peer,
> 1,000,000+ social, and self-help care. The course also pro-
media impressions
vides participants with an understanding of the
prevalence of various mental health disorders in
the U.S. and the need for reduced stigma in their
communities.
The 12-hour Mental Health First Aid course has
been offered to a variety of audiences and key
professions, including police/corrections staff/
first responders/security personnel; educators/
school administrators; human resources profes-
sionals; members of faith communities; homeless
shelters workers; nurses/physician assistants/
primary care workers; social workers; consumers
and family members; and caring citizens.
Mental Health First Aid was created in 2001 by
Professor Tony Jorm, a respected mental health
literacy professor, and Betty Kitchener, a nurse
specializing in health education, and is auspiced
at the University of Melbourne. Five published
studies in Australia show that the program saves
lives, expands knowledge of mental illnesses and
their treatments, increases the services provided,
and reduces overall stigma by improving mental
health literacy. In the USA, Mental Health First
Aid is coordinated by three national authorities
— the National Council for Community Behavioral
Healthcare, the Maryland State Department of
Mental Hygiene, and the Missouri Department of
Mental Health.
The national authorities certify instructors to im-
plement Mental Health First Aid in communities
throughout the United Sates. Each Mental Health
First Aid site develops individualized plans to
reach its community, but undergoes tight cre-
dentialing to guarantee fidelity to the original,
tested model.

To learn more and find a Mental Health First Aid course near you or to find out how you can
become a certified instructor, visit www.MentalHealthFirstAid.org or contact Susan Partain
at 202.684.3732 or SusanP@thenationalcouncil.org

NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 61

 Beyond Bars
continued from page 58
says. “We don’t try to minimize or alter the safety
factor in what we present.” Nor do they convey that
there will never be a situation in which use of force
will need to occur.
Mental Health First Aid training has also helped
officers overcome challenges in negotiating the
mental health system. They realize that just as they
experience frustration with the long waits they may
encounter when they take an individual to a hos-
pital emergency room, mental health professionals
also get frustrated in their efforts to get people the
help they need. This realization has forged greater
mutual respect between the mental health and law
enforcement communities.
“We’re trying to get everyone talking the same lan-
guage,” Bernardo says, adding that employees at all
sites at which a person with serious mental illness
might appear should possess the same basic knowl-
edge of mental illness.
With 25 officers participating in each Mental Health
First Aid course, the program has already reached
most of the state’s police departments. Bernardo
says officers’ evaluations of the training have
praised the team approach to instruction.
Although Coffey says a formal evaluation of the pro-
gram’s impact in terms of street response has not
yet taken place, he knows from anecdotal informa-
tion that officers are applying the skills creatively
and effectively. He cites a recent example from his
own police jurisdiction to support this.
Police in the city of Warwick reported to an apart-
ment building where a man with schizophrenia had
barricaded himself in his residence after having bro-
ken into a neighbor’s house. Coffey says the typical
response to such a call would have been a tactical
one triggered by the alleged breaking and entering.
But the neighbor’s knowledge of the individual’s ill-
ness, combined with the fact that a responding of-
ficer had taken the Mental Health First Aid course,
triggered an entirely different set of responses.
Coffey says the officers at the scene were able to
contact the man’s family members, who communi-
cated key information. Within an hour, police were
able to defuse the situation. Instead of transporting
the man to the police department cell block, where
trouble in calming him would likely have occurred,
62 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
Just as police departments have acquired new methods for
applying non-deadly force in dangerous situations, the knowledge
acquired in Mental Health First Aid training gives officers strategies
for trying to prevent a situation on the street from escalating.
The training became available to police officers in Rhode Island
shortly after a number of highly publicized incidents in the state
that ended tragically with an officer’s use of deadly force on a
suspect with mental illness.
he was sent directly to a hospital for evaluation. lates the auditory hallucinations that plague many
In what was perhaps the most surprising devel- people with a psychotic illness. When asked to com-
opment of all, Coffey says, the bail commissioner plete an exercise while listening to the simulator,
agreed to conduct necessary paperwork at the hos- the officers experience obvious frustration — and
pital so that the man could receive needed services begin to understand what a suspect with serious
with no delays. “That’s unheard of,” Coffey says. mental illness might face when trying to respond to
an officer’s commands.
This anecdote is one example of how greater men-
tal health awareness and reduction of stigma can “That is the single most persuasive method we
change a community’s mindset. “We kind of open have,” Coffey says.
their hearts a little bit,” Coffey says of the participat-
ing officers. Richard Leclerc is the President and CEO of Gateway Health-
care, overseeing all operations of over 700 employees within
Some participants are encouraged by their local the organization. He is on the Board of Directors of the National
chief to enroll in the course, but many volunteer to Council for Community Behavioral Healthcare and the Rhode
participate in what has become one of the acad- Island Council of Community Mental Health Organizations.
He chairs the Rhode Island Governor’s Council on Behavioral
emy’s most appreciated course offerings. “This is Health. Leclerc is a member of the Academy of Certified Social
absolutely working,” Coffey says. Workers and the Association of Mental Health Administrators
and also a Licensed Independent Clinical Social Worker.
Perhaps the biggest eye opener for all participating
officers is the course’s use of technology that simu-
Join the Gateway Healthcare team and the National Council for in-depth
workshops on Mental Health First Aid training and applications for law
enforcement and corrections communities at the National Council’s 40th
Annual Mental Health and Addictions Conference & Expo (March 15-17,
Disney World, FL), the National GAINS Center Conference (March 17-19,
2010, Disney World, FL), and the International Crisis Intervention Team
Conference 2010 (June 1-3, 2010, San Antonio, TX)
 Your Voice Matters

Join us in Washington, DC
National Council
6th Annual
HILL DAY
JUNE 29 – 30, 2010

In-person visits from constituents have more influence on Congress

than any other type of communication! Join hundreds of your colleagues
from around the country on visits to elected officials to advocate for policies
that protect and expand access to adequately funded, effective
MENTAL HEALTH and ADDICTIONS services.

Register, record Hill appointments, get briefing materials, and reserve

discounted hotel rooms at www.TheNationalCouncil.org/HillDay
Bring a team—board
Questions?
members, medical directors,
Email RebeccaF@thenationalcouncil.org or call 202.684.3735.
local law enforcement allies,
state legislators, county
commissioners, consumers,
and family members.
 Beyond Bars
E-learning for Corrections:
Viable Training Option in a Tough Economy
I n December 2008, the American Correctional As-
sociation surveyed state departments of correc-
tions and juvenile justice and asked them to identify
specific areas of operations designated for budget
cuts. The top three areas for adult agencies were
staffing, non–education-related offender programs,
and training. Juvenile justice agencies designated
similar areas.
These results are not surprising. Nearly every day,
the media announce more company layoffs, and
executives talk about cutting budgets to survive the
economic downturn. “Vulnerable sectors, notably
retail and the government are cutting back on train-
ing,” notes Susan Vardoe, president of Ninth House,
an e-learning company. She says, “One government
agency told me they are too busy buying gasoline
and bullets. It’s all they can afford to do.”
The financial struggle in most states and counties
means that correctional training departments are
confronted with the challenge of training staff at all
levels with fewer dollars. Corporations faced with
this same dilemma are able to scale back or drop
programs deemed a luxury or unprofitable. In cor-
rections, however, training is not a luxury — it’s a
necessity. Yet there is good news. Unlike their corpo-
rate counterparts who are often forced to deal with
the bottom line, correctional trainers have the op-
portunity not only to deliver training but also to de-
velop staff even during the worst economic times.
64 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1
The solution to the dilemma is to leverage technol-
ogy to an organization’s advantage. The most easily
available, cost-effective technology is e-learning or
online training. “E-learning offers many advantages
that are even more compelling in a tough economy,”
points out Stephen Flavin, executive director of Bab-
son Executive Education.
There are many benefits to e-learning:
>> Consistency: Even when trainers use the same
lesson plans, delivery of the training varies from
class to class simply because no two people are
alike. For instance, trainers have different deliv-
ery styles and may emphasize different sections
of the content. Similarly, they have varying levels
of experience that influence the training. Online
training, in contrast, provides the same training
to all staff — there are no obvious or subtle dif-
ferences. The state of Iowa launched an inter-
nally built online system in 2009. Terri Schuster,
Training Specialist II (or “e-trainer”), emphasizes
that online training ensures the agency is deliv-
ering “one clear, consistent message.”
>> Centralization: All documentation can be main-
tained in one location. Staff progress can be
monitored on a daily basis, and reports are read-
ily available to document completion of training.
>> Cost effectiveness: In many cases, online train-
ing costs less than traditional learning, and more
Diane Geiman, Manager, Online Corrections
Academy, American Correctional Association
staff can be trained for fewer dollars. The Florida
Department of Juvenile Justice offers nearly 200
department-specific courses online. Mike Mc-
Caffrey, director of staff development and train-
ing, says that online training is “definitely a cost
benefit during these economic times,” and it has
saved the department “a lot of money.” He pro-
vides a good example of the potential savings. If
25 staff are brought to Tallahassee, the central of-
fice location, for 1 week of training, the cost would
be approximately $25,000. Teaching the same
material online would cost considerably less.
>> Time effectiveness: Online training removes
geographical barriers because staff can take
the courses at various locations throughout an
area. It also solves the problem of trying to get
staff and trainers in one place at one time. As
Terri Schuster points out, online training allevi-
ates the problem of “having to find half a day
or several days to relieve staff for training.” In
addition, learning time is often reduced. Online
courses can be designed in shorter time blocks
or staff can work on longer courses in 1-hour or
longer time blocks.
Yet, the quality of the training material does not
need to be sacrificed. Well-designed online courses
can be as effective as classroom training and, at
times, more effective. Some researchers believe
that learning retention is higher for online training
than for traditional classroom training.
Sample E-learning Corrections Courses
A well-designed course is one that is created according to
strict standards. As Stephen Flavin reminds us, “Informa- Essential Learning has partnered with American Correctional Association and its On-
tion is not instruction.” An interactive course must engage line Corrections Academy to provide a full range of e-learning solutions to meet the
learners throughout and include proper testing or evalu- specific training needs of adult and juvenile correctional agencies. Courses are offered for
ation. Flavin cautions wisely that “effective e-learning is
pre-service and in-service training ; compliance with legislation, ACA accreditation,
not taking existing course material from a classroom, put-
professional licensing, and ACA re-certification; and agency-specific training.
ting it on the web and rolling it out and calling it a day.”
However, you can convert that valuable material to online The corrections library includes courses such as
courses. H Corrections and Mental Illness: H Sexual Abuse and Assault Intervention
ACA believes that online training is one part of an overall An Overview for Corrections Officers (PREA)
correctional training program. The association relies on its H Supervising Mentally Ill Offenders H Intoxication and Withdrawal for
many years of training and correctional experience when H Overview of Suicide Prevention for Corrections Officers
assisting correctional agencies and facilities in navigating Corrections Professionals H Grief and Loss in the Corrections Setting
the e-learning landscape. An agency’s needs, both learn-
H Crisis Management for Corrections H Understanding Addiction:
ing and monetary, are priorities throughout the process. Professionals An Overview for Corrections Professionals
ACA has partnered with Essential Learning, the largest H Disciplining Offenders: Enforcing Rules H Legal Issues and Women Offenders
e-learning provider in human services online training, and Regulations H Mental and Physical Health Issues for
to offer a vast library of courses tailored to corrections H Working with Incarcerated Persons: Older Inmates
professionals — including behavioral health courses ac- An Overview for Corrections Professionals H Overview of Substance Abuse for
credited by national organizations — through the Online
H Working with Incarcerated Persons: Corrections Officers
Corrections Academy. As a result, the OCA now offers more Best Practices in Treatment H Supervising Mentally Ill Offenders
than 70 corrections-specific courses to meet agency train-
H Disciplining Offenders: Report Writing H Security and Offender Management:
ing requirements and national standards. Topics include
supervision, management, leadership, ethics, medical and H Professional Ethics in Corrections Supervising Offenders in Programs and
H The Transition to Correctional Supervisor on Work Details
mental health, security, and special management offend-
ers (e.g., women and elderly people). New correctional H Ethical Behavior in Corrections: H Corrections and Mental Illness:
courses will be added on a regular basis, through the joint Best Practices An Overview for Corrections Officers
efforts of ACA and Essential Learning. H Fire Safety in Corrections H Security and Offender Management:
Preventing and Responding to Emergencies
Non-corrections-specific courses are also offered and H Security and Offender Management:
focus on topics such as workplace issues (e.g., commu- Escorting and Transporting Offenders H Women Offenders and the Correctional
Environment
nication and problem solving), Occupational Safety and H Supervising Offenders in Segregation Units
Health Administration compliance, and computer skills. All H Security and Offender Management:
H Overview of Suicide Prevention for Preventing Escapes
the academy’s courses may be used by certified correc-
Corrections Professionals
tions professionals for recertification. All ACA-developed H Understanding Mental Health Treatment
courses are approved by the Commission on Accreditation H Nursing Health Assessment in Corrections in the Corrections Setting
for Corrections for preservice and in-service training. H Security and Offender Management: Using H Maintaining Security Part 1
Force in the Correctional Environment
Online training is a tool that your correctional agency can H Suicide Prevention in
use regardless of its budget, and it can be implemented H Co-Occurring Disorders: An Overview for Juvenile Correctional Facilities
Corrections Professionals
painlessly. Classroom training is being supplemented, not H Co-Occurring Disorders:
supplanted. H Introduction to Mental Health Issues An Overview for Corrections Professionals
for Correctional Officers
H Motivational Interviewing for Corrections
Diane Geiman is the Online Corrections Academy Manager at the H Managing Offender Resistance Professionals
American Correctional Association. She also serves as the Academy’s H Ethical Standards for Corrections H Disciplining Offenders: Report Writing
instructional curriculum developer. Geiman has more than 20 years of
Supervisors
experience in developing training programs for criminal justice profes-
sionals. She has received numerous awards for both print curricula
and comprehensive video programs on topics such as criminal and The complete Corrections Course Library is available at www.aca.org/onlinecorrections.
juvenile justice, medical and mental health, supervision, management,
and law.

NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1 / 65

 Member Spotlight March 2010

National Council Member Spotlight

A National Council publication featuring members in action

National Council for Community Behavioral Healthcare

Congratulating the 2010 Awards of Excellence Honorees

Excellence In Service Innovation

Supported by a grant from Mental Health Weekly

Burrell Behavioral Health, Springfield, MO

The Journey Home Project
Programs of Significance
Mental Health Center of Denver, Denver, CO
Court to Community Treatment Program
Community Partnership of Southern Arizona, Tucson, AZ
Criminal Justice Team
Touchstone Mental Health, Minneapolis, MN
Intentional Communities

Excellence In Health Information Technology

Supported by a grant from Qualifacts Systems, Inc

Northern Arizona Regional Behavioral Health Authority, Flagstaff, AZ

NARBHAnet Telemedicine Network
Programs of Significance
Behavioral Health Link, Atlanta, GA
Tracking delays and improved coordination associated with crisis lines
Colorado Behavioral Healthcare Council, Denver, CO
Health information technology program that united the state of Colorado

Excellence In Risk Management

Supported by a grant from the Mental Health Risk Retention Group and Negley Associates

Institute for Community Living, New York, NY

Assessment and intervention program for clinical risk in a multi-service behavioral healthcare network
Programs of Significance
Beech Brook, Cleveland, OH
Advancing the emotional well being of children
Southwest Behavioral Health Services, Phoenix, AZ
Managing risk from a strengths-based perspective

66 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1

 Member Spotlight March 2010

Excellence In Addictions Treatment & Prevention

Hartford Dispensary, Manchester, CT
Continuum of recovery-based services in an opioid treatment program
Programs of Significance
San Luis Valley Mental Health Center, Alamosa, CO
Preventing child substance abuse, delinquency and behavioral issues
Threshold Services, Inc., Silver Spring, MD
Integrating dual disorders treatment and supported housing

EXCELLENCE IN CONSUMER AND FAMILY ADVOCACY

Supported by a grant from Qualifacts Systems, Inc

Austin Travis County Integral Care, Austin, TX

Central Texas African American Family Support Conference
Programs of Significance Affiliate Members
Turn-A-Frown-Around Foundation, Freehold, NJ
Improving the lives of persons who have lost hope The National Council for
Community Behavioral
May Farr, Pacific Clinics, Arcadia, CA
Healthcare thanks all our
Improving the behavioral healthcare system
affiliate members for
outstanding service to the
EXCELLENCE IN GRASSROOTS ADVOCACY (STATE) behavioral health industry.
Association for Behavioral Healthcare, Natick, MA H Anasazi Software
Campaign for Addiction Prevention, Treatment and Recovery
H Askesis Development Group
H Credible Behavioral
EXCELLENCE IN GRASSROOTS ADVOCACY (LOCAL) Healthcare Software
Colorado West Regional Mental Health Center, Glenwood Springs, CO H Defran Systems
Grassroots advocacy program to retire debt
H Echo Group
H eHana
UP & COMING LEADERSHIP
H Essential Learning
Rosa M. West, Vice President for Specialty Programs and New Initiatives,
Meridian Behavioral Healthcare, Inc., Gainesville, FL H Foothold Technology
H Genoa Healthcare
VISIONARY LEADERSHIP H Hazelden Publishing
Mary Anderson, Board Member, Newaygo County Mental Health Services, White Cloud, MI H Mental Health Risk
Howard Bracco, PhD, CBHE, President & CEO, Seven Counties, Inc., Louisville, KY Retention Group
David Guth, CEO, Centerstone of America, Nashville, TN H Negley Associates
Jay Reeve, President & CEO, Apalachee Center, Tallahassee FL
H Netsmart
Richard Van Horn, President Emeritus, Mental Health America of Los Angeles, Los Angeles, CA
H Peter and Elizabeth C.
Tower Foundation
EXCELLENCE IN PUBLIC SERVICE
H Qualifacts
Pamela Greenberg, President and CEO, Association for Behavioral Health and Wellness, Washington, DC
H UNI/CARE
Carol McDaid, Principal, Capitol Decisions, Inc., Washington, DC

68 / NATIONAL COUNCIL MAGAZINE • 2010, ISSUE 1

 Become a Mental Health
First Aid USA Instructor
Mental Health First Aid USA is taking communities across the country by storm,
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Contact Susan Partain at the National Council, SusanP@thenationalcouncil.org

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Don’t miss the Mental Health Mental Health First Aid USA is coordinated by the National Council for Community Behavioral Healthcare,
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