Well, good morning, everyone. It's Amy Cohen. Welcome. I am a clinical psychologist and director of SMI Advisor, and I am so pleased that you're joining us for today's SMI Advisor webinar, Bridging the Legal and Clinical Interface for Justice-Involved Individuals with SMI. Next slide. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Next slide. Today's webinar has been designated for one AMA PRA Category 1 credit for physicians, one CE credit for psychologists, and one CE credit for social workers. Credit for participating in today's webinar will be available until April 23, 2024. Next slide. Slides from the presentation today are available to you. You can download them in the webinar chat. Select the link to view. Next slide. Captioning for today's web presentation is also available. Click Show Captions at the bottom of your screen to enable. Click the arrow and select View Full Transcript to open captions in a side window. Next slide. And please feel free to submit your questions throughout the presentation by typing them into the questionnaire found in the lower portion of your control panel. We are going to reserve 10 to 15 minutes at the end of the presentation for Q&A. So as a question comes up, feel free to type it in and we will keep it until we get to the end. Next slide. And now I am so pleased to introduce you to our friend of SMI Advisor and the faculty for your webinar today, Dr. Deb Pinals. Dr. Pinals is an Adjunct Clinical Professor of Psychiatry and Director of the Program in Psychiatry Law and Ethics at the University of Michigan. She also serves as a Forensic Expert to SMI Advisor and Senior Medical and Forensic Advisor for the National Association of State Mental Health Program Directors. Dr. Pinals, welcome and thank you so much for joining us today. Thank you, Dr. Cohen, for that great introduction and thank you very much to SMI Advisor for inviting me here today to speak to you all about the criminal legal system and working with people with SMI. I just want to remind people or let people know that I have no relationships or conflicts of interest related to the subject matter of this presentation. I do serve on the Board of Representatives for the National Commission on Correctional Health Care on behalf of the American Psychiatric Association. So what are we going to accomplish today? My hope is that by the end of this webinar, you will be able to describe some common legal issues that arise at arrest, detention, court and community release processes. Also that you will be able to describe how legal issues such as bail, privacy laws, risk assessment and rights can intersect for individuals with SMI who are in the criminal legal system. And also discuss case examples and problem solving those clinical and legal intersecting issues that can arise. Please also, as Dr. Cohen said, put your questions in the chat because I'm hoping we can have some robust discussion at the end of this presentation. So let's begin. The first learning objective, as I said, is for you to be able to describe common legal issues that arise at arrest, detention, court and community release. I want to remind you that there is a model, a framework that has been promulgated nationally called the sequential intercept model. And what this model says is that individuals with SMI or individuals in general go through criminal processes in a series of sequential decisions that have to be made. The sequential intercept model, which stems from an article that was first published by Mark Nunez and Patty Griffin in Psychiatric Services in 2006, says that if we could identify people with SMI in the criminal legal process and then reroute them out of the criminal legal process and into treatment, we could reduce the overpenetration of the population of people with SMI who are in the criminal legal system. When the first article about this was published, it started with intercept one. That point in time when an individual with SMI encounters law enforcement, an arrest may ensue, and then they move through the system through initial detention, court hearings, then to jail, court processes, to the time that they reenter into society from a carceral setting and maybe are monitored through parole or probation. Subsequently, in 2017, an article was published looking at intercept zero that said if we could move ahead of the time when police are involved and really work on crisis services, we could potentially prevent the entry altogether of people with SMI into the criminal legal system. This model has become a framework upon which we really think about these legal issues that may emerge and weigh opportunities to redirect people into treatment. I wanted to start there to just get your mind thinking a little bit about what are the legal issues that come up at these different stages for people with SMI. I'm going to start by talking about arrest. There are many times where we see situations, and I certainly see this when I work in the psych emergency room, that an individual with SMI, let's say, may have engaged in behavior outside of a coffee shop where they may be yelling to passersby, or they may hurt someone, they may assault someone, or they may ... Today, I was at a local coffee shop and I saw somebody that looked like they had ... They might have been hearing voices and may have been intoxicated. I don't know because I didn't evaluate them, but it looked ... Somebody was asking for money and was in the coffee shop and acting a little bit, perhaps, unpredictable. Now, if law enforcement were called to those scenes, there is some discretion that may be available to law enforcement to make some choices. Now, when I'm working in the emergency room and I see that somebody is brought to the emergency room by law enforcement in that moment, it means that the choice that was made was to bring the person to the emergency room for an evaluation. Now, there may also be a criminal complaint that's written up, almost like a ticket, that the person will need to answer to later on as a crime, a potential criminal charge, or there may be a civil infraction that gets written up, and either way, that person may have to deal with that. But sometimes it's confusing to us as clinicians to understand, well, why in this circumstance did law enforcement choose this clinical route, taking them to a crisis center or an emergency room, and in another circumstance, put a full-on arrest with custody and take them to the local jail? That's because, again, there is some allowance for discretion of a law enforcement officer, and they are going to be trained about which circumstances allow them that option for clinical versus the criminal legal route. And it may be based on the type of behavior, it may be based on witness statements, it may be based on whether there's a victim that's being injured, and it may be based on policy or legal requirements. So, for example, in many jurisdictions, when there is a domestic violence situation or something that's perceived as a domestic violence action, whether it's towards a parent, whether it's towards a spouse, there may be specific rules that require somebody to be removed if there is a victim in a domestic violence situation and have criminal charges attached. So the discretion is important, and more and more emphasis is being placed on trying to help law enforcement move people towards treatment when that is an option. But sometimes that is not an option for them, and law enforcement enacting their public servant role is sometimes they must detain someone. When law enforcement does detain someone, it must be based on certain factors. For example, there must be reasonable suspicion of a crime for criminal detention. The person being detained must match who they think is the suspect, and there must be availability of some evidence of their involvement in the crime. So in other words, a law enforcement officer cannot lawfully just go out and take anyone they want and detain them for any reason that they want. There has to be some data and some evidence that supports that decision. So you can think about situations where you've treated somebody with SMI or maybe you're somebody with lived experience yourself listening to this webinar and thinking about what was it that allowed me to be placed in custody in that particular moment. The other thing that is important to realize is that law enforcement has played a large role in our society in transporting individuals with severe mental illness. Many people see this as a problem, and many policymakers are looking at how can this be changed because law enforcement shouldn't be in the business of transporting individuals with severe mental illness just for transportation purposes. This study out of the Treatment Advocacy Center showed that an average of 10% of law enforcement agencies' total budgets were spent responding to and transporting people with mental illness in 2017. Again, many of those transports included transporting people to places of clinical settings. The average distance to transport an individual in mental health crisis to a medical facility was five times farther than the distance to transport them to a local jail. And what we know from the studies looking at where there are discretionary options, if something is five times further, because law enforcement also have a job to protect their community, they may do the most expedient thing, which is to transport an individual to a jail. Nationwide, there was an estimated $918 million spent by law enforcement on transporting people with serious mental illness based on the study out of 2007 that was produced in 2017. Now again, many communities are looking at this. Many states are trying to work on enhancing non-emergency medical transport, which can be a Medicaid benefit, and really looking at other transportation means to help individuals with serious mental illness get from point A to point B without the need to draw on law enforcement to do that. We really want our partners in law enforcement to be saved for doing the work that we need them to do when they need it. Now another place where we need to think about the legal intersection for people with SMI is not just when they are perceived as being perpetrators of crimes, but we know that the incident of violent victimization for people with SMI is more than four times greater than the rate in the general population. And so people with SMI, when they are recording crimes, it's also important to think about this. In a study from the National Crime Victim Survey data, I'm not sure what the S stands for, but among studies that assessed violent victimization in the past year, prevalence ranged from 25.3% to 35% prevalence rates of victimization of people with SMI compared to the general population of 2.9% rates of victimization. So much higher than four times greater the rates of reporting violent victimization for people with SMI. Now, let me just say another few words about reporting crimes. Very often individuals with SMI, because the stigma attaches that they are perpetrators of violence more than they are victims when we know that the data is just the opposite, very often their reporting of crimes may not be looked at with the same credibility as people who don't have SMI. Also if they have communication challenges like disorganization or delusions or they're hearing voices, it may be difficult for their report of the crime to be understood by public officials. Now let's look at criminal police custody broken into pieces. When somebody is first placed in custody, they would be read their Miranda rights. We all know about Miranda rights, you have the right to remain silent, you have the right to an attorney, anything you say kind of will be held against you in that sort of language that's read to them. They are provided information as to why they are being arrested. Then once they have been placed in criminal police custody, there is the allowance for the police to restrict their movement by placing that individual in handcuffs or by moving them into a cell, for example, in a police lockup. These can be really traumatic circumstances for anyone, but also and especially for people who have trauma histories and also may have serious mental illness. Now when somebody is read their Miranda rights, there is something called competence to waive Miranda rights because the Miranda rights are perceived as a legal right. If somebody is going to waive their rights, that must be a knowing, intelligent, and voluntary waiver. It can be that later on in a criminal case that somebody's Miranda rights can be examined as to whether they, when they gave their confession, which would mean that they're waiving their right to remain silent, whether they competently waived that Miranda right. There is some case law regarding Miranda rights waivers that are important. There was a case called Colorado versus Connolly, which is a U.S. Supreme Court case in which a man with serious mental illness approached police saying that he had killed someone and told the police that voices made him confess. When this case was up before the Supreme Court, the question was, could his voluntary waiver of rights be suppressed because he was hearing voices? In that case, the Supreme Court basically said that his confession should be allowable because there was no evidence of police coercion. Because individuals confess to crimes for all sorts of reasons, whether it's a guilty conscious or psychotic voices, that's not something that police can know about in that moment. It's not the job of the police to get into the total mind of the individual who may be confessing to a crime. Instead, what the court should look at in terms of suppression of voluntary confessions is police conduct and whether there was coercion by police. It was determined in that particular case that his voluntary confession should be allowable. Let's move on to another legal issue that comes up in cases that we see unfold when people are arrested or when people are detained. That is the issue of restraint. What do I mean by restraint? In this context, what I mean is essentially restricting an individual's freedom of movement. It might include handcuffing an individual or detaining them in a cell. What are police allowed to do with regard to handcuffing an individual with serious mental illness? The rules and the laws may vary by jurisdiction, but there are very clear parameters for what is legally permissible by law enforcement. I'm going to give you an example of two mental health laws to show you the variety of ways in which this can be looked at. In Massachusetts, for example, there's something called Massachusetts General Laws, Chapter 123, Section 21. In Section 21, it states that any person who transports a person with mental illness to or from a facility for any purpose authorized under this chapter shall not use any restraint that is unnecessary for the safety of the person being transported or other persons likely to come in contact with the person. Under Chapter 123, which this law relates to, is the mental health law that allows for involuntary civil commitment. What this essentially says, this Section 21, is that if a person is transporting someone, whether that's an ambulance or a law enforcement officer, if they are transporting them for a purpose such as involuntary commitment, then they are not allowed, remember, it starts with the not allowed to use restraint that is unnecessary, so it puts the burden of proof of what is necessary on the transporter. But it does allow that restraint to occur if they believe, if the transporter believes it is for the safety of the person or other persons likely to come in contact with the person. And so this goes on further to say in the case of persons being hospitalized, the applicant shall authorize practicable and safe means of transport, including where appropriate department or police transport. And then it goes on with more and more details about what restraint can look like. And this is an important thing for people to realize as to why things might be happening to your patient or client, an individual with serious mental illness, that if there's a safety issue, there is an authorized allowance for restraint. Now another state that I want to highlight is Michigan. And in this, I'm just going to highlight in this part of the Mental Health Code, this excerpt of the Mental Health Code, in section 427, it allows for a peace officer to provide for protective custody. And it says, if a peace officer observes an individual conducting himself or herself in a manner that causes the peace officer to reasonably believe that the individual is a person requiring treatment, which by the way is defined in section 401, related to a person with mental illness who poses some risks of harm to themselves or others, the peace officer may take the individual into protective custody and transport that individual to a pre-admission screening unit. and this allows for some ability for peace officers to transport. In Section 276 of the Mental Health Code, which actually speaks a little bit to some of the individuals with substance use disorders, but it goes on further to delineate, a peace officer may take an individual into protective custody with that kind and degree of force that is lawful for the officer to arrest that individual for a misdemeanor without a warrant. And that means that in taking the individual, a peace officer may take reasonable steps to protect himself or herself, and the protective steps may include a path down search of the individual in his or her immediate surroundings, but only to the extent necessary to discover and seize any dangerous weapon that may on that occasion be used against the officer or other individuals present. The peace officer shall take these protective steps before an emergency services unit or staff provides transportation of an individual to an approved service program or an emergency medical service. Now I highlight these two laws just to show you that in your state, in your jurisdiction, there are probably similar laws that codify both the allowance to restrain an individual, the allowance to even pat down an individual or search an individual, and the limitations of those allowances to only vary circumscribed circumstances. All right, I'm going to move us along. And again, if you have questions, please feel free to add them to a chat. Now bail factors, when somebody is admitted into bail or is released on bail or denied bail in the United States, what this means is that a court has made a determination that the person is either, either would be dangerous if released, or that there would be a likelihood that they would fail to appear for a future court appearance. Now some jurisdictions use both dangerousness and failure to appear as what is considered in allowing a person to be released. Some states it's one or the other. So if it's a failure to appear state, the only thing that the court is looking at is whether this defendant is likely to fail to appear for a future court appearance and therefore needs to be detained. Now bail has historically been based on money so that somebody can post bail, and that has often disadvantaged people without means who don't have the wherewithal to post that kind of bail to be able to be released. Many states are undergoing bail reform to try and take money out of that equation. But nonetheless, these are non-clinical determinations where courts will look at factors. Some states have 18 factors that can be considered in bail, and some of those are has this person failed to appear in the past? What is the nature of the crime that they're charged with? Would they be likely motivated to stay in their community? But many states have in their bail factors, whether the individual has a mental illness or a substance use, and that can be a factor that counts against them as being looked at as more dangerous or more likely to fail to appear for court. And I am working with others, and many people are looking at this as one mechanism to understand is this an opportunity to look at statutory reform? For example, if people with mental illness are looked at in a way that's different from other individuals, but it's a complicated issue because if there are also historical factors that need to be considered, the court is really interested in having people appear for their court appearances and obviously not have society be inflicted with dangerous people. And so it becomes a really complicated area of interface when we're talking about people with SMI who may have histories of behaviors that the court may look at as dangerous. And so it becomes a very complicated thing where people with mental illness or substance use may be more likely to be denied bail. And so we have to understand that a little bit more. And to the extent when somebody has been released, it's important to work with our patients, our clients to help them show up in court when they have a court appearance so they don't get a failure to appear on their record. Now let's talk about legal issues that may arise at the court level with regard to specialty courts. There are many specialty courts around the country. Drug courts are the most prevalent. There are mental health courts as well as veterans treatment courts that are established as a means of helping people who have been court-involved related to their veteran status, related to their substance use or related to their mental health condition. And the goal of these specialty courts are to reduce arrest rates, reduce overall days incarcerated and help people improve in recovery from illness and substance use conditions and improve their linkages to services. And what these courts do is they provide what's called a specialized court docket or court list for certain defendants and engage in a problem-solving model. So rather than just adjudicating guilt or innocence, what they do is really try and help problem-solve as an alternative to incarceration and as an alternative to traditional criminal court processing with the idea that if people can get together to help this person move in a better direction, we can help reduce their likelihood of re-arrest and reduce their entry and deeper entry into the carceral setting. People who are in specialty courts have to agree, so their participation is voluntary. It is true that legally, and if they don't participate, their alternative may be serving time in jail or maybe being sentenced. But nonetheless, it is an option for them to participate and engage in a voluntary way, having oversight by a judge in the community attached generally to probation as well as treatment programs where their cooperation with the treatment plan that's set out for them is court-ordered and court-supervised and where non-adherence may be sanctioned. And this can be tricky because people in these specialty courts may be at risk for being over-monitored because they need to be accountable, but at the same time, there is data to suggest that it can be helpful in reducing their likelihood of being re-arrested in certain situations. And the determination and success from these is usually defined by predetermined legal criteria that are established at the outset of the specialty court. Now, drug courts and mental health courts are not identical. Drug courts take people in who have drug-related offenses. A mental health court can have an individual whose originating offense varies, but generally speaking, there is some nexus to their mental health diagnosis or they have an identified mental health diagnosis that can be treated through the mental health court intervention. Drug courts usually take people that are considered high-risk, high-need for criminal recidivism. Drug courts tend to be more structured with strict sanctions and advancements in phases, whereas mental health courts tend to be more person-centered and flexible in their modeling tailored to individual strengths and needs. Drug testing is usually a mainstay of drug court, and mental health courts may involve drug testing, but because the issues may not relate to drug use or substance use, there may not be as rigorous of a drug testing requirement. There is community-based treatment available for people in drug courts and similarly for people with mental health courts, but there also may be dedicated staff that are assigned to be at court and help problem-solve with the lawyers and the judges and the probation officer. In this study, it's an older study that was published in the Archives of General Psychiatry in 2011. Looking at four mental health court sites across three different states, it was found that compared to treatment as usual, annual arrests of people in the mental health court were reduced, and annual arrests post-mental health court were less, and time spent in jail was also considered to be less. With involvement, you can see that the treatment as usual group had 152 jail days, whereas the mental health court group had only 82 days, so there was a significant reduction in jail days for mental health court involvement, and this was one of the more rigorous studies looking at mental health court involvement. Access to the mental health courts, however, can vary according to the jurisdiction. Not every jurisdiction has a mental health court, and again, the criteria may vary based on diagnosis. Some states have laws excluding participation of people with violent crimes in mental health courts, and so inclusion and exclusion criteria may vary, and again, whether somebody comes into a mental health court because their symptoms were directly related to the criminal offense may vary in different jurisdictions. It could be somebody just has a diagnosis that could benefit from mental health court involvement, and they've repeatedly been charged, and so the court is trying to reduce the cycling. The criteria also, usually mental health courts are post-adjudication, and so they may require, so that if that is the case, they would require the individual to enter a plea of guilty and take as their quote sentence this alternative sanction, this mental health court participation, which would require them to be competent to stand trial to enter that kind of a plea. So those are some of the legal issues that we see people encounter that are important for you to think about when you're serving somebody with serious mental illness. Now let's talk a little bit, take a deeper dive in how these issues play out for individuals with SMI. So what this might mean, if somebody is denied bail, it may mean that somebody with SMI is detained. It may mean they need to find money to gain release. It may mean, as I said before, that they're less likely to be released, and it may mean that they're exposed to others in jail and to others who have committed criminal, who have engaged in criminal conduct. And all of this can impact a person's life trajectory. If a person with SMI is detained in a police lockup, they may not have access to the medications, they may have more symptoms, they may feel more trauma, they may have difficulty relating to other people, and this can, again, impact their stability. So what can we do as clinicians? We can really work and understand what is happening to the people we're serving and advocate for them to make sure that they get their medicines, that they are able to have contact with somebody if that's, if it's known that they're being arrested and detained. Now we know that about 1.7 million people are in, about 1.7 million people are in some kind of carceral setting, this is from the Vera Institute. And we also know that many, many more people are on probation and parole at any given time. And why is this important? It's important because if somebody has a difficulty where they are, have a probation or parole violation, they will be moving back in and out of that carceral setting. And there can be real treatment discontinuity between these settings. And so this is really important for us to know as providers. Community supervision, probation can be pre-trial or post-trial. It can be ordered at the time of trial or sentencing by a judge and a probation officer will monitor adherence to the person's compliance with treatment, whether they have refrained from contacting any individuals that they're told not to contact and whether they sign releases of information for there to be communication with treatment providers. Parole is usually monitored by a parole board. They also will have community field officers that monitor compliance with the terms of parole. And also that a person can return to prison if the community-based conditions are not met. And this is all really important, again, for people that were serving with serious mental illness who may be moving in and out of carceral settings because of violation of terms of parole or probation. And sometimes people can be on both probation and parole with different requirements from each entity. We do know that persons with mental illness are more likely to have revocations off parole or probation. This is a study looking at probation. And it's important to be mindful of that, again, as we're serving those individuals. Now, we could say that this is because of their mental illness that they're more likely to have this criminal involvement. But as I've mentioned in other SMI advisor webinars, one of the things we understand is that there are many other dynamic risk factors that people with mental illness may experience that put them at risk of criminal involvement that predict criminal recidivism more strongly than mental illness. And these criminogenic risk factors include a history of antisocial behavior, antisocial personality patterns, antisocial cognition, and antisocial attitudes as the big four, as well as family or marital discord, poor school or work performance, few leisure or recreation activities, and substance use as risk factors for repeat criminal involvement. So the intersection of individuals with serious mental illness and these criminogenic risk factors can create more challenges for people to stay out of the criminal legal system. So one of the things that we've talked about, again, in prior webinars and I've written about and others have written about is this idea that as providers working with people with SMI, it's really important that we think about how much coordination do we need to have with the public safety officers, like probation, like parole, so that we can target populations and help reduce their chance of recidivism and improve their positive functioning in the community. So what this graphic depicts is how we work with other entities. So for example, in the bottom left corner, if you have someone that you're working with that has low criminogenic risks and really is functioning pretty well, they have low functional impairments, then you can really work in parallel with their probation officer. And there's only coordination when needed as needed. It's not as important that there be tight coordination. However, if you're working with somebody who lands in the top right corner, where they have high criminogenic risk factors, a lot of criminal history, a lot of antisocial factors, and among those other eight criminogenic risk factors, and they have high functional impairment, then it's very helpful to coordinate with probation and with parole more tightly. And so the treatment plan should not only include what the individual needs to do, but what should we as treatment providers do in terms of how often should we be reaching out to make sure that we're helping this person stay on a pathway toward recovery. And that involves really understanding what the different roles are between a treatment provider and a correctional supervisor. Of course, as a treatment provider, our primary goal is to alleviate suffering and help that individual reduce their symptoms. As a correctional supervisor, that probation or parole officer is going to be looking at public safety and reducing criminal recidivism. So we can work together with partnering with advocacy for the patient, as well as advocacy for the public, the court, or whoever's overseeing the monitoring, and develop techniques where we build and foster engagement and use each other's strengths to the best advantage to help an individual receive the care that they need and make sure that they're maximally engaging in that care. All right, switching gears a little bit. I want to talk about privacy laws at the criminal and health care interface for people with mental illness. There are two primary laws that we talk about often, HIPAA, which is the Health Insurance Portability and Accountability Act, which really is the federal mandate for health care among the health care services it covers is mental health care. And then there's 42 CFR Part 2, which really dictates these are the code of federal regulations which dictate privacy laws for people receiving services for substance use disorders. It's important to realize that there are different record systems between jails and health care and mental health clinics that operate under these provisions of these laws, and that very often, even though we might want to share information, releases may not have been obtained. And that makes it difficult to do medication reconciliation and really understand a person's long-term history. We rely often when people are arrested and in a carceral setting on the individual's self-report, and it takes some time to gather information for what might have been going on in the community. It's very important to recognize that getting an individual or asking an individual to sign a release can be a simple remedy for solving the problem of information-sharing barriers. 42 CFR Part 2, as I said, limits communication for people in substance use treatment. And I've already talked about what HIPAA says. I've talked about the importance of a valid release allowing for communication. It's also important to know that state laws may further dictate information sharing. They cannot be less restrictive than HIPAA or less restrictive than 42 CFR Part 2, but they can be more restrictive. And so sharing information can be complicated, but this is where working together and helping provide information where it can be shared and encouraging information sharing can be important. And an interesting study that was recently published by Pope and colleagues showed that people may be okay with information sharing where it's needed. So taking into account their personal perspective, it may be the person we're serving wants that information to be shared. So we shouldn't make assumptions that they don't. I also want to talk about people's rights when they are court involved. There's something called the Legal Action Center that's a really important resource that can be available for people who might require medication for addiction treatment. And in this Legal Action Center, they provide a sample treatment letter, publications, information for defense attorneys and training materials to help people understand what their rights are and the right of having their treatment provided and not dictated by legal professionals, but working with healthcare professionals. There are other governing laws that protect against discrimination. For example, the Americans with Disabilities Act is a very important law that helps protect individuals from discrimination and provides for accommodations so that they are treated fairly. The Rehabilitation Act of 1973 similarly protects against discrimination and governs when people are receiving services through federal entities. The Fair Housing Act, as well as the Workforce Innovation and Opportunity Investment Act are all important federal laws that protect individuals. And they also protect against discrimination. Now, finally, I just wanna end with some brief case examples and problem solving those around clinical and legal intersecting issues that can arise. So Mr. A has a history of schizophrenia. He's at a donut shop making noises and responding to voices. That would seem to be today's example. He starts yelling at passersby and police are called. So what do we know about Mr. A today? First of all, the police may have the right to use discretion as to whether to arrest him or take him into care. And it's important to realize that Mr. A does have rights, that he can't be taken into custody unless certain parameters are met. And if he is taken into custody, then the criminal route will follow. If he is taken into treatment, and evaluated, however, he may still have to answer to a criminal complaint that has been filed. So it's important that we understand that he has rights and that the police may have some discretion about what they do within those rights. Now, if the fact pattern changes and the police see him strike a customer, causing the customer to fall to the ground and bleed from a nose injury, then that discretion may be removed because you have a victim and a potential felony level offense. And in that case, the police may need to, by law, arrest Mr. A and take him into custody. Again, he still should have rights and potential outcomes still, again, can be that at some point in time, he may be eligible for a diversion program because of recognition that what happened was related to his mental illness. Should he get to the point in his criminal case where he pleads guilty, he may be eligible for a mental health court. Now, here is another case example. Ms. B has a history of bipolar disorder. While manic, she started to believe she owned her building or she rented an apartment. She was up all night making phone calls and playing very loud music. She became irritable and threatening with neighbors. Police were called. They took her to a local crisis center and she received stabilizing medication and ongoing treatment. And a month later, she had a scheduled court date as a criminal complaint had been filed against her from her prior behavior. What will happen with the criminal complaint? Well, anything really could happen. It could be that she and her defense attorney are able to navigate an alternative and a diversion by saying that she's in treatment, that she's doing well, that she's stabilized. And it may be that the prosecutor does not pursue criminal prosecution after that. It may be that she is instead offered the opportunity to plead bargain, or it may be that she decides she wants to fight the charges and she pleads not guilty. Now, in this circumstance, why was she not taken into custody? Again, it's because there is police discretion in all likelihood because there was no specific victim and police saw her as being ill that they allowed her to be taken to a treatment center in lieu of taking her into criminal custody. She may be eligible. The next question I ask is, is she eligible for a local mental health court? She may be eligible. If she goes down the criminal pathway and enters a guilty plea, she may be eligible for mental health court in a state where there's post adjudication mental health courts. And how will her mental health history be accessed by her attorney? That can be tricky if she's not able to describe that she has a mental health history. Her attorney may hire an expert looking at the facts and circumstances. There may be multiple things that call out to the attorney that she has a mental health history. Here in this case, she was arrested for disorderly conduct and threatening a public official. And again, depending on the charges, it may make a difference for how her case plays out. So in conclusion, let me just say, so we have time for questions. Individuals with SMI are at risk for criminal legal involvement, especially if they're also facing houselessness or experiencing a co-occurring substance use challenge. Criminal and clinical systems have different legal guideposts that allow interventions and these interventions may differ depending on context. However, it's important that we break down silos. Consideration of continuity of care should be paramount so that people can continue their medications and their treatment as much as possible. But obviously when there is a risk of public safety, other laws may come into play. Public safety itself is dependent on many factors outside of the person's serious mental illness. So with that, I'm going to conclude. I've left references for you to look at and thank you for your participation and interest. And I'll turn it over to Dr. Cohen. Dr. Pinals, thank you so much for such an informative presentation. As always, I learn a lot from listening to you and we have many questions. So let me move kind of quickly before we shift into Q&A. I just want to take a moment, let people know that SMI Advisor is accessible from their mobile device. They can use the SMI Advisor app to access resources, education, upcoming events, complete your mental health rating scales and even submit questions directly to our team. You can download the app at smiadvisor.org forward slash app. So let's get straight to the questions because we've got a lot. We'll go to the next slide, which is just the slide that we'll hold on. So a lot of questions about what is, a lot of questions and issues about the monitoring, okay? And so that one person put it very clearly, what do you mean by over-monitoring or over-focus on accountability for mental health court participants? That's a great question. One of the things that we know is that people can sometimes, people can sometimes make poor choices but it doesn't mean that there's additional risk. So for example, I don't know about you, but when I have 10 days of antibiotics, I skip a dose of my medicine. In a mental health court, if somebody skips one dose of medication, that can create a serious problem. So if it's being very, very closely monitored, now I'm not suggesting that that's a good thing for somebody with mental illness to do, but that can be an issue. Also, we know that people with substance use disorders may relapse. We had a situation where somebody was in a specialty court type arrangement and he had a relapse over a weekend, but was willing to get back into care. But because of the relapse, he was sanctioned and put in jail. So sometimes when you're watching people very closely, they will make errors in judgment. And if people are holding people extremely accountable, then it can lead to sanctions that can be an issue. So it's a really hard balance to figure out, what is the right amount of monitoring that lets people be people, but really deals with issues where there can be real risk. Okay. So one quick question, then a longer question. So can mental health courts test for mental health medications? Mental health courts can- Like they're being taken and prescribed. They can do drug screening, but they don't usually test, for example, for clozapine levels. However, they can work with the clinical providers and the clinical providers can do a clozapine level and then provide that information to the mental health court. Okay. So another person reflected on this monitoring issue and said, too many people are entrusted with monitoring who are not mental health professionals. They have maybe limited or poor training and we need to get the field of law enforcement on board. This person has found too many departments are relying on the annual training, which is only a few hours, and their discretion, which is limited. They're not mental health professionals. How can we bridge this gap between whoever people are assigning to be the monitors and the mental health professionals so that the monitoring is more with a therapeutic mind, a mental health mind? How do we do that? Yeah, it's a great question. And that's where that grid comes into play. So it's really about reaching your hand across the aisle to try and coordinate with a probation officer and see how often you need to check in. More and more probation departments are taking approaches that have a quasi-therapeutic bent, although we have to remember that their job is not therapeutic. Their job is public safety and making sure people comply with terms. And that's fundamentally where they land. Philosophically, that's where they have an obligation to land that way. But the more I think we partner to present options and help show alternatives that may help keep people safe, the potentially better off we will be in that, in going in the direction that you're suggesting. Great. So along those lines, someone asked, can you speak to how about law enforcement's any HIPAA issues regarding care coordination? Care coordination. Like what are their limits in HIPAA? Well, law enforcement are not HIPAA entities. They're not healthcare providers. So they do not have those kinds of roles. However, they do have other roles about certain things. Some of their data is not totally public, but they generally would not have as much privacy requirements as a healthcare professional. So they certainly, when they drop somebody off to an emergency room, can provide the information about what was going on and the circumstance that can help the clinician make the best decision. So that would be an answer that I would give. And I can say more if you want, but there are plenty of other questions I see. Yeah. So I've been thinking about this myself and as my advisor has been thinking about this, when you have a care court that suggests that they should get X, Y, or Z to help in their recovery journey. And what if X, Y, and Z doesn't exist in their county or their area? Is there a chance that they would then be incarcerated? How do we build up the community so that it can handle kind of a recovery menu so that people can stay out of jail and recover? How do we build up that? Or are there cases where that doesn't exist in, I'm sure there are, across this country? Yeah. I mean, again, this is where partnership matters and that's where I think the Legal Action Center came into play because a lot of courts were saying we wanted people to have this medicine and not that medicine, which was an overreach of the courts. So now, I think we've come a long way recognizing that judges aren't the ones to be recommending which medication somebody should get. Similarly, what kind of treatment? We need to have the treatment professionals at the table to say, this is what's available in this community. These are our options. What is the issue that you're concerned about? This is how this service will help address that issue. If somebody is ordered into something that is impossible for them to comply with, I mean, it is the person who is sanctioned for not complying, but that's where we need to help advocate for our clients to make sure that what the courts are ordering are realistic. Now, someone wrote in that they have, and again, you and I have probably heard this many, many times, but let's repeat it. They are finding it hard to communicate with detention centers to coordinate care for their individuals with SMI. How do we bridge that? Do we, how do we figure out the person who's gonna answer the phone? What do we do to really be able to develop a communication avenue with detention centers? Yeah, in my experience, leadership meetings are important. Sometimes community memoranda of understanding can be helpful, but having a leader-to-leader meeting to discuss shared interests and develop those communication pathways can be very important. It is very helpful to know how to call a health services unit in the local jail and speak to the clinician so there can be clinician-to-clinician contact. Right, so, I mean, part of this, and maybe I'm speaking out of turn here, correct me if I'm wrong, a lot of these issues are making sure that there is some sort of group where we're communicating, talking through issues, and it's gotta be an ongoing group, right? I mean, this is not a one-and-done kind of thing. Correct, it's ongoing. These are very tough systems. Very, you know, they've been built on lots of different rules and laws. They have not traditionally partnered. There's more and more partnerships occurring, but it should be an ongoing conversation. Absolutely. So here's a, as if there aren't challenging cases, here's a challenging idea that someone's putting forward. So here's what they say. We're struggling with folks in our treatment courts that are exceptionally symptomatic or prioritize reduction in their charges over engaging with treatment. Of course, we don't wanna exclude people based on symptoms or diagnosis, but sometimes don't see a successful path for many. We really don't want to over-monitor them either, but that also seems to be happening. And they wrote, maybe a little tongue-in-cheek, I'm Googling who does best in mental health courts, but I'm finding little. So she's talking about how do we, first of all, do we try to think about who can succeed and best use the mental health court to become a more functioning person as part of our community? Or do we take everybody and what do we do if we feel like there are certain groups that just don't have a lot of hope? Any thoughts on that? Well, I think more research needs to happen on all of these specialty courts because we're learning a lot. And each one can be a little bit different in terms of how it's managed locally. That's why I cited that one study that looked at several courts. So I can't answer who will do better in a mental health court because I would say the mental health courts have variability across them. What I can say is that there is a need to recognize that serious mental illness is a chronic relapsing and remitting condition, and that we wanna help people achieve recovery, which may not mean perfection, and help people who have co-occurring substance use conditions as well at the same time. And sometimes it's just recognizing that holding that hand and supporting people in their recovery is a part of the lifelong journey of having a serious mental illness. And so the longer we can keep people out of jails and in care and in employment and in positive family contexts, the better. But it can take a lot of work and for a long time, and people can't just give up hope if somebody does have a relapse. Right. I mean, somebody's always gotta be the holder of the hope, right? And recognize that it's a waxing and waning course, and it's something that we just keep fighting because at some point there's going to be a breakthrough and people are going to stabilize and we just can't give up hope on anybody. But I recognize this person's frustration in sometimes people are so ill, it's hard to know kind of where to start and how to get them just one step forward. So I recognize that very much. Well, as usual, I've loved talking to you and I know our audience has more questions and we're just running out of time. So if there are any more topics covered in this webinar that you want to discuss with colleagues in the mental health field, next slide, post a question or a comment on SMI Advisors Discussion Board. This is an easy way to network and share ideas with other clinicians who participated in this webinar. And if you have any questions about this webinar or any other topic related to evidence-based care for SMI, you can get an answer within one business day from our SMI Advisor National Experts on SMI. And Dr. Pinals is one of the people who answers some of these. So you might get an answer from her. This service is available to all mental health clinicians, peer support specialists, administrators, anyone in the mental health field who works with individuals who have SMI. It's completely free and confidential. Next slide. SMI Advisor offers more evidence-based guidance on working in forensic settings, such as the three video series that share strategies to help you adjust to the correctional environment, provides essential treatment tips, and discusses difficult circumstances and how to tackle them as correctional mental health providers caring for individuals with SMI. These are some of our best assets at SMI Advisor, and I hope you'll take advantage of them. Short videos, but really talking you through working in this environment. Access these videos by downloading the slides or clicking on the link in the chat. Next slide. Claim credit. For participating in today's webinar, you need to meet the requisite attendance threshold for your profession. After the webinar ends in just a minute, please click continue to complete the program evaluation. The system then verifies your attendance for credit claim. Sometimes it takes up to an hour and can vary based on local, regional, national web traffic and use of Zoom. So be patient, but either right after or take a little coffee break and then come back and check again. Last slide. Please join us next week on March 1st as Dr. Amanda Aloma presents Social Determinants of Health in People Living with Psychiatric Disorders, the Role of Pharmacists. Again, this free webinar will be March 1st at noon Eastern time, which is a Friday. Thank you for joining us today. Thank you, Dr. Pinals. And until next time, take care.

Dr. Pinals

SMI Advisor

bridging legal and clinical interface

justice-involved individuals

serious mental illness

Sequential Intercept Model

mental health courts

drug courts

privacy laws

community support