Hello and welcome, I'm Amy Cohen, Associate Director for SMI Advisor and a Clinical Psychologist. I am pleased that you are joining us for today's SMI Advisor webinar, Introduction to the Interface Between Serious Mental Illness and the Criminal Justice System, Strategies for Realigning Patients Towards Treatment. 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. And now, I'd like to introduce you to the faculty for today's webinar, Dr. Debra Pinals. Dr. Pinals serves as the Director of the Program in Psychiatry, Law, and Ethics and a Clinical Professor of Psychiatry at the University of Michigan Medical School. In addition, she is a Clinical Adjunct Professor at the University of Michigan Law School. Dr. Pinals is the Medical Director of Behavioral Health and Forensic Programs for the Michigan Department of Health and Human Services. She is the current Chair of the American Psychiatric Association Council on Psychiatry and the Law and is board certified in Psychiatry, Forensic Psychiatry, and Addiction Medicine. Dr. Pinals has almost 20 years of experience working at the interface of justice and behavioral health. Dr. Pinals, thank you for leading today's webinar. Thank you, Amy. It is a pleasure to be here today and to be participating in today's webinar. I want to start by just saying that I have no relationships or conflicts of interest related to this particular subject matter for this presentation. Today, I'm hoping to cover three main things for your learning objectives. First, I want to describe the basic elements of the criminal justice system. Then, I want to describe data regarding individuals with serious mental illness in the justice system. And finally, I'd like to delineate for you the sequential intercept model and the stepping up initiative as reform strategies to reduce the population of individuals with SMI from the justice system. Let me start by describing the adult criminal justice system in general. First, it's important to realize that the criminal justice system is a system along a continuum with a variety of component parts. And that to understand our patient's experience and the individual who are in the justice system, it's important to take apart the continuum and look at it across the various elements. For example, the criminal justice system involves arrest, prosecution, and punishment for individuals who have been found to have violated laws. Often, detention and confinement within correctional facilities is part of the process during a case processing and a sentencing determination. And we'll be talking about each of these elements in a little bit more detail. A few other highlighted points that are important to realize. In today's webinar, I'm focusing on the adult criminal justice system. The juvenile justice system has common elements but also very distinct elements. One of the things that's important to realize, especially as people with SMI often emerge in their emerging adulthood years or in their young adult years, is that when they encounter a justice system, it may vary depending on their age and the jurisdiction in terms of which justice system they may encounter. The age of the adult jurisdiction is evolving. Generally, what I'm going to be focusing on is jurisdiction affecting individuals 18 and older in age. When an individual is encountering the justice system, if they are held, for example, in a confined setting, in the adult system, we would call that jail. In the juvenile system, we might call that detention. There are different terms that are used in the adult and juvenile system as well. For example, in the adult system, because of the law's recognition that adults have the ability to form the requisite guilty mind, the wording is guilty if somebody is found to have committed the offense, whereas in the juvenile system, which is framed and designed on the model that youth are still in development and we have the opportunity to rehabilitate them into becoming more law-abiding adults, the terminology is different. It would be called a delinquency adjudication. Similarly, after a guilty finding in the adult system, we think of the term as punishment, whereas in the juvenile system, the term that is more generally used would be commitment. Raise the age is an important concept for people working with individuals with SMI to understand. Raise the age is the movement across the United States that recognizes that brain development tells us that individuals under a certain age are still evolving and their personalities and their way of thinking about right and wrong and making decisions is also still evolving. In many jurisdictions, the age of juvenile jurisdiction is being raised, where years ago, many states would try even 16-year-olds as adults. Now with raise the age, individual jurisdictions are moving that to age 18, which means that anyone under the age of 18 might be therefore tried as a juvenile, which takes on a different framework of more rehabilitation as opposed to the more traditional punishment model that we see on the adult side. So it varies across states, and it's just important to realize that this is something that is evolving. There's also an evolution in terms of the youngest age by which somebody could be charged with an offense, and that's also shifting generally to across jurisdictions. So I would encourage people interested in this area and thinking about this to pay attention to these movements that are occurring and to be familiar in your own jurisdiction with what are the age cut-offs. Again, the legal age will determine which criminal or delinquency system gets involved, but time of onset of acute symptoms of mental illness may mean involvement in both systems. Changing the path of criminal justice involvement requires us to begin with looking at what happens after an arrest. In an arrest situation, arrest is a global term, and it can mean a variety of different things, even though we think of it as one thing. If we look at it in a refined, detailed way, it can mean contact with law enforcement, whereby the police will make a determination about filing a criminal complaint and then even detaining the individual in police custody. Now contact with law enforcement can also involve something called deflection, which might mean that they deflect the individual into an alternative course where there is no paperwork filed in a criminal way against that individual. Oftentimes, police have discretion in how they approach a situation. There are other times where there are mandated responses, and where we see some of the challenges for individuals with SMI is where there might not be an easy alternative for law enforcement officers, or there might be a sense that the arrest is the better route for the individual because of potentially some lack of alternatives. When an individual is held in police custody, they are usually in what's considered a police lockup. Again, this is a global term, and jurisdictions will have their own words for these places. Generally, these are small, run by a local municipality. Some municipalities have agreements whereby an individual might be transferred to a local jail to be held in initial custody. Usually the length of stay can be for hours or days until the court opens, because these are temporary holding places until the individual can deal with the charges or face formal charges in court. Generally speaking, these are cells with no attached health services. People working in emergency rooms might be familiar with an individual who might be brought from the local police lockup over to the emergency room for some acute medical need, such as suturing, a laceration, or even suicidal ideation. So, therefore, the services that might get used for health care often include local emergency rooms. Often, police are standing by because the individual being held is in custody, and they will be returned to the custodial place of confinement. When an individual is brought to court, when court opens, they will be arraigned on a criminal charge. Now, an arraignment involves generally the formal laying of the charges or asserting of the charges against the individual. There are other things that happen in these initial court processes that are important to think about for individuals with SMI who might be facing an arraignment. For example, one of the issues is going to be a determination of indigency, which means whether the individual can financially afford their own lawyer. In the United States, if an individual defendant is determined to be indigent, then they will be appointed a public defender. If they are not determined to be indigent, then the expectation is that they would be able to retain their own attorney. There are also bail determinations that are made. In a bail determination, and some jurisdictions use the word bond, there is a determination usually around two different factors, although, again, I would just emphasize that I am simplifying some of these concepts because there are very specific legal nuances in every jurisdiction. But from an overarching viewpoint, a bail determination is generally made on one of two grounds or both grounds. For example, one ground is failure to appear. If an individual has a track record of not appearing for prior criminal complaints, then they might be seen as more likely to not appear for their criminal matter in the future and then this allows, if that determination is made, the judge to set a bail, which is a financial amount of money that if the person cannot raise would then lead them to be held in custody. Another basis for a bail determination across the United States could be a dangerous determination. Now, this is not the same as a clinical risk assessment that we might do in an emergency room or in an inpatient unit. These are not clinical assessments at all and clinicians are generally not involved in these. These are often based on the type of crime, prior criminal offense record, other factors, which ironically might include a history of mental illness, but this is only looked at under legal terms and legal circumstances for the judge to make the determination about dangerousness. The defense attorney would be arguing that the individual will appear and would not be dangerous, whereas the prosecution would be arguing the likelihood that they won't appear if needed at future court dates and that they might be dangerous or that they are dangerous and then the judge will make that determination and then make a determination about whether to set bail, deny bail, or release the person on personal recognizance whereby they can be out and about in the community. Now I want to talk about jail. Jails are governed through the county sheriff's office. County sheriffs are elected officials. They may have other duties in some jurisdictions. The sheriffs have some road patrol responsibilities or they might be contracted to provide certain road patrol responsibilities, but in general, a major duty of a sheriff is to govern the county jail. County jails are local institutions whose populations will vary and after an individual is arraigned and the determination of bail is made, an individual who's held in custody would be detained in a jail. What's fascinating about jail is that they actually house different populations. For example, a large proportion of individuals held in a jail are going to be people that are pre-trial. These are people that have been arrested and been detained whose lawyers are working on developing defense strategies who are found to need to stay in this custodial arrangement and awaiting their trial. There will also be individuals who have been found guilty and are convicted and are serving generally less than a year of a sentence. In most communities and in most states, jails are designed for individuals whose sentences are going to be less than a year. If anyone is serving more than a year, they would be transferred to a prison, which I will be talking about later. In addition, jails house people who have gone through the trial process but have been sentenced to a term of probation but then violate probation and they may be brought back into jail pending action on the probation violation, awaiting a different kind of process. In addition, jails can be used to hold people in civil contempt for, for example, egregious examples of failure to pay child support. In addition, a county might have contracts to use beds within its jail for other purposes such as immigration detention, which is, which is a whole different, follows under a whole different set of rubrics through federal immigration laws. So a jail can have a mixed population of persons and the services and the way the jail is structured might mix those populations or might not mix those populations. Jails can also house juveniles. Generally, if a jail houses juveniles, those do have to be separated by sight and sound separation. The numbers of individuals within a jail vary, but common ranges are from just a few. You can have a jail of 50 people or 400 people in a midsize community to a few thousand people that are held in the jail. Now what's important to realize in a jail is that there's a high turnover rate because of this mixed population. So even for a jail that has a population of say 500 people, they might do bookings of 10,000 people in a given year because people might be held for only short periods of time. They might be held until a family can post bail. They might be held pretrial waiting action on other activities. There's a high turnover of individuals in the jail. For a psychiatrist working in the jail, that can be a very challenging thing because when you meet with the individual, you may be trying to understand what their mental health history is and identifying what medications they've been on. You might start medication, set up a follow-up appointment only to find out that they were released. So this raises other challenges and I will be talking about this later in our webinar strategies that have been developed to try and address some of these challenges. Again, the total length of stay is generally less than one year. The stay might be longer if the individual waits pretrial for a longer period of time because even though individuals in the United States have a right to a speedy trial, there are reasons that trials get delayed. Also, somebody might have multiple charges and might end up spending that time of less than one year on each sentence but serving different sentences on different charges. And so they might end up spending more than a year in jail. That's not uncommon. Again, jails and mental health services are important to understand. Jails do have mental health providers. Usually larger jails have specific services. Services often contracted mental health service providers or local community mental health providers that are more present on a daily basis. Smaller jails might have contracts whereby, for example, a psychiatrist would come in half a day a week to help ensure that the individual has the proper medication. There are standards for mental health services in jails and the American Psychiatric Association has produced the Psychiatric Services in Jails and Prisons that was reissued in 2016 in its third edition. There are other national bodies like the National Commission on Correctional Health Care Standards that put out mental health standards for jails and other entities as well that help establish what are the standards for mental health services. Generally, the standards would require an intake screening for mental health as well as a referral for further assessment, mental health assessments and evaluations, mental health treatment, and community reentry and transfer planning for people being released. Within the jail, there's a whole framework of classification and housing determination in terms of what unit individuals should be placed on. And again, larger and more intentional jails might have unique mental health housing, but oftentimes that won't be the case. There also might be restricted housing, which keeps people more locked in a cell for longer periods of time, and this can be a serious issue for individuals with SMI. There are programming and programming challenges often because of space considerations and the mandates of the jail. Release planning can be complicated, again, as I said, by little advance notice at times because there are many factors that lead to release decisions that are outside of the jail's control. Further court processes that we will just go over in other webinars include the potential for an individual with SMI to have their competence to stand trial raised and whereby if they are found incompetent to stand trial, they might be routed into a forensic system. Treatment providers should maximize continuity of treatment regardless of the path taken by the criminal defendant, and it is important for people listening to think about this from a person-centered perspective in terms of understanding the path that an individual might take throughout these processes. Other court processes include the general trial process, a decision to enter a plea bargain or go to a full trial, and then finally the adjudication, the determination of guilt, not guilty, not guilty, or not guilty by reason of insanity or in some jurisdictions a no contest determination, and then finally, after a guilty finding, a sentencing determination. Sentencing can include time served because any time spent in a confined setting would count as time served. It might include probation. It might include incarceration. It might include incarceration plus probation. It might include incarceration followed by parole, and it might include incarceration ending with release and no parole. There are also alternatives to incarceration throughout the United States in varying degrees and varying jurisdictions. For example, for people with SMI, probably the most relevant are the availability of mental health courts, which might be pretrial, but most often are considered to be specialty courts for post-adjudication means as an alternative to incarceration after a plea is entered or after a guilty finding in which an individual is monitored by a court with regular appearances and involvement with a judge and a team to look at alternatives to sanctions from incarceration that link individualized to specialized community supervision in lieu of incarceration. I'll talk a little bit more about that later. Prisons are governed through the State Department of Corrections. Their populations include inmates sentenced to one or more years of incarceration. Their release dates, even though they may seem like they are finite, they can shift because individuals are generally going to be eligible to earn good conduct time, which can also make release planning somewhat challenging, and many releases are going to be attached to parole supervision or actually probation supervision from earlier offenses. The numbers of individuals housed in a state prison can vary, but range and generally can include thousands of individuals at any given time. It is not unusual for states to have 30,000, 40,000 individuals held in state prisons across the state. The total length of stay, because of the way they are designed, is for one year or more. An individual can move from one facility to another within the State Department of Correction, which means that unlike a county jail, which is local to where the individual might reside, an individual who might reside in one county when they are in the community might be incarcerated in a prison and released from a prison far from their natural environment. Again, all of these present challenges for individuals generally and specifically for individuals with SMIs. Within the prison system, because it is a confined place for longer periods, you will generally see mental health providers who are available to provide all levels of care that would be available in a community setting, which can include inpatient, what is considered a prison-level inpatient level of care, to crisis services. Standards for mental health services are also required in prisons, including intake screening, assessments and evaluations, general mental health treatment, community reentry and transfer planning. There are also classification and housing decisions, such as specialized housing units and restricted housing as distinct for people with serious mental illness. Programming within prisons, again, is more varied, generally speaking, due to longer length of stay and the ability and mandates required of them. And release planning, again, can be complicated by geography between the facility and the natural community, as well as the duration of the incarceration. Now, I've mentioned probation and parole. There is also something called pre-trial services, also sometimes called probation in some jurisdictions. Probation is generally under the auspices of a court or a judge, whereas parole is generally under the auspices of a parole entity, sometimes an agency that is run within the Department of Correction or by the same state agency, or sometimes by an independent agency that has, and in all jurisdictions, there's generally a parole board that will make determinations about parole eligibility and community release. And some individuals, although people may not realize this, might be supervised by both parole and probation because of different cases that are going on in their lives. Now, let's talk about SMI and the criminal justice system. This is a very critical issue in our nation. We know that incarceration in the United States, by population, far outweighs incarceration in other developed countries. And this is a huge issue, and prison reform is happening throughout the United States from a variety of different angles. But what we're talking about today is what this means specifically to individuals with SMI. To understand that, it's important to understand how correctional populations are defined in the United States. When we think about the correctional population as a whole in the United States, we see it is generally divided by those that are held in prison, those that are held in jail, and those that are under probation or parole supervision. Although the incarceration rate has declined since 2009, all of the decreases in the incarcerated population have been due to the prison population, while the jail population has remained relatively stable. And in the community supervision population, we see that there has been a decline in probation population, but not as much of a decline in the parole population. If you look at the numbers in the United States based on data from 2016, we have about 6.6 million people under some type of correctional supervision. The incarcerated population includes about 2 million, whereas those under community supervision take up the bulk of the population. But what's important is that because of the way community supervision works, where there are probation violations or parole violations, individuals may return into the jail system or the prison system, and so this is a very fluid system overall. Now, what does this mean for people with serious mental illness? There are different ways that data has been collected to understand these challenges and these issues. The Bureau of Justice Statistics put out data in 2017 that showed that one in seven prisoners and one in four jail inmates reported serious psychological distress in the past 30 days in comparison to one in 19 of the general population. Now, that is not exactly the same as SMI, as the SMI advisor would define it, but it is important to realize that incarceration, that those individuals that are incarcerated will report this level of psychological distress. About 75% of those that reported serious psychological distress had also said that they had received prior mental health treatment. Again, that does not exactly equate with SMI in terms of schizophrenia and bipolar disorder, but we can look at other data to help us understand that. We know that prevalence of individuals with serious mental illness are higher in prisons and jails than the general public, and here is data that the Council of State Governments put out looking at some of the studies that had been collected, for example, showing that people with serious mental illness, about 16% of the state prison population has a serious mental illness, and about 17% of the jail population, and almost 10% of the probation or parole population, 7% to 9%, compared to the general public, which is at about 5.4% for serious mental illness. You can see from this slide the data on substance use disorders, as well as those with co-occurring disorders, which are at alarming rates compared to the general public. Other interesting studies have come out. For example, a study published in Psychiatric Services in 2011 showed the higher risk of arrest among public mental health service recipients, with the highest risk being for arrest on misdemeanor-related charges. And then one study looking at one public mental health system showed approximately 25% of individuals with either schizophrenia or bipolar disorder had served by one public mental health system, were involved in the criminal justice system during a two-year prior look-back, and the cost per person were approximately double those without criminal justice involvement. Now, many people would say that if we could just treat the mental health symptoms of these individuals, we would decrease their chance of criminalization, and that would be nice if it were true, but the reality is there are many reasons why people with mental health and serious mental illness are arrested that are similar to the reasons that people without mental illness are arrested. And although expanding mental health services is a great idea always, it is not going to be the total solution to the issue. Part of that can be seen in this one study that was published in 2014 by Peterson and colleagues that showed that when we look back at arrests, many of the arrests that we see are not directly related to psychiatric symptoms. In fact, in this study, they found that 65% of arrests were completely independent from psychiatric symptoms, whereas about 7.5% were directly related to psychiatric symptoms. For example, an individual who might be delusional or hearing voices telling him to steal a sandwich might get arrested for a theft, but that would really only account for some of the arrests that we are seeing. Other contributors to risk of arrest, which people with SMI are at greater risk for, include social determinants of health, and that is a big issue. Poverty, for example, homelessness, and other issues. We also see other contributors of arrest, including antisocial features and what are called criminogenic risks, which do not include serious mental illness. That has been promulgated by data that is used primarily in the criminal justice system that looks at the risk factors for people to be involved or re-involved in the criminal justice system. There are generally eight main risk factors that tie to people's involvement, and that includes a history of antisocial behavior, antisocial personality patterns, antisocial cognition, antisocial attitude, family or marital discord, poor school and work performance, few leisure or recreation activities, and substance misuse. Now, so therefore, what is the relationship between mental illness and crime? Mental illness is generally considered something called a responsivity factor, which we know needs to be addressed because, of course, we want to treat people with serious mental illness. In those cases where it is directly related, symptoms of mental illness can be connected. For example, there has been a study showing bipolar symptoms that are frequently associated with criminal behavior. But again, I don't want people to leave this webinar and say bipolar disorder is directly linked to criminal behavior because when you look at the nature of the arrests that are involved in individuals with bipolar disorder, it can be things like walking naked in public. It can be things like, you know, erratically behaving in a public setting. And so we don't want to assume that this criminal conduct is necessarily similar to violent conduct. Also, comorbid antisocial personality disorder, substance use, and PTSD were more likely to be associated for arrests with violent crime than actual psychosis. In fact, decreasing symptoms of mental illness alone, therefore, will only have a modest effect on criminal behavior. And this is why it's important for the mental health system to be more savvy about the criminal justice system and understand how to serve our patients holistically who might have some of these other issues going on. Because mental illness can be a driver for some behaviors, traditional treatments must not be ignored, but they will not reduce most crimes. Challenges for mental health service providers working for people with SMI in the justice system include the lack of understanding of the justice system, which is why it's wonderful to see so many people signed up for a webinar like this. There's also a lack of comfort and training with some patients' personality style. There's the stigma of involvement in the criminal justice system, which as soon as you hear that a patient has criminal involvement, it is not uncommon for individuals to therefore interpret these to make the assumption that the individuals being served are going to be less safe. And so there might be concerns for safety, even if it's based on stigma due to a label of criminal attaching to patients. Now, I am not saying that we should discount concerns about safety, and I am not saying that some crimes are violent, because of course some crimes are violent, and we have to pay attention to that. I do believe that one of the challenges, however, is the double stigma of mental illness and a criminal justice involvement label that gets attached to people and then assumptions get made about who these individuals might be. And we have to look from, again, from a person-centered perspective at individuals on an individual level and understand their individual needs, challenges, and even risks if they pose them. Trainings like this can help improve the comfort with this as a foreign system and a foreign culture to most mental health professionals. Now, there are two major frameworks that I want to describe that have attempted to help communities come together to look across the aisle from the justice system and the mental health system in partnership to better serve the individuals, their families, and the communities as a whole in a safe and smart way. The first one I want to describe is the Sequential Intercept Model. This model was first posited by Munitz and Griffin, published in Psychiatric Services in 2006. It is now ensconced in federal law and has been further established through the work of the SAMHSA GAINS Center in large part. It started as a five-intercept model, but in 2017, a sixth intercept, Intercept Zero, was added to help describe the framework. And essentially, the Sequential Intercept Model takes the position that the criminal justice system occurs on a continuum, that there is a recognition that there is an overpenetration of people with serious mental illness and co-occurring substance use disorders in the criminal justice system. And the only way to reroute them into the treatment system is to take that continuum and look at it as potential intercept points where decisions could be made for alternative pathways that move people from the justice system into the treatment system. So, I'm going to take each of these intercepts one by one to describe them just briefly. For example, at Intercept Zero, the idea is if there are sufficient crisis services, individuals could be potentially deflected from arrest and deeper penetration into the justice system. There are specialized law enforcement approaches that have been established, such as crisis intervention teams and co-response teams that help to accomplish some of those goals. At Intercept Two, this is at initial detention and initial court hearings. There are prosecutorial diversion programs, boundary spanners, court clinicians based in local courts, as well as pretrial specialized probation services that are specialized to serve people with SMI. And it is important for practitioners to understand what is going on in their local jurisdiction to avail themselves of these potential intercept opportunities. Intercept Three involves jails and courts. And here we see specialized services within jails, mental health courts, again, as alternatives to incarceration, and then specialized linkages to community mental health service providers for individuals. Intercept Four involves carefully planned reentry services. The idea of suspending Medicaid versus terminating Medicaid so that when individuals are released from jails and prisons, they can actually return to their usual services without having to reapply for their Medicaid benefits. There is in-reach by community providers and linkage to aftercare services that are evolving with different evolving models. And transfer of treatment information flow mechanisms that have been refined in particular jurisdictions to allow information for the services and the mental health care received within the jail or the prison to be transferred to the community provider for hopefully more seamless continuity of care. At Intercept Five with parole and probation, again, we see specialized mental health caseloads emerging across the country or training for general parole or probation officers to better serve individuals even if they're not taking on a specialized caseload, linkage to community supports, and then, of course, building in crisis planning so that probation and parole can find alternatives to reincarceration for the individuals that they are supervising without compromising public safety. Another major initiative that is important to mention is the Stepping Up Initiative. This initiative garners partnerships at the county level to reduce the populations of people with mental illness in jails. It is partially supported by the American Psychiatric Foundation, the National Association of Counties, and the Justice Center Council of State Governments, as well as other partners. And to date, there are approximately 500 counties that have signed resolutions that say that together the county leadership will come together to reduce the population of individuals with mental illness from the local jails. Information is available at stepuptogether.org if you're interested in seeing whether your local county has signed on. Stepping Up asks for the community leadership to look at key questions and then monitor the results. The six key questions the leaders must ask include, is the leadership committed to reducing this population? Do they have timely screening and assessment available to identify those individuals with serious mental illness? And do they have baseline data to measure their progress over time? Has the county conducted a comprehensive process analysis and service inventory? And have they prioritized policy, practice, and funding to ensure that this decrease in populations of people with mental illness will, in fact, occur? And the final question that they ask counties to ask is, are they tracking progress? Now, I've been involved in many counties and many jurisdictions, both consulting and trying to drive some of these changes. These two models work hand-in-hand in a very nice way because to address these six questions, one often ends up looking across the sequential intercept model and vice versa. And so these initiatives are very important to think about to drive change forward, to improve the lives of individuals with SMI who are in the criminal justice system. With that, I'm going to conclude and open up for questions by saying that people with SMI are at increased risk of criminal justice involvement. And much work is being done to decrease these trends. And it's a very exciting time to get involved. Historically, the criminal justice system has been a black box mystery for behavioral health providers. Stigma attaches to individuals with criminal justice involvement as much as stigma attaches to saying somebody has mental illness. And when an individual has both, it can be more than doubly stigmatizing, leading to rejection from programs, social ostracism, and a whole host of other challenges that make it harder for an individual with SMI to achieve recovery. Practitioners and the public can benefit from information to reduce the mystery, reduce the stigma, and increase competence, skills, and the rewards in working with and helping the justice-involved population. So thank you very much for signing onto this webinar. Thank you for your interest in this very critical and important topic. And with that, I'll open it up to questions.

Dr. Debra Pinals

Webinar

Serious Mental Illness

Criminal Justice System

SMI Advisor

Sequential Intercept Model

Stepping Up Initiative

Reducing Stigma