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Supporting Clients Who Have Been Justice-Involved
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Hello and welcome. I'm Dr. Benjamin Druss, a Professor of Health Policy and Management and Rosalynn Carter Chair in Mental Health at Emory University, as well as a member of the SMI Advisor Clinical Expert Team. I'm pleased that you're joining us today for today's SMI Advisor webinar, Supporting Persons with SMI Who Are or Have Been Justice Involved. 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. Now I'd like to introduce you to the faculty for today's webinar, Dr. Debra Peinold. Dr. Peinold serves as the Director for the Program in Psychiatry, Law and Ethics and is 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. Peinold is the Medical Director of Behavioral Health and Forensic Programs for the Michigan Department of Health and Human Services. She's 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. Peinold has almost 20 years of experience working at the interface of justice and behavioral health. Dr. Peinold, thank you for leading today's webinar. Dr. Debra Peinold Thank you very much, Dr. Dress. It's a pleasure to be here today to lead this webinar on working with persons and supporting persons who have been justice involved. I want to just note that I have no relationships or conflicts of interest related to the subject matter of this presentation. In today's webinar, I want to cover three learning objectives. One, describing some of the challenges clinicians face in working with clients who have been criminal justice involved. Two, discussing approaches used by the criminal justice system to identify and reduce criminal recidivism to increase learners' awareness. And three, describe what trauma-informed approaches can facilitate working with individuals who have been justice involved. So, let me start with the first objective. Let's discuss challenges clinicians might face in their work with justice-involved patients. I came to this through my own experience and through the experience of numerous colleagues with whom I've worked at this interface of mental health and the justice system. In fact, I got interested in this whole field early on in my residency when one of my patients with schizophrenia was arrested, and I was very curious to learn more about what his experience was like. But what I realized over the years is that there's many challenges that mental health service providers have when working with people with serious mental illness in the criminal justice system. First, there's a lack of understanding of the criminal justice system itself, and we've provided two prior webinars that hopefully help enlighten the mental health community a little bit more about what happens in the criminal justice system. Second, there's a lack of comfort with some patient personality styles. And drawing from my own personal experience again, I do recall when I first worked in a women's correctional facility, some of my own colleagues wondering why I would want to work with people in that correctional facility and thinking that they would have difficult personality styles and it would be a hard patient population. As it turned out, it's a really fascinating and important patient population to work with. Third, there's counter transference and transference issues that can emerge from criminal justice involvement. Everybody wants the public to be safe, and people in the criminal justice system have been accused of or even convicted of, or people with SMI might have been found not guilty by reason of insanity for crimes that are not tasteful. And there's also lots of thoughts about what it means when somebody is justice involved. And so there can be transference and counter transference issues in working with our patients. Also, when you work with this population, generally speaking, you're working with high demands and limited resources. Everybody is stretched thin, trying to do the best they can with not enough resources. And what we know happens in these kind of environments is the risk of burnout. When the challenges of the patient population and the resources exceed the capacity to manage them, some days it feels very difficult. And so it's important to get enriched by trainings and knowledge and colleagues who do the work together to help address some of those burnout factors. There's also some real issues with stigma and fear. In the fall of 2015, the Council of State Governments Justice Center put out a resource guide on the overvaluation of risk for people with mental illness, with the idea that, unfortunately, people with serious mental illness are often labeled by our society as more violent than others. And we could talk for a long time about the complexity of the literature on the relationship between violence and mental illness. And we know that there's a small percentage of increased risk of violence. But by far, the people with serious mental illness are not the major drivers of violence in our society. Nonetheless, once somebody is criminal justice involved and potentially has serious mental illness, there is a lot of stigma and fear that goes with them. There's concerns for safety, even if based on that stigma, due to the label of criminal or forensic being attached to patients. So there are some unique challenges. Again, the benefits of working with the criminal justice-involved persons with serious mental illness are not discussed. And to that end, the American Psychiatric Association Council of Psychiatry and Law's work group on correctional mental health put out a resource guide that's available to the public called Resource Document on Why Should More Psychiatrists Participate in the Treatment of Patients in Jails and Prisons? Talking about some of the benefits that hadn't previously been discussed that broadly. There's other resources similar to that also produced by the Council of State Government. Another challenge is there can be feel like there's gaps of information. Just yesterday, I was in a meeting where we were talking about how we could share information between the local jail and the local community mental health center. Information sharing across behavioral health and justice systems can be challenging. There's HIPAA for mental health privacy and health privacy. And then there's 42 CFR Part 2, which relates to privacy for substance use treatment services. And these can be viewed as barriers. But there are ways to help address this. And there are many documents, including those coming from SAMHSA itself and the Council of State Governments and others that help the field understand how information sharing can actually happen. What are the real limitations and what are some of the perceived limitations to information sharing across systems? For patients with serious mental illness in the criminal justice system, there are a number of biases that can emerge. We did a study that was published in psychiatric services years ago that looked at the relationship between race and ethnicity and forensic clinical triage positions, finding that, in fact, people in minority communities were in some ways more heavily stilted into more correctional and forensic environments with more security. This is similar to what we see in the criminal justice system. And we also see throughout the health care system some racial and ethnic disparities that are really important to address. So when you're talking about individuals with serious mental illness in the criminal justice system, you have potential for bias upon bias that results in real challenges that we need to overcome to make sure that our patients are getting access to the full range of services no matter what culture or community or race or ethnicity they come from, and that we can be culturally competent in addressing their needs. Also, there can be differential treatment. One study that was published in the Journal of the American Academy of Psychiatry and Law in 2010 was an interesting study comparing people found incompetent to stand trial to a civil population or to a community population. What they found is that once the individual was found incompetent to stand trial, they had differential outcomes and longer hospitalizations even when they were deemed no more dangerous than a community sample. The theory of the authors and of those of us who have worked in the forensic system is that very often just the label of the criminal justice attachment or the forensic label puts people in either legal statuses or clinical views or other views of the justice system that creates this perception of increased risk, and so they end up staying in committed settings longer than others. There's fractured services and disruptions in care because of all of these issues, which creates other challenges for individuals and for providers working with this population. Overcoming these challenges is something that's really important to do. First of all, recognizing rewards that come with working with this patient population, as I said before, is really important. Trainings like this can help improve comfort with a foreign system, and finding collegial support can be another way to help provide getting better outcomes for our patients. Finding ways to take care of oneself and working with the population is always important. It's always important no matter who we work with, and developing some system savvy as a way to build internal capacity are ways to overcome these challenges. And what I always say is just dive in, take on the roles, work with people with SMI in the justice system, and you will learn every day, as I still do, more and more about how we can overcome these challenges. Second, what are the approaches used by the criminal justice system to identify and reduce criminal recidivism? Through this webinar, this section of the webinar, it will be important, I will be reviewing these various approaches, and it will be important for the people listening to attend to this so that you can have, again, more system savvy, so you can see things from the lens of the criminal justice community. I think I've showed this slide on other webinars, but I want to show it again here to make the point. One of the things that we know is that for people with serious mental illness, or for people with mental illness in general, who are in the criminal justice system, oftentimes, in fact, most often, their crimes are unrelated to the symptoms of their mental illness. This was a study by Peterson et al. in 2014 that looked at arrest records of individuals with mental illness and did a correlation of how many of those actual crimes had a direct relationship to the psychiatric symptoms. As you can see from this slide, over 70% or 75% were either mostly independent or completely independent from the mental health symptomatology. There were some, of course, that were completely directly related. That would be an example of somebody, for example, who's hearing voices telling them to steal a sandwich, and they're responding to those commands of hallucination. That would be completely direct. But what is causing all of that to occur? There are a host of factors that relate to why people commit crimes, and we know more and more that people with serious mental illness often commit crimes for the same reasons that other people commit crimes, again, which may not have anything to do with the symptoms. It may have to do with conditions of poverty, the neighborhoods in which they live, substance use, and other variables. Where there are symptoms of mental illness and crime, there are various studies that look at different things. For example, in one study, again by Peterson, bipolar symptoms seem to be more frequently associated with criminal behavior than psychosis itself. Again, when we talk about criminal behavior, how it's defined matters. For example, if somebody is bipolar and acting erratically, the crime might be a minor crime, but it might be a reason for somebody getting in contact with the criminal justice system. Comorbid antisocial personality disorder, substance use, and PTSD were more likely associated with arrest for violent crime than psychosis in this other study that I participated in by McCabe, Christopher, et al. in 2012. So therefore, we know that decreasing symptoms of mental illness alone, although very important, will only have a modest effect on overall criminal behavior in our society. However, because mental illness can be a driver for some behaviors, traditional treatments must not be ignored. But again, they will not reduce most crimes. So the criminal justice system has taken an approach to look at what drives criminal recidivism by looking at something called criminogenic risk factors. And we know we need better understanding of these factors. But for the most part, persons with mental illness, again, will commit crimes because of these criminogenic factors more than their mental illness alone. So using traditional clinical assessments to assess risk to the drivers of criminal behavior or any issues related to violence and suicide risk, while very important clinically, may not fully tell you whether this person will be likely to engage in criminal behavior or not. The criminogenic risk factors that were identified first by Andrews and Vonta in the 1990s are these eight risk factors. History of antisocial behavior, antisocial personality patterns, antisocial cognition, antisocial attitudes, family and or marital discord, poor school and or work performance, few leisure or recreation activities, or substance misuse. These are considered the eight criminogenic risk factors most correlated with criminal justice recidivism. And you'll see mental illness is not on this list. And that's for the reasons I stated previously. Mental illness, however, falls under what's called a responsivity factor, as does trauma, culture, housing, and the like. And these are the underlying variables that might make somebody less amenable to the efforts of the criminal justice system to enhance public safety. What do I mean by that? If somebody is on probation supervision, for example, but they're too depressed to come to their appointment, or they're too disorganized to keep track of a calendar, they may not be responsive to the supervision that they're being offered. But it's not driving crime, per se. Now, in the criminal justice system, there are many risk assessment tools that get discussed. For example, and these are just some of them, the Correctional Assessment and Intervention System, the Correctional Offender Management Profile for Alternative Sanctions, otherwise known as COMPAS, the Level of Service Inventory Revised, LSIR, and the Level of Service Case Management Inventory, the LSBMI, the Ohio Risk Assessment System, the ORAAS system, which is used in many states, the Static Risk and Offender Needs Guide, the STRONG. Now, there are some recent critiques of these risk assessment tools as perhaps being racially or biased or biased by perhaps placing people of poverty in greater risk categories, and more research needs to be done looking at that. It's something we have to pay attention to. But these are tools that are considered evidence-based in the criminal justice system, and they're very often used. You could ask yourself, do you know in your community what is used by your probation department, by your prison system, or by your jail? I work, for example, in a prison system with a prison system that uses the COMPAS to determine the level of risk, recidivism risk, as people are releasing and at other points in their incarceration. Also, a local jail uses the LSBMI. By knowing what the criminal justice system is looking at in terms of risk factors, it's helpful as I think about how to approach treatment planning. What happens when risk is identified? According to the risk-need-responsivity paradigm, all of those eight criminogenic risks are modifiable risk factors to reduce criminal recidivism. The criminal justice system and researchers have developed cognitive behavioral strategies for correctional populations specifically that often focus on those antisocial cognitions and thoughts. We're seeing more and more behavioral health systems start to utilize these. There's more research, of course, that needs to be done, and I'll talk a little bit about how they apply or don't apply to the serious mental illness population. But it's, again, important to know that you might hear about these, and I'm going to talk about a few examples of them. These CBT for correctional populations focus on behavior, on thoughts, and societal responsibility related to their antisocial acts. The goal includes reduced recidivism. The general tenet of these types of programs are once the criminal justice system identifies who's at high risk and has high criminogenic needs, then one should approach treatment separately from the low-risk people. In many ways, the criminal justice system separates out low-risk offenders from high-risk offenders with the idea that the high-risk offenders are the ones where the resources should be targeted if we really want to reduce crime in our society. So, let me give you some programmatic examples that address these offender needs. These examples are for educational purposes only, and, again, I will speak to the application of these models to the SMI population after I tell you a little bit about these approaches. One model established by Little and Robinson in 1985 is called Moral Reconation Therapy. It aims to advance moral reasoning among participants. It was originally designed for a prison-based drug treatment program in a therapeutic community. Again, it is used as a cognitive behavioral approach that covers domains and treatments such as beliefs, attitudes, and behaviors, relationships, reinforcement of positive behavior, building sense of self and identity, helping frustration tolerance, and decreasing hedonism, and building moral reasoning. Another example that I pulled for your knowledge is something called Thinking for a Change, or T4C. This is a cognitive behavioral program as well that examines cognitive restructuring to reduce criminogenic thinking, including rationalizing criminal behavior, minimizing the sense of negative consequences, and it also encompasses social skills development and work within problem solving. It's been studied on populations with adult and juvenile offenders, and it's used quite often in correctional systems. Another model that's been promulgated more recently is something called the Good Lives Model. This is a model that takes a more strength-based approach to offender rehabilitation, as opposed to focusing solely on the criminogenic risk factors. It assumes that criminal behavior can result from difficulty using pro-social behavior to achieve goals, and it helps offenders set goals and aspirations and develop individualized plans to meet goals in positive ways. It is used with sex offender populations as well as other types of offenders, and there is some research on its use with people with serious mental illness. In fact, I worked in a program where the Good Lives Model was applied to people with serious mental illness who also had risks and behaviors related to problematic sexual behavior. And again, because it takes a strength-based approach, some would say that it fits well into the paradigm of recovery that is used in the mental health system. Now, I tell you about these cognitive behavioral strategies and the risk-need-responsivity model, but I also want to point out, as I said, to some caveats with regard to this population of people with serious mental illness. Most of this research on the criminal justice population was done studying the basic criminal justice population, and many of the studies originated out of populations that also focused on substance use, people with substance use disorders. They weren't researched fully initially on populations involving persons with serious mental illness. However, it is thought that these risk-assessment tools are likely helpful in assessing the risk of recidivism even in a population of people with mental illness because, as I said earlier on, people with serious mental illness often commit crimes for the very same reasons as people without serious mental illness. Not all crime is directly linked to symptoms of serious mental illness, and these risk-assessment tools attempt to address some of those other factors, those eight criminogenic risk factors. However, the CBT-type treatment are important to think about. They may be more effective than psychiatric treatment alone, but only in appropriate populations and only if used in a way that we understand, and oftentimes there's limited research to how they should be applied to people with active symptoms of serious mental illness. So further research is needed to see how R&R principles specifically treat the population of people with SMI and criminal justice involvement. Symptomatic treatment is still gonna be critical. So for example, if you have a patient with disorganized thinking, delusions, they may be hearing voices, obviously we wanna approach that the way we traditionally approach mental health care and not just rely on these R&R principles or trying to address criminogenic thinking. When these cognitive behavioral therapies are applied to the serious mental illness population, often we see clinicians modifying the manual so that they work with people that might have more cognitive limitations, processing limitations, or other limitations. As we all know, when we're using a manualized treatment, anytime you modify the manualized treatment, you're really not using a fidelity standard to the model. And so again, we need more research about how this all plays out. Also, this idea of responsivity, which Andrews and Bonta talked about in the risk-need-responsivity paradigm, as a principle itself needs further research support. Nevertheless, since this is such a large part of the conversation in the criminal justice side of the coin, it's important as we're talking about working with populations of people with serious mental illness to understand what's happening from the perspective of the criminal justice providers. So now we're gonna talk about some practical strategies for working with the justice-involved SMI population. So supervision and treatment collaborations are gonna be important. People that are criminal justice-involved, most of them are living in the community, either under probation or parole supervision of some type. And what we have found over the years of doing work with this population is that the more we can intentionally coordinate between treatment professionals and supervising entities, the more we can help our patients achieve their own recovery goals. For example, if their goal is to live independently in an apartment or their goal is to have a job, it won't help them if they keep getting arrested or they keep having technical violations for not following the terms of their probation. So in that example I gave before of somebody who's too symptomatic or disorganized to monitor a calendar or who's too depressed to show up for a probation appointment, that could result in what's called a technical violation and potentially, with too many technical violations, results in a period of incarceration, which thwarts the individual's goal. So we really have to understand the type of supervision our patients are under. How many of you are asking your patients, are you under the supervision of a parole or a probation officer? And if you are, what are the terms of your probation and parole? We also have to help parole and probation understand the mental health supports that people need. When the mental health supports that people need are clearer, it may help probation and parole who often feel alone with paying people who might be symptomatic and feeling like this exceeds their capacity to support them. So this idea of intentional coordination between treatment professionals and supervising entities is somewhat different. When I was in training, the idea of coordinating felt like in some ways we might be getting our patients into trouble. And while there are nuances that need to be worked out, because indeed probation and parole do have the authority to make sure that the person is following the terms of their probation and parole, what we find is with people with serious mental illness and often co-occurring substance use conditions, the criminal justice system is trying to maximize the public safety goals, which involve trying to get the person into the right kind of treatment prior to causing them to be recidivated and sent back to jail. So intentional coordination with agreement and understandings of each other's roles can be important. What you see to the right here is a grid that we use in some of our programs where we look at the level of need people might have, what their criminogenic risks are. If they have high criminogenic risk and very high impairment in terms of their level of mental illness and substance use disorder, then they might need a tightly coordinated plan so that they don't inadvertently get in trouble for not following through with their probation. Or you have somebody that's able to be more functional with regard to their mental health symptoms and has low criminogenic risk, well, that coordination doesn't need to be as intentional and you don't want to over-supervise them because if you over-supervise them, you know, they might have some minor challenges that might result in a violation, which really otherwise wouldn't have resulted in a violation. So really trying to sort out what that intentional coordination can look like. When there is coordination between the treatment system and correctional supervision, it's important to understand the different roles and responsibilities of each side so there's not confusion. There is some overlap. But remember, as a treatment provider, our goal is to help our patients reduce their symptoms and alleviate their suffering. Our primary duty is to our patients. We might use methods such as monitoring their mental status exam and regular appointments. We use techniques like engagement. There might be legal mandates that are required if they are under some legal oversight. But linkages to services of all kinds and then developing standards of care and following privacy rules, those are our roles and responsibilities. The correctional supervisors have different roles and responsibilities. Again, their overarching goal is often to maintain public safety and to reduce criminal recidivism. Their agency is to the public, to the court, to parole, or whoever the correctional oversight body is. It's not to the individual. But that does not mean that they ignore the individual. It means that they have to work with the individual to ensure that the mandates are upheld. They also monitor. They also have regular contact. They might use cross-verification through drug screens and evidentiary hearings when there are issues that arise. They also use legally mandated oversight. They use engagement strategies to enhance compliance. And more and more correctional supervisors are learning motivational interviewing and other types of techniques, which, again, may have some benefit in the serious mental illness population, where we might use something like illness management recovery to help people understand their illness. They provide linkages to services. They follow court orders. They think about terms of release. And then they don't have the same communication constraints. So once we understand each other's roles and the limits of our roles, it actually helps with that intentional coordination and decreases frustration. Now, there are specialized approaches, such as mental health courts, specialized mental health probation caseloads for people with serious mental illness, specialized reentry planning for people coming out of correctional environments that can be utilized to help people with a serious mental illness. Finally, we have to think about the role of trauma and how trauma-informed approaches can facilitate working with individuals who have been justice-involved. Trauma is a major risk modifier, both for criminal justice recidivism and for other types of risk. The ACEs study looked at adverse childhood events prior to the age of 18, looking at household challenges, abuse, and neglect, and identifying the more adverse childhood experiences an individual had prior to the age of 18, the higher the likelihood that they would have a whole host of challenges as adults, both health and risk-taking behavior. And the ACEs study, the typical ACE pyramid available on the CDC website, shows that the more you have these adverse childhood experiences, the more you have social, emotional, cognitive impairment, adoption of health risk behaviors, which gets into the whole criminal justice framework, disease, disability, and social problems, and the like, and even early death. Well, these adverse childhood experiences can translate into trauma and exposure and overactivity and changing the developing brain when they happen prior to the age of 18. And trauma, as we know, disrupts the natural alarm system. Normal stress leads to action-focused or goal-directed behavior, but extreme stress puts us on high-alarm mode, our cognitive processes shut down, and our emotions increase. After exposure to extreme stress, there can be chronic aftermath where our bodies are in high-alarm mode, and oftentimes people that have been trauma-exposed live in high-alarm mode. So one of the things that that may lead to is perhaps excessive reactivity, volatility, and the like. And we see, in fact, that people in the juvenile justice system, in psychiatric settings, in jails and prisons, in substance use systems, have very high levels of trauma, and earlier and more prolonged trauma leads to greater biological and developmental disruption. Trauma and violence is an important factor. PTSD symptoms associated with the perpetration of violent crime and more substance use with hyperarousal as an independent mediator was found in one study. A lifetime history of aggression was related to childhood traumatic experiences in another study. And prisoners with substance use having higher numbers of prior incarcerations, more juvenile convictions, and more institutional violence and suicide attempts had higher scores on childhood trauma, impulsivity, hostility, and worse resilience. And we know criminal justice and in other institutions where people with serious mental illness are, including psychiatric hospitals, can be traumatizing in and of themselves. There are the pre-arrest circumstances, the arrest circumstances, disruptions in social networks, exposure to high noise levels, exposure to individuals with traumatic and tragic life circumstances, exposure to individuals with antisocial and violent propensities, loss of control, humiliation, public exposure, and just the fear of the unknown can all be very traumatizing. So if we think of trauma and experiences of trauma early on and even in adulthood as being mediators or contributors in some cases to subsequent behavior that might lead to further justice involvement, it's important to think about that. So we have to understand that there are complex pathways to both violence and crime. Of course, not all crime is violence and not all violence is criminalized because some of it goes non-criminalized. But we know that there's a whole relationship between childhood history of abuse and adult victimization, personality development and factors, mental health factors and substance use, and all these social and contextual factors that come into play. So working with our SMI criminal justice involved population requires us to have an awareness of these complex pathways that our patients might be exposed to. And it means we need to be trauma-informed using universal precautions means assuming all of our patients have had trauma exposure, thinking about when they are just as involved to use procedural justice techniques which maximizes the sense of fairness and the sense of justice for people who are facing these criminal justice circumstances, helping people feel like they are in safe environments and have a safety network and a community, holding hope for our patients and providing them with peers who can relate to their experiences and help them in their recovery. Which means that one of our jobs while working with people with serious mental illness involves helping them build resilience. Resilience is also complicated. This is not a whole lecture on resilience, but some of the things we have to do is help our patients build self-esteem, modeling behaviors desired, helping them identify stress clusters, helping them self-reflect to the extent that they can and helping them establish mindfulness. Even with patients with serious mental illness, helping them with these factors can be very useful for the criminal justice involved person with serious mental illness. We also have to think about what system adaptations might be beneficial. For somebody that's been exposed to traumatizing environments and has had a long history of traumatic incidents growing up, environments that we send them to can be very traumatizing, as I said. So what can be changed in our environment? Hospitals around the country are trying to renovate their units to be more friendly, less institutionalized, more welcoming, and less traumatizing. We also want to think about making sure that our patients are given task demands that meet their capabilities. Because when we exceed their capabilities, things feel out of control, stress erupts, and behavioral dysregulation can often be the result. We have to do more around workforce development to help our workforce understand some of these issues and help our procedures be modified in a way that are more trauma-informed in terms of system adaptation. Other trauma-related factors to consider in supporting justice-involved individuals, including the fact that understanding that our population is much more likely to be victims of violence and crime than perpetrators. Exposure to violence and crime obviously can be further traumatizing. New data is emerging on positive childhood experiences that can help offset those negative experiences. So as we look at serious mental illness as perhaps emerging in very young adulthood, we want to think about what are these positive childhood experiences that can help potentially put people on a more positive trajectory? And we have to think about prevention and the person with serious mental illness as a parent, because that can be one of the adverse childhood experiences itself. What resources might be needed for their children? We don't want to lose sight of the fact that our patients with serious mental illness might be parents. There's also balancing respect for autonomy versus mandates and obligations, again, going back to that procedural justice. And when autonomy is overridden through civil commitment, guardianship, or forensic commitment, it doesn't mean we don't respect the person, it doesn't mean we don't explain what's happening, we don't talk to them about what they experienced when they went to court. These are ways we can help them feel that the system is on the whole more fair and more just. We want to think about their whole health, because we know that there's a frequent co-occurrence of serious mental illness and substance use disorders in the justice involved, as well as health conditions that might otherwise go unattended. And so understanding translation and resetting behavior and attitudes can also be very helpful for our population. Remember that many of the individuals that are justice involved with serious mental illness have been in the justice system for much of their lives, if not from young adulthood, adolescence, in juvenile justice to adulthood. And so maladaptive behaviors that may be apparent on the psychiatric unit or in the outpatient clinic may have been adaptive behaviors in another setting, in the justice setting, where survival was built on other types of skills. One model that's been promulgated by my colleague Merrill Rodder and his colleagues was something called Spectrum, which helps people understand what can be adaptive in correctional settings and how it translates into community settings. For example, when you learn a correctional setting not to snitch, it might translate to don't tell your doctor anything. The rubric don't trust in a criminal justice system, which can be survival, might translate to don't engage. So the more we understand that about our patients, that they may be coming from a place where they're using what were adaptive behaviors in one setting that become maladaptive in another, the more we can help them feel more comfortable. So let me conclude with a summary that says working with persons with serious mental illness with justice system involvement and histories can be extremely rewarding. Perceived and real challenges can be ameliorated with training and experience and consultation. The criminal justice responses to recidivism are very well developed. So more research is needed focused on the serious mental illness population and as it relates to the justice system. But we as professionals can gain skills through trauma awareness, systems awareness across systems, and knowledge of resources available for support. I hope this webinar provided just one of those resources and I hope you dive in further to learn more as you work to do best by your patients. Thank you.
Video Summary
In this video, Dr. Debra Peinold, a Clinical Professor of Psychiatry, discusses the challenges clinicians face in working with individuals with serious mental illness (SMI) who have been involved with the justice system. She emphasizes the importance of understanding the criminal justice system and developing comfort with working with justice-involved individuals. Dr. Peinold also highlights the need for trauma-informed approaches when working with this population, as many of them have experienced adverse childhood experiences and may have been exposed to trauma in the justice system itself.<br /><br />She discusses approaches used by the criminal justice system to identify and reduce criminal recidivism, including risk assessment tools and cognitive-behavioral therapies. Dr. Peinold notes that while these approaches have been well-studied in the general criminal justice population, more research is needed on their application to individuals with SMI.<br /><br />Dr. Peinold concludes by discussing practical strategies for working with justice-involved individuals with SMI, including the importance of supervision and treatment collaborations, trauma-informed care, and system adaptations. She emphasizes the need for intentional coordination between treatment professionals and correctional supervisors to maximize the individual's recovery and reduce recidivism. Overall, Dr. Peinold emphasizes the importance of understanding the complex needs and experiences of individuals with SMI who are justice-involved and providing them with appropriate and effective support.
Keywords
Dr. Debra Peinold
Clinical Professor of Psychiatry
serious mental illness
justice system
trauma-informed approaches
criminal recidivism
risk assessment tools
cognitive-behavioral therapies
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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