Hello, and welcome. I'm Dr. Amy Cohen, a clinical psychologist and director for SMI Advisor. I am pleased that you are joining us for today's SMI Advisor webinar, Supporting Persons with SMI in the Community After Release from a Correctional Setting. 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. Today's webinar has been designated for one AMA PRA category credit for physicians, one continuing education credit for psychologists, one for social workers, and one nursing continuing professional development contact hour. Credit for participating in today's webinar will be available until March 28th, 2021. Slides from the presentation today are available in the handouts area, found in the lower portion of your control panel. Select the link to download the PDF. 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've reserved 10 to 15 minutes at the end of the presentation today for Q&A. And now it is my pleasure to introduce you to the faculty for today's webinar, Dr. Deborah Pinals. Dr. Pinals is the Medical Director of Behavioral Health and Forensic Programs for the Michigan Department of Health and Human Services. She is also the Director of the Program in Psychiatry, Law and Ethics at the University of Michigan. Dr. Pinals' research interests include the legal regulation of psychiatric practice, law and psychiatry, and justice and behavioral health. Dr. Pinals, thank you for leading today's webinar. Thank you, Dr. Cohn. It is a pleasure to be here today to be speaking to the participants in this webinar. I just want to 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 I'm hoping that we can accomplish today is a number of different things. First, I'd like to discuss reentry with you and data regarding outcomes for persons with mental illness and substance use disorders returning to the community from incarceration. I think that's really important to get some grounding into why this is such a critical matter for all of us to understand. Second, at the end of this presentation, I'd like you to be able to understand and discuss these emerging models of support following release and related data regarding critical time intervention, fact models, and mission criminal justice, which I'll explain during the presentation. And then finally, I'd like to discuss actions that can be helpful for providers as they support individuals with SMI returning to their communities from incarceration. There will be a time, as Dr. Cohen said, afterwards for question and answer as well. So let's start with the first objective, discussing reentry and data regarding outcomes for persons with mental illness and substance use disorders returning to the community from incarceration. Just as a backdrop, in 2009, the total correctional population in the United States was estimated to be approximately 6.3 million people. Now, what that means is not all of those people are behind walls or behind bars. Of the total correctional population, about 2 million people were in some type of correctional or carceral facility, 734,000 in jail, and about one and a half million people in prisons around the United States. The remainder of people under correctional supervision were under some sort of community supervision, like probation or parole. And this is important to realize because when we think about the correctional population, we typically think of the hardened facilities like jails and prisons, and we think about as the only place that is considered correctional. However, it's important to realize that individuals under community correctional supervision are at risk for returning into a carceral setting as well, if they have violations of their terms of probation or parole. So it's a very fluid population that we're talking about. And when someone is treating an individual with SMI who's returned from a carceral setting, it may be possible or likely even, and I'll talk about the data, that they will be returned to a jail setting or to a prison setting. And that's one of the things that we really hope that through specific interventions, we can reduce. So as a reminder about community supervision, let me just explain. Probation is something that can be pre-trial or post-trial. Probation is ordered at a time of trial or sentencing by a judge. In other words, a person might be sentenced to a period of probation. Probation officers monitor adherence to terms such as compliance with treatment, refraining from contact with certain individuals, and even requiring individuals to sign releases of information so that probation can be aware of what's happening in an individual's treatment. Parole is generally operated by a separate body, often its own agency, with a parole board that ultimately makes release decisions. And this is an entity that decides release with conditions after someone has served a sentence. So they may leave a prison setting or even a jail setting on terms of parole. The duration within the sentence is determined by a board. In other words, an individual could be sentenced for a period of time, but after some window of that time ends, they could become what's called parole eligible, in which their case is brought before a parole board for review, who then determines whether they can be released on parole under terms. Some people serve out their sentence within the correctional environment and don't end up on parole conditions. But most people coming out of prisons do end up on parole conditions. When somebody is released on parole, there can be a community-based parole officer who is monitoring adherence to the terms of that parole. Now, interestingly, some individuals can be on both parole and probation supervision. And I'm not going to get into too many details about that, but other than to say that as somebody treating an individual with serious mental illness, it's helpful if they have been justice involved to understand whether they're under any terms of supervision by either probation or parole to understand what their requirements are. So what do we know about people leaving jails and prisons? Unfortunately, the data is very humbling. What we know is that individuals with serious mental illness are convicted of felonies, show poor follow-up with treatment services, and up to 40% re-arrest within three years. For individuals with co-occurring disorders, there's equally stark data. Of 61,000 Texas prison inmates, those with co-occurring psychiatric and substance use disorders had higher risk of multiple incarcerations over six years. Parolees with dual diagnosis are at increased risk of parole revocation for technical and non-technical violations within 12 months after release. A technical violation is something like non-adherence to the terms of the supervision, whereas a non-technical violation is something like committing a new offense. And so something as such as not showing up for an appointment that one is supposed to show up for could be considered a technical violation that results in a parole revocation. Post-release outcomes are also stark when it comes to risk of death. And sometimes we talk about re-entry as a matter of life and death. The risk of death of released prison inmates is 12.7 times higher within two weeks of release than for state population residents. And the leading causes of death include drug overdose, suicide, homicide, and cardiovascular conditions. Now, this particular study by Binswanger and colleagues was not a study about people with serious mental illness. But nonetheless, it's an important reminder that where we have individuals with co-occurring disorders or those who might be at risk for suicide, that we have to be mindful of the life and death matters related to prison release. So re-entry is considered that term where people shift from moving from a carceral setting or a correctional setting into the community. And there are many challenges that have been identified in multiple studies in the literature. For example, individuals leaving a prison or jail often have few financial supports to sustain them. By virtue of being incarcerated, they will have disrupted social supports and need to navigate the world with those disrupted social supports. Some of them by virtue of some of their conduct and some of them by virtue of other factors that are going on in terms of that disruption. Also, individuals are disproportionately released to communities of poverty that creates other challenges related to social determinants of health. They're often facing homelessness and unsanitary conditions, which contribute to worsening health overall. And also, homelessness is associated with risk for rearrest. There can be ongoing demoralization and strain for individuals who are trying to navigate the world after being set aside in a correctional environment. For individuals with serious mental illness, they can be at increased risk of suicide, reincarceration, and or hospitalization as a result of disruptions of care and lack of support. They can have limited medication supplies. And although most jails and prisons have policies regarding helping individuals have medications upon release, often those medications may be distributed to them in a paper bag. As they leave, they could get lost if the person's homeless and has nowhere to place them. They also may not be able to follow through on appointments that are set up for renewing prescriptions or getting seen by a psychiatrist or another prescriber. Medicaid is another issue. Many people, if not most people who are being released with serious mental illness, are Medicaid eligible. And their Medicaid is generally going to be turned off while they're in a correctional setting because Medicaid does not cover treatment services other than hospitalization in certain cases for individuals who are in jails and prisons. And so, many states have moved towards something called suspension of Medicaid instead of termination of Medicaid. So, it may not be that the Medicaid is completely turned off, requiring a reapplication for Medicaid upon release, but it might be that it's completely turned off. In those states where the Medicaid is simply suspended, the idea is that as soon as Medicaid is made aware that this person has been released, their Medicaid can be reinstated without a reapplication. However, even in those states where Medicaid is suspended, there can be challenges navigating health plans, making sure that they have the right identification, and other things that make it difficult upon reentry to maintain continuity of care. And then finally, there's a lot of stigma associated with reentry. There's already more than enough stigma associated with serious mental illness. But put on top of that stigma associated with having been in a correctional environment, it really has more than a doubling impact on some of the negative outcomes that might happen for individuals. And that stigma, I would say, is pervasive across systems. And oftentimes, because individuals providing care and treatment for persons with serious mental illness are not familiar with what it means to work with somebody who has a correctional history, may themselves have some stigmatizing concerns. I can certainly tell you that in my own experience, when I started to work in prisons, some of my own mental health professional colleagues didn't understand what drew me to that type of population without realizing that, in fact, the population is essentially the same people that they were taking care of just at different points in their trajectory of their lives. Some of them may have committed some serious offenses that can be difficult for individuals to work with. But I would say that the population can be very rewarding in terms of successes that can be achieved. But stigma concerns remain very strong for employment, for access to care, and a whole host of other issues. So now that I've identified some of the challenges related to reentry and some of the statistics that we know are out there, it's really important to think about ways to overcome negative outcomes and to help our clients or patients who have serious mental illness be able to fare better in the world post-incarceration. So I'm going to turn us now to the second learning objective that I have for you, which is to discuss emerging models of support following release from incarceration. The first model I want to talk about is called critical time intervention. So critical time intervention is a model of support that was developed as an intervention to help transition an individual to the community from some type of other setting, such as a shelter or a hospital. It's been around for more than a decade, way more than a decade. And it has proven to be very successful in several ways for individuals with serious mental illness. The model design is such that it is a program of a time-limited add-on support with a nine-month case management program in its original form. The focus is on building connections in the community, and because it works from a transitional model in the sense that it helps people move from one place to another, it has phases and stages that it uses as people gain attachments and stability with more permanent types of supports. The individuals working in critical time intervention use motivational and problem-solving to assist the client navigate the transition. And the work aims to have durable supports in place as one of the goals of the transition. In other words, they start working with the individual with the goal in mind that this will be temporary support, and that part of the job of the temporary support is to link people tightly to services and supports that will become durable for that individual. In other words, it's somewhat like a bridge model. There's three key phases within critical time intervention, including engagement and early linkages, where the idea is really establishing a relationship with an individual pre-release with monitoring, focus, and then post-discharge follow-up in the studies looking at reentry. So, for example, I've identified just these two stages, the two phases that you can see from this study in 2017. In phase one, the critical time intervention staff visited the client twice a week, communicated with in-reach staff within the prison at least weekly, visited housing provider and family caregivers at least twice, communicated via visits, calls, and or emails with housing providers or family caregivers on a regular basis, at least fortnightly, and communicated also with community mental health providers at least fortnightly. So, in other words, during this phase one, there's that engagement where you're really trying to get to know the client, get to know their natural supports, and maximize communication to help bridge that transition to release. In the second phase, two weeks post-release, they visited the client at least once per week or maintained other types of contact, visited and or talked by telephone with the client at least four times a week, and then communicated with community mental health providers at least four times a week, visited housing provider family givers at least once, and then visited and or talked by telephone with housing providers or family caregivers at least three times. And I hope what you're seeing is that there's a very prescriptive way to help the individuals providing the support navigate what the work is that they are supposed to do. So, rather than just say, we're going to assign you a case manager and just let the case manager figure out whatever it is they need to figure out, it really gives a much more formulaic way of giving the case manager or the navigator the models for how much support is needed and what would be required of that support. And then in phase three, there's less frequent contact because presumably the individual leaving the prison is now getting more and more attached to their more permanent supports. So, the model of critical time intervention is that the intensity shifts over time. Now, there's been a lot of work done on a critical time intervention. There's even the Center for the Advancement of Critical Time Intervention, and you can go to the website to learn more information. In this one study by Lennox and colleagues from 2020, they looked at qualitatively what was happening as the work was unfolding. Themes for individuals upon release included their uncertainty about post-release plans, the inadequacy of housing, the need for support during transitions, and the importance of continuity of care. For the critical time intervention participants, by having CTI, they felt less anxious about release, more supported with housing, access to services, and community reintegration. Now, some clinicians in this study found that CTI's intervention was positive, but also raised some concerns about its time-limited nature. Nonetheless, the studies are very positive about its impact on helping people maintain stability. For example, in this study out of the UK of CTI and reentry, they looked at a randomized study of 150 male prisoners with severe mental illness who were randomized to receive either critical time intervention or what was considered treatment as usual upon release, which meant not having this additional support of CTI. In this study, they found that CTI improved engagement with community mental health teams compared to controls at six weeks, 53% versus 27% with the control group, with continued engagement even beyond at six months. Now, of note, there were no differences in engagement patterns between groups at 12 months, which does raise further questions about long-term stability and what might be needed either in additional supports or with the handoff for the providers that are receiving those individuals to be able to continue the work of the critical time intervention providers. Nonetheless, this study shows a very positive outcome for ongoing engagement with the use of CTI. The next model I'd like to discuss is forensic assertive community treatment. You may have heard of ACT teams or assertive community treatment teams. Well, now we're going to talk about FACT teams. FACT teams are very much modeled after the ACT model, which as many of you may realize is a model that was designed as a hospital without walls, recognizing that many individuals with serious mental illness were at risk of multiple returns to psychiatric hospitalization. The assertive community treatment model basically said, let's build the hospital without the walls in terms of having this multidisciplinary team that can meet the person where they're at, help them get their medications, help them support them in whatever housing they're in, and really keep tabs on them with supports and mental status monitoring. And that ACT model has a large evidence base to support its efficacy for people with serious mental illness who've gone in and out of psychiatric hospitals. So the FACT model takes that same premise, but adds a component of preventing incarceration as opposed to just hospitalization as an outcome that we want to reduce for those individuals at risk of incarceration who have serious mental illness. And so it is considered to be time unlimited, and it assumes the need for longer term support. It can be titrated as needed over time, meaning when people need more intensive services, it ramps up. The team does more outreach when it needs less intensive services and people are more stable, they can reduce their contacts. But essentially, the individual is under FACT services for a longer duration of time. Typically, there's limited caseloads to make sure that the team can appropriately address the individual's needs. Now SAMHSA has established key components of forensic assertive community treatment. Specifically, they have identified that there should be forensic services that address criminogenic risks and needs, which I'm not going to get into in great detail, but there are other SMI advisors that are available to you that cover the criminogenic risks and needs issues. But essentially, criminogenic risks and needs are those factors that are associated with repeated arrest and incarceration. Sometimes criminogenic factors are associated with violence, but predominantly they're about re-involvement with the criminal system. And those include things like antisocial personality traits, as well as disruptive families, and lack of positive pro-social activities during the day and other factors. And so they, in the FACT team, they will address some of those additional risks to try and reduce the likelihood of the individuals being re-arrested or re-incarcerated. They also have, in terms of the key components, they also should have client eligibility based on a set of well-defined criteria, including the criteria of having been incarcerated multiple times. They should provide client access for round-the-clock individualized psychiatric treatment and social services that address the immediate needs and improve stabilization for their clients. And fourth, there should be service delivery by an integrated multidisciplinary team, including an individual especially equipped to deal with the criminal justice matters. Also one of the key components is cross-system mental health and criminal justice team member training, so that everybody on the team is aware of the mental health needs and the criminogenic issues, so that everybody is sort of rowing in the same direction in terms of supporting the individual in the FACT team. There's also implementation fidelity to ACT and quality control. Both critical time intervention and FACT and ACT have fidelity monitoring where there should be some ability to assess whether the teams are actually following the model that has the positive evidence base attached to it. I'll speak a little bit more about that in a moment. And there's also should be flexible funding and implementation support for the FACT team to be able to continue. The third model I want to focus on is called mission criminal justice, and I was fortunate enough to help co-develop this with my colleague Dr. David Smelson out of UMass Medical School. And this is a model that we've used in several settings, including specialty courts and reentry services. We have worked on this model, not targeting specifically people with serious mental illness, but always people with co-occurring mental health and substance use disorders, of whom some of them do have serious mental illness, if not many. And what mission criminal justice is, is an integrated approach that uses a fidelity-based model to help support individuals as they are justice-involved. We have measures in terms of fidelity measures that track integration of the complex service structure and consultation throughout, and I'll explain it a little bit further. Essentially, the core elements of mission criminal justice, which mission is an acronym that stands for maintaining independence and sobriety through systems integration and outreach and networking, and then criminal justice is the CJ. The core services of mission CJ include critical time intervention that I've already explained to you, dual recovery therapy, which is a cognitive behavioral-based model for helping people with co-occurring substance use and mental health conditions, and then peer support. In addition to focusing on the symptoms and the illnesses, the model provides support services such as vocational and educational supports and trauma-informed care. Now, the mission model itself has been around for a long time, first developed working with veterans who were facing homelessness, and the adaptation that included the criminal justice angle was the incorporation of a risk-need responsivity framework to help the staff that were supporting the individuals in their community integration with criminal justice supervision or reentering from a jail or prison. By using that risk-need responsivity model, the team is also focused on criminal recidivism reduction. The team members in mission criminal justice consist of a case manager specialist and a peer support specialist, and these individuals have tasks that they are to do with the person that they're supporting. They are to deliver 13 dual recovery therapy sessions. Clinical, therapeutic, and diagnostic expertise should be added to the mix, and the case manager intervenes during clinical emergencies. The peer support specialist delivers at least 11 peer-led sessions. They provide expertise based on personal experiences, and we have many of our peer support specialists are peers with criminal justice involvement as well as mental illness and substance use conditions, and they facilitate use of a participant workbook that gives the participants in the program some homework and exercises that they can follow to help improve their outcomes, and the peer support specialist provides active community outreach, and the case manager specialist and the peer support specialist are very much tied together as a team to help support an individual who is involved in the criminal justice system. Mission CJ has key goals of improving clinical outcomes and functioning, and many of the studies surrounding Mission CJ have shown that there are improvements in clinical outcomes. Also, the goal is to maximize community tenure in a pro-social direction by reducing the chance of rearrest, reducing the likelihood of serious criminal activity, preventing incarceration, and reducing jail days overall, as well as reducing mental health and substance use symptoms, all with the hopes of helping that individual achieve their recovery goals, which presumably include being able to stay in the community without risk of reincarceration. Mission CJ key goals also include identifying and linking individuals to comprehensive and effective community-based behavioral health care. It is a model, again, of transitional support that is meant to link individuals to more sustained treatment. It has other goals of preventing homelessness, and as I said, the mission model was first established to prevent homelessness, and so the training for the staff, there's a lot of information available about homelessness, as well as enhancing public safety as another goal. This is an example of a flow diagram of how mission criminal justice might work, and this is taken from one of the programs that I was involved in where we were working to help with reentry services for individuals with co-occurring disorders coming out of a particular jail. First, there's the work of identifying who might be eligible for the service, and that requires work within the jail to have referrals sent to screeners who can identify that the person has a co-occurring condition of mental health and substance use disorders, and that usually is done four to six months prior to release, and then the inmate is approached regarding their interest in the program. They can be screened for their eligibility for the program, and then once they are deemed eligible and are voluntarily willing to participate in the program, they can be attached to the team, the mission criminal justice team. In this case, it was integrated reentry and peer support in the western part of the state that we were using this in, and we were integrating various aspects of care, including medical care, and furthermore, once that attachment is made, the reentry support specialists, which is the case manager and the peer support specialists, would meet with the inmate in pre-release groups for approximately three months prior to release to help with engagement and rapport building. Then the individual would be released, and then the further critical time intervention features would continue with program contacts, and then, of course, as we were doing these under grant funding, we were doing assessments and evaluation of the services as we went along, and the individuals would continue to get support for up to six months in this particular program following their release, and throughout that time, there was fidelity monitoring to the service provision. So, in adding the criminal justice component and the criminogenic risk, one of the things that mission criminal justice does is it asks whether there's a criminal recidivism risk score or risk assessment that is being done by the correctional system that can be integrated into the treatment plan. So, this is an example of something called a compass, which is a pretty commonly used type of scale that is used in criminal justice settings to look at risk of violence, recidivism, or failure to appear, as you can see in this particular sample report picture that I've downloaded from the internet just so that you can have a picture of it, and then this compass looks at various aspects of the individual's characteristics that help understand where they have risks, greater risk factors for ongoing criminal recidivism, and the mission criminal justice team takes all of this into account as they're building out linkages and supports, and so the client is always at the center. The team that provides the wraparound supports helps that individual engage in housing, educational and vocational supports, general medical care, work with their criminal justice supervisors, if any, help them with substance use treatment, mental health services, and benefits. They also work closely, as I said, since this is a criminal justice behavioral health partnership, they work closely with correctional supervision, and they work out where their roles are and how they can leverage each other's roles to help the individual achieve recovery, and I'll get into this a little bit more, but there are clearly some differences in roles that can be used in concert to help that individual sustain that community tenure, maintain public safety, and reduce further symptoms. The mission criminal justice model has also evolved to include a treatment support planning tool that helps pull in that criminal justice information into a behavioral health treatment plan with a focus on co-occurring disorders as well, and this is just a part of the tool that's been used for the case managers and peers to help guide their thinking, data collection, and information gathering to help guide how they're going to work with the client around treatments, so, for example, they might look at these criminogenic risks that are seen on the left-hand side of this chart, such as this individual may have significant antisocial behaviors, antisocial personality patterns, antisocial cognitions, and peers, in addition to their mental illness, and that needs to be addressed separate and distinct from providing antipsychotic medication for their delusions or for their voices, and so what that means is in terms of approaches by the staff, education of the individual about some of these risks, frequent contact with them, strong communication between the provider and probation and parole to help reduce the likelihood of re-engagement in antisocial behaviors. For example, to address the antisocial peers, there may be additional work of the peer support specialist engaging the individual in activities that allow for prosocial associations like volunteering, community service, and using that peer support specialist just to foster hope and positive connections. Another example is if the individual also has antisocial cognitions. Many programs have utilized something called cognitive strategies for criminal justice thinking, like moral recognition therapy or thinking for a change, and, again, there's another SMI advisor webinar that talks about these issues. Some of them have been adapted for people with serious mental illness, and there's not as much direct evidence supporting those adaptations, but, nonetheless, this is a standard approach and may be appropriate for certain clients, but it has to be individually assessed, and then, of course, dealing with trauma and providing trauma-informed supports is going to be important as well, as well as looking at other aspects of risk, like family and marital relationships, employment and education needs, leisure and recreation, and, of course, substance use and engaging individuals in appropriate substance use, including medications that can help address, for example, opioid use disorder and alcohol use disorder, something that very often individuals with serious mental illness aren't getting access to as much because people are more assuming that they have serious mental illness and perhaps not giving them that co-occurring treatment approach that might be most helpful. There's also, throughout the mission criminal justice intervention, program reviews at a leadership level, frequent case conferences to allow the case managers and peers to talk about what they're dealing with and, in fact, to talk to each other to support each other because it's really hard work to help these individuals. There's clinical consultation available. There's often discussions about ensuring that roles are clear, and then there's monitoring documentation and data reporting to help quality improvement along the way and supervision of staff to help guide them in their approaches. Now, besides these three main models, there are other things to think about in terms of helping individuals being released from correctional settings that are important to be aware of. For example, some communities have specialized probation or parole officers who are specialized in mental health matters. If your community is one of those, it might be helpful to understand a little bit more about how those officers are working, but oftentimes these are individuals who go to extra training, who are more aware of where the services are and how to identify the services appropriate for the individuals under their supervision. There's also a big movement, an important movement around peer support specialists, especially those with criminal justice history to help support individuals achieve success, provide role modeling, and help hold hope for the promise of being able to achieve stages of recovery. Now, there's been also a lot of work looking at how the conditions of confinement can impact people's activities and behaviors, really, where they may learn things that are adaptive within a prison or a jail setting that then become maladaptive in a community setting. And so it's really important to think about, as a treatment provider, just generally the conditions of confinement that the individual was in and maybe look at some of those behaviors as learned behaviors through a system of adaptation to complex environments. Now, in other countries, this is a picture of a jail in another country, there's a lot that is being done looking at architectural design of carceral settings and trying to make them more humane environments so that that adjustment to community settings isn't as difficult. And some places in the United States are looking at that type of architecture and social justice. But as a provider for individuals that are coming out of jails and prisons, it's also important just as an individual, for me, for example, as a psychiatrist, to talk to my patient about what they might have experienced and understand those behavioral adaptations that may be something to focus on in treatment. Finally, the third and final learning objective is to discuss actions that can be helpful for providers as they support individuals with serious mental illness returning to their communities from incarceration. Even if you don't have any of those models available, although having shown you these models, these might be things that you want to incorporate into your own systems or practices. But importantly, the work of re-entry requires a lot of planning. And the APIC model is a framework that's been established for many years regarding guidelines for helping people transition from corrections to the community. And it includes four main components, assessing individuals who might have behavioral health needs and risk, and then planning to help make sure that they get attached to treatment at appropriate treatment levels. And then identifying critical periods, especially time surrounding release, where people are often at risk of going in a different direction than what they thought they were going to go in for a variety of complex reasons. So really being there to support them during those critical periods of time. And then policies and practices that enhance continuity of care. Finally, coordinating, supporting firm but fair adherence to treatment and supervision, developing information sharing mechanisms across behavioral health and justice system, supporting cross-training and data analysis. And so essentially what is the current thinking around this with a lot of evidence behind it is really looking at opportunities for collaboration. Utilizing a new behavioral health framework or not so new, but really pulling in what works in recidivism reduction, what works in mental health treatment, what works in substance use disorder treatment, and bringing it all together. There are also common themes for consideration as we look at the next generation of research in reentry. This is a study out of Michigan, the Center for Behavioral Health and Justice through Wayne State University. Dr. Cheryl Kubiak has been instrumental in the Michigan Mental Health Diversion Council with her team of excellent researchers. And they've done studies looking at individuals coming out of jails and found that individuals with community mental health relationships were more likely to engage in treatment post-release. So the longer that I'm in this business, the more I believe in what I learned when I first started in psychiatry, which is about the value of the human relationship and the value of valuing the people that we're serving as people and really building that rapport and treatment alliance. And so this study really shows that post-release connection was much strengthened by pre-release relationships. And that brings me to talking about some studies related to engagement. There's been some interesting research to try and get at what are the elements of positive engagement. And with the goal of thinking about how do we keep people engaged in treatment and minimize their disengagement? If you look at retention, we know that there's problems with access to care, but another metric is looking at retention and care. And retention and care is really an issue that we have to pay attention to for people with serious mental illness, often with co-occurring substance use disorders who are criminal justice involved. It's about motivating the client to attend treatment and removing barriers to continuity. And it's not as much about fixing the client, but really about fixing the system to make the system more client-friendly to help provide the services that are going to be useful for that individual. Looking at attendance, participation, and attitude about services can be really helpful because these all interact. If somebody doesn't like the services they're receiving, it's not very likely that they're going to continue in them. Continuity of relationships pre- and post-release is another element of engagement. Disruptive and disengaged individuals can present challenges for providers, but it's important to look at the reasons for that disruption and that disengagement. And that's often the subject of case conferences that I'm involved in, when the teams are struggling mightily to engage somebody and looking for different angles to do so. And having those conversations allows that opportunity. There's also attitudes and interpersonal skills of the caseworkers and providers, the value of reminder letters, phone calls, praise and rewards for attendance, the removal of barriers like assisting with transportation, maximizing flexibility, arranging other types of supports, relationship and therapeutic alliances, I've said, helping establish a shared decision-making and supported decision-making framework, so individuals are really empowered to make the best decisions for themselves, and really humanizing case management roles, so it's not just about documentation and meeting criteria, but it's really about that relationship building while doing the things necessary. And this person-centered approach to risk mitigation can change the equation from whether the individual is high, medium, or low risk as a label, but really understanding how did they get into this situation, how can we help them have hope so that they can move themselves off the highway that they've been on, which is complex and full of barriers, and really move them into a better pathway. So, the common elements of positive programs include education, training, engagement, consultation, support, community connections, identifying mechanisms to review data, identifying means of improving services. This is an example that I'll just give you briefly of data that we collected in one of our missions criminal justice programs where we were doing fidelity monitoring. If you look at the chart to the right, the orange bar reflects what was expected in terms of fidelity, and the gray bar reflects what was the actual service, and you can see in the first few months, our providers were not meeting the terms, the fidelity terms, they weren't engaging with people to the level that was expected. Well, rather than looking at our providers and saying, what's wrong with you, we spent a lot of time talking to them. In this particular example, one of the challenges was they were having difficulty getting access to individuals within the jail. In another example, people were afraid to go into communities where there was violence in those communities, and so we established safety protocols and other factors to help overcome those barriers for the providers to help meet the clients where they were at, and you can see the engagement and the actual service delivery actually exceeded expectations afterwards. So, going over the challenges of what's happening can really help the staff and give them hope so that they're not just being reprimanded for not doing what you want them to do or not succeeding. It's hard work, and it's really important that everybody be working together in doing this. There's also the opportunity to build out brochures, and all of the programs I've been involved in, we develop brochures to help inform clients, families, and others about what the program does, where they can go for additional help, and other sorts of resources that might be useful, and then cross training. As I said, there are differences between probation and parole and treatment providers. Remember, a treatment provider's primary alliance is to the patient, whereas in correctional supervision, they have alliances to the public, to the court, to the correctional oversight body, and yet they can work together in partnership to leverage each other's strengths. They do have common elements in terms of monitoring, but they might be monitoring for different things. For example, a treatment provider might be monitoring a mental status for somebody with serious mental illness, whereas correctional supervision will be monitoring compliance with terms, and so I think it's really important to be aware and take time to think about what those relationships can be and what roles there are so there's not confusion, and instead of overlapping and being confused, there can be a way of working together, and this is a model that Prins and Osher promoted out of Council of State Governments in 2009 to really look at this way of designing treatment where somebody with high risk of criminal justice involvement and high functional impairment due to serious mental illness might need a really tightly integrated model of correctional supervision and treatment so that I, as the psychiatrist, my case manager and peer team, and the probation officer are working hand-in-hand, talking to each other to help make sure that we are supporting the client to the best of our abilities so that we can reduce their chance of recidivism. Somebody with less needs might need less coordinated supervision, but in our mission criminal justice model, we ask the staff to come up with these grids to understand how they should be working in collaboration with community supervision. It's always important to remember the issues of trauma, behavioral health, and justice and how they overlap. We know that there's high levels of trauma in this population, and so being trauma-informed in our approaches is very important as we move to support people coming from systems of incarceration to community settings. The relational strategies, as Angel and colleagues point out, are critical. Developing that relationship bond, pre-release engagement strategies, and then re-entry engagement strategies where there's both instrumental and emotional support. Instrumental support being helping with those logistics and planning and getting appointments and helping with identity, ID cards, but then that emotional support to help people deal with the anxiety and stress, and both should be measured as successes. Also, providing non-judgmental and empathic responses to individuals and using relational leverage to include linkages to resources and family engagement if there is an extended support network that's a positive influence for that individual. It's really about building safety networks for individuals with their families, friends, rebuilding relationships that are broken when possible, if not providing those peer supports that can be helpful to get people reconnected to society, working with the community at large, spiritual connections, faith-based connections, and other criminal justice partners. So, in summary, there are many clinical approaches that can be utilized after a turn from incarceration. So, although communities may feel frustrated and like there's nothing we can do about this endless revolving door for individuals with serious mental illness or revolving in and out of criminal justice systems, I would say that we really have some tools available to us. We need to learn more and do more. Re-entry is a period that is fraught with risk and potential for success. Stigma and barriers to support are drivers of negative outcomes. And we, as providers, I'm so grateful to all of you for listening because we, as providers, have the opportunity to reduce our own tendencies to be drivers of negative outcomes and really hold the hope that needs to happen for these complex populations. And there's a lot of promising research demonstrating models that could help reduce the cycle of incarceration and relapse. The models that I've shown you are certainly not the be-all, end-all of everything that there is, and there will be models that will come and we'll learn more and more about engagement. And I would encourage all of you who are listening to think about this as strategies in your own practice to help the individuals with serious mental illness to sustain recovery in a meaningful way. And with that, I'll end and turn it over for questions. Dr. Pinal, it's always a pleasure to have you as part of SMI Advisor, and this is another one of your excellent presentations. Before we shift into Q&A, and there are quite a few questions coming in, I would like to take a moment and let the audience know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access our resources, education opportunities, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. You can download the app now at smiadvisor.org forward slash app. So, you know, one of the questions that came in, Deb, that I thought was interesting because I just heard someone ask this question on another call, which is how do we work with the system that is blocking a lot of peers from being employed because they have a past criminal justice involvement? So the idea is we'd like more of those people to be able to be part of the team to offer hope, to work the system with us when we have criminally justice involved clients, but then we can't hire these peers. So any ideas about that? Thoughts about, is there any legal way we can work on that? What can we do? Yeah, I would say that that's a really important question, and part of my first initiative with Mission Criminal Justice involved hiring a peer who had a criminal justice history and it turned into a whole big complex fiasco, not because he had done anything wrong, in fact, he was one of our strongest peers, but because of the alarm bells that went off for people that we had hired somebody with a criminal justice background, and this was before that was even something that was talked about. So one lesson I learned from that is the importance of transparency that people need to understand who we're hiring. Second of all, there are protections even for people who are not hired as peers, you can be hired with a certain criminal justice background. So you want to make sure that the individuals that you're trying to hire are not disproportionately disadvantaged over somebody who's not going for a peer support role, because that's something I've noticed is as soon as you flag it, people pay more attention to it when technically speaking, like in the example I was telling you before, the person was hired on perfectly fair legal grounds. So you can't disproportionately impact somebody who's going to be working in a peer role compared to others. Second of all, there are ways, for example, we have gone to leaders of correctional systems and explained that these are staff that we are working with. So some of the rules about coming into prisons or jails, or who they're willing to hire, they've been able to understand that if this is somebody in a professional role, that they can have this job. Some of the people I've had as peers who are under, for example, parole supervision, the parole board has given permission for them to work if they're under the supervision of a team and I don't mean in the correctional sense of supervision, I mean in the employment sense. And so I think there's barriers that can be broken in that way. And so going to the leadership and trying to advocate for this, I think is one way. There's probably going to be laws emerging related to this issue over time because it's such a need. And many states have really started to reexamine some of the restrictions. Wonderful. A couple people have written in and said, where can I learn more about dual recovery therapy? So you can go to missionmodel.org. It does have its own website and it will give you additional information and certainly through the literature, there's lots of peer-reviewed studies looking at dual recovery therapy. Wonderful. So a lot of people, just lots of compliments are coming in, of course, and I think it just reflects how much need there is for information and questions and support for these kinds of people. One of the things I wanted you to talk about for a minute is, how can we relate to our supported employment specialists to help develop job streams for these individuals once they get out? I think, again, that's going to be advocacy around those issues that will help in that regard. There are peer support programs and certifications that the states offer for individuals, and some states have a special track, almost like a subspecialization on, some call it a forensic peer, some call it a criminal justice peer. And so pointing people in the direction of being peer support themselves can be a positive first job, for example, for people that need to establish some employment traction, and also just working with the employment specialists to help them understand the supports that the individual is going to be getting with the treatment services that they're going to be receiving, which sometimes allays fears. There's also the importance of the Americans with Disabilities Act, as we're talking about people with serious mental illness and employment, and making sure that there's conversations with the individual you're treating or supporting to make sure that they understand when do they talk about their serious mental illness and how they can ask for accommodations in employment supports. So that brings me to another question, which a couple of people wrote in. Are there any laws to protect individuals when they reveal that they have a previous criminal history, when they're being employed? Well, to be employed for certain sensitive positions, there may be exclusions. For example, if you're going to do child care, if you have a history of child sexual offending, you're not likely to be hired in a child care position, just as an example. And that does make some sense from a safety standpoint. There are protections, obviously, in the Americans with Disabilities Act for people with serious mental illness, but correctional involvement is not a disability, so it doesn't fall under the ADA. But there are laws that protect individuals around their criminal histories. There are laws when you apply that tell you, they ask you specific questions. And there can be some guidance available through human resources around some of the rules related to that. And some places will expunge records, and so you're not allowed to look at things, convictions that happened as a youth or other types of things that will be expunged from the record. More and more people are doing that. The other thing I would say is there are, in some states, tax benefits for employers hiring people who have a history of incarceration. And so some employers are actually pro-hiring because they'll get some tax relief. And I've seen stickers on restaurants before COVID of hiring people, people with criminal justice history welcome. So it's also useful sometimes to try and find positions where that is going to be a welcome thing and not something that people are going to be worried about. A couple of people wrote in, and it warms my heart because they clearly want to measure and show that these programs that you've presented today are worthwhile. And they said, how can we measure retention in care? Well, retention in care is duration of care. If it's a chronic illness, how many people are dropping out of your program. And we've learned a lot with seclusion restraint prevention. And I say this very often, we look at seclusion restraint as a treatment failure. Dropping out of care is also a treatment failure. And I think it's really important to do reviews, clinical reviews of people who've dropped out of care to understand, A, is there an opportunity to re-engage them? B, has the system done something to not inspire that individual to stay in care? And what lessons can be learned for future involvement with individuals? When a person leaves prison, do they have to have a place to go immediately like an apartment or or a hotel or a friend, or can they be released without a place to go to? The release is a legal determination. If there is a finite sentence, then by law, the prison or jail is required to open the door at the time that the release is required. Unfortunately, some jails release at midnight, which makes it really difficult for people to get to where they need to go. And that's something as a policy matter we're trying to combat. But legally, a release must happen when a release must happen. So the goal is to do that in-reach and try and set things up before the person leaves. But once they walk out the door, especially individuals with co-occurring substance use disorders and mental illness, there's a host of reasons why within that first 72 hours, all good plans can fall apart if there's not the right safety net there to support them to move towards what they had been planning during pre-release. Is there any way we can improve housing availability post-release for those that are registered sex offenders? That is a huge issue in our society. There are different states that are trying to tackle that. There are zoning laws that sometimes preclude people from living in particular neighborhoods if they have a sex offense charge. And that's something that's going to require some ongoing advocacy. So I'll leave this as our last question, and it's not an easy one. But the person says, when people are released back into the community, many times they're sent back to the same area, same location as before, surrounded by the same challenges. It's something that's being discussed with the person being released back in the community. But what can we do to help them? Yeah, that's a very common scenario. And again, if you're being person-centered, that individual may feel most comfortable in that environment. So on the positive side of that, even though it's a neighborhood that we might say has a lot of destabilizing influences, it may also be for that person less destabilizing in a certain way than others. And so what we really need to do is meet the person where they're at and understand, is there going to be queuing friends that used to be drug dealing with them, or taking drugs with them, where they'll be queued and then likely to re-engage in substances? What supports can be put in place to help learn from lessons passed around what fell apart for that individual that got them into the jail in the first place? I mean, we've had programs where we've brought local police in to help with a re-entry plan to be aware that this individual with the proper signed release, to just say, hey, this person's coming back out to the community. They're really interested in doing better. They don't want trouble with the police. They want to be... And so it helps the police also understand who's there and what supports are available. We say, oh, we're the treatment team that's here to support them. And so there's ways that you can look at that to try and build supports and that safety net within that community. Sometimes those communities are not ideal. So that discussion is really important with the individual to weigh the pros and cons. Dr. Pinals, thank you for staying with me past the hour. There were some questions, audience members, that I wasn't able to get to, and I apologize for that. Please feel free to put in a consult to SMI advisor and we will get an answer back to you. I would also say that a number of people in the comment section asked if they would like to listen to this talk again or would like to share it as part of a grand rounds or with some of their teaching fellows or others, please know that it will be in the SMI advisor catalog next week and know that when you listen to it as an enduring, you can still claim credits. So sharing it with your colleagues is an excellent idea and an easy way for people to get free continuing education credits. Again, if you have any follow-up questions about this or any topic related to evidence-based care for serious mental illness, our clinical experts at SMI advisor are now available for online consultations. Any mental health clinicians can submit a question, receive a response from one of our SMI experts. Consultations are free and confidential. SMI advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the mental health addiction and prevention TTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes. You'll then be able to select next to advance and complete the program evaluation before claiming your credit. And lastly, please join us again next week on February 3rd, 2022, as Mark Fagan and Brian Bean with Thresholds in Chicago join us in presenting Engage or Enrage? De-escalation Strategies for Mental Health Crises, Part One. This is going to be a two-part series, and the first one, again, is next week, February 3rd, 2022, at 3 p.m. Eastern time. Please join us. There's going to be a lot of very concrete information about de-escalation. I think it's going to be a great talk. Thank you for joining us today, and until next time, take care. you

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