Hello and welcome. I'm Dr. Deborah Peinels, Director of the Program in Psychiatry, Law and Ethics and Adjunct Clinical Professor of Psychiatry at the University of Michigan Medical School. I also serve as a forensic consultant for SMI Advisor. I'm very pleased that you are joining us today for this SMI Advisor webinar, The Roles of Forensic Social Work in Caring for Individuals with Serious Mental Illness. 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 1 credit for physicians and one Continuing Education credit for social workers. Credit for participating in today's webinar will be available until August 14, 2023. Slides from the presentation today are available to download in the webinar chat. Select the link to view. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We'll reserve about 10 to 15 minutes at the end of the presentation for the Q&A. Now, I'd like to introduce you to my co-presenters, the faculty for today's webinar, Tess Parker and Kelly Schaefer, and I'm very excited that they've agreed to join me because I think you'll learn a lot from them. Tess Parker has diverse experiences as a clinical therapist and facilitator. As a former director at a large behavioral health provider, she leverages her master of social work from the University of Denver in a career dedicated to serving individuals experiencing mental health emergencies in both outpatient and residential settings. Tess has an uncanny ability to strategically identify critical gaps in care and then create programs to bridge those gaps and truly save lives. Kelly Schaefer, my colleague in Michigan, has clinical experience working in the Michigan Department of Corrections and Michigan Department of Health and Human Services State Psychiatric Hospital System and has been employed at the Center for Forensic Psychiatry since 2008. Ms. Schaefer is the director of social work and serves as the forensic liaison in assisting forensic consumers and providers in hospital and community settings throughout Michigan. She is also a certified forensic examiner conducting competency to stand trial evaluations in Michigan. Thank you both very much for leading today's webinar with me. These are our disclosures, which as you can see, none of us have disclosures that are relevant to the subject matter of this presentation. Let me begin by just outlining what we hope to accomplish today. We have several learning objectives that I thought I would go over. First, we want to describe the field of forensic social work that plays a critical role in multidisciplinary approaches for work with people with SMI. I as a psychiatrist am particularly excited about this presentation because just having this presentation alone shows the multidisciplinary perspectives that we are hoping that you see in your own work. Second, we want to help you apply knowledge of forensic social work to real world contexts by hearing of individual experiences of forensic social workers. Third, we want you to be able to describe at the end of this presentation some of the challenges and opportunities for forensic social work across settings. Let's begin. I'm going to take a moment to just describe the field of forensic social work that plays a critical role in multidisciplinary approaches for people who work with individuals with SMI. Many of you may be familiar and some of you less familiar about the intersection of people with serious mental illness and the criminal legal system. This is a slide that depicts what's called the sequential intercept model. It is a model that's recognized nationally. It was first written about in a psychiatric services journal by Drs. Mark Munitz and Patty Griffin, who said, we know that there's an overrepresentation of people with mental illness in the criminal system. If we could just identify them and intercept decisions that are being made about them that push them deeper into the criminal system and point them instead into treatment settings, we could turn the tides for those individuals' life pathways so that they are able to access treatment more than carceral settings. Across this intercept model, there are opportunities for forensic social workers to work with any number of disciplines, including legal professionals, other behavioral health professionals, and the like at every one of these places. There's also a burgeoning field of forensic social work research, which is interesting. For example, several studies that were looked at in preparation for this presentation showed a study looking at previously incarcerated fathers and co-parenting mothers and relatives and examining the needs of fathers who were facing release from prison, showing that their needs were multimodal. They needed socioeconomic, self-care, and social support services that emphasize family connections, which is an area of study among social workers. In that study, they've also found that self-determination and personal agency are some of the needs and challenges that fathers face in reentering after being in a carceral setting. We often forget that patients with serious mental illness may be fathers, and so some of this may apply to them as well. We also see that dual-system youth, those that are involved with child welfare and juvenile justice system involvement, are very common. There was a study, for example, out of Los Angeles showing that two out of three youth with their first JJ contact had interacted with child welfare services, and rates were higher for females and Black youth. These populations can have high needs for mental health. They have histories of trauma and need trauma support services and SUD treatments, and this is where forensic social work can really play an important role. For serious mental illness and family systems, as we think about SMI and incidents with parents responded to by police, this was an interesting recent study that showed that calls to police in Philadelphia in 2013 between adult children and their parents showed calls involving people with SMI was not associated with weapons, but was associated with need for assistance with offender behavior and substance use and family circumstances. Another place to remember as we grow out crisis services, how important multidisciplinary supports are going to be for stabilizing family systems. Persons with SMI who do go on to commit violence are more likely to target family members, with family rates of victimization reported at 20%, especially when SMI is involved for the person with the SMI. Calls for the need to support the capabilities of family members to prevent and manage family conflict are really important. Again, another role where forensic social work can be pivotal in helping address and prevent violence amongst families. Now I'm not a social worker, but the National Association of Forensic Social Work is a very relevant body that has its own system and organization, and I encourage anybody that's interested to look at that. Also, the National Association of Social Workers has a code of ethics that speaks to some of these issues. It's important to note, too, that this forensic social work is not a brand new thing, even though there's more and more organizational involvement. The first juvenile court was established in 1899, and that was staffed in large part by people who are social workers. In the ethics framework of the National Association of Social Workers, it describes the mission of the social work profession as rooted in a set of core values, and that these core values embraced by social workers throughout the profession's history are the foundation of their unique purpose and perspective. The value of service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence. I think all of those values are embodied in our speakers today, who I've had the privilege of working with, and who will talk about their own experiences as forensic social workers. Remember, when working with people with SMI, these multidisciplinary perspectives are critical. We've already done a webinar on forensic nursing, which I encourage you to look at, and all sorts of webinars related to working with people with SMI in the criminal legal system. It's important to remember that we're always counting on teams to help with their area of expertise, and each voice has an important role at the table. The systems issues, the family dynamics, the importance of considering benefits determinations, the communication to multiple contributors, to treatment planning, all is really critical and helps the forensic social worker role be pivotal in treatment supports. I'm going to turn this over now to Kelly Schaefer, who's going to speak to us more about forensic social work. I'm actually going to turn this over to Tess right now. Tess is going to start us off, I think, today. Great. Yes. Hello. It is a pleasure to be here with all of you today. As we dive into the topic of our webinar, I want to start by bringing definition and clarity to the field of forensic social work, and that starts with what is forensic social work? As Dr. Pinal said, we can look to the National Organization of Forensic Social Work, and they define forensic social work as the application of social work to questions and issues relating to law and to legal systems. This specialty of our profession goes far beyond clinics and psychiatric hospitals for perhaps criminal defendants being evaluated and treated. A broader definition of forensic social work that's a lot more comprehensive also looks at social work practice, which in any way might be related to legal issues and litigation. That can be both criminally and civilly. Child custody issues might be addressed, involving separation, divorce, neglect. So it's important to keep in mind that like social work, forensic social work has so much breadth and is incredibly comprehensive. So let's take a look at our next slide. What's also important when we start to set the table for forensic social work is looking at the different functions of the forensic social work practitioner. For clarity, you can see that we've broken down these functions and organized them into three different groups on the slide. If we start with our dark blue slide, we can see that forensic social workers provide consultation, education, and training to different legal entities. This might be law enforcement professionals, correctional systems, or other. We also see them providing diagnosis, treatment, or recommendations for the criminal justice population on mental status. Other functions might also include policy and program development work, which we're going to talk about later today in the webinar, offering training and supervision, serving as subject matter experts, and so forth. The functions of a social worker are actualized in many settings, some of which are shown on this slide, and that includes hospitals, probation and parole settings, mental health and or substance abuse courts, juvenile settings, and many of these we're going to be talking about later in terms of how does the profession look different based on the setting we're working in. The last piece that I want to orient us all to is a little bit about the history of forensic social work. Dr. Pinals did a beautiful job of setting the table for us and getting us started. The history of forensic social work dates back to the progressive era and post-World War I. In the 1800s, social work as a body was identified with corrections for the first time. During that time, many social reformers were involved with prisons, reformatories, or other institutions. The first juvenile justice court in the United States was started in around 1899. Around 1915, the Women's Bureau within police departments were first established. What we saw several years later was that there were police social workers embedded in over 175 unique locations in the United States. The next period occurred at the aftermath of the Great Depression and the New Era deal, where we saw in the 1930s that more and more forensic social workers were starting to be hired and employed to work in teams in tandem with psychiatrists and psychologists to treat individuals involved in the criminal justice system, to provide evaluations, and to start to get an idea of what do prevention and intervention efforts look like. During the aftermath of World War II and the development of the post-war economy, significant strides were made in developing more community-based councils and forensic programs. If we move to the 1970s and we start to see social workers beginning to work in professions around probation and parole, and this increased dramatically. By the 1970s, we saw that probation departments were established in all 50 states, and this led also to a large influx of the social work employment and employment of the forensic social work employees. Of course, in the 1970s, deinstitutionalization occurred, and many juvenile justice institutions and state hospitals were closed as a result, as we saw a push for services to be offered and housed in the community, so a push for services that were less restrictive, more person-centered, and able to meet individuals in the community where perhaps more of their support system was. And lastly, that brings us to the 1980s and 1990s, where more than $2 billion at that time was allocated throughout the nation, really, to aid for victims of domestic violence, sexual assault, and other violent crimes, and from there, we just saw a huge emergence and push for more forensic social workers. So with that, I am now going to hand it off to Kelly to talk to us a little bit more about what does forensic social work look like in forensic hospital settings? Yes, thank you, Tess. That was my mistake. It was you going first. Okay, Kelly, I'll go to the next slide. All right. Thank you, Tess and Dr. Pinals. As a social worker in a forensic hospital setting, we are offered an opportunity to work with a very complex patient population. Most of our patients here at our hospital are diagnosed with schizophrenia, schizoaffective disorder, bipolar, and less frequently with major depression with psychotic features. Our population has a lot of comorbidities that require us to adjust our treatment to their individualized needs. Some of these may include substance use. Probably about 60 to almost 80 percent of individuals admitted into our state hospital system have a co-occurring alcohol or substance use condition. We also work with individuals who have intellectual disabilities, cognitive impairment, traumatic brain injuries, and other medical conditions. Our work interfaces with both criminal court and probate courts, and social workers conduct individual and group therapy, biopsychosocial assessments. We work as valued members of a multidisciplinary treatment team and are always keeping discharge planning and risk mitigation at the forefront of our treatment. I'm going to share a little bit more about my experience working in Michigan at the Center for Forensic Psychiatry, pictured here. In the mid-1970s, the Mental Health Code guided the development of this facility to ensure that appropriate forensic services were provided to individuals with mental health needs in our criminal justice system. The Forensic Center provides both evaluation services and treatment services. Our evaluation services division conducts competency and criminal responsibility evaluations for all defendants throughout the state of Michigan. Our treatment services division provides inpatient psychiatric treatment to individuals who have been adjudicated incompetent to stand trial or not guilty by reason of insanity. In Michigan, social workers complete training to become certified forensic examiners, allowing us to conduct competency to stand trial evaluations for defendants in Michigan. The requirements to become a certified forensic examiner are detailed in the administrative rules as an extension of the Mental Health Code. Some of these requirements include having a master's degree, being a licensed social worker, completing a number of didactic trainings to obtain additional knowledge of the court system, mental health law, criminal law, and other relevant forensic issues. We also observe competency examinations and then conduct them under supervision. We observe and conduct expert witness testimony and also complete a mock trial. After completing the requisite training, social workers then conduct independent competency to stand trial evaluations. During this evaluation, we are determining whether the defendant's capacity, excuse me, we are determining whether a mental condition is interfering with the defendant's capacity to proceed with the legal case. And if something is interfering, is treatment likely to be effective and could they attain competency within the statutory time limits? During a competency evaluation, we gather information from another number of sources, including a clinical or forensic interview of the defendant. We review court and police documents. We may obtain collateral information from medical, mental health, or correctional providers. We may seek psychological testing. We consult with attorneys or other individuals who have information relevant to the referral questions. We submit our report to the court and sometimes provide expert witness testimony. For those individuals who are ultimately adjudicated and competent to stand trial and admitted to our facility, the social workers provide competency restoration treatment that is designed to stabilize their mental condition and to help them better understand their charges, the court process, and to be able to work with counsel rationally to better assist in their defense. The ultimate goal for these patients is to attain competency and return to court. Treatment is typically comprised of pharmacotherapy by our psychiatrists, competency skills training groups, and individual therapy. Social workers also provide progress and or restoration reports to the court, offering our opinion on the defendant's competency. When treating ISD patients, we always try to be mindful of their legal status. These are individuals who have not been convicted and our documentation and discussion of these individuals should reflect the pre-adjudicative status and not reveal defense strategies or other information related to their account of the alleged offense. Sometimes we encounter clinical and ethical considerations when treating ISD patients. At our facility, we are often faced with the dual role of being both forensic evaluator as well as treatment provider. Because these individuals are court mandated for treatment and our main goal is competency restoration, they will ultimately return to court to face their charges. Sometimes with this population, we as treatment providers may disagree with some other defense strategies of our clients and or may want them to receive the best possible outcome, which can sometimes be contrary to the desires of our patients or what may happen in the criminal justice system. Having clear boundaries and being cognizant of which hat we are wearing becomes important. Okay, I'm gonna switch gears a little bit and talk about working with individuals who've been adjudicated not guilty by reason of insanity, as the focus of treatment is much different. So our main goal when we work with individuals who are NGRI is to stabilize their illness and to help them develop improved understanding of their illness, increase treatment adherence and assist in the development of coping skills and supports to assist in their eventual transition back to the community. This typically involves pharmacotherapy, individual group and family therapy and assessment of community supports and systems. We are continuously considering discharge readiness and the least restrictive setting that can sufficiently mitigate their risk. Finding that ever important balance between risk and protective factors is essential. Great, the most important documents completed by the social work profession is the biopsychosocial assessment, which can be vital in guiding treatment and as it helps to identify risk factors and protective factors that may contribute to more positive treatment outcomes. While these assessments contain standard portions, we try to look at the assessment through a more forensic and risk mitigation lens at our facility and try to delve a little more deeply into certain portions of the assessment that are helpful in working with our population. For instance, when working at the legal history, when looking at the legal history or history of violence sections, we really wanna capture the person's history of all prior arrests or convictions or other violent acts that may have occurred outside of law enforcement involvement. And if we're able to know, were there any mood or psychotic symptoms or substance abuse occurring at the same time? Were they taking medication? We look closely at any past parole or probation outcomes as these can be additional important tools in helping to understand how a person made you on a conditional release. We look closely at the NGRI offense. We wanna develop a thorough understanding of the offense, factors that may have contributed to it. If a person was returned to the hospital while on leave, we wanna know, was treatment non-adherence part of it, substance use, medication changes, or could a possible change in placement or change in level of services have contributed to the decompensation? We look at risk of violence and elopement, any past history of elopement at hospitals, correctional settings, even in community settings, or if there were other significant incident reports or behavioral incidents that are important to us to consider when considering risk and in guiding discharge planning. We also wanna look closely at substance use and treatment. Was any substance use occurring during the time of legal involvement? What types of treatment has the individual been involved in and their level of participation, level of understanding? We conduct, of course, a thorough mental health treatment history assessment. We wanna look at past hospitalizations. Were they voluntary or involuntary? What is the constellation of symptoms that precipitated the hospitalization? What is their outpatient treatment history? How did the patient do in various levels of supervision and placement throughout the continuum of care? And then, of course, in looking at those real biopsychosocial factors, understanding how social and environmental stressors may have resulted in their functioning or decompensation that occurred in the community. We wanna explore educational attainment, cognitive functioning, occupational history, financial supports, and medical concerns, and to see how those could impact someone's transition to the community. What are the family dynamics that are going on in the home? And this is particularly important if somebody is discharging back to their home. We really wanna understand and get a better idea if there's been any passive violence towards family members. And then finally, as we move out towards discharge planning, the development of a discharge plan with our forensic population is often guided by the social worker at our facility. Thankfully, in the state hospital system, we often have the gift of time to ensure that many of these factors are in place prior to release. However, we do know that this is not always the same experience that many of our community hospital settings have the luxury to have as they often may be working with forensic clients, but sometimes need to develop these plans very quickly. At our facility, though, prior to release, we are engaged in a lot of collaboration with community mental health providers, hospital treatment teams, family members, support persons, and the patient. We really strive to ensure that community providers receive all of the necessary information related to the person's needs, and that essential information is not lost during the transition. We work to develop risk mitigation strategies that are very individualized and tailored to that person's unique needs to hopefully reduce their risk for relapse and assist the individual in meeting their goals. We know sometimes this can be a little bit tricky if the recommended services aren't available in certain communities. For example, many rural communities may have limited numbers of supervised group home settings. As social workers, we need to remain flexible, and treatment planning may need to involve some thinking outside the box. Do we need to contract with providers outside the community of residence, or do we need to establish more enhanced supports like ACT or in-home community living supports to better meet their needs? And then finally, too, we want to try to do a lot of work with families, particularly if the patient is going home, to really get an assessment of the home, determining who's going to be in the home, what kind of items may be in the home, how many hours would someone be there to assist and offer support, what kind of stressors might be going on in the home. We really strive to help families understand the person's illness prior to their release, to know about available supports and resources. Sometimes we might also seek a leave of absence to assist in preparation for their eventual transition. And then of course, once the individual is out in the community, we are always looking to modify the services or placements as directed by their progress in treatment. Thank you. All right, thank you so much, Kelly. So in the last several years, I've had the opportunity to work with the forensic population in both the state of Michigan and as well as in Ohio, and excited to share just a little bit about that experience and what that work looked like. So if we start with Michigan, the state of Michigan operates three inpatient hospitals for adults, the Carrow Center, Kalamazoo Psychiatric Hospital, often referred to as KPH, and Walter Ruther. As a clinician, I was able to work closely with these three state hospitals for a unique purpose. So using previous treatment records, interviews, screenings, and different risk assessment tools, interviews, screenings, and different risk assessment tools, I met with individuals in the state hospitals who were found not guilty by reason of insanity to make recommendations on treatment interventions that could be employed to assist these individuals to be able to discharge successfully from the state hospital to a community-based setting, such as a long-term residential setting, or elsewhere, many of the options that Kelly described earlier. As Kelly described earlier, my goal and subsequent recommendations were focused on determining and identifying the least restrictive setting that an individual could be discharged to while also successfully mitigating risk. So it really is like walking a tightrope or a balancing act of ensuring that we are providing care in the least restrictive setting while also ensuring the safety and the mitigation of risk. When meeting with these individuals in the state of Michigan at these state hospitals, I was trained at that time and utilized what's called the HCR-20 risk assessment. The 20 HCR-20 risk factors are dispersed across three scales. That includes looking at or assessing an individual's risk through a historical lens of what's happened in their past, a clinical lens, and also a risk management lens. So a lot of those factors were focused on the history and then also focusing on those clinical and risk management strategies. What's great is that the HCR-20 risk assessment can be used when a person is entering a treatment facility, such as the state hospital. It can be used during the course of their treatment as a consideration for release to the community. This risk assessment was incredibly helpful in constructing a very comprehensive formulation of violence risk and not only violence risk, but also future risk scenarios. So we talked about, we can do everything on our end to really make sure that we have a plan in place for that discharge day and get the person to their next level of care. But the HCR-20 provides an opportunity to start to plan and look at what do potential future risk situations look like. It also provides appropriate risk management plans and informative communication of risk. So it takes all of those different elements and provides a really nice framework. And that moves me to the state of Ohio. So in addition to my time and work with the forensic population at the state hospitals in Michigan, I've had the opportunity to work with behavioral health stakeholders in the state of Ohio to develop residential programs and treatment facilities for individuals, most often the forensic population who are ready to step down and discharge from the state hospital. It feels like a blessing to be able to do this work as a forensic social worker, to help these individuals in their discharge planning from a higher, really restrictive level of care to a community-based alternative. And as Kelly shared, ensuring that all of those elements that inform a successful discharge are actualized. Great. So we provided references for you that were used in this presentation. And before we go to the Q&A, I wanna just pull Tess and Kelly back up to ask a couple of questions of you, myself or our participants to hear. So first I wanted to ask each of you, what drew you to forensic social work? And maybe I'll start with Kelly. Good question. I guess just in my undergraduate training, I really always enjoyed the mental health arena. And then I had done some internships working in jails and that really sparked my interest. And so I knew I just wanted to do something that really involved working within the criminal justice system with the mental health population. And it just is a population that is rather underserved and it just was very appealing to me. And Tess, what drew you to the work? Yeah, that's a great question. One of my areas of passion and a lot of the work that I do today involves the services that are operated on our behavioral health crisis continuum. So that continuum includes the state hospital system, inpatient psychiatric units, crisis residential units. We're starting to see more and more psychiatric or behavioral health urgent cares pop up. And so I've always been passionate and motivated to helping individuals get the treatment that they need in the least restrictive places and facilities possible, knowing that a lot more of those services are going to be person-centered and trauma-informed and making sure that those individuals have access to the right sized care. That's really great. And since we have people that might be maybe uncomfortable working with the population of justice involved or people with violence histories or even people with serious mental illness, what would be advice that you would give of lessons that you learned along the way in sort of evolving to becoming a professional forensic social worker? And I'll start with Tess this time. Yeah, certainly. So I think regardless of the population, whether you are in school to be a social worker or a behavioral health professional or you've been in the field for a number of years, we often all have a population that we might feel less comfortable working with. So although I never felt uncomfortable working with the forensic population, I would say that helpful tips or recommendations would be opportunities like this webinar, education. I think, for example, the Center for Forensic Psychiatry, if you don't know what the amazing work and outcomes that they achieve, then the more informed you can be and the more education and training you can be a part of, I think that really helps to dispel myths around violence or individuals found not guilty by reason of insanity. So I would certainly say education and training and also just really leaning into supervision and professionals in the field. Great, Kelly? Yeah, I kind of have to echo a bit what Tess said too about supervision and support of colleagues because we do encounter a lot of heavy material, of course, in our profession. And it's always been helpful to me to just sort of separate, of course, like what happened with the offense and then the individual that we're working with. And I think in our profession, we're able to see people kind of at their worst moments, sometimes following a really serious episode of violence and then kind of the transformation that can occur and helping them to process that can be really powerful and just kind of remembering those types of experiences. But just even being in the field for 20 years, I mean, there are still some cases that just get you. And I think we have a really great bunch of colleagues here at the Forensic Center and throughout the state that we can really bounce ideas off of or just kind of just share some of our thoughts and experiences so that we're not taking a lot of things home with us or anything like that. And what would you recommend? I see questions are pouring in, so I don't want to hog them, but I think I have one more minute. What would you recommend for a forensic social worker working with a psychiatrist, a peer support worker, or a nurse, any other discipline? What is your, from your perspective, what do you think are some lessons for either how we would work with you or how your colleagues should work with us? And maybe Tess can go first this time. I can't keep- Sure, yeah, I'm happy to. And Kelly, feel free to jump in. I think, again, I just, I kind of zoom out to any type of population that we're working with in terms of, I don't know that it's different, that I wholeheartedly believe in the multidisciplinary team approach and have been fortunate enough to work with psychiatrists and brilliant psychologists and psychiatrists and peers with lived experience and social workers. And although there is always, or hopefully always, space for disagreement or healthy conversation, without that comprehensive approach and all hands on deck in terms of looking at things through different lenses, I don't think we're able to offer those individuals served the best care and recommendations. We do them such a, we do right by the people we serve when we have everyone possible at the table helping on their care. Nice. Kelly, anything to add? Yeah, I think just, again, everyone offers their own expertise and we know our population is so very complex. So it's really nice to have those open dialogues with your colleagues and, because everyone has an important part that helps the individual in their, you know, reentrance to the community and in their outcomes. So just open communication, which thankfully again, here we have a lot of that. That's great. All right, I'm going to move us along because I see we have a number of questions coming into the Q&A. So I wanted to just thank you very much for this really interesting presentation and keeping up with my not so professional slide advancing. Got to work on that skill. But before we shift into the Q&A, I want to take a moment and let you know that SMI Advisor is accessible for people watching. It's accessible from your mobile device. Use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our SMI expert team. Download the app now at smiadvisor.org slash app exclamation point. If you have more questions, this is the time that you can add them to the Q&A and I see that many of them are coming in. So let me just pull up the Q&A and go through them. Okay, can you speak to the main differences between a licensed professional counselor or other disciplines like that within forensics from an LCSW in forensics? A licensed professional counselor, a licensed professional associate, different jurisdictions may have different initials too. And either one of you. Yeah, the only item I think helpful to add to that question is that I do think it depends on the state and the licensure in terms of, for example, licensed master social workers often are able to work in the forensic settings or in a variety of settings. Whereas I know I've had colleagues who have the LPC credential and that limits them in working in certain hospital-based settings. So I've not heard of any limitations specifically to working with the forensic population. I think it would just depend on state and licensure guidelines. Great, anything else, Kelly? Okay, another question comes from Melissa Serrano. I work in Denver. Some resources are limited or the funding for these resources are limited. What can we do as professionals to give individual support, especially in the correctional field? I'll let Kelly answer this one where resources might be limited. Yeah, I know we probably all are encountering that in various ways here. I know in Michigan, we're looking at state hospital beds that are diminishing, which of course puts a lot of burden on the community resources and sometimes they are limited. In terms of what we can do, I think just continuing to have a lot of dialogue between community providers, legislators, and even like the state hospital system, I know here has been helpful, and at least on our end in Michigan, we've been trying to do some work to ensure that we're working more closely with community providers so that there is more continuity of care, at least with those who've come from a state hospital system and are transitioning to the community. I think that's a really good answer. I have some thoughts. Tess, do you want to add to that or? Before I do? Go ahead, Dr. Peinels, and I'll jump in. Yeah, I mean, I think you said it right. And I think one of the things you said in your presentation, Kelly, was just that sometimes when you have a limited resource, like in a rural area, you might not have the secure setting that you're looking for, but maybe the person can have their risks sufficiently mitigated without a secure setting, but with additional staff support and additional frequency of checks, which is a really important part of the care. Frequency of checks, which we call in Michigan community living supports, that kind of thing. So how do we, I think it takes some nimbleness to talk about, well, what is it that we're, what risk are we trying to mitigate and how can we think about it instead of just sort of a very concrete, we have these levels of care, which understandably we have to be able to bill for services, but really trying to be flexible about how to make care work for the person instead of having the person fit into care that might not be quite as available. And the other thing I would say, and this person asked about correctional fields, is partnerships. The workforce shortages are everywhere. They're high in the court system, they're high in corrections, they're high in behavioral health, there's workforce shortages everywhere. And so partnerships and leveraging partnerships, I think is another strategy, as well as really thinking about the use of peers as part of that workforce, not to supplant where you need other types of professionals like forensic social work, but to augment. Tess, do you have other thoughts? Yeah, I'll just tag on to what you said, Dr. Pinellas. I think, you mentioned rural areas. I think certainly regardless of what region we might be working in or what state we are in, behavioral health services in general often lack the capacity to meet the demands of the community in which they're situated. And certainly that is intensified by COVID or the shortage of behavioral health professionals in the workforce. But I think that causes us to be nimble, to be creative, to form partnerships with the counties next door to ours and find ways of doing that partnership that doesn't compromise on care coordination and the person served. Great. All right, another question was, what's my experience working with forensic social workers? And I would say some of it relates to Tess and Kelly, which is why I was so excited that they agreed to be part of this. I work with Kelly, especially around some of these decisions about discharge, where I have to review some of the cases for people found not guilty by reason of insanity who've committed some pretty serious offenses. And before they're ready to go out into the community and Kelly and I have partnered on many cases. And oftentimes, she will have more information about the family situation, about what the community setting is like. She's available for me to call, email, whatever, often at any time, day or night. And I think just that collaboration and having a trusted partner helps because these are really hard for me. They're hard decisions. They're stressful for the patients. They're stressful for the communities and any potential victims or family members. And so there's like, these are high stakes issues. And I feel like having a partner like Kelly is really helpful. And Tess, in talking about the HCR 20, which I'll ask you about a little bit, we worked on some of these initiatives as we were looking at some of the patients across the hospitals to understand how to translate what they looked like at the hospital into what they would need into the community. And that isn't always an easy translation because a hospital is so structured and the community is less structured no matter how much structure you put into it. And so having Tess and colleagues translate that, again, just gives you another piece of data to lean on before you sign discharge paperwork or sign off on those types of decisions. So I think the partnerships are key. And certainly having these two have high quality and knowledge is incredibly important too. Now, one of our viewers asked about the HCR 20 and wondered if it applies to benefits determinations at all and how does it translate? I'll leave that to Tess. Sure, yeah. No, not that I'm aware of. It doesn't have any direct relation to the benefits piece of it. I do think that that element is critical in discharge planning and making sure, I mean, that's true of if an individual is being released from a correctional facility, making sure that they have their benefits turned on and activated. So I think that's a critical and essential part of discharge planning, but the HCR 20 really focuses on, again, those historical risk elements, future risk scenarios. So it doesn't quite hit on more of those logistical benefit discharge planning elements. Okay, great. And that becomes important because we really need to make sure that benefits are available for people, regardless of what their risk levels are. Let's see. Somebody asked, wow, we have questions really coming in, which is great. Do you believe there are sufficient options available for forensic education and training at the bachelor's and master's level? When I graduated with my MSW in 1994, there weren't many forensic courses available in our program. I don't know who wants to tackle that. Kelly? Yeah, I guess, you know, even when I graduated in 2002, there wasn't a lot of actual forensic social work courses that we took as well. But I feel like a lot of our clinical courses that we're taking are so instrumental in helping to guide us to this forensic social work. And then, of course, finding those opportunities through internships. I know I was fortunate enough when I received my master's degree, I was able to intern here at the Center for Forensic Psychiatry, and then also in a jail setting, just knowing those were kind of my interests and where I wanted to utilize my clinical skills. So I think seeking out those internship opportunities can supplement any master's level or training that you have. Great. Tess, any thoughts on that? Yeah, I agree with Kelly. I certainly wish that there would have been more college or course-specific information or training related to the forensic population. I do think now, though, with so much growth of partnerships with law enforcement and correctional settings through mobile crisis teams or through 23-hour observation units and police drop-off, that we're starting to see a lot more growth in training and education opportunities focused on serving the criminal justice population or the forensic population. So I am hopeful that we are moving in the right direction. Great. Okay, I'm going to just take a moment. A couple questions have been, show the app information again. So I'm going to just show the app information, switch the slides, and then we'll keep going with the questions and people can get that information. Somebody might be tuning in from around the world because they typed that SMI has been enormously helpful and there's wonderful resources and these courses can be taken any place in the world. So that must be somebody who's calling in from afar. So that's great. Somebody else asked, what therapeutic techniques have your patients found most helpful when coping with their experiences? I know you mentioned, I think, Kelly, that sometimes we're treating people who've had just a really difficult moment and engaged in some irreparable harm that then they have to live with. And so what therapeutic techniques do you find helpful? Yeah, I mean, just coming at things from a trauma-informed care is always, I think, vital for all of us. I think some of the most powerful tools that could be helpful is like family therapy or family sessions, because with a lot of our population here, sometimes some of the offenses involve family members. And so those can be so powerful to have both the patient and the family together in that room and kind of if it's safe and if it's possible, but just helping to process what happened, helping to educate the families a little bit more about what was going on, as they come from varying levels of understanding about mental illness. Those have been some of the most powerful experiences, I think, in my career here, just with families and or reuniting with following a very serious event that occurred with a loved one. We also have a family education program here at our hospital. The social work department puts it on and we get speakers and monthly, and then families come and kind of learn more about it. And then they also connect with one another about their experiences, which is really helpful. Tess, anything? Yeah, I would echo what Kelly said. And also I, and I think the CFP does such an amazing job at this as well, is when I think about treatment or therapeutic approaches that have been helpful in working with this population, I think it even extends beyond what we might think of in terms of our traditional options like CBT or DBT and into, for example, like I remember finding so many helpful interventions and approaches working with the occupational therapists and developing a sensory diet plan for an individual. Perhaps they had really unique sensory needs or needed help with daily task development. So whether it was partnering with OT or a physical therapist or nursing, just really, again, taking on all of those different components and looking at their care through a more comprehensive lens. That's great. Another example of great multidisciplinary thinking to really help address the person's needs. That's really great. All right, I think I have time for one more question. What advice do you have for forensic social workers new to the field? And I apologize that we haven't been able to get to all the questions. There's so many questions coming in. If you have consultation, and I'll talk about this in a moment, we do have a consultation service. But in the meantime, what advice do you have for forensic social workers new to the field? Tess, you want to start? And then we'll let Kelly- Sure. I guess I'd start by saying a very warm welcome. I always get excited to meet others. I remember like first meeting Dr. Pinellas and Kelly and just feeling so excited to have kindred spirits and people who just were invested in this type of work. So first, just like a lot of excitement. And then in terms of advice, I think just lean into the community. There are so many amazing resources and listservs and trainings and webinars and asking questions and leaning in. And I think just really finding those opportunities to serve individuals and continuing to promote the amazing work that's being done. Yeah, I think just seeking those opportunities that allow you to be in environments that allow this type of work to happen. And then again, just, especially new social workers to the field and there's just relying on your colleagues for support and as much as you can early on, because the longer you do it, the easier it's going to get. But it's vital, I think, for new social workers who are learning all the dynamics of this complex patient population and asking, don't be afraid to ask questions and as you learn. Yeah, that's great. I think I'm going to squeeze in one more question, which is about racial health disparities. Because I think that's so important in talking to this, about this population, because we know people with SMI, there's disparities in the healthcare system, there's disparities in the criminal system. And so you get intersecting disparities and silting of populations. And so this question comes in asking, how are these being addressed given higher prevalence of black and brown individuals who are incarcerated? And are there any particular quality assurance measures or other things that you do to help think about things from a disparities lens and an equity lens? Tess? Oh, I was going to, Kelly, I don't know if there's things specific in the Center for Forensic Psychiatry. I know that this is in the previous agency I was employed at. This was tracked and accounted for through a lot of quality improvement metrics and metrics collection. It was embedded or making sure that those health disparities were screened for and that subsequent interventions and treatment were applied, making sure that we were providing the best care and tailored care to those individuals. And I'll just throw in that our Medicaid office, Medicaid is asking, CMS is asking that disparities be tracked more closely now as a measure. So we'll see that. And we've done some research of our forensic population with some of our trainees. One of them did a project looking at who was coming into the forensic system and presented that data to see what the disparities are. So I think it's a really important question. The other thing is, I think people are all trying to diversify the workforce to try and have the workforce be more matched to the community. That can be challenging, but in the Department of Health and Human Services, we're taking lots of measures to make sure when we're doing hiring and that sort of thing that we're looking at maximizing the ability to have a diverse workforce. And we're also doing internal work with our staff. We're doing civility surveys and trying to understand how people are feeling as staff with regard to feeling respected and making sure that there aren't issues or trying to minimize when there are issues or eliminate the issues that might arise from staff who might feel like there's disparities in how they may be treated. And so that's another, it's taking care of the caretakers as well as looking at the people we're caring for is I think the lens that we're approaching from. And I didn't mean to cut you off, Kelly, but I didn't know if you had anything to add to that. Nothing further. I think you highlighted a lot of the things that we're doing in our department here, so. Yeah, great. All right, so I am gonna have to move us along. I really appreciate the lively discussion from our viewers and I will move us along. And if there are any topics covered in this webinar that you would like to discuss with colleagues in the mental health field, post a question or comment on SMI Advisors Webinar Roundtable Topics Discussion Board. This is an easy way to network and share ideas with other clinicians who participate in this webinar. If you have questions about this webinar or any other topic related to evidence-based care for SMI, you can get an answer within one business day from one of SMI Advisors National Experts on SMI. This service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals who have SMI. It is completely free and confidential. Access that, access the credits are here. You can see the website. SMI Advisor offers more evidence-based guidance, forensic psychiatry, such as professional experiences in correctional psychiatry, adapting to the environment. This video offers firsthand, oh, this isn't the CMEs yet, sorry. This is a featured resource. I didn't read my notes well. SMI Advisor offers more evidence-based guidance for forensic psychiatry, such as professionals, experiences in correctional psychiatry, adapting to the environment. This video offers firsthand experiences and tips for mental health professionals working in correctional settings on how they adapted to this challenging setting. Access the video by clicking on the link in the chat or by downloading the slides. There's a series of these that are coming, and I think people will find them very interesting interviews. Now, 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 please join us tomorrow, June 16th, as Jason Phillips presents Cultural Competence in Mental Health Treatment, Understanding and Addressing Diverse Cultural Backgrounds. That will be a wonderful extension to our discussion that we ended with today. Again, this free webinar will be tomorrow, June 16th, from 12 to 1 p.m. Eastern time. That's tomorrow, Friday. Thank you very much for joining us. As always, it has been a pleasure to participate in the SMI Advisor Webinar Series.

Forensic Social Work

Serious Mental Illness

Consultation

Assessments

Discharge Planning

Multidisciplinary Approaches

Risk Assessment

Trauma-Informed Care

Family Involvement

Racial Health Disparities