Hello, and welcome. I'm Dr. Amy Cohen, a clinical psychologist and director for SMI Advisor. I am pleased that you're joining us today for today's SMI Advisor webinar, The Sequential Intercept Model, Using Assisted Outpatient Treatment to Reduce the Need for Competency Restoration. Next slide. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA-funded 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. Next slide. One continuing education credit for psychologists, and one continuing education credit for social workers. Credit for participating in today's webinar will be available until May 22nd, 2023. Next slide. 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. Next slide. And please feel free to submit your questions throughout the presentation by typing them into the questionnaire found in the lower portion of your control panel. We'll reserve 10 to 15 minutes at the end of the presentation today for questions and answers. Next slide. Now, I'd like to introduce you to the faculty for today's webinar, Dr. Mark Munitz. Dr. Munitz is Professor and Chair Emeritus of Northeast Ohio Medical University, and served as the Margaret Clark Morgan Chair of Psychiatry there from 2007 to 2019. He helped plan, implement, and study jail diversion programs for individuals with serious mental illness, including the CIT program, also called Crisis Intervention Team, and mental health courts. Dr. Munitz is the co-developer of the Sequential Intercept Model, which has been widely adopted throughout the U.S. He also helped plan and support implementation of coordinated specialty care programs, which you know are for individuals experiencing their first episode of psychosis. This has been implemented throughout Ohio under his leadership. Thank you, Dr. Munitz, for leading today's webinar. And thank you very much, and thanks to everyone for being here. It's a great privilege to be talking with you this afternoon. I have to start with my disclosures, and I am a consultant to the Treatment Advocacy Center and to PEGS Foundation, a family foundation in Hudson, Ohio. And my presentation, as has always been the case over the years, is the result of collaboration with a lot of colleagues and partners. And I particularly wanted to thank Dr. Deborah Pinals, who talked to me at some length and shared some slides, but more importantly, some insights into the issues I'm going to be talking with you about today, as well as Dr. Patty Griffin, my co-collaborator at Sequential Intercept Model, who also gave me some good food for thought as I prepared this talk. I like to point out that I'm a community psychiatrist, not a forensic psychiatrist, and I don't have the forensic training. I can joke that many of my best friends are forensic psychiatrists, but I think I have a somewhat different perspective being community-focused. So I'm going to try to squeeze in a lot of information over a really very short time, and I think a lot of the material will be mostly familiar to many of you, if not all of you. But I'm hoping by the end of the talk, as I get into a conversation about the crisis that we really have in this country of using our state hospital beds for competency restoration and company assessment, and talk about the potential role of assisted outpatient treatment as part of the solution to this really complex problem, I hope that will be perhaps somewhat newer and provocative and food for thought. So I don't think I need to spend a whole lot of time on this problem. Everyone at this point knows, we've been talking about it for decades, unfortunately, now, that we have an over-representation of people with serious mental illness in the criminal legal system. If roughly 5% of the general population has serious mental illness, by which I mean the schizophrenia spectrum disorders, bipolar spectrum disorders, major depression with psychosis, if that's roughly 5% of the general population across criminal legal populations, whether it's jails, prisons, probation, parole, et cetera, three times that number, at least, are present people with serious mental illness. If you break it down by gender, it's roughly three times for men and six times for women. And unfortunately, we're seeing more women over time in correctional settings. And it's more often than not, probably on the order, as I said, 72%, three quarters, have a co-occurring substance use disorder. So what accounts for this over-representation? Well, for a long time, and probably still, we refer to criminalization of mental illness. We talk about the fact that deinstitutionalization started 50 plus years ago and really continued until the present, led to the loss of particularly state hospital beds, and people didn't get the supports they needed in the community, ended up symptomatic and went to that system that couldn't say no, the criminal legal system. And there's some truth to this criminalization hypothesis, no doubt about it, but it's also very much oversimplified. We now know that there are a host of social factors and public policies that have contributed to this problem that I'm calling over-representation. And we're increasingly learning from our colleagues in the criminal justice world about the contribution of criminogenic risks and needs that also contribute to this problem. And so, because this is a complicated, messy problem, I put together a complicated, messy slide with this attempted event diagram. So looking at untreated, why do we have so many people out in the community with untreated symptomatic mental illness who are coming to the attention of the criminal legal system? Well, part of it, I think we have to acknowledge is that our service system just doesn't offer all the services that we ought to do. There are many things we know how to do, but for a variety of reasons have not put together a system to deliver those services. There's also the reality that there are some patients who are treatment resistant, that is they do not respond to any of the treatments that we have. And there are also patients who are resistant to treatment, that is they don't want the treatments that we're offering them even when they're available. These are the folks who don't appreciate that they're ill even when they get better in response to treatment as a result of anosognosia, the fact that they're not able to, as a result of their illness, they're not able to recognize that they have an illness. Now, the criminologists have been studying what leads to recidivism among the general criminal legal population, and they've identified a number of both static and dynamic risk factors. This is a list of what they refer to as the big eight dynamic risk factors. And things like antisocial behavior and antisocial personality patterns are things that people from my generation, at least in psychiatry, we didn't know anything how to help other than punishment through the criminal justice system, if you will. We've learned better from that, and I'll talk about that very briefly in a couple of minutes. And we're increasingly aware of the social determinants that have contributed to this problem. Unfortunately, in the US, a huge proportion of people with serious mental illness are living in poverty, are homeless or insecure in their housing and in their food. There is ambient exposure to violence and to substance use. And we've had policies, and I think I should have put structural racism at the top of this list, but policies like the war on drugs and getting tough on crime that have also added to this very complicated problem. And I found this quote recently from the Marshall Project, it happened to be talking about my current hometown, Cleveland, Ohio, and a former federal public defender, Harvard law professor had this to say, what I've highlighted, a vast number of people who we sweep into the criminal system are not actually criminal in any meaningful sense. They're not scary, they're not dangerous, they do things we don't want them to do. And so she's describing people who are frequently cycling through the nation's jails, and particularly here the Cuyahoga County, greater Cleveland area jails, and is pointing out that the specialty dockets that were set up, mental health courts and drug courts, don't really help this portion of the population, which is probably larger than those who volunteer for these specialty dockets. So my story is that I was a county medical director for Summit County, Ohio, greater Akron area, back in the 1990s, late 1990s, we were beginning to think about why do we have so many of our patients with serious mental illness in our local jail? And that led to the good fortune of getting a consultation from the SAMHSA GAINS Center, which sent to us Dr. Patty Griffin as a consultant, which is how I got to meet Dr. Griffin. And we began working together after she provided a wonderful report to Summit County, we realized that we thought about these issues in a very similar fashion and began to work together on what evolved into the sequential intercept, as I'm going to describe. So this is an old slide, and I use the word criminalization, and I have this little asterisk. It's an oversimplification, that term, of what is better characterized as the over-representation of people with serious mental illness in the criminal legal system. The challenge is that criminalization is a whole lot easier to say than all those other words. But I'll try to avoid that going forward, I'll probably slip up a couple of times. So what we can, some simple observations are that people move through the criminal justice, criminal legal system in predictable ways. And so that creates an opportunity at each point in which a person moves through the system from the point of initial contact with law enforcement all the way through the process as we'll describe in a second. Each of those points presents an opportunity. We can think of it as a public health opportunity to intercept that person from the criminal legal system and divert them to the treatment system. So we wrote this paper up and published it in Psychiatric Services in 2006. Hank Steadman is not a co-author, but he contributed greatly to our thinking as we put this to gether. And this paper has had a remarkable traction, which has been very gratifying to me personally. I never imagined it would be so useful to the field. And in the paper, we had two different graphics, and this is one of them to describe our thinking about this model. And this is what I call the funnel graphic. And I use that to make the point that I believe that the best, biggest impact, biggest bang for the buck, if you will, is intervening as early in the process as possible. So working with law enforcement and our emergency mental health services should intercept the largest number of people, those who get through that point, then there's an opportunity immediately post-arrest at initial detention, initial hearings, those who get through that, and so forth through Intercept 3, the jail and prisons, courts and forensic system, reentry, Intercept 4, and community corrections and community support Intercept 5. Now, at the very top of the funnel highlighted is what we call the ultimate intercept. And we argued that best clinical practices, a shorthand for an accessible, effective mental health system is going to prevent justice involvement in the first place, and we in mental health should be striving to create such systems and provide such care as much as possible. So somewhat to my surprise, 10 years later, in November of 2016, Policy Research Associates, the umbrella for the GAINS Center, made a big splash introducing what they described as an expansion of the sequential intercept model to prevent criminal justice involvement with the concept of Intercept 0. And I think Intercept 0, as they depicted here, was brilliant in many ways. It really highlights the need in the U.S. to enhance the crisis response continuum, woefully inadequate in many communities. But I also thought that they made a mistake in two other important ways. And so my taking exception to Intercept 0 as presented is that I think it's a mistake to separate the role of the criminal legal system in Intercept 1, law enforcement, from the role of crisis services, because diversion at each of these intercept points requires collaboration across the two systems. There needs to be a partnership between law enforcement and the mental health system for the CIT program, for example, to be effective. And there need to be partnerships at the level of the court and at the jail and all the way through. And so my belief is that Intercept 0 is a much more marketable term. I think it resonates with people much better than the ultimate intercept, which is kind of a wonky, clunky term. But I like to view them as interchangeable, and I expand Intercept 0 to more broadly describe an accessible, effective, criminologically informed mental health treatment system in our communities. So I wanted to talk about a few basic assumptions that I think we all need to make, and I hope many of us do, but they're not always articulated, so I'm going to go forward and do that. And one is to expect criminal legal involvement in community mental health settings serving individuals with serious mental illness. So if you're in a community mental health center or a community mental health practice serving this population, just as you expect co-occurring substance use, which is something we had to learn over the last 20 plus years, we need to expect justice involvement. I take a little bit of exception to segregating mentally ill offenders as if they are different than the rest of the community mental health population, because they're so much a part of the community mental health population, whether we know it or not. The studies show as many as 71% of people in community mental health settings with serious mental illness have a history of justice involvement. We have to treat the jail as if it's part of the community. I know early in my career, if one of my patients went to jail, it felt like a respite. I got a break. That's not the right way to think about it. We have to follow our patients into the jail and out of the jail. And when I say I, I'm not necessarily talking about I as an individual, but we as a system. And we need to tailor care and supervision based on risk and need, and there's both clinical risk and criminogenic risk that we need to take into account as we put together care in partnership between the mental health system and the criminal legal system. So just a restatement of my view of intercept zero being synonymous with the ultimate intercept. It's an accessible, effective, criminologically informed service system to meet the needs of people with serious mental illness, including addressing co-occurring disorders that include substance use disorders, trauma, which is ever present in this population. They've been traumatized by their illness. They've been traumatized both by the health system and the criminal legal system. And we need to also consider co-occurring other medical needs, non-psychiatric medical needs have to take into account addressing criminogenic needs and the whole array of social needs, which are enormous, as you know. So very briefly on this issue of criminogenic risks and needs, I know this was a concept that was new to me until relatively recently, and I'm still certainly not an expert on it, but criminologists have studied these, these risk factors, as I described earlier, those big eight in people with serious mental illness who are involved in criminal legal settings. And it turns out that they score higher on these risks for recidivism than people in the system who don't have a serious mental illness. And so my colleagues and I have argued that criminogenic risk and areas of needs should be assessed by us in the mental health settings. We're generally not doing that very much, although I think it's beginning to happen a bit. And we have learned from our colleagues in criminology that there are cognitive behavior treatment approaches to addressing criminogenic needs in the general justice involved populations. And there are a number of researchers who are adapting those approaches to use with this serious mentally ill population. And arguably those interventions, just as we try to integrate treatment of substance use with mental health treatment for serious mental illness, we should be integrating criminogenic, the CBT treatments to address criminogenic risk. Now there are important services for subpopulations of patients. It was mentioned that I had some involvement early on in helping to develop coordinating specialty care for first episode psychosis. This is getting a lot of traction, SAMHSA, Block Grant is supporting it, which is terrific. And these programs are developing all over the country and they're needed. We also need to enhance access to long acting injectable antipsychotic medications. I think those are generally underutilized. We know clozapine is woefully underutilized and it's still the one treatment that works for psychosis when nothing else does. We need to have adequate presence of assertive community treatment teams, including forensic act teams for those who are appropriate for that intervention. And then I add to this list and highlight, because I'm going to be talking about it a bit more, assisted outpatient treatment or AOT, for those who are unable to appreciate their need for treatment to which they have previously responded. These are those folks who lack an appreciation, insight, if you'd like to call it that, that they're ill even when they've responded and are better. So definition of AOT comes from a document that a couple of us at NeoMed, my university, worked on in tandem with folks from the Treatment Advocacy Center, and is referenced below and in the references at the end. And it defines assisted outpatient treatment as the practice of providing community-based mental health treatment under civil court commitment as a means of motivating an adult, it's another double typo, I apologize for that, with mental illness who struggles with voluntary treatment adherence to engage fully in their treatment plan. So it's using a court order to help the mental health system engage with a person who's having trouble engaging voluntarily. And it's also at the same time focusing the attention of treatment providers on the need to work diligently to keep the person engaged in effective treatment. Now, I used to take offense at this idea that I, as a treatment provider, a term I don't particularly like as a clinician, needed to be committed by a court order to take care of my patients. But I've come to realize that I was likely to be quite naive. I think I'm at risk of that. And that all of us who are trying to provide treatment to these very difficult populations, we're human and we do the natural thing. And the natural thing is to treat the people who want our help, who come asking for it. And it's very easy not to go that extra mile for the person who's not asking for help and is actually actively telling us they don't want our help. And that can be quite challenging. And it turns out, as we'll see, that the data suggests that, in fact, both patients and treatment providers are impacted by the court orders. Now, a court order is an AOT order can be a one-off. For AOT to really be effective in a community, there needs to be an AOT program. And this paper, referenced below, defines an AOT program as an organized, systematic effort within a mental health system to ensure that AOT will be made available to those who need it to live safely in the community. So there's not a passive waiting for somebody to think about AOT, but an active effort organized and systematized so that anyone who's falling through the cracks, who's not continuing with treatment because they don't see the need for it, when appropriate, based on that particular state's law, will be offered AOT. Important to emphasize that AOT is not a criminal court process. This is through the civil courts. It's not the same as a mental health court, which is generally run by the criminal courts. And it's not enforced by the threat of contempt of court or jail. If there's an incentive to avoid its hospitalization, it's not the threat of court or jail. So there's been a considerable amount of research on the effectiveness of AOT. This is controversial, of course, because there's an element of coercion, and it hasn't been studied enough, and we still have lots of questions that we need more research to answer. But Dr. Marvin Swartz and Jeff Swanson at Duke did some early studies in North Carolina that were promising and did a very extensive study more recently of Kendra's Law in New York State. And so this is Dr. Pinal's information through Dr. Swartz summarizing what he found, and it's written in a very modest way. What they found in their study of New York's AOT law, that New York's AOT program improves a range of important outcomes for its recipients. And they're the outcomes you would hope for, increased engagement in treatment, reduced hospitalization in sub-subpopulations, reduced incarceration, that the increased services available under an AOT order clearly improve the recipient outcomes. So critics of AOT argue, well, you just need to increase services. You don't need to court order. So the next finding that they make to counter that is that the AOT court order and its monitoring do appear to offer additional benefits in improving outcomes. That's additional benefits over the increase in services. And then the final point is that the AOT order exerts a critical effect on the service providers. So there is something about this bi-directional commitment, if you will, that we're committed to our patients and are better able to engage them in ongoing care. So I'm going to switch gears at this point and talk a bit about competency assessment and restoration. I call this the big picture. I don't think any of this will be new to most of you. So we've been saying for a long time, and unfortunately I think it's still true, that about 2 million individuals with serious mental illness cycle through our jails every year. Many or most are charged with non-violent misdemeanors, kind of patients I described earlier from the law professor. Recent studies show, and this is a study I'm quoting from Michael Compton and his group in New York state, that larceny and the example of larceny was shoplifting and trespassing were among the most common reasons individuals with serious mental illness were arrested. So these are disturbing crimes. They might be disruptive, but not violent, not creating public safety risks. But increasingly these individuals are being referred for competency to stand trial assessments, and a portion are found incompetent to stand trial, and they're referred for restoration. And most of all of that is happening using limited hospital and jail resources that it's pretty easy to argue could be better used. Slide from Dr. Pinals with headlines from all over the country. This is Lebanon PA, I believe, Denver, and a newspaper from Mississippi all talking about the bed shortage in the hospitals, leaving people waiting in jail for lengthy periods of time, in some cases a year or more, waiting for a bed to be assessed and or restored to competency for a low-level crime for which they likely would have been released had it just gone through the criminal justice process, been adjudicated, and if found guilty would have had a short sentence. So this problem, which I really do believe is a national crisis, has been reviewed very nicely in a pair of papers that Dr. Lisa Callahan from the GAINS Center and Dr. Pinals from Michigan published in Psychiatric Services back in July of 2020. I particularly liked the second paper because of its title, Evaluation and Restoration of Competence to Stand Trial, Intercepting the Forensic System Using the Sequential Intercept Model, which is really congruent with what I'll be saying as we go along here. They're trying to get people out of the forensic system into the treatment system. Also a review that attempted to do a meta-analysis of competency restoration research. I think part of the findings is that that research is still lacking, unfortunately, but it gives us some clues. So here's my attempt to summarize some of what are in those three papers. One is that the number of forensic patients in state psychiatric hospitals has been increasing dramatically. I can almost say exponentially. And this is now old data, but from everything that I have seen and heard, and I know in our state of Ohio, as I'll show you near the end of my talk, the numbers keep going up. And the majority of these forensic patients are there for either an assessment of competency or for competency restoration. Many thousands of patients are ordered for competency evaluations every year. A relative minority are found incompetent to stand trial, but most of these evaluations are done in jails, which is increasing the pre-adjudication jail days. There are wait lists for the evaluations. And then if they're found incompetent to stand trial, there are wait lists to be transferred to the hospital. The median length of stay for competency restoration was found to be 147 days. 81% were restored to competency. And Callahan and Pinals point out, no studies have examined the time to restoration in comparison to treatment as usual. I don't know that we need studies when you look at these numbers, and I'll make the argument in a bit that it's very clear that treatment as usual takes up much less time. So I like this graphic from the Vera Institute of Justice. It's just making the point that jails are not good places to be for anyone, and they're particularly not good places for people with serious mental illness. Patients get worse very often, and it's a very traumatic experience, and patients can learn bad behavior when they're in jail. So misdemeanants, who are a good portion of the folks we're talking about, who are not a public safety threat, spend excessive time in jails and hospitals for little yield. Generally, the charges are either dropped at the end of the whole process, or the person may be found guilty of a misdemeanor and released based on time served while waiting for all this process to go along. One of the important points that Dr. Pinals and Callahan make again and again, and others make it as well, is that treatment for the purposes of competency restoration is not the same as treatment to promote recovery. Competency restoration is a treatment to allow for education, and connection to treatment in the community and community resources generally are not made by people going through this process. And these folks are using limited state hospital capacity that could be available to civil patients who increasingly find no room at the end. And so I believe there has to be a better way, and I think there's been a lot of thought as to what the better way might be, and I'm going to talk about some of my thoughts and that of others as we go forward. So there are alternatives to hospital-based competency restoration, and again, the best way would be preventing criminal legal involvement altogether. But if criminal legal involvement has occurred, there's a lot of attention that's been given, I think increasingly, to Intercept 3, what happens as part of the forensic process. And included in that are thoughts about using outpatient restoration or secure residential, and I'll talk about both of these briefly in a moment. But I'm going to argue that we should be doing more work at Intercept 2 along with the work we've been doing at Intercept 1, that is early deflection or diversion, avoiding or minimizing jail stays, and not raising the competency question at all, because once that question is raised, the quagmire begins. So Dr. Pinal's had the wonderful metaphor of thinking through how to sort outpatients, similar to Harry Potter's sorting hat. And so I'm going to try to go through some of the sorting, I'm thinking about sorting. So if public safety risk is low and hospitalization is not necessary or appropriate, this is a place where I think outpatient restoration of competency makes sense. And while doing the restoration in the community, one is also connecting that patient to the array of mental health services and supports or any additional needed services in the community. You know, Gowensmith has written and talked about this extensively, he's probably the expert I'm aware of on this issue. I love the title of his paper, Looking for Beds in All the Wrong Places. So outpatient restoration, I think, does play a role. My bias is a relatively small role in sorting out these folks. Then there are circumstances where public safety risk is moderate or high. But the person's illness is stable, they're not acutely psychiatrically ill. They don't need to be in an acute psychiatric hospital, which is what our state hospitals are today. So here, I'm suggesting, and not my own suggestion, others have as well, secure residential treatment for restoration rather than hospitalization. Now, not all the states have secure residential treatment programs outside a hospital. Ohio does not. I know they're thinking about it. But I think there's a hesitancy in part because they're not accredited entities at this point in time. They don't have JCHO checking on their quality and safety. And so I think if secure residential alternatives to hospital are developed, secure residential alternatives to hospital are developed, we need to be cognizant of the need for careful oversight. Now, what we have historically done makes sense to me to continue to do for those people who need a hospital level of care and a secure setting. So these are people who are psychiatrically unstable, and likely that means that they would meet inpatient hospital civil commitment criteria and are also been charged with a serious felony and clearly present a public safety risk. Those are the folks who the forensic hospitalization makes total sense to me. Now, I wonder who hasn't heard this, who's been caring for people with serious mental illness who've ended up in jail. This person doesn't belong in jail. This is terrible. Well, who's saying that? Well, I hear this from police officers. I hear it from prosecutors, defense attorneys, judges, as well as clinicians, and certainly from family members. We hear this so often from our friends in NAMI. And I think this is the statement around individuals who are psychiatrically unstable and don't appear to present a public safety risk, especially if their mental illness is treated. It won't even be a public annoyance if their mental illness is treated, to be frank about it. So we've been working really hard to keep individuals such as this out of the criminal legal system and assure that they get the treatment that they need. And I know I've spent much of the last 20 plus years in my career working on spreading the CIT program in our state and across the country. And there are thousands of CIT officers who have been trained to recognize mental illness and to refer to treatment whenever possible and avoid arrest whenever possible. These are police officers, and in many cases, they're supervisors and they're chiefs who embrace the guardian role for law enforcement as much as, or possibly even more than the warrior role. They don't get a lot of publicity, but I think that needs to be recognized. And I think with the emergence of 988 and the interaction between 988 and 911, hopefully there will be integration between those two important crisis lines and the emergence of mobile crisis in many communities and co-responder models. We can do more of this and intercept people at intercept one and not have them enter the jail. But there are still going to be people who are booked in jail meeting this description, seriously mentally ill, unstable. If they were treated, they wouldn't be a public safety risk. And so I know in many communities, there are jail transfers from the holding unit at a jail to a hospital emergency room for evaluation. Why shouldn't there be? If someone is arrested and they're in the midst of having an acute myocardial infarction, certainly hope they're going to be transferred for medical stability. If they have a broken arm, similarly, why not if they're having an acute psychiatric condition? And it's very possible if someone is sick enough that they then would be admitted to the hospital and perhaps the charges would be dropped at that point in time, if it's clear that the person is going to be engaged in treatment. So I think that's fine and well, and it ought to happen as much as possible, but I'm suggesting a more systematic approach to doing more or less the same thing to assure the best outcomes we can with these folks. So as early as possible in the process, I'm suggesting, and before the issue of competency to stand trial has been raised ideally before an initial hearing, there's screening that happens. This is considered a best practice of mental health screening that then leads to a priority assessment to determine whether the person needs to be in the hospital. For an individual who's assessed as meeting civil commitment criteria and as not being a public safety risk if their mental illness is treated. And so I can understand people raising their eyebrows and saying, well, public safety risk, that's a kind of a tricky assessment. And how do we know? And I think that's fair, but I also think it's likely that a majority of the people we're talking about, certainly many of them are what I would refer to as familiar faces. They're people we know that the system knows the mental health community knows them and the police know them and the jail knows them. And for those in particular that have responded to treatment, it's clear that when they're treated, they're different people. Ideally in this system that I'm describing, a prosecutor would agree to drop charges without prejudice. And then the individual would be rapidly transferred to a hospital using the emergency civil commitment process. And when appropriate, here's where I believe assisted outpatient treatment comes into place upon discharge for those who meet the criteria. Because this then assures both the criminal court that was willing, the prosecutor and our judge was willing to consider dropping the charges and the civil court that ordered the treatment, that it's assuring them that they're going to get the follow-up they need in an effort to stop the cycle of recidivism, the revolving door. Now for this to work, and I described this as aspirational. I know this is very challenging for any community. There has to be available rapid mental health screening in the jail, the ability to assess if an individual meets civil commitment criteria and to initiate the emergency commitment process. It needs to be timely communication of key information with the prosecutor or possibly the judge who's willing to consider dropping charges without prejudice. Immediate access to state hospital or better yet a community or private psychiatric hospital. And there needs to be an established AOT program to assure continued treatment post-hospitalization. It's a heavy lift. I believe it can be done. And I think the key to it is trust across the system, which means people need to know each other. They need to be talking on a regular basis, some sort of a mental health criminal justice forum that meets on a regular basis to create those relationships. Sometimes that started through a CIT program or a stepping up program or something on that order. There are many advantages, I think, to intercept to diversion. It avoids an extended jail stay to allow competency assessment and court determination of the need for competency restoration. I don't think I can emphasize enough how important it is to minimize exposure to the jail for our patients. I think that's really important. It avoids an extended hospital stay for competency restoration. And just using the example, looking at having talked to some folks in Ohio, if an average length of stay, say, is 90 days, and our average length of stay for civil patients is probably a bit under 15 days, you could theoretically treat six civil patients for every one competency restoration case that's diverted over time could really free up some beds that are greatly needed for people who are not involved in the criminal legal system. And we're assuring that people are not dropped out in the community with no supports after competency restoration is resolved by using AOT when appropriate. So just to, this is a slide from Dr. Pines, and just to make the distinction between these two processes really clear. One is civil, which I think is preferred over the criminal system for our patients from a stigma and multiple other reasons. The purpose is treatment, not restoration, which is not treatment. So competence restoration is not intended for treatment. The duration is based on the commitment law. The criteria are tied to mental illness and risk. And the intervention for someone who's not adhering to medication is based on the civil rules in that state. So I'm going to close with a brief update on what we're doing in Ohio. I thought it was fair to talk about what we're doing in my state. I was involved in this prior to my retirement and was glad to be able to catch up and see we've made some progress, but in my opinion, not nearly enough yet. But you can see from the numbers that our forensic population in our state hospitals is approaching 90% in 2023. Last I knew there were 1,050 beds in Ohio. That's roughly the right number. And so you can imagine how you can do the math on how few beds there are for a state of 11 million people for patients who need civil hospitalization. After years of discussion and debate, a bill that's known as Senate Bill 2 became effective in Ohio in August of 21. It prohibits a court from ordering a criminal defendant from undergoing inpatient competency evaluations if they're charged with a nonviolent misdemeanor and it prohibits inpatient competency restoration. So they can't go to the hospital for the evaluation and they can't go to the hospital for restoration if they're charged with a nonviolent misdemeanor. If they're deemed in need of competency restoration, there are three options given under this bill to the court. One is to dismiss the charges. The second is to order outpatient restoration and outpatient restoration programs are starting in this, they've been around actually for a long time in Ohio, but have very small numbers from what I understand. The third option is to file an affidavit of mental illness with the probate court to initiate the civil commitment process. This permits two-way communication also, the laws permits two-way communication between the criminal and probate courts, which is really important so that the criminal court judges know that they have access to information that they feel they need from the probate court if the person goes to civil commitment route. So it's too early to assess the impact of this bill. One of my complaints about it is it still requires the competency assessments and that's not in the hospital. So it's very likely to be in jail. And so people are going to sit in jail potentially for extended periods of time. But several counties are doing some innovative things that they should be commended for. Hamilton County, the Cincinnati area, which historically had the largest number of misdemeanors found incompetent to stand trial, has a prosecutor now who's flagging cases and in some cases dropping charges and then having pretrial services file an affidavit for civil commitment. Everyone's held in jail until the probate hearing happens. So progress, but not all the way there yet. And Franklin County, Columbus, where the state capital is, the state hospital Twin Valley in Columbus is working with its referring counties to dismiss charges and refer for civil hospitalization. But that's only after a finding of incompetent to stand trial unrestorable. Now, I was very pleased to hear that they're using private psychiatric and general hospital inpatient psychiatric units for these transfers. So that's a, in my mind, a big step forward in getting local hospitals and private psych hospitals to agree to take someone coming out of jail, these so-called mentally ill offenders. It's not clear that in Franklin County, they're using AOT routinely and we don't really have any follow-up. So my final question to you all is, you know, is this idea, this aspiration that I'm presenting of a better way for the subpopulation of patients who really don't need to be in the jail. Is it feasible? And what gives me encouragement is I have talked to prosecutors and jail administrators who think this is a good idea. They want to change the way they currently do business. And despite what we read in the paper, there are so many CIT officers who want to divert people from the jail, who know that it's not in the patient's interest or the community's interest to confine people to the jail when what they really need is treatment. So I ask, why not prosecutors, sheriffs, and judges? I know it's potentially political, but there are people for whom we can start with on this and then it could expand. And it seems to me that we're at the best opportunity that I can remember in my working career because of all the federal funding available to expand services. I think we have a great opportunity to improve our systems. And the question is, do we have a vision and the leadership needed to bring about the changes that we hope will come about? So I'd be curious to hear from you in the Q and A or by email after whether your state or county are using Intercept 2 for diversion, because I see that's the next step of work for those of us in the jail diversion, make our mental health system better process. Bibliography that you'll have in the slides, giving you the references that I referred to, and that completes my presentation. Thank you very much for your attention. I really do appreciate everyone being here today. Thank you, Dr. Munitz. Really appreciate that. And I definitely learned a lot. You covered a lot of ground in just 45 minutes. Very impressive. So I wanted to let the audience know before we shift into Q and A, I want to take a moment, let you guys know that SMI Advisor is accessible from your mobile device. Use the SMI Advisor app to access our resources, education, 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 a few questions came in during your talk. So I wanted to roll through a few of these. So, and definitely several people wrote in and said, excellent presentation. They really enjoyed it. So I just wanted to pass that along as well. So can you share what you believe, and the person put valid in capitals, what are some valid tools to help assess criminogenic risk? Like how could we like identify risk or do we? Yeah, there are tools and I am not an expert in this area. And I'm three years post-retirement and don't remember what I used to remember. So I'm not the one to answer that question, unfortunately. But our probation partners are probably, and pre-trial service folks are probably the best people to ask for, there are a number of tools that I'm just not remembering at this moment. That's okay. So we can share with this individual, they can write into SMI advisor and I will write so. And I can get you an answer to that. Yeah, yeah, yeah. So the individual who wrote into this can write to SMI advisor at smiadvisor at psych.org. And we will get you an answer to that. So what do you, here's another question. What do you suggest regarding someone with an SMI who are treating themselves with substance abuse? This person has been ordered multiple times to drug rehab to no avail. Well, this is a typical scenario that we see as clinicians, isn't it? So as a clinician, what kinds of things do you do when you've had multiple referrals? Very much like you talked about, about kind of lack of insight for the need of treatment. You talked a little bit about that, or maybe this person's had a couple of failed attempts at rehab. That of course always happens. So how do you kind of use, I'm assuming you use some kind of motivational interviewing techniques. How do you get them to consider treatment? Yeah. So one point that I think is important to make is that because the person is using substances and maybe doesn't want to quit, if they're willing to meet with you, we should treat them for the mental illness. If they're willing to have the mental illness treated, even while they're using substances and working over time and motivational interviewing is certainly a tool that one would use to try to engage them over time, essentially treating them where they're at. Early in my career, what used to happen is I can't treat you for your mental illness until you get sober. And the people on the substance use side said, I can't help you get sober until you get your mental illness treated. And they were each pointing fingers in the other direction. That is not helpful. And that's not the way to do this. So we try to address both at the same time, but if someone's ready to have their mental illness treated, they're willing to take, for example, antipsychotic medicine, but they're still using, perhaps they're willing to engage with you to talk about why they're still using and what they get positive from it and what they get negative from. I think I'm describing in very primitive terms, motivational interviewing. Yeah. Just sticking with people, I think is what's most important and not ruling them out because they have a substance use problem. Right. And I think you're right. It used to be years ago that we would say you can't have this until you stop that. And I think we've thankfully moved to a much more welcoming atmosphere. And the fact that the person is talking to you about your use is a real credit to your skills as a clinician, because if they're not hiding it from you, that really means that you've developed some rapport with them. And so, like you said, Dr. Munitz, this idea of kind of sticking with them and hoping that at one point they'll be accepting of this idea is probably one of the best ways forward. And I'm sure as a clinician who wrote in, I'm sure that's the kind of thing you're doing. Don't think there's any magic pill, unfortunately, to get them. That's for sure. Hey, I've thought of a couple of the assessment instruments. Oh, okay. I knew you were multitasking there. I could tell. There are two that I can remember, but again, I'm not an expert and I'm not up to date necessarily, but there's one that I believe is called the COMPAS, and don't ask me to tell you what the acronym stands for, but I believe they use in New York state. And then there's something called the LSI, the Level of Service Inventory. That's another assessment tool, but there are others and we can find out more later. Okay. And I sent this person our email address to be able to help them. All right. So are there, how about this one? What is an affidavit of mental illness with probate court? What does that do? Yeah. And this is going to vary from state to state. I heard yesterday from someone who was describing living with a roommate who was having recurrent psychotic episodes and didn't realize they were ill. And he was in a state where a citizen can't easily initiate an involuntary commitment. So an affidavit for mental illness in Ohio, and I think this would be true in most states, is a process, is a document that is executed as part of a process to go to the court, the civil court in Ohio, their probate courts, to initiate a civil commitment on a non-emergency basis. In our state, there are two different ways to get someone evaluated as to the need for an involuntary hospitalization. One is an emergency process where a person can literally be, it's a petition where a police officer or potentially a psychiatrist or some other professionals could transport the person to an emergency facility to be evaluated then and there. Or one can go to the probate court or an arm of the probate court and request to complete an affidavit that will then initiate a process. Again, it's going to look a little different in each of the states, but a process that would include some sort of psychiatric evaluation if it hasn't been done and would lead to a court hearing to initiate either an inpatient or outpatient, assisted outpatient treatment order. Great. You know, one of the advantages of having the audience that we have, which are just really smart people, someone wrote in some risk assessments and they mentioned the RANT, R-A-N-T, the ORAS, O-R-A-S, and the C-C-A-T. That's from one of our audience members, just letting the group know that that's a few that this person wrote in about. Do you feel we need more education and training in regards to handling those with mental illness? This was done in the San Jose Police Department. I mean, I guess, do we feel that we're ever done understanding it? No. Right? Don't you agree that we can always do more? Yeah, absolutely. And there are different levels of training. So, for example, in Ohio, over the years, we've now increased the required basic mental health training that every law enforcement officer gets in their academy. And then there are ongoing reviewed, you know, continuing education. And then for officers who volunteer for the crisis intervention team program, there's the 40 hours of traditional CIT training. Similar training is needed by judges. And it's probably worth mentioning the APA's Judges Psychiatrists Leadership Initiative, partnering psychiatrists and judges to educate other judges around mental illness. I think that's a terrific program. I've had the privilege to be involved in it a bit in the past. Every level of the criminal legal system definitely needs more training. And ideally, I think cross systems training, where we train together, so we learn from one another, because most of us don't know much about the criminal legal system. So we wouldn't allow a person to participate as a trainer in a CIT program, without first going and writing spending some time with a police officer on patrol to get a sense of what their job is like. And I think that principle can apply broadly across the board. Great. So we have many, many questions. I'm going to just, we only have time for one more. But I will just let the audience know, if you have more questions, of course, you can write to us as my advisor, and I'll talk about that in a minute. But what are your thoughts about eliminating competency restoration for all misdemeanor offenses? Some states have done it like New York. Yes. Yeah. I know that's being talked about and being done. And I think it's a reasonable idea, if there's a good plan to assure that the people who've shown up with charges of a misdemeanor, get the treatment that they needed. And that's really what I was trying to describe in my sort of my aspirational plan for what we would do with this. Because if we don't do that, and they just try, you know, so no restoration, we're not going to go to trial and you're just back in the community. It's just going to be a revolving door. And we want to avoid that. Right. Right. Well, thank you, everyone, for being such an active audience. And there were so many questions we didn't get to. If there are any topics covered today or in this webinar, or any other topics that you would like to discuss with colleagues in the mental health field, you can post a question or comment on our SMI Advisor webinar roundtable topics discussion board. And I noticed a lot of you were answering each other's questions, so it might be a good place to go. It's an easy way to network, share ideas with other clinicians who participated in this webinar. If you have questions about this webinar or any topic related to this or anything about caring for individuals with SMI, you can get an answer within one business day from SMI Advisor. This service is available to all mental health clinicians, peer support specialists, administrators, anyone else in the mental health field who works with individuals who have SMI. It's completely free and confidential. So we'd love to hear from you if you have questions. Now, SMI Advisor offers many evidence-based guidance around AOT. And Dr. Munitz has been involved in a lot of these along with the Treatment Advocacy Center. Here's one, the flow chart for participants on AOT, how an individual works through the AOT system. It examines the step-by-step process for participants in the program. You can access this resource by clicking on the link in the chat or by downloading this slide, the slides. 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 takes up to five minutes after we end today. You'll be able to select next and advance and complete the program evaluation and then claim your credit. Please join us on March 31st as Andrew Hannigan presents Ethical Practice and Boundary Setting for Mental Health Professionals. And we know this is a really important topic for many of us. So we hope you'll join us on March 31st at 12 noon Eastern time. That's a Friday. Thank you for joining us today. Thank you, Dr. Munitz. And we'll see you all next time. Take care. Bye-bye. you

Sequential Intercept Model

Assisted Outpatient Treatment

competency restoration

serious mental illness

criminal legal system

diversion

mental health treatment

collaboration

law enforcement

judicial system