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Catalog
Understanding Correctional Mental Health Services
Presentation and Q&A
Presentation and Q&A
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Hello and welcome. I'm Dr. Benjamin Druss, Professor and Rosalynn Carter Chair in Mental Health at the Rollins School of Public Health at Emory University and health systems expert for SMI advisor. I'm very happy that you are joining us for today's SMI advisor webinar understanding correctional mental health services. 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 AMA PRA credit, one credit for physicians, one continuing education credit for psychologists, one continuing education credit for social workers, and one nursing continuation professional development contact hour. Credit for participating in today's webinar will be available until February 14th, 2021. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. 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 10 to 15 minutes at the end of the presentation for Q&A. Now it's my pleasure to introduce you to the faculty for today's webinar, Dr. Deborah Pinals. Dr. Deborah Pinals is the medical director of behavioral health and forensic programs for the Michigan Department of Health and Human Services. Dr. Pinals is also the director of the program in psychiatry law and ethics at the University of Michigan. Her research interests include the legal regulation of psychiatric practice, law and psychiatry, and justice and behavioral health. Dr. Pinals, thank you so much. We're really looking forward to today's webinar. Thank you so much, Dr. Drost, for that wonderful introduction and welcome everybody to this webinar. This obviously is a topic that is of great interest and I'm delighted and honored to be able to present it to you. I just want to point out that I have no relationships or conflicts of interest related to the subject matter of this presentation. I do serve on the Board of Representatives for the National Commission on Correctional Health Care on behalf of the American Psychiatric Association. For today, I've put forth several different learning objectives for you. I'm hoping that after listening to this presentation, you will be able to better evaluate the prevalence rates of serious mental illness in jails and prisons. We're going to review case law and national standards that are used to help guide mental health services in jails and prisons. I'm hoping you'll be able to assess the realities of correctional environments that make delivery of care challenging as it applies to your own work with people who might be justice involved and determine the basic elements of mental health care within correctional settings, including an important aspect which is re-entry coordination. So let me start at the beginning with learning objective one, evaluating the prevalence rates of serious mental illness in jails and prisons. So the correctional population in the United States is evolving. And of course, COVID-19 has impacted the correctional population in ways that we don't even fully understand as of yet. Data going back to 2019, before the pandemic, showed that there was a decrease in the overall total correctional population for the 12th consecutive year. The decline in the incarcerated population during 2019 was primarily due to a decrease in the prison population, which I'll get into in a moment. It was notable, however, that of the people under community supervision, the parole population grew by 6.6%. And it was indeed the only correctional population with an overall increase during that decade under study. Again, because of COVID-19, we don't yet fully know what the impact is and what the impact will be as we hopefully come to the waning times of COVID-19. Just to remind you, when I'm talking about a correctional population, it's important to realize that we think broadly about what that means. Not everybody is in an institution or in a locked setting. Many of the people, in fact, the majority of people under correctional supervision, are living in the community. Of the total incarcerated population, we have basically jails and prisons, which I've covered in some of my prior SMI advisor webinars. The prison population is about twice as big in our country as the jail population. And we'll go into this a little bit further as I describe them so that you have an understanding because what these institutions look like creates changes in how mental health services are delivered and how they can be delivered. In addition, there's community supervision. Individuals, about 4.4 million people are under community supervision, which means they're assigned a probation officer or a parole officer who monitors their compliance with the terms of their supervision. More people are under probation than parole supervision, and they have different meanings. And again, I'll go over those as well. But those populations, that gives you a snapshot of what we're dealing with. It's also important to realize that this is a fluid population because, for example, if an individual violates the terms of their probation or parole, they will often be sent back into a jail or prison. And similarly, as people are leaving jails and prison, they're often under community supervision, although not always. And so there's a very strong interrelationship of movement of people through these systems. And so as I think about it as a forensic psychiatrist and as a system psychiatrist, we're really thinking about what does this mean for people with serious mental illness in terms of access to continuity of care. It's also important, I don't think we can talk about our correctional system in the United States, and many people are looking at whether the word correctional is the proper word, but it's important to realize that there's tremendous racial disparities between the U.S. and its incarcerated populations. And that's something that needs and is getting intentional attention, but needs more of it so that we understand where those disparities are coming from and how to address them. So among the correctional population, for us in the mental health field, it's also important to understand what is the prevalence of mental health problems reported by prisoner and jail inmates. So this data is fairly complicated actually, because the way it is collected in big data systems is under a variety of ways. There have been several studies that have really gone in and done very rigorous diagnostic classifications of inmates. Those studies are somewhat older now. There are other studies that look at self-reports of psychological distress. And you can imagine that the data that you're getting may depend on how you're collecting it. However, some of the best data we have is not that current, and it's a hope that it will be more current and more data will be forthcoming. But this was published in June 2017, but it really looks back at data from 2011 to 2012, where it found that one in seven prisoners and one in four jail inmates reported serious psychological distress in the past 30 days, in comparison to one in 19 of the general population. Now, there is some thought that the measurement that was used has some ability to correlate with serious mental illness, but it is a proxy measure to that, because it is a self-report of serious psychological distress. About 75% of those that reported serious psychological distress did report that they had also received prior mental health treatment, which again, helps us to narrow some of our understanding of who this population is. This is really important to think about, because we're talking about one quarter of jail inmates and over 10% of prison inmates. In another study looking at prevalence rates that was produced through the Council of State Governments and Fred Osher and colleagues, they estimated the proportion of adults with mental health, substance use, and co-occurring disorders in this graph here, where compared to the general population, looking at a variety of studies, it was thought that about 17% would qualify for what we would consider serious mental illness, such as schizophrenia, bipolar disorder, and the like. And 16% of state prison populations, and then from there, about 7% to 9% of probation and parole. Now, there were also individuals at high rates who had substance use disorders, and one of the things we know that is gaining increased attention is the prevalence rates of individuals with co-occurring substance use when serious mental illness is diagnosed. And that's something that we always have to tackle in our clinical services, is to think about both conditions simultaneously. And you can see from this chart what they found is the prevalence rates of 72% of individuals with co-occurring substance use disorder when a serious mental illness was diagnosed, and 59% of individuals in state prisons. Looking at the data from a different lens, and depending on the lens you're looking from, you're going to find different numbers, but I hope what I'm trying to convey in this is that we have to pay attention to this population that intersects with serious mental illness and the criminal legal system. There are two studies that I often cite. They go back to 2011 and 2013, but I think they're highly relevant. One was by Bill Fisher and colleagues, and it was published in Psychiatric Services. And basically, it studied a group of public mental health service recipients in Massachusetts, and found that the odds ratio of having been arrested was higher than the general population, and that there was the highest risk was for arrest on low level, what we call misdemeanor charges, among those with serious mental illness. In another study by Jeff Swanson and colleagues, also published in Psychiatric Services, he looked at data from Connecticut, and found that approximately 25% of individuals with either schizophrenia or bipolar disorder served by the public mental health system was involved in the criminal justice system during a two-year data review. So one quarter of the population served by the public mental health system had some history of criminal justice involvement. He also found that the cost for these individuals were approximately double to those without criminal justice involvement. And I think in many ways, that can go back to what I said before in terms of continuity of care and other factors, including co-occurring substance use that might be driving some of those costs. Another important point that I want to make is a study that came out alarmingly in July of 2021, which showed that the mortality rate of individuals in local jails was rising. And what's more concerning for this webinar today is that the suicide rates, especially, were among one of the causes for the rising mortality rates, rates. Of course, drug and alcohol intoxication, which is also relevant, was another factor driving the all-cause mortality rate. And so despite interventions, like we're seeing in the general population, suicide and substance use become major drivers in mortality rates, and something that I think we all want to think about and pay attention to. Here was another, this was data that drilled down on that suicide rates in local jails and state and federal prisons. And again, from 2001 to 2019, the number of suicides increased 85% in state prisons, 61% in federal prisons, and 13% in local jails. This is a number that we have to pay attention to and really try and mitigate against further increases. So I hope by now you understand some of the prevalence rates of mental illness in jails and prisons. And now I want to move us along to learning objective number two. In this part of this series, I want to review case law and national standards to help you understand how mental health services are guided in jails and prison by these cases and national standards. First, it's important to realize that just like anyone, we all have constitutional rights in the United States, and we're fortunate to live in a state where we do have these types of rights. Many of these rights are directly applicable to inmates as well, who have, by virtue, whose constitutional rights are not removed just by virtue of incarceration. So they are entitled to First Amendment rights of religious expression and communication, Fourth Amendment rights to prohibit unlawful search and seizure, Eighth Amendment rights where they should not be subject to cruel and unusual punishment, which is often the source of litigation when examining what's called the conditions of confinement in a carceral setting. And then, of course, Fourteenth Amendment rights, which give people the access to fair due process and equal protections of the law. And this relates to things like disciplinary hearings and segregation and a whole host of issues where constitutional rights come to play. There's also, so taking into account the constitutional principles, I want to give you some historical background on health care, because these start to weave together into what is shaping out and what is the current landscape of mental health services within corrections. In terms of the health care and corrections, we can look back into 1977 when the American Medical Association published Correctional Health Standards and then helped establish what is now known as the National Commission on Correctional Health Care, which some of you might be familiar with the Joint Commission. I would say that NCCHC is probably most similar to the Joint Commission focused on health care standards within correctional environments. The American Nurses Association has published standards regarding nursing care, has published standards regarding nursing care in correctional facilities. The American Bar Association has joined in publishing standards for criminal justice. And even the American Psychiatric Association has printed several reports on psychiatric specific services in jails and prisons, which was recently updated. And I'll talk about that a bit more. And so there has been an evolving expectation of standards for health care. Now, I'm going to toggle a little bit back and forth between case law and health care standards so that you can understand how they relate. But toggling back to landmark cases related to the care of persons with mental illness, it's important to recognize that there was a ruling by the U.S. Supreme Court in 1990, which spoke about the involuntary administration of medication for prisoners and when that would be allowable and not allowable. Now, in psychiatric care, we are still involved in some cases with involuntary administration of medication. Of course, we know a lot about the importance of patient engagement and maximizing voluntary participation in treatment as a way of sustaining engagement over time. But there are going to be those circumstances where individuals might decline medications and the involuntary administration of medications becomes part of delivering care. And that goes in the civil setting and in psychiatric hospitalization, as well as in prisons. However, what the parameters are in psychiatric hospitals are different from what they are in prisons. And this is partly based on Washington versus Harper, which spoke about the importance of determining both medical appropriateness and institutional security as factors that would be considered in terms of the involuntary administration of non-emergency medications for individuals who would be refusing treatment. Another critical case going back a decade, even earlier, was Vitek versus Jones, in which the U.S. Supreme Court ruled that there needed to be fair due process when an inmate is transferred from a prison setting to a psychiatric hospital. Many prisons, as we'll talk about, well, prisons in general, as we'll talk about, have what they would consider a psychiatric hospital level of care within their systems. But there is this other factor of when an inmate is transferred out from a prison to a psychiatric hospital, there may be a need for greater due process legally. Other critical cases that have helped the delivery of mental health services evolve in correctional settings include a very important landmark case called Estelle versus Gamble, which essentially said by not providing health care services to a prisoner, that could constitute deliberate indifference and a violation of the Eighth Amendment prohibition against cruel and unusual punishment. And essentially Estelle versus Gamble established prisoners as the only population within the United States that has a constitutionally protected right to treatment to avoid this unlawful violation of constitutional rights. A second case, Bowring versus Godwin in 1977, extended this specifically to mental health care. And so although there are other institutions where we are providing mental health services, the prison population becomes the one with the constitutional right to treatment. Bell versus Wolffish in 1979 further extended this concept but used a different constitutional argument by applying the 14th Amendment to pretrial detainees having a right to mental health and substance use disorder treatment. So the idea behind that is because, generally speaking, because prisons are a place where people are sent as part of their punishment, in jails where people are still, many people are still pretrial, the idea of punishment doesn't apply. But instead, the 14th Amendment right to due process and equal protection does apply to pretrial detainees so that this is the argument that is often made in litigation when jails are not providing or alleged to not be providing proper mental health or substance use treatment. And then finally, a more recent case, Brown versus Plata, was a case based in California in which there was prison overcrowding. And this was two cases that were consolidated by the US Supreme Court, one looking at medical care, another looking at psychiatric care, in which they said that the overcrowding in the institution ultimately constituted a violation of Eighth Amendment by depriving inmates of adequate mental health and medical care. These cases have really driven important change in systems in terms of care delivery. So what is the constitutionally minimal adequate mental health services that an inmate could receive? A federal decision called Ruiz versus Estelle in 1980 helped delineate some of the minimally necessary services in the conditions of confinement. And they delineated six essential elements. First, that there should be systematic screening and evaluation of everyone coming through a correctional environment to determine what their level of treatment might need to be, whether it's nothing, they don't have a mental health issue at all, or something that gets flagged that warrants further care. There also needed to be some de minimis treatment available to individuals, as well as participation in that treatment, not by correctional officials, but by trained mental health professionals. There needed to be the establishment of an accurate, complete and confidential record. And there needed to be safeguards against the inappropriate use of psychotropic medications and access to appropriate psychotropic medications, as well as a suicide prevention program. In 2016, the APA produced the third edition of its report on psychiatric services in correctional facilities. And it covers a gamut of topics. So this does not really do it justice. And I would urge anyone interested in this topic, to consider looking at this document. But it includes information about screening, referral and evaluation specific to psychiatric services, treatment and community reentry as some of its broad based topics. Now, when an individual is brought into a correctional facility, there are going to be what's called housing determinations or classification standards. And through an understanding of their risks, the prison or jail will have a way of sorting people into particular units or wards or pods, different terminology might get used in different settings. And it may be based in part on their criminal history, it could be based on their institutional adjustment, if they're having a difficult time adjusting, it could be based again on their criminogenic risk or likelihood of reoffending or the risk of violence. It could be based on their treatment needs, for example, in those settings where there are specialized units that provide enhanced treatment. And it could be based in some ways on inmate vulnerability or request for an inmate who might want to be in what's called protective custody, for example. And housing determinations become a very big part of how a facility is managed. And it can have implications for individuals with serious mental illness, depending on where they're placed. Some of the placements will allow greater movement outside of an individual cell. Others will not allow greater movement and will have minimal movement outside of a cell. With the most restrictive being placed in a cell with one hour outside of cell time within a 24-hour period. And that's considered restrictive housing. Now, going back to standards to understand this, there are a variety of ways that these facilities are looked at from accreditation in terms of correctional systems. The American Correctional Association is the body that covers all aspects of managing an institution. And it also does have some healthcare standards. But this is not its major focus. It's really looking at the total institution, what's the safety, security, housing management, personnel management, administrative management, infectious disease protocols and the like. And the standards are coming from this correctional standpoint about how to ensure the safe and appropriate delivery of a correctional environment. Again, with some health guidelines and some mental health guidelines, but not a major focus in this area. Facilities that are accredited, if you ask, if you work or deal with a correctional facility, if they are accredited, most will be accredited by the ACA. Not all are accredited by any accrediting body. But if they are accredited, the ACA is probably the most common accrediting body. In terms of specific accrediting bodies that look at the healthcare services and mental healthcare services within jails and prisons, as I said, NCCHC is the one that comes to mind, I would say most often. And again, with the caveat that I do sit on the Board of Representatives. But I will point out that most facilities in the United States, by far, are not accredited by the NCCHC. So although the NCCHC publishes standards, provides consultation, and offers an accreditation, most facilities will not be accredited. However, there are other ways that there can be accreditation, and I'll talk a little bit about that. These healthcare standards separate manuals for jails, prisons, and juvenile facilities. They have separate standards for medical, mental health, and opioid use disorder, for example. And we'll also take into account the institutional size. Other non-correctional specific entities that can offer some accreditation within carceral settings include the Joint Commission, although again, their history is with healthcare settings, not correctional healthcare. And so there is some adaptation that comes along with that. And then CARF, which is the Commission on Accreditation of Rehabilitation Facilities, and some correctional facilities will utilize CARF for an accreditation. And it is important to recognize that even if a facility is not formally accredited, because of many forces at play, including litigation, including the desire for best practices, and wanting to provide the care and treatment for the inmates under its authority, many correctional facilities will lean on these accreditation standards and develop programs that would potentially and hopefully meet the standards, even if they don't pursue the formal accreditation, which has cost and monitoring involved. There are also states and counties, mostly states, I would say, and the federal and the Federal Bureau of Prisons that have developed their own standards through law, policy and whatnot, that often are very parallel to these types of standards. So in terms of mental health services, within correctional settings, it's important to, again, go back to the beginning, screening, assessment, referral and evaluation. The goal is always to offer timely access to quality services. When people are passed through a correctional environment, they go through different doorways, if you will. There's booking, what we call reception, when they first arrive, and then they get processed, then they may get sent to a unit where they wait for their classification for where they're going to be housed. And so this is where screening on admission and reception becomes critically important, so that any individual, all individuals are screened first by a non-qualified mental health professional in a general, broad layperson screening, which will trigger a more rapid assessment, but then eventually screened by a qualified mental health professional within usually 14 days, if somebody has been flagged by a generalist, either an officer or during the health screening by a nurse for needing to be seen by the qualified mental health professional. There's generally not going to be a qualified mental health professional that will be at the gate of reception. And that's something I think for mental health practitioners you don't often realize. I know when I started working in correctional facilities, I had a lot to learn, because I kind of had, my only experience was working in a psychiatric hospital, so I had this impression that because it was a locked setting, that people would be kind of accessing the same kind of services, but it's a prison or a jail, so it's a very different environment. So screening is going to be done by a correctional officer initially, then by a nurse, and then if a flag is raised, and that means that those screenings have to raise the flag by a qualified mental health professional more urgently, but otherwise it may be two weeks before somebody is seen by a qualified mental health professional for that further screening. If somebody is screened positive, there would be a comprehensive mental health evaluation with the diagnosis, and there also has to be a way for referrals to be made at any point in time during the incarceration, so that an individual who comes in looking pretty good or sort of still in shell shock about what's happening but not reporting any symptoms, someone can make a referral for more urgent access to a qualified mental health professional. Also, besides referrals from staff, there's often something called, the language may differ in jurisdictions, but many jurisdictions call these KITES, which are ways that inmates can communicate their needs to staff. It's basically a request to be seen, and those requests are supposed to be reviewed. There's policies for timeliness of those reviews, and then there's 24-hour crisis services that are supposed to be available, and record-keeping that's done that's accurate, complete, and confidential. Sorry. All right. Now that you understand, hopefully, a little bit more about accreditation and standards and case law and how that plays into this, we're going to talk about the realities of correctional environments that make delivery of care challenging. Again, let's go over these correctional settings so that you have a complete understanding of them. There's different facility types. We have lockup, jail, prison, detention, all very different in terms of how they're driven. There's also U.S. military prisons, jails, and detention centers. There's also the federal prisons, which run through their own national coordination and policy development. When first arrested and placed under custody, people will be placed in lockups. These are very short-stay facilities, often in local municipalities. You may have seen pictures of that on television, where you see people with the local officers standing by. They're high-volume. People come in. I look at them as typically where people are held from arrest and determination of custody, because not everybody arrested is placed in custody, to arraignment, which is when their first court appearance is. Some communities use local jails also as the lockup. You can imagine, again, for somebody, let's say with schizophrenia, who's on Clozapine, if they are arrested, which, again, we saw from the prevalence data, 25% of the people in the public mental health system have gone through the justice system, many of whom have gone into custodial settings or correctional settings. Access to their Clozapine is going to be really important. If they're on medication for managing opioid use disorder, that is often really challenging for people during these short stays. All too often, we see people who are not maintained on their medication during these acute periods. Then, after they go to court, and they're arraigned, they may be determined to not be eligible for release, and so they will be sent to a jail. Now, jails are typically county-run. They typically house pretrial populations awaiting court proceedings and adjudication, and the length of stay is variable with, again, high turnover of populations. They also hold sentenced populations. Typically, jails will only house people who are sentenced for one year or less. However, an individual may be facing multiple sentences, and so they could have consecutive sentences. Somebody could actually be held pretrial for a long time because it may take time for their trial to unfold, and then they may be sentenced for a year or a sentence for a series of years. You can see people sitting in jail for many, many years, even though they're designed to be more facilities for people for less than a year. It's important to also realize that they serve other community functions. For example, people held in civil contempt might be held in a jail. People might be sent there for local public health reasons. These jails might have contracts to provide services for immigration. They might have used some of the cells for temporary housing for state or federal inmates, and they might actually provide temporary housing for juveniles pending transfer or bail bond violators, or they may hold individuals for the military, protected custody, or contempt of court, and so there can be a number of different populations that move in and out of these lockups or jails. Prisons are usually for people that are confined for more than a year. They're typically operated by the state, or we have the Federal Bureau of Prisons, which operates a network of prisons throughout the United States. They use or operate or contracts for their operation. They usually house higher populations. Usually, they're big facilities, greater than 500 beds. I remember walking into my first prison being astounded to see a facility with something like, you know, 3,000 or 6,000 inmates that might be in one facility. Often, individuals will come to prison after an extended period in custody awaiting jail, or they might come directly from the community if they have violated their parole. This is a picture of a prison complex. Prison complexes have, again, special housing. Usually, they have a general population, which is not considered special housing, and then there can be specialized housing, again, for the focus of psychiatric services or mental health services. Individuals might be in residential treatment units or residential treatment programs for having certain conditions that warrant additional supports. There can be inpatient level of care, according to the prison's framework. Sometimes, individuals with serious mental illness will be placed in administrative segregation for being on protective custody if they're more vulnerable, or they could be placed in disciplinary segregation if their behavior leads to disciplinary action. Unfortunately, we do see individuals with serious mental illness disproportionately placed in disciplinary segregation in the similar way that we see individuals with serious mental illness placed in jails and prisons in the beginning because sometimes their behaviors are aberrant and they're met with punitive responses as opposed to treatment responses. There are separate juvenile facilities. There are specific age definitions for who would qualify to be in a juvenile justice facility. In the juvenile justice world, detention is usually the pre-trial terminology, and commitment is usually the place where juveniles might be sent if they need to have secure setting after being committed, which basically is like a finding of, I hate to say it because it is supposed to be different, but it is sort of the equivalent of a finding of guilt. Although juveniles aren't considered criminally culpable, they're considered to be delinquent if they're found to have committed the act for which they were charged. Recall, too, there's community supervision, probation, which can be pre-trial or post-trial. Probation is going to be ordered at the time of trial and sentencing by a judge. Probation officers monitor adherence to terms such as compliance with treatment, refraining from contact with certain persons. They may require individuals to sign releases of information between the probation officer and the treatment provider to allow conversations to occur. And similarly, for parole, there's going to be releases of information. However, parole is going to have a different framework. It's a determination of release after an individual has served a sentence. There's usually a parole board that determines whether somebody is eligible for release under the terms of parole. So when somebody is sentenced, they're sentenced with the possibility of parole or without the possibility of parole. And then they'll have community-based parole officers that monitor adherence to the terms. If there is a violation of adherence, which could include non-adherence to medications or treatment, there could be a violation of parole. More and more behavioral health systems are working with these entities to try and look at issues around how to best move people more into the treatment system instead of penalizing non-adherence to treatment. But it's a complicated situation because of the public safety interface. In terms of demographics, males are in prison at rates four times the rate of females. However, females are among the fastest growing prison population. I should say older adults are also among the fastest growing prison populations. Female inmates have higher rates of mental health problems than males. And that's also true for medical disorders and drug dependencies. More than 80% of females have one or more lifetime psychiatric disorder. I'm not getting into the data about trauma, but we know that there's a huge overlap between trauma histories for female and males involved in the criminal system, as well as involved in the mental health system. And when you take both those systems together, you're pretty much looking at a trauma history somewhere along the way. So moving on to our final learning objective determining basic elements of mental health care within correctional settings, including re-entry coordination. Psychotropic medications are going to be really important to identify at that screening and referral process. We want continuity from the community for sure and access to prescribers. There can be challenges, however, because there's often formulary distinctions in terms of what's available within the carceral setting compared to the community setting. And so somebody's medications may be changed upon admission to a jail or a prison. Again, the provisions for medication over objection may or may not be available, even though there's legal standards that apply to prisons, there's not clear legal standards that apply to jails. Engagement strategies can be challenging without proper attention to these issues. How to engage somebody and how to have correctional officers, for example, engage people with serious mental illness and adherence to medication is usually not part of correctional officer training, although hopefully that is shifting. And so the APA did produce a recent document looking at non-emergency involuntary medication for individuals with mental disorders in US jails that helps explain some of these complexities. And I would urge you, if you're interested to look at that, you can see when you get the slides and the PDF from this webinar, I think you can just Google the title of this that's on this slide and you will find it. There's also the issue of correctional suicides, as I said, and the rates in prison are estimated at two times the general population and they are the suicide is the leading cause of death in jails. And again, it has increased over the years. The most common method of suicide is by hanging. And the most common correctional setting is in that acute period in lockups. Within prisons, suicide is the second leading cause of death. And most suicides occur after the first year of confinement. And one of the major risk factors is the presence of mental illness. Again, there's litigation that has looked at these issues at correctional suicide that point to issues of how contracted providers within these facilities are providing care, how correctional settings are monitoring individuals within their walls, how screening is being done and triaged, and what's the availability of staffing and training. These are key themes that often emerge in litigation against the facilities when there has been an inmate suicide. It's also important to realize, sorry for the way these slides are being driven, the button's very sensitive. It's also important to realize that post-release outcomes are very important. We know that re-entry can be a matter of life and death as people leaving prison are at magnitudes higher risk of death within weeks of release. And that includes from drug overdose, cardiovascular death, homicide, and suicide. So the APIC guidelines set the stage for assessing, planning, and identifying and coordinating the needs for individuals as they're leaving correctional facilities. Also, information sharing standards become important, even though there are limitations given from HIPAA and 42 CFR Part 2 for substance use treatment. The state laws also can help govern where information can be shared. And remember that a valid release allows communication. So sometimes people say, well, we can't communicate because of HIPAA. However, you have a probation officer who's required the individual to sign a release of information. And so you have a valid release. And so there doesn't have to be barriers to communication very often through that release of information mechanism where the individual has authorized that. It's really important as a best practice to think about how to work together with your correct, if there is a correctional supervision supervisor involved in a patient's life, to work with them, to mutually coordinate, to help that individual achieve recovery and not recidivate and get themselves back into the criminal system. A lot of work going on around the sequential intercept model, which really looks at how we can look as movement occurs for individuals from arrest, from crisis services to arrest, to that initial detention, to jails, to re-entry and community corrections and back. Really looking at identifying individuals with mental health needs and figuring out what's a better approach to serving them besides routing them through the criminal system. Correctional systems is something that is designed to keep our communities safer. It has its role. However, we want the right people to go through it and people who don't need to go through it, but need treatment to be able to access a treatment system. So let me just conclude by saying it's really important to understand the myth of correctional settings that they are not the same as an inpatient psychiatric setting. They're not designed as a therapeutic harbor. So when there's this idea that let's just have our patient arrested because they'll be able to get the care that they need within the jail, that may not be the case, although standards of care are evolving. The revolving door of the criminal justice system can be traumatizing for individuals and that there's a high risk of gaps in care due to various systems involved, which then leads to higher morbidity and mortality associated with disruptions of care, not to mention recidivism back into the criminal system. So it's really, I think, behooves us as practitioners to maximize our understanding of the realities of the criminal justice system, the laws, and the best means of coordinating care between treatment and corrections and courts that can be helpful. Some of my fondest memories involve being a psychiatric provider within a prison. And I think you have some really wonderful practitioners working in these settings. We need more people to want to work in these settings, even with their constraints. And it's really important to remember as practitioners to reach across those boundaries and try to coordinate care for our patients to the best of our abilities. Remember that substance use and mental health treatment and correctional settings has to receive and continues to receive important attention locally and nationally, and it will serve the individuals we're working with most if it's coordinated across community settings. And so with that, I've provided references in the slide deck, and I want to thank you for your attention to my information. All right. So while we try to reconnect Dr. I just want to let everyone know that SMI Advisor is accessible from your mobile device. You can use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, and even submit questions directly to our team of SMI experts. So feel free to download the app now at smiadvisor.org app. So, Dr. Pinos, what I'll do is I will pull up the Q&A tab, and I'll just read them to you, and you can respond. Perfect. Okay. So one question is, can you please identify where and how these care options are being carried out as part of reentry or mentoring? Where and how these care options are being... Say that again. I'm sorry. Where and how they're what? So the question is, can you please identify where and how these care options are being carried out as part of reentry or mentoring? So, in terms of reentry, where and how they're being carried out, you know, within correctional facilities, there are usually something called reentry coordinators that help arrange for people's treatment needs when they leave the carceral setting, getting them situated with benefits, which is a huge issue, and the like. And so it'll be within the facility. Oftentimes, reentry planning happens three to six months prior to release. It is a little bit challenging or very challenging because release dates can be moving targets, and so sometimes you plan an appointment, but the person didn't get released, or sometimes you plan an appointment, they got released two weeks earlier, and then you don't know where they are. They've been lost to follow-up. So those reentry coordinators are increasingly focusing on connecting people to community. In terms of mentoring, I think there were two parts to that question. You know, I would consider reaching out to your local, perhaps if you have a department of psychiatry with forensic psychiatry where there's work in corrections, there might be an opportunity for some mentoring through those routes. And certainly through SMI Advisor, we have a whole line of webinars related to the criminal legal system. And Dr. Dress, can you hear us now? I can. Can you hear me? Yes, we can. Sorry about that. Yeah, lost internet connection. So we have a question. I'm not sure which ones you've gone through, but I was curious just in the last few minutes whether you have any thoughts about the issue of solitary confinement, how that's used and what the implications might be for populations with serious mental illness. Yeah. So, you know, we've been working in the APA to kind of address those issues. We do know that individuals with serious mental illness, you know, in solitary confinement, just like other individuals can have some increased risks of perhaps not getting better at the minimum, they may have some increased risks related to worsening symptoms. So it's really important that programming is available to individuals and that they are in those settings for the least amount of time. There's been a lot of work to address ensuring that there can be access to programming for people with serious mental illness. This has been attended to a lot, especially in the prison settings where, again, there's been a lot of litigation around this. And so there's usually rules that get set forth about standards and maximum lengths of stay and what kind of hours out of cell should be offered and what kind of programming should be offered. And so, and there's still some, there's still a lot of work to be done in this area, and there's a lot of work to be done in this area, especially, I think, also in jails where individuals might be with serious mental illness locked in a cell where, because of their behavior. Thanks. And again, if you haven't answered this already, I'm wondering, there was a question about suicide precautions in jails and prisons. And I'm wondering what that looks like for someone who may not be familiar. There was a question about this. How might this be similar or different to a clinical setting? And how might this be and what are the implications for care delivery? So suicide precautions in a correctional setting can look very different, and they do look very different from a clinical setting. Usually, if somebody is on a suicide precaution, they will be confined to a cell. They may have restricted access to any items. There's usually something called a suicide smock, which is something that is unrippable so that you can't make fabric cords that you could then use as a ligature risk. And so there may be people that are wearing only the suicide smock while they're under what can be called eyeball or one-to-one watch with an officer sitting outside the cell. And that is how a suicide precaution would be implemented. Then there can be other types of monitoring. There can be video surveillance. As people seem less of a suicide risk, they can be given items back and then watch maybe with more intermittent checks and monitoring. But it doesn't necessarily mean that they're going to have, you know, as enhanced treatment like you might see on an inpatient setting. Again, the standards are evolving, and there are more efforts to provide improved mental health care for individuals that are suicidal. But it's the institutions, the carceral setting is an institution whose primary mission is security and safety. And so to keep a suicidal individual safe, they will remove the potentialities of items that can compromise that. It's also important to realize that not all correctional facilities are new, and some of them are extremely old. And so ligature risks might be present that haven't been addressed. Okay. Thanks so much. I think we are out of time now for Q&A. So we'll move into the final slides. I want to thank you again, Dr. Pinals, for such a wonderful presentation on an important topic. So if anyone has questions about this or any other topic related to evidence-based care for SMI, our clinical experts are now available for online consultations. Any mental health clinicians can submit a question and receive a response from one of our SMI experts. Consultations are free and confidential. SMI Advisor is just one of many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you to explore the resources available on the Mental Health Addiction and Prevention TTCs, as well as the National Center for Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics, from school-based mental health through the opioid epidemic. To claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes. You'll then be able to select Next to advance and complete the program evaluation before completing your credit. If any of you missed any part of the talk or want to revisit the talk, it will be on our catalog at smiadvisor.org, beginning this coming Tuesday, January 18th. Please join us in two weeks on January 28th, 2022, as Dr. Pinals joins us again presenting Supporting Persons with SMI in the Community After Release from a Correctional Setting. Again, this free webinar will be January 28th, 2022, from 12 to 1 p.m. Eastern Time. Thank you again for joining us. Until next time, take care. you
Video Summary
In this webinar, Dr. Deborah Pinals provides an overview of mental health services in correctional settings. She discusses the prevalence of mental illness in jails and prisons, the constitutional rights of inmates, and the challenges of providing care in these settings. Dr. Pinals also covers topics such as screening and evaluation, psychotropic medications, suicide prevention, and re-entry coordination. She emphasizes the importance of understanding the unique realities of correctional environments and coordinating care between treatment providers and correctional facilities. The webinar is part of an initiative called SMI Advisor, which aims to help clinicians implement evidence-based care for individuals with serious mental illness. The webinar was designated for AMA PRA credit and continuing education credits for psychologists, social workers, and nurses. It is available for viewing on the SMI Advisor website.
Keywords
webinar
mental health services
correctional settings
prevalence of mental illness
constitutional rights of inmates
challenges of providing care
screening and evaluation
psychotropic medications
suicide prevention
re-entry coordination
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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