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What Happens When Your Patient with SMI Gets Arres ...
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I'm Amy Cohen, Associate Director for SMI Advisor and a clinical psychologist. I am pleased that you're joining us for today's SMI Advisor webinar, What Happens When Your Patient with SMI Gets Arrested? 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. And now, I'd like to introduce you to the faculty for today's webinar, Dr. Debra Peinold. Dr. Peinold serves as the Director of the Program in Psychiatry, Law, and Ethics and a Clinical Professor of Psychiatry at the University of Michigan Medical School. In addition, she's a Clinical Adjunct Professor at the University of Michigan Law School. Dr. Peinold is the Medical Director of Behavioral Health and Forensic Programs for the Michigan Department of Health and Human Services. She is the current Chair of the American Psychiatric Association Council on Psychiatry and the Law and is board-certified in Psychiatry, Forensic Psychiatry, and Addiction Medicine. Dr. Peinold has almost 20 years of experience working at the interface of justice and behavioral health. Dr. Peinold, thank you for leading today's webinar. Thank you so much, Amy, for introducing me, and thank you for inviting me to do this presentation. I just want to let people know that I have no relationships or conflicts of interest related to the subject matter of this particular presentation. Today we're going to try to accomplish three main objectives. First, I want to describe the steps from arrest to court to incarceration to release so that you can understand them. I'd like you to be able to learn from this webinar the basic elements of forensic systems, which often can be a mystery to people who aren't deeply involved in them. And last, I'd like you to be able to describe how to enhance potential for continuity of care for persons with serious mental illness who find themselves involved in the criminal justice system. We know that a disproportionate number of persons with serious mental illness are arrested, and that's in part why for SMI Advisor, this educational series is important because anyone caring for people with SMI are potentially going to encounter a patient who does get arrested. We also know through data that crimes of arrest for people with serious mental illness are most frequently minor crimes referred to in the law as misdemeanors. In some cases, persons with serious mental illness might be arrested for serious crimes referred to as felonies, and these can range in severity depending on the behavior involved. Of course, there are some that are going to be extremely serious, but there are going to be others that are less serious to society. And so when we think about people with serious mental illness who are arrested, we want to make sure that we don't make assumptions immediately that people with serious mental illness are only getting arrested for the most extreme crimes like murder and rape and things like that because that further stigmatizes the population. We don't want to minimize either when people with serious mental illness or when any people for that matter are arrested for serious crimes. And all of the things when I teach about this subject are really trying to balance the need to preserve public safety, but also minimize the risk of overvaluing the concerns that stigma brings with the issues of people with SMI who are involved in the justice system. It's important also for providers and clinicians to realize that the path of an arrest can vary for any given individual. Even though in the last webinar, we talked about the sequential intercept model and understanding that arrest to incarceration does have some logic to it and it can be followed. For any given individual, there are so many things that can make their pathway vary. And so we want to be prepared as a clinical workforce to understand that variability in the justice system. So why should a mental health professional understand what happens when a patient is arrested? First, the potential to communicate is really important because it could facilitate treatment continuity. We should really be mindful of the fact that when a person with serious mental illness is arrested, regardless of their culpability or guilt, the risk for them to have deterioration in their condition is high and the risk for them for further victimization is high. And so without getting into any kind of advocacy stance for whether they should be found responsible or not found responsible, as treating clinicians, we also want to be sure that we help people with serious mental illness access treatment for their condition. By going through a webinar like this, the hope is to provide greater understanding from the patient's experience. That way, we allow more support for their families and other providers who may have questions about the individual who was arrested and about how to serve them in the future, which can be another sticking point. So I want to take this webinar from the perspective of the provider who's sitting in their office and the patient with serious mental illness, their mother calls and says, my son John was arrested last night when I called 911. What will happen to him now? I have received many such phone calls from panicked family members who don't know whether they did the right thing or not when they called 911, who maybe weren't expecting that John would be arrested and instead thought that John would end up in an emergency department. There are differences, of course, across jurisdictions, but there are many common themes. So we're going to walk through, assuming John lives really in any town USA, to give broad principles, again, from the practitioner's perspective who's receiving this phone call from the mother. A few notes to comment on before we get into the details. First, I chose to use a case example with a male-identified person named John because most arrests do involve men. Again, I want to point out that this webinar provides basic information for case processing. There may be certain phrases or terminology or pathways that might be different in a particular jurisdiction and one thing a practitioner can do is learn more about the nuances within their jurisdiction because knowledge is a great way to help our patients with serious mental illness. Also, I want to point out that in choosing a male-identified person named John, I don't want to ignore the significant issues that come up for women and transgender individuals who have unique experiences in the criminal justice system. Some would say female offenders are one of the fastest-growing populations of individuals in the criminal justice system. And when it comes to serious mental illness, we do see a lot of female offenders or females with serious mental illness who are pre-trials coming into the justice system. For transgender individuals, there's much more to discuss and much more that we're learning. And the criminal justice system can be uniquely stressful as it is often based on binary gender identity with male facilities and female facilities, for example. And though some of this may be changing as laws evolve and as practices evolve, it's important for us as providers supporting our individual patients with serious mental illness who may identify as female or who may identify as transgender that they may have unique experiences. I believe the content of this presentation is going to be generally generic in terms of the case processing, but I want people to keep that in mind as you think about the different presentations. And so although I used a male example, I don't want you to only have in your head what might happen for a man. So to begin with, the police response. In any given community, there might be a crisis drop-off site. There might be an emergency department, and there will be, for sure, a police lockup or a place where police can detain somebody who might be in custody. The police have tremendous discretion on what they do when they encounter a person with serious mental illness who is engaging in some type of behavior that is of a certain nature. Now, the discretion may be less when they hear more from witnesses about what happens, if there's victim injury or property damage, if there's a use of weapons, or even in certain situations if it's a domestic situation. So in the example where John's mother calls, if the police see this as a domestic violence situation, which it may qualify for, there may be no option but arrest, because many states have specific laws that require for a domestic violence situation for an arrest to occur. And again, the specifics may vary depending on the jurisdiction, but it's important to realize that. Where there is discretion, things like disorderly conduct or very minor offenses, that's when police might be able to bring people to an emergency department. And in a community that has a crisis center that's outside of the emergency department, they may be able to bring the individual to the crisis center. What other factors contribute to police decisions to divert from arrest? Well, one factor might be how the police are trained and whether they are trained to utilize specialized responses for people with serious mental illness. Many communities are adopting something called crisis intervention team training for their police, which is essentially a specialized response of police officers that also involves specialized policies for what to do when the police encounter a person with serious mental illness, as well as agreed upon arrangements for drop-off sites for the police to access when they encounter an individual in the streets who looks like they have serious mental illness. What also will matter is whether there are alternatives for mental health services that are readily available to police. As I said, crisis centers or emergency departments can make all the difference for where police might take somebody. Also relationships with community mental health. If a police department or a particular police officer does not have a good experience with community mental health or does not know how to access community mental health, they might not readily do that. And so as practitioners, reaching across the aisle and building those relationships can be quite helpful. If they see that there are processing efficiencies or inefficiencies, that may also make a difference. Early studies looking at when police had discretion found that when police found a practical solution that would not tie up too much police officer time, but would lead to an outcome of a person accessing care, police would be more likely to use that practical alternative. When they found there were no efficient alternatives, then arrest became the more efficient choice. And so we really need to think as a system about how to maximize those options for people with serious mental illness who may not need to be processed through the justice system. Of course, there are going to be behaviors where there are victims, weapons, and the like where there will not be police discretion, and we need to rely upon the public safety system to manage at that particular intercept point. Other examples of specialized police responses that are important to be aware of are something that we call police-based specialized response. I mentioned already the crisis intervention team model as the most commonly cited example where police are themselves specially trained to intervene. There are other models called police-based specialized mental health response. Those often include something that we call a co-responder. Typically it might be a social worker who rides in the squad car with police to the scene of an incident and can help readily access mental health services for that individual, again, where discretion allows that to occur. And finally, the third general model that we see in police responses includes the mental health-based specialized mental health response. That typically involves a publicly funded mobile crisis unit that allows for families to contact a mobile crisis intervention, for example. It might allow families to have access to the mobile crisis service when there's a good relationship where police know if they get a call for somebody who seemingly has a mental illness to reach out and contact the mobile crisis unit to co-respond simultaneously, perhaps driving up in separate vehicles but coming to the scene at the same time. Or in some communities, the police will arrive on scene first, knowing that the mobile crisis unit is coming right behind to provide access to services. This can look very different. And I would ask the people signed up on this webinar to ask yourselves, do I know in my community how my police respond? Do we have such a special intervention? If we don't have one, is there a way to think about building one? It's good to know because when you're working with your patient with serious mental illness, as you're developing crisis planning for them, because we know that people with serious mental illness may have chronic and relapsing conditions, and they may find themselves in crisis, and they may find their mothers calling 911, that it's helpful to know what's out there for them as a resource. And so proactively, before the crisis even occurs, for example, there can be some outreach to local law enforcement or to those mobile crisis units to really learn how they work and what might happen if a call is placed from that phone number. Now John's mother has already faced the fact that John is arrested. And so now we should be thinking about what can she do? And what can the clinician who provides services for John do? So the specialized training for police often includes training on what's called de-escalation strategies and specialized protocols, again, that might involve policies. So when John's mother calls, one of the questions is, did she notify law enforcement that the call was related to a person with serious mental illness? More and more police departments that are adopting CIT and other protocols are also establishing policies and actually gathering data on when a call is placed that involves a person with serious mental illness. Even dispatchers who answer those 911 calls are being trained to ask follow-up questions about whether a person has serious mental illness or to flag when a mom calls to say that somebody has serious mental illness, because that generates different policies. So although John has already been arrested, this could be a question to ask John's mother, and it could be something for John's mother to be aware of in future incidents as these issues might reemerge. By invoking these types of protocols, the idea is that people who have serious mental illness and police who are responding to these calls can institute those policies right from the get-go so that there can be a more safe response that is planned and more thoughtful in that emergency, even in that emergency situation. So after arrest, what happens next? Well, if John is held in custody, he will likely be placed in a police lockup until court opens. And this can mean overnight if he's arrested on a Thursday night, because court will open on a Friday morning. Or it can mean a 72-hour hold if it happens on a Friday night on a Monday holiday and court opens the next Tuesday morning. So what does that mean for John with regard to his medications? John is a man with serious mental illness. He takes antipsychotic medications. He may take other medications as well. Who's going to get him his medications? Oftentimes a police lockup doesn't have access to medications, but they will allow families to bring medications in. There might be an arrangement in the local community that John is transported to the local jail where medications may or may not be readily available. So for John's mother, one question would be, how do I call in? How do I get John's medications over to him? And it may be helpful for the clinician to help facilitate that. When court opens, there will likely be a formal process, often called arraignment. So what is an arraignment? Now the process to get John to the arraignment will be the citation or the summons or other terminology used in a local community. But the arraignment is the stage when there is a formal accusation of the criminal charge in court. After the arraignment, an attorney can be assigned. But the court will likely be asking John several questions to determine his indigency status, which basically means, can he afford his own attorney? If he cannot afford his own attorney, then he will be eligible in all likelihood for a public defender in jurisdictions where there is access to a public defender. This could be from a pool of people, or it could be attorneys that sign themselves up to serve as public defenders in given situations, because in the United States, an individual does have a right to representation. The public defender's office, or this individual who's assigned to be the public defender, if John is determined to be indigent, may or may not be as active in John's case as one might hope. And that's not to disparage people working as public defenders. It's just to talk about the reality of the demand and the caseload. But this is another thing that John's mother can get involved with, or the clinician. There is nothing wrong with speaking to John's public defender if John has been assigned to one. If John has not been assigned to a public defender, then that means somebody has to pay for his defense. And that would probably involve John's mother, or his family, or someone who takes care of John in some way and helps him access that defense that he might be needing in this particular situation. Now, in some jurisdictions, the prosecutors will be very active prior to arraignment and allow what's called prosecutorial diversion. That allows John an opportunity to be diverted out of the criminal justice pathway and processed away from immediate arraignment and a release to the community, sometimes on some conditions. And so whether that exists in one's jurisdiction or not is another question that practitioners can ask themselves. Does our prosecutor in this jurisdiction allow for prosecutorial diversion prior to arraignment? At arraignment, there's generally going to be a hearing to determine whether John needs to stay in custody or released on bond. Now, the bond determination, sometimes called bail determinations, which I'll talk about in a minute, typically rests on one or two issues. And it typically rests on the likelihood that John will fail to appear in court at future court dates and or his dangerousness. And the dangerousness determination is not based on clinical data regarding dangerousness. It is based on a variety of factors that the courts consider, including John's prior arrest history and other types of issues that are factored into a legal determination of dangerousness, not a clinical determination of dangerousness. And so there's a process that happens in court that will determine these factors. Unfortunately, for people with serious mental illness, there may be a higher likelihood that they will be deemed unlikely to appear in court or dangerous, partly because they have had a high risk of prior involvement in many situations. And there may have been difficulties that have led to their inability to appear in court at prior hearings, even, for example, having been psychiatrically hospitalized when the court thought that they were going to appear could mark them as not appearing in court. And so this is one of the challenges that many people that are involved in criminal justice reform or in thinking about advocacy for people with serious mental illness are trying to examine, because people with serious mental illness may be less likely to be released on bond because they meet the criteria for a high risk of failure to appear or they meet the criteria for dangerousness. When they are released on bond, that establishes a sort of contract with the court that they will reappear and that they will not engage in any harmful behavior. A bail is going to be set, and different communities use bail and bond in different, sort of interchangeably, so these can be complicated constructs. But generally speaking, bail includes setting a financial dollar amount that the defendant pays to be released. It can also include other stipulations of their behavior and what they need to participate in while they're released in terms of conditions of release. And it's generally the amount of money can be set by formulas. There is bail reform happening across many jurisdictions right now because there's been some recognition that bail disadvantages people of poverty. But again, persons with serious mental illness may have unique challenges for even small amounts of money. And if they can't afford to raise the amount of money that is set for their bail determination, they may be more likely to be held in custody. And so there's a number of factors. And again, in this situation, we're talking about a situation where John has a very active mother. Unfortunately for people with serious mental illness, there may not be somebody out in the community that's advocating for them, that's posting their bail and helping them be released. So they may be held within the custodial setting waiting for their court date. Now, what if John is acutely symptomatic in court? John's lawyer or others in court might request an evaluation of John's competence to stand trial. This is a very important constitutional issue in court. In the United States, a defendant cannot be tried if they appear incompetent to stand trial. The courts are not permitted to proceed to trial if the defendant is determined by the judge to be incompetent to stand trial. And competence to stand trial can be raised at any point in time in the court proceedings all the way up to the guilty finding. So how does competency to stand trial work? There would be, if the issue is flagged, and again, any player in the courtroom has an obligation to flag this issue because it is considered so important to not try an incompetent defendant, there would be a request for a competence evaluation. That is competence to stand trial. Competence to stand trial is not the same as competence to make treatment decisions. It is not the same as somebody who has a guardian who's been determined unable or incapacitated to make treatment decisions, and a person who is under guardianship can still be found competent to stand trial. So without getting into too many of the details of why that can be, it can be very confusing for people, it's important just to realize that it is a different process with different evaluations taking place, looking at different legal issues and the capacity issues of the defendant with serious mental illness, whose symptoms may or may not impact their abilities as a criminal defendant. So the competence to stand trial evaluation is going to be conducted generally by a forensic evaluator. In any given state, who's qualified to do those forensic evaluations will be different. In some states, it might be psychiatrists and psychologists. In some states, social workers are allowed to also do these evaluations. In some states, these evaluations are done through the state. In some states, these evaluations are done through the local county. And in some states, there's qualifications that are required for those evaluators. In other states, it's more loosely defined, in statutes or in regulations or in rule. Regardless, there will generally be a competence to stand trial evaluation conducted by some authorized forensic evaluator, and then a competence to stand trial hearing and a finding by the judge. And the judge might find that the person is incompetent to stand trial, or they might find that the person is competent to stand trial. And if they are competent to stand trial, they will return back to the usual criminal case process. When a defendant like John or Mary or anyone is found incompetent to stand trial, they will possibly be ordered for restoration if they are thought to be restorable. There is another pathway where they could immediately be found unrestorable, but I'll get to that, assuming the individual is found potentially restorable to competence to stand trial. There, they will go through a period of restoration. In states across the country today, that restoration typically will happen in a state hospital. However, there is a big push right now to look at that more closely and to say, not everybody who needs that restoration service needs to be in a state hospital level of care. There's a whole host of issues related to this that are coming to the fore. And for this webinar, I'm not gonna get into the details about that, but people on this webinar should realize that more and more states are developing strategies to think about competency restoration outside of the state hospital. Competency restoration has traditionally meant getting the individual basically able to serve as a defendant in a criminal case. It generally has not included all the things involved in treating serious mental illness, helping support that individual with their recovery in a more broad sense. And that also is getting reexamined. After the period of competency restoration and the duration of competency restoration can sometimes be determined by the level of crime for which the defendant is charged, depending on the state and the state laws, there will be re-evaluations of their competence to stand trial and new competency hearings. There might be findings that the individual is now competent to stand trial after the period of restoration, and they will again be returned to the usual case process and often returned to jail custody after that competency restoration period. One of the risks for people with serious mental illness is that when they're returned to the jail, even if they were stabilized on medication, they will somehow destabilize and go right back to the beginning where their competency will be raised again. Some people will be found incompetent to stand trial and unrestorable, and those individuals might be civilly committed to a hospital or they might be civilly committed under assisted outpatient treatment. And again, there's much happening in this space. So for any individual like John, the pathway might look different. And the duration of time that they spend in any of these different areas might be different. Again, competency evaluations can take place in the jail, in the community, or in the hospital. Competency restoration is most commonly done in state hospitals, but again, there are new models emerging for community restoration. There are some states that have developed jail restorations. Those do have some controversy related to them, especially if people need a higher level of care and jails are not generally considered therapeutic environments. They're designed to be jail for pretrial detention and sentencing, even when they do provide care and treatment within the jail. Restoration includes treatment, but mostly involves helping defendants overcome deficits related to their role as criminal defendants. And again, restoration can involve waiting in jail and being returned to jail. And so what we need to think about for John is the continuity of care may be disrupted if John is moving in and out of various systems where he might or might not receive treatment. If John is found competent to stand trial and returns to the trial process and remains competent to stand trial to get through the trial process, he might plead not guilty by reason of insanity, which could involve additional evaluation. Only a small percentage of people raise this defense and use it successfully. So although there may be some myths that all people with serious mental illness end up being found not guilty by reason of insanity, that's actually a myth because only a small percentage of people will raise the defense and only a smaller percentage will successfully be able to find themselves not guilty by reason of insanity. If an individual is found not guilty by reason of insanity, those individuals will typically be committed to a state hospital for an evaluation period about whether they need ongoing care and treatment within the hospital. And then when they are committed to the state hospital, the duration of commitment can be long. However, it is really important for the people on this webinar to also realize that more and more we are looking at people found not guilty by reason of insanity and looking at community integration for those individuals, again, recognizing that they have been found not guilty and that it is their mental illness that related to the original behavior. And there are many states examining how to minimize institutional-based care when that is not felt to be what they need for clinical or even public safety reasons. So this is an evolving area. Okay, if John is found guilty through a trial or through a general plea bargain, which is the most common way that trials go, John might actually be sentenced. He might be sentenced to probation and time served, leading to his release back to the community, and he might have a probation officer now attached to him with conditions of probation. Some of those conditions might be compliance or adherence, and in the court's view, it would be compliance, to the terms of his treatment as part of his probation. He might be sentenced to probation via a mental health court. He might be served time in jail for a less serious case, or he might actually be sentenced to prison for a more serious case, and there could be some combination of these. So what is a mental health court? A mental health court, the mental health court model was generated after the drug court model was emerged in 1989, and there's far fewer mental health courts around the country than there are drug courts, and they are different from drug courts and veterans treatment courts because they focus on people with mental illness, and so oftentimes, if somebody with serious mental illness is going to be sentenced or plead to a specialty court, they will find themselves in a mental health court, which we did speak about in the first webinar in the criminal justice series on SMI Advisor, which is available to you. Mental health courts are specialized court dockets for certain defendants with a particular challenge. Again, in our case, we're talking about people with mental illness. Generally, a defendant would voluntarily participate in the mental health court, and it would involve a judicially supervised treatment plan or other court conditions where the person would, the participant, would come back into court on a regular basis and meet with the judge and the mental health court treatment team. Nonadherence might be sanctioned, but the goal of the specialty court is to avoid sanctions and to really try to use positive rewards and avoid overmonitoring of people who might be found to have made certain, for example, have small slips in their adherence that would otherwise land them in jail. So the goal is to try and keep people out of jail and use positive rewards and avoid sanctions, the most serious sanction involving jail time. Success or graduation is usually defined according to predetermined criteria, generally compliance with the plan. Who is eligible for mental health courts? Again, it's a narrowly tailored population of people with mental illness. Typical participants include those with schizophrenia, schizoaffective disorder, bipolar disorder, depression, trauma-related, and anxiety disorders. Each mental health court determines how flexible to be on eligibility requirements, and they can operate on a case-to-case basis. Things that might be taken into account include the person's treatability, their motivation to voluntarily participate, their criminal offense itself. Some states have rules that don't allow violent offenders to enter into mental health courts. Victims issues, some states have rules that require victims to agree to allow the defendant to have an alternative to incarceration that involves a mental health court, and defense counsel to advise that may impact the selection of the individual and the impact of the individual to select the mental health court. Usually, the referrals pass through a series of filters and assessments that determine whether the individual with serious mental illness is eligible for the particular mental health court. There are studies that have examined whether mental health courts are effective, and for example, in this four-site study of mental health courts by Stedman et al., published in 2011 in the Archives of General Psychiatry, studies showed that compared to treatment as usual, people in mental health courts showed fewer arrests post their involvement in mental health court and fewer days in jail, which are traditionally some of the outcomes that one would want to see for mental health court participants. Now, what happens for an individual who's in jail or in prison? Mental health services can vary across jails and prisons. There are standards that are required to be met, but in fairness, those standards are complex and can be variable depending on how the jails or the prisons allocate their resources and how they work across those standards. Care is constitutionally required to be commensurate with community standards, and jails and prisons, however, as I've said, are complex environments that make differences in balancing security and treatment needs complicated. A prison will generally have more levels of care and be run by the state, but they will generally have, across the state prison system, an inpatient level of care, outpatient and residential treatment units, whereas a jail may be more limited in its space and in its scope, and persons with serious mental illness might be more at risk for disciplinary infractions, which can also impact their housing determination within a jail or a prison, and that's something also to be looking for with John, who might need some advocacy from the outside for people to understand that his behavior may be related to serious mental illness. Still, for a jail, for example, there may be limited options for how to manage aberrant behavior, and we also have to worry about the risk of John being victimized within a population such as a jail or a prison. Reentry services are very important as well, and those constitute the effort to provide aftercare arrangements for individuals who have been in jails and prisons, and there can often be specialized reentry for people with serious mental illness. There's some guideline documents that are very useful to review and familiarize yourself following the APIC framework for reentry, which essentially stands for assess, plan, identify, and coordinate. Assess and screen for individuals' behavioral health needs and their risk once they've been determined to have those needs, begin planning that includes individualized treatment planning and collaboration across behavioral health and justice systems, identifying critical periods, especially periods surrounding release, and policies and practices that enhance continuity of care, and then finally coordinate firm but fair adherence to treatment, and if they are under probation or parole supervision, working together to help establish what those terms of supervision are, develop information-sharing mechanisms, supporting cross-training, and looking at data analysis. Now, back to the call from John's mother. Now that I understand more about what might happen to John, she says, what should I do? So here are some things you could advise John's mother. Don't just give up and say, there's nothing we can do, he's arrested, we just have to let the system play itself out. I believe that our role as clinicians is to help the family members and the people we serve, and inform ourselves about what actual options there might be. For example, consider, is there a release of information signed across systems? The mom can go and visit John in jail and encourage him to sign a release. Consider whether there is emergency circumstances that would allow two-way communication, and if not, listen and ask questions of John's mother, because we also have to understand, is there a release for the clinician to speak to John's mother? I think there's always an opportunity to listen. If John's mother wants to go in and get a release of information signed, great. Also, the clinician can call the healthcare service provider within the jail, and consider whether there are jail service providers that can be connected to your clinic to coordinate that care. Consider how to inform health service providers about John's current medications. If there is an emergency, that might justify whether there is not a release. There might be rules in local communities about care coordination exceptions to privacy considerations. Consider advising John's mother to call John's lawyer and say to John's lawyer that he has serious mental illness. There are ways that John's lawyer can effectuate communication as well. For example, John's lawyer can approach John and ask John to sign a release of information. Consider advising John's mother to contact the jail, because John's mother is not bound by HIPAA, and John's mother can let the jail or the lockup know John has serious mental illness. And then finally, the clinician could advise John's mother to reach out to a local NAMI group to gain additional support. Some local NAMI groups, for example, are producing information sheets that John's mother could complete to hand off to the jail so that the jail knows information about John that John may or may not be willing or able to share because of John's own active symptoms, his own fears, his own concerns, and he may have his own needs to keep his information also private, but John's mother has her needs as well. So together, both needs can potentially be upheld. Other considerations to think about. Does John have pets or children? Who's going to support them if John is arrested and needs to be in custody for a period of time? Who will help pay John's rent if he is in custody for an extended period of time? What does John do for a living? Does he have a job? What supports can be in place to help John return to employment after arrest? Who from his mental health services team can connect with him in jail to support him and remind him that he will receive care upon release? There is a lot of stigma and shame with arrests, and it might be that John wants no contact with anyone. This is a very difficult situation because individuals who are disconnected from supports upon arrest and for persons with serious mental illness, reconnecting to those supports can therefore be very difficult. So it can be very challenging to both support John's request for privacy and also support John in more broad ways. And so if John's mother can't visit him or he doesn't want to visit his mother, it may be that the clinicians have an opportunity to visit him or to at least get a message to him to reach out that they are there to support him should he change his mind and want further contact. When John returns to treatment services, because most people who are arrested will eventually return to the community, it is important that he is greeted in a welcome way. Working with patients to understand their arrest and criminal justice experience can help, and it can help guide planning for any future crises. Again, arrests and legal processes, as well as incarceration, can be traumatic and life-changing. Don't be afraid to talk to John about these experiences. His risks of rearrest are higher if he's already touched the criminal justice system, so planning for the future can be helpful to avoid future contacts. His risks upon reentry are real. They can include increased risk of social isolation, recurrent symptoms, problems acquiring medications, and even suicide and violence or return to substance use, so there needs to be ongoing clinical assessments to support an individual with SMI's needs. There can be stigma associated with criminal justice involvement, and the clinic might be reluctant to take him back, and that's a real issue that we need to tackle as providers. It may be that we need to do a case conference to say, hey, John's coming back. We hear he's about to be released. What do we need to do to prepare ourselves and to deal with the clinic's own challenges in thinking about, hey, can we really work with John? Was his behavior too much for us? In most cases, there are ways to get around that, so it's important to support staff who might now have concerns about how to continue to treat him and to remind them that John is still John, and even though he had justice involvement, we want to understand what really went on. Maybe it was an offense that is beyond the clinic's capacity to manage or the private practitioner's ability to manage. Maybe he does need a system of wraparound supports to support him, but don't make assumptions without looking directly at the issues and being willing to talk about it as a group. It's important for people with serious mental illness to have advocates for their individual needs and also to support the staff who may have their own challenges, may feel under-resourced and overwhelmed, so that we can return John to a stable treatment environment that's best suited to meet his needs. And I think with there, I'll stop, and thank you again for allowing me to present this information to you. I hope you found it helpful. Thank you.
Video Summary
The video features Dr. Debra Peinold, a clinical professor of psychiatry and Director of the Program in Psychiatry, Law, and Ethics at the University of Michigan Medical School, discussing what happens when a patient with serious mental illness (SMI) gets arrested. Dr. Peinold describes the different steps involved in the criminal justice process, from arrest to court to incarceration to release. She emphasizes the importance of understanding these steps and how they can vary for each individual. Dr. Peinold highlights that a disproportionate number of people with SMI are arrested for minor crimes and cautions against assuming that SMI individuals are only arrested for extreme offenses, as this further stigmatizes the population. She also discusses factors that influence police decisions on whether to make an arrest or divert the individual to mental health services. Dr. Peinold provides insights into competency evaluations, mental health courts, and reentry services for individuals with SMI involved in the criminal justice system. She concludes by offering suggestions for supporting the families of individuals with SMI during their involvement in the criminal justice system and ensuring continuity of care for these patients.
Keywords
Dr. Debra Peinold
clinical professor
psychiatry
serious mental illness
arrested
criminal justice process
mental health services
competency evaluations
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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