Best practices for mentally ill - Mod9

Overview

This brief outlines best practices for addressing mental illness within the criminal justice system, emphasizing diversion, therapeutic jurisprudence, coordinated care, and evidence-supported treatments in law enforcement, courts, competency restoration, and jails.

Best Practice Model (BPM): System Flow

• Goal: keep mentally ill individuals out of jail; ensure continuity of care across settings.
• Core elements:
  • Pre-arrest diversion by trained law enforcement into treatment.
  • Post-arrest diversion to problem-solving courts.
  • Court supervision with case management in the community.
  • In-jail mental health treatment when custody is necessary.
  • Competency restoration in hospitals/community.
  • Mental health probation tailored for serious mental illness.
  • Long-term community treatment with seamless transitions.

Law Enforcement: Crisis Intervention (CIT)

• Community-Oriented Policing (COP): partnerships, problem-solving, prevention.
• Response models:
  • Police-based specialized police response (e.g., CIT officers).
  • Police-based specialized mental health response (on-site consultants).
  • Mental-health-based mobile crisis response.
  • Combination police–clinician teams.
• CIT essentials:
  • 40-hour training, de-escalation, empathy, role plays, resource mapping.
  • No-refusal receiving facilities to minimize officer downtime.
  • Benefits: fewer arrests/injuries, quicker transfers, more treatment referrals, reduced SWAT callouts.
• Future needs: broaden research, reduce stigma, expand training, strengthen police–mental health cooperation.

Problem-Solving Courts

• Therapeutic Jurisprudence (TJ): treatment focus to reduce recidivism and improve well-being.
• Mental Health Courts (MHC):
  • Often voluntary for misdemeanors; felony MHCs may be non-voluntary.
  • Team approach: judge, attorneys, clinicians, case managers; frequent reviews.
  • Eligibility commonly requires Axis I diagnosis linked to offense; varies by jurisdiction.
  • Outcomes: reduced arrests, hospitalizations, homelessness, probation violations; improved service use.
  • Issues: voluntariness for impaired defendants; co-occurring substance use demands integrated care; provider capacity limits.
• Mental Health Probation:
  • Smaller caseloads (~45; specialists ≤35 severe cases), intensive supervision, linkage to services.
  • Officer training: mental disorders, crisis skills, medications, supervision strategies.
  • Challenges: higher revocations among mentally ill on standard probation; balance punitive and therapeutic roles.
• Drug Courts:
  • Phased treatment, frequent status hearings, incentives/sanctions, random testing.
  • Graduated sanctions can lower re-arrest; retention (≈12–24 months) is key.
  • Needs: integrated dual-diagnosis care, adequate beds, standardized sanction frameworks, attention to disparities.
• Domestic Violence Courts:
  • Priorities: victim safety, offender accountability, coordinated services.
  • Practices: vertical prosecution, protection orders, approved batterer programs, close monitoring.
  • Mixed evidence on batterer treatment efficacy; longer, monitored programs show better reductions.

Competency Restoration Programs

• Legal context: Jackson v. Indiana limits indefinite confinement; Dusky standard guides competence.
• Best-practice components:
  • Comprehensive assessment: psychosis, cognition, mood, brain injury.
  • Individualized treatment plan with didactics on legal processes.
  • Anxiety reduction and psychoeducation; repeated, simplified modules if needed.
  • Medication management with capacity assessments; periodic reassessment.
  • Risk assessment for violence when civil commitment considered.
• Practical constraints: restoration begins only after court ITP finding; settings vary by risk and offense.

Treatment in Jails: Practices and Programs

• Constraints: short, unpredictable stays; high suicide risk early in detention.
• Recommended components:
  • Screening on admission; suicide risk protocols and observation.
  • Psychotropic medication availability; daily observation; crisis intervention.
  • Staff training; mental health housing units; case managers.
• Psychosocial interventions:
  • Short-term, goal-focused CBT/DBT; skills training; therapeutic community approaches.
  • Behavior programs (token economies, contingency management).
  • Group therapy with clear rules, safety measures, and confidentiality limits.
• Symptom-focused care:
  • Psychosis: antipsychotics (including atypicals when indicated), behavior therapy.
  • Depression/anxiety: SSRIs/SNRIs; careful use of TCAs; avoid MAOIs and benzodiazepines.
  • Sleep: non-pharmacologic measures prioritized; avoid prescribing for side effects.
  • Aggression: CBT anger management; lithium, beta-blockers, carbamazepine, clozapine as indicated.
• Female inmates:
  • Higher rates of PTSD, depression, substance use; emphasize trauma-informed care.
  • Safeguards against sexual misconduct; programs for relationships, parenting, reentry.
• Recidivism reduction:
  • Target risk–need–responsivity factors: antisocial attitudes, peers, substance dependence, skills deficits.
  • Progressive reentry planning; assertive case management; seamless handoffs.

Structured Practices and Examples

Key Terms & Definitions

• Therapeutic Jurisprudence (TJ): Legal approach prioritizing therapeutic outcomes without compromising justice.
• Crisis Intervention Team (CIT): Police program training officers to de-escalate and divert mentally ill individuals.
• Mental Health Court (MHC): Specialty court diverting eligible defendants to treatment with judicial oversight.
• Incompetent to Proceed (ITP): Defendant lacks rational/factual understanding or ability to assist counsel.
• Competency Restoration: Treatment and education to restore trial competence within legal timeframes.
• Risk–Need–Responsivity (RNR): Model targeting criminogenic risks, needs, and tailored responsivity.

Action Items / Next Steps

• Expand CIT training and ensure no-refusal psychiatric receiving capacity.
• Build coordinated, cross-agency databases to align services and formularies.
• Strengthen and fund specialty courts; integrate dual-diagnosis and trauma services.
• Implement standardized competency restoration protocols with periodic reassessment.
• Enhance jail mental health units, staff training, suicide prevention, and brief CBT programs.
• Develop women-specific, trauma-informed community programs for reentry.
• Establish stakeholder task forces (court, corrections, health, community) to phase in BPM elements and monitor outcomes.