Community-based Behavioral Health Services for Justice-involved Individuals

Traditional efforts in treatment for mental illness and substance use disorder for justice-involved individuals has been concentrated on providing tools and training for criminal justice professionals and was expensive and ineffective. Re-focusing on providing knowledge, skills, and training about justice-involved individuals to behavioral health providers helps them to provide community-based services to this population effectively and at reduced cost.

Why is this an important subject for behavioral health providers?

Being aware of the needs of justice-involved individuals, and having current and appropriate information, resources, and tools empowers providers to:

• Enable provision of services to underserved populations – The subpopulation of those with current or former involvement with the criminal justice system with mental and substance use disorder is one of the populations that community-based behavioral health providers and systems serve. According to Larke Huang, Ph.D. Director, Office of Behavioral Health Equity Substance Abuse and Mental Health Services Administration (SAMHSA), “Every year, approximately two million individuals with these disorders cycle in and out of local jails.” (SAMHSA’s Eight Guiding Principles for Behavioral Health and Criminal Justice webinar, March 28, 2019). Consequences for the persons in this population include longer stays in prison, and increased risk of self-harm. The impact of even brief incarcerations does not stop with the individual, but also severely impacts families and children.
• Limit disruptions that may worsen outcomes for justice-involved individuals – Those with behavioral health issues are disproportionately represented in jails and prisons in the US (Bronson, et al., 2007; Bronson & Berzofsky, 2017; and Steadman & Osher, 2009). Those who undergo arrest and incarceration experience consequences that can further disrupt their lives, such as loss of employment (including future opportunities), physical and behavioral health problems, homelessness, and problems with social and family lives (Lowencamp, et al., 2013).
• Prevent interruptions in treatment for mental illness and substance use disorder – Lapses in treatment may occur during detention that may result in difficulty resuming treatment and contribute to relapses, re-incarceration, use of emergency departments, and hospitalization (Langan & Levin, 2002; Frank, et al., 2014; Mallik-Kane & Visher, 2008; Wang, et al., 2013).
• Obtain clinical and case management skills to provide effective services – Having the knowledge, skills, and training to provide services to justice-involved individuals at the community level instead of in institutional settings.
• Implement treatment based on the latest research and follow the eight principles of community-based behavioral health services for justice-involved individuals – Behavioral health and criminal justice professionals are better able to collaborate across systems and provide quality care if both are following the same evidence-based treatment and treatment principles (SAMHSA, 2019).

Challenges for Behavioral Health Providers

Changing the way services are provided and the professionals who are responsible for providing them does not happen without adjustments and challenges are inevitable. Jennie Simpson, Ph.D., Senior Drug Policy Advisor, Bureau of Justice Assistance, U.S. Department of Justice, is the main author of Principles of Community-based Behavioral Health Services for Justice-involved Individuals: A Research-based Guide. In developing the guide, she and colleagues spoke with both providers, criminal justice professionals, researchers, and experts and found the following common key challenges for providers:

• Partnerships – With law enforcement, pre-trial services, courts, and community corrections; Necessary for shared and new clients
• Knowledge of criminal justice system and concepts – Who, what, when, where, why, and how?
• Effective and responsive treatment, recovery and support services for justice-involved individuals – Evidence-based treatment for justice-involved individuals with mental and substance use disorders; addressing criminogenic risk and need factors: necessary part of effective treatment; case management and support services specific to justice-involvement

In addition, in working with justice-involved individuals providers need to also consider the added complexity of working with the criminal justice system, additional skills necessary to address criminal justice involvement, and the element of stigma attached to working with the justice-involved population – research finds that providers report lower regard for individuals involved in the criminal justice system than those who are not involved in the justice system (Bandara, et al., 2018).

Eight Guiding Principles

To establish common ground for behavioral health providers and professionals within the criminal justice system and to help overcome the challenges both groups must meet, eight guiding principles were developed that reflect both a vision and values for serving justice-involved persons. The principles are meant to assist communities in providing the necessary services rather than continuing to provide them in institutional settings such as jails, hospitals, and prisons. The document helps agency leaders and program developers to consider staff training, evidence-based practices and other elements necessary in the revised delivery of community-based services rather than institutionally-based services. The eight principles (with abbreviated descriptions) are:

1. “Community providers are knowledgeable about the criminal justice system. This includes the sequence of events, terminology, and processes of the criminal justice system, as well as the practices of criminal justice professionals.” This image illustrates the sequence of events that occurs in the criminal justice system when a person enters it.
2. “Community providers collaborate with criminal justice professionals to improve public health, public safety, and individual behavioral health outcomes.” Partnerships and collaboration include information sharing to ensure continuity of care and care coordination and to facilitate re-entry and problems that can occur during the critical transition into the community, such as overdose and suicide.
3. “Evidence-based and promising programs and practices in behavioral health treatment services are used to provide high quality clinical care for justice-involved individuals.” Treatment should be tailored to individual needs and based on research. Integrated treatment for co-occurring disorders should also be provided.
4. “Community providers understand and address criminogenic risk and need factors as part of a comprehensive treatment plan for justice-involved individuals.” Criminogenic risk – the likelihood that an individual will engage in future illegal behavior – should be addressed using evidence-based and promising practices that address each individual’s risk profile.
5. “Integrated physical and behavioral health care is part of a comprehensive treatment plan for justice-involved individuals.” Because the risk of both infectious and noncommunicable chronic health conditions is high among incarcerated persons, physical and behavioral health care should be integrated, coordinated, and convenient to improve access for each individual.
6. “Services and workplaces are trauma-informed to support the health and safety of both justice-involved individuals and community providers.” The high rate of trauma among justice-involved individuals and the impact of early trauma on individuals necessitates the need for trauma-informed care to include the safety and wellbeing of both clients and practitioners.
7. “Case management for justice-involved individuals incorporates treatment, social services, and social supports that address prior and current involvement with the criminal justice system and reduce the likelihood of recidivism.” Case management can reduce the obstacles justice-involved individuals face in finding housing, employment, and in coordinating health and behavioral health care upon re-entering the community.
8. “Community providers recognize and address issues that may contribute to disparities in both behavioral health care and the criminal justice system.” Structural bias is reflected in the disparities experienced in both behavioral health and criminal justice systems based on race, ethnicity, gender, sexual orientation, and economic status. Understanding these biases enables positive treatment and justice outcomes and prevents their perpetuation.

Next Steps

This brief overview may raise questions for behavioral health providers and other professionals. Some of the following – and more – questions are answered within the guide:

“Why should community-based providers understand the criminal justice process?”

“What is diversion?”

“What are reentry services?”

“What are community corrections programs?”

“Should community case managers coordinate with law enforcement, jail, prison, probation, parole, and other criminal justice professionals?”

“What strategies exist for behavioral health and criminal justice collaboration?”

“What evidence-based and promising programs and practices to treat mental and substance use disorders can be used for justice-involved populations?”

“What happens to Medicaid coverage when an individual is incarcerated or returns to the community after incarceration?”

The guide provides information and practices that behavioral health providers can implement in their daily practice with patients or clients who are involved in the criminal justice system. In addition, many resources for topics such as collaboration, reentry, clinical care and case management, health care coverage, criminogenic risk and recidivism, trauma, and special populations are included in the guide. Some of the resource links have been uploaded into the CASAT OnDemand Resources & Downloads page.

The archived Gains Webinar SAMHSA’s Eight Guiding Principles for Behavioral Health and Criminal Justice contains additional information in more detail. SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation “focuses on expanding access to services for people with mental and/or substance use disorders who come into contact with the justice system.” And has a wealth of information and resources that behavioral health providers can use to become more familiar with justice-involved individuals, the systems that have traditionally served them, and training opportunities for learning to serve them better within communities.

What have we missed? Do you know of additional resources for serving individuals who are or have been involved with the criminal justice system? Share your thoughts and resources in the comments below!

References

Bandara, S. N., Daumit, G. L., Kennedy-Hendricks, A., Linden, S., Choksy, S., & McGinty, E. E. (2018). Mental Health Providers’ Attitudes About Criminal Justice–Involved Clients With Serious Mental Illness. Psychiatric services, 69(4), 472-475.

Bronson, J., Stroop, J., Zimmer, S., & Berzofsky, M. (2017). Drug use, dependence, and use among state prisoners and jail inmates, 2007-2009. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. 1-27.

Bronson, J., & Berzofsky, M. (2017). Indicators of mental health problems reported by prisoners and jail inmates, 2011-12. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics. 1-17.

Frank, J. W., Linder, J. A., Becker, W. C., Fiellin, D. A., & Wang, E. A. (2014). Increased hospital and emergency department utilization by individuals with recent criminal justice involvement: Results of a national survey. Journal of General Internal Medicine, 29(9), 1226-1233.

Langan, P. A., & Levin, D. J. (2002). Bureau of Justice Statistics Special Report: Recidivism of prisoners released in 1994 (Publication No. NCJ 193427). Washington, DC: Bureau of Justice Statistics.

Lowencamp, C., VanNostrand, M., & Holsinger, A. (2013). The hidden costs of pre-trial detention. Retrieved from http://www.arnoldfoundation.org/research-report-hidden-costs-pretrial-detention

Mallik-Kane, K., & Visher, C. A. (2008). Health and prisoner reentry: How physical, mental, and substance abuse conditions shape the process of reintegration. Washington, DC: The Urban Institute.

Steadman, H. J., Osher, F. C., Robbins, P. C., Case, B., & Samuels, S. (2009). Prevalence of serious mental illness among jail inmates. Psychiatric Services, 60(6), 761-765.

Substance Abuse and Mental Health Services Administration: Principles of Community-based Behavioral Health Services for Justice-involved Individuals: A Research-based Guide. HHS Publication No. SMA-19-5097. Rockville, MD: Office of Policy, Planning, and Innovation. Substance Abuse and Mental Health Services Administration, 2019.

Wang, E. A., Wang, Y., & Krumholz, H. M. (2013). A high risk of hospitalization following release from correctional facilities in Medicare beneficiaries: A retrospective matched cohort study, 2002 to 2010. JAMA Internal Medicine, 173(17), 1621-1628.

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