Mental Health Court: In Concert With Community Treatment

1. Mental Health Court: In Concert With Community Treatment Forensic Mental Health Association of California March 16, 2006 Kathleen Connolly, LCSW David Fariello, LCSW

2. Program History • 1980 • Citywide Case Management links high users of San Francisco psychiatric inpatient facilities to community services • 1985 • Citywide reconfigured as a clinical case management program

3. Program History Cont. • 1990 • Case manager added to treat severely mentally ill adults being discharged from jail • Increased to 2 FTE with monies from jail overcrowding settlement • 1999 • Citywide becomes part of Sheriff's Department response to the State Mentally Ill Offender Crime Reduction Grant • Program increases in size and complexity

4. Program History Cont. • January 2003 • San Francisco’s Behavioral Health Court starts • July 2004 • MIOCR Grant funding ends • Forensic Program funding continues

5. Client Demographics • 100 Severely mentally ill adults • 18-59 years old • 75% Men, 25% Women • 47% African American, 35% White, 12% Latino, 6% Asian • 83% single never married, 13% Divorced or Separated, 4% Married/Living together • 21% High School graduates; 7% some college • 96% Unemployed

6. Client Demographics Cont. • Diagnosis • 73% Schizophrenia/Schizoaffective Disorder • 16% Personality Disorder • 13% Mood Disorders • 8% PTSD • 5% Paranoid disorder • 96% Substance Abuse Disorders • Crack-cocaine most common • Alcohol #2 • Amphetamines and heroin

7. Multidisciplinary Team • Project Director • Clinical Supervisor • 7 Case Managers • Social Workers, MFTs, and Interns • Occupational Therapist • Counseling Assistant • 2 part-time Psychiatrists • Licensed Vocational Nurse

8. Collateral Agencies • Jail Psychiatric Services • Jail Aftercare Services • Money Manager On-site • Lutheran Social Services • Adult Probation Officer On-site • SF Public Defender’s Office • Housing & Urban Health Clinic • Residential Dual Diagnosis Programs • Hotel Managers

9. Provide Structure • Wraparound Services available at clinic • Group Programming • Social Opportunities • Vocational Training • Saturday Program • On-Call Service • Community Building/Celebrations • Community Activities • Daily lunch

10. FORENSIC CHECK-IN STRESS MANAGEMENT GROOMING “HEARING VOICES” DBT SKILLS TRAINING CREATIVITY WRITING ART CITYWIDE GROUP PROGRAM ANGER MANAGMENT AFRICAN AMERICAN MEN SINGING HARM REDUCTION CURRENT EVENTS CHESS CLOZARIL WELLNESS YOUNG ADULTS WOMEN DUAL DIAGNOSIS LGBT SUPPORT MOVIE COOKING

11. Masters Level Therapists Individual Therapy Family Therapy Group Therapy Crisis Intervention Assertive Outreach Advocacy Case Management Brokerage Medication Management Teach rather than “do for” the client Outreach/fieldwork Therapeutic approach Long-term relationship Small Caseloads 13:1 Clinical Case Management

12. Engagement Process • Referral from JAS • Assessment • Link with client in custody • Develop a discharge plan • Advocate for client in court

13. Discharge • Welcome client to community • Assist client in obtaining entitlements • Provide housing vouchers if needed • Psychiatrist and Medical Appointments • DMV/Muni Bus Pass • Provide Miscellaneous Items • Alarm clock, cigarettes, bus tokens, clothing, hygiene products, etc.

14. Treatment Interventions • Align with client around goals and assist client throughout the court process • Develop individualized treatment plan based upon client’s functioning level • Use of UAs in treatment of substance use • Use of daily meds/daily checks • Incentives and Sanctions

15. Role of the Therapist in Relation to the Court • Traditionally the criminal justice system does not work in the best interest of a client’s rehabilitation • In Mental Health Court, the therapist helps shift focus • Provides advice to the Court on treatment interventions • Becomes educator to the Court • Serves as client’s advocate and supporter • Manages public safety

16. Use of the Court as Treatment Intervention • Ability to understand the legal status of clients • Creative use of incentives and sanctions • Utilize the Court as reinforcement of treatment options and make client realize consequences of behavior • Better treatment outcomes

17. Goals of Treatment • Stabilization in community • Adjudication of criminal case • Attachment to mental health services that continue after legal obligations end • Transition client from the legal system to the community mental health system

18. Treatment Issues • Prevalence of Substance Abuse • Residential vs. Outpatient Treatment programs • Long-term nature of the work vs. economic realities of mental health treatment

19. Transference Issues • Many clients suffer not only from severe mental illness and chronic drug use, but from difficult and an unstable childhood • Foster care and/or Juvenile Detention is a central part of their experience • Institutions quickly assume the role of an all-powerful, punitive parent

20. Transference Issues Cont. • Clients quickly develop a hostile dependency toward institutions • Survival strategies are developed in jail • Demanding, confrontational, threatening behaviors which do not allow for feelings or weakness are the rule • The BHC and connected treatment inadvertently reinforces the transference • Treatment is required and monitored • The probation officer works at the treatment site

21. Transference Issues Cont. • On-site Money management is often part of treatment • Clients can be remanded for treatment non-compliance • Race, gender and class differences between staff and clients reinforce power differentials

22. Counter-Transference • Two clients--the client & the community • Staff work hard and are thinly stretched • Staff feel responsible if a client fails and returns to jail or is sent to prison • Staff respond to incessant client “demands and “crisis’ • Staff and other providers can be split by clients

23. Counter-Transference Cont. • Behavioral changes are slow • Frequent treatment plan reconfiguration • BHC remanding-sometimes leaves staff dispirited • Treatment alliance can feel strained • Therapists begin to feeling like another probation officer rather than an ally

24. Work Through The Issues • Acknowledge circumstances from the beginning • Treatment is not entirely voluntary. • Explore and support experiences of racism, disadvantage, powerlessness • What does the client want? • Now and in the future • What does client see as the obstacles to achieving goals?

25. Work Through The Issues Cont. • Work from the very beginning to have clients do with you rather than do for them • Set out markers to turn over more activities to the client • e.g. How does the client assume management of their own funds? • Set limits that the clinician needs to live by and avoid “jack-in-the-box” relationship • Counter-transference is normal, expected and a valued clue to clinical information • Don’t dismiss it!

26. Future of Forensic Case Management • Increased vocational skill building • Getting better at discharging to a lower level of care • “Restorative Justice” • WISH project • Diversion and Prevention- keeping severely mentally ill clients OUT of the criminal justice system