Best Practice Service Delivery Protocol
Illness self-management foci place emphasis on how best to help individuals learn the skills and knowledge for lessening the impact of their mental illness in terms of impact on their personal lives while also striving to establish a sense of personal wellbeing and control over their destinies (Meuser and MacCain, 2005). Management of ones mental illness is an important goal of practitioners in the area of psychiatric rehabilitation, especially for individuals who have been, or are currently, jailed. Managing mental illness can help patients make better treatment decisions, reduce the impact of their problematic symptoms, or lessen the severity of relapses and re-hospitalizations.
According to Hertz (2000), inmates and other patients with psychiatric disabilities oftentimes have recurring troubling symptoms, such as, hallucinations or delusions, mood swings, depression, or anxiety, apathy or anhedonia, other dysfunctional behavior, and concentration or memory problems Taken in context these symptoms can be distressing psychologically and add to ones functional impairment. Illness self management, cognitive behavior techniques targeted at cognitive restructuring, and other coping strategies can reinforce and increase the patients ability to cope with their mental disabilities, certain situations in their lives, and the world around them ( Hertz, 2000).
In 2004 a subcommittee on criminal justice was created from the Presidents New Freedom Commission on Mental Health to identify intervention responses and their effectiveness toward development of programs that can be adapted to the special needs of inmates with mental illness in the following settings
Programs that divert minors with severe mental illness out of the criminal justice system.
Services in correctional facilities to target inmates with severe mental illness who have committed crimes worthy of incarceration.
Discharge plans that can link inmates with severe mental illnesses to community based services upon release from those correctional facilities (Mueser and Mackain, 2005).
Toward this end, it is my belief that adopting a program similar to that of GAINS, SAMHSA, or one of the others methods like PAI or ACT or any of the others that have been tested in correctional settings, along with the APIC model, could prove beneficial in managing the integration of existing health, mental health, substance abuse, and social services such that services rendered meet the patientsinmates needs. Goals should hinge on, but not be limited to, the improvement of patientinmate outcomes related to self-sufficiency and reducing recidivism in the Durham County Jail.
Purpose of Study
The purpose of this research project is to examine best practice models identified in the literature for providing mental health services to inmates in jail and recommend a model for the implementation at Durham County Jail. The research further seeks to highlight and explain how the Durham County Jail can benefit from implementing a Best Practice Service Delivery Protocol. Research will be completed to analyze data regarding best practice service delivery protocols that may lead to delivery of better services to inmates with mental disabilities in the jail.
Problem Statement
Is there a best practice protocol or model that can be uniquely adapted to the needs and requirements of the inmates in the Durham County Jail
Can the AIPC (Assessment, Planning, identification, and Coordination) model help them understand and adapt to their various mental disabilities by minimizing the impact of their mental illnesses on their lives (both on the inside and duringpost-probationparole) while providing them with a sense of personal wellbeing and control over their destinies such that patients and practitioners can lessen recidivism
Approach
This study will be a qualitative approach in that it will encompass a number of studies across a couple of decades by numerous professionals in the area of psychoanalysis and mental disabilitiesdisorders. Data will be presented from symposiums, forums, discussion groups, interviews, etc. of multi-disciplinary teams, comprising those working in the detention facility in Durham County, administrators, sheriffs, county and state mental health and substance abuse professionalsadministrators, courts and law enforcement personnel, elected officials, patients and their families. An exhaustive literature review will highlight journal articles, books, and other information derived from professionals on the topic of mental illness as it relates to inmates and recidivism rates in Jails where rehabilitation has been the goal of such treatments and interventions.
Outcomes anticipated as direct result of this study should touch on improvement of quality and scope of the information available to mental health care professionals, especially those working in the criminal justice system in the state of North Carolina, as well as, targeting systemic change in the organization and financing of services to the inmate population. Achieving improvement in the quality and scope of information in the area of mental illness and its proposed treatment of inmates in the Durham County Jail means increasing collaborative efforts on behalf of practitioners and helping them to develop practical applications for a best practice service delivery protocol. The APIC model is the one believed to be the best fit for this particular situation, but this APIC model should take into consideration the particular conditions consistent with jails, correctional facilities, and prisons, including the political environment, and fiscal realities, that go hand in hand with implementation of such practices, methods, and policies.
Relevance to Social Work
The relevance of such discussion is that mental health care practitioners will be better equipped and prepared to handle psychiatric rehabilitation and potential recidivism of inmates in the Durham County Jail. This discussion is directed toward selection of a single best practice service delivery protocol and adoption of the APIC model. The APIC model used as best services delivery protocol can create opportunities for multiple jails, correctional, or prison systems to participate as teams. A team based approach, originally introduced by Eli Lilly in treatment of schizophrenia toward this problem with mental illness and recidivism can be a critical ingredient in garnering change and appropriation of funding at the local and state levels on issues of recurring mental health and substance abuse that service in the criminal justice system in their state (Mueser and Mackain, 2005).
It is anticipated that in order for this APIC program to work optimally it may be necessary to integrate or merge the services provided by mental health and substance abuse. It is hoped that this cooperation and collaboration between closely aligned departments (mental health and substance abuse) can produce significant improvements above those realized in the current system. Research suggests that jails are a good point to begin development of such services targeted at persons who have been diagnosed with recurring or co-occurring mental health or substance abuse disorders by linking community based services to those of the jail based program (Teplin, 1990). Please note that programs that serve women with co-occurring mental health or substance abuse issues may require additional attention because there are huge deficits currently in meeting their specific needs.
Chapter Two
Literature Review
According to Teplin (1990), The American Bar Association mandates that persons with perceived mental illnesses be directed toward treatment instead of incarceration. Practically speaking most police officers do not look further than arrest records when picking up persons for crimes or other criminal incidents. As such, diagnosis and treatment for those with mental illness leads oftentimes to arrest as management for those disorders. More than likely these marginalized persons may have already been rejected by halfway houses, hospitals, andor detox facilities. Furthermore, Abram and Teplin (1991) believe that because these persons profiles are so complicated by having multiple disorders they have been dropped from treatment programs and as such find themselves guests of our criminal justice system.
Osher and Drake (1991) found that there are many more persons with co-occurring disorders cloistered away in our prisons and jails than are part of mainstream society (1991). Ruiz and Edens (2008) therefore affirms high rates of co-occurring psychiatric disorders within the justice, an observation justifiable based on the fact that individuals with mental illnesses are more likely to abuse and depend on drugs. Ruiz and Edens (2008) attest to this affirming that researches on the PAI drug problems (DRG) scale have generally proved a positive correlation between mental health and substance abuse problems. Comparative to their normal counterparts and due to their cognitive impairment, offenders with mental illnesses are less likely to avoid arrest and more likely to be convicted since they lack the necessary mental capacity to effectively defend themselves, (Edens and Ruiz, 2008). New guidelines and mandatory sentencing have resulted in longer jail, correction, and prison periods for those with co-occurring mental disorders. It is also noted that homelessness and impoverishment oftentimes plays itself out as a result of that revolving door scenario.
The relationship between crime and drugs has been investigated for decades with studies indicating that there are individuals who fall in the criminogenic or substance-abusing offerenders category, (Deitch, Koutsenok Ruiz, 2000). Lurigio and Swartz (1994) believe that persons who need (use) drugs commit crimes in order to continue to supply their drug dependence. According to the Bureau of Justice Statistics (1992) there is a heavy correlation between heroin and cocaine use and crime. Studies show that there is a three time increase in criminal acts of those considered users compared to nonusers. Cognitive and emotional disorders associated with persons who suffer from co-occurring mental illness are increasingly likely reasons why these persons may be apprehended for commission of crimes.
Eden and Ruiz (2008) believe that, there is a huge need for detection of persons with mental disorders in the correctional setting because each year more and more persons with mental illness are incarcerated. The importance of this early detection lies in the ability to separate those who are violent substance offenders from those who are not violent. In such instances, the non-violent offender may then be diverted to treatment programs as early intervention is proven to lessen management problems during incarceration.
History of Different Models and Theoretical Framework
The ACT (Assertive Community Treatment) treatment model is a highly integrated and intensive service delivery model that serve aid people with symptoms of mental illness which may result into severe mental and functional difficulties thereby interfering with their normal operations such as having friends, working and living independently, (Morrissey and Meyer, 2005). ACT lasts as long as it is deemed necessary combining supportive services such as vocational rehabilitation and peer recovery services with treatment and is cross-disciplined from the care perspective. ACT was devised in the 1970s in Madison, WI and specifically targeted prevention of the revolving door that enabled repeat hospitalizations of persons with mental illness (Marx, et.al., 1973). ACT has been a part of over fifty-five well established studies, in the USA and abroad.
FACT is an outcropping of ACT with the simple premise of preventing incarcerations and arrests (Morrissey and Piper, 2005). All FACT practitioners have histories with the criminal justice systems and previous involvement with co-occurring substance use disorders making them ideal candidates for helping others in the same or similar situations.
ICM, or Intensive Case Management, has been used in the criminal justice system under the guise of Forensic Intensive Case Management (FICM), (Marshall, et.al., 1998). This method is similar to ACT, but without the team based approach. Rather it links coordinated services with patient treatments and generally has more lax transition times. For example, the method may provide jail-based case management services while organizing for release or implement a community based case management service following the release. Currently there are 12 states with 26 programs of this type available to persons in the US criminal justice system.
APIC, (Assessment, Planning, Identification, and Coordination) is a widely recognized model for community reentry for jailed offenders that depicts the importance of mental health assessment beginning at the point of entry and ending with probationparole (Edens and Ruiz, 2008). Most practitioners in the field concur that the symptoms that receive the most referrals in correctional settings is depression. However, it would be remiss to not note that there is an inordinate number or persons in our correctional facilities who suffer from severe mental illness and disabilities ranging from bi-polar disorder to manic depression and schizophrenia. According to Boothby and Clements (2006), many of these persons have previously been exposed to trauma that set the stage for development of their mental illnesses
PAI, or Personality Assessment Inventory, is another tool used on a multiple scale for measurement of psychopathology and personality disorders, both in the correctional and forensic setting (Edens and Ruiz, 2008). PAI is a very cost effective tool in evaluation of low reading levels (typically 4th grade) that is associated with reduced administrative costs and time while reaping solid information in terms of psychometric properties affiliated with personality disorders and risk toward violence. The model gives inmates better access to mental health initiatives enabling prisoners access to psychiatric specialists besides contributing to their rehabilitation and safe successful integration into the community. These aggression scales have proven useful in such measurement in identification of inmates who are more prone to violent actions while incarcerated.
WRAP (wellness recovery and action plan) is the brainchild of Mary Ellen Copeland (Copeland and Mead, 2004). Her generalized program was standardized such that it could be used to help persons with recurring health and emotional problems experience healthier and more rewarding lives. There are seven components of WRAP, creation of a daily maintenance plan, identification of triggers, early warning signs potential crisis signs, development of the actual crisis plan, making changes in lifestyle, setting up a support and self-advocacy team, increasing ones self esteem, and relief of stress and tension.
Empirical Studies
According to Mueser,et.al (2002) there has been extensive research completed on the topic of illness management, his results contend that people with psychiatric disabilities are able to learn and retain information about their disabilities and treatments, but that the end results, including relapse, re-hospitalizations, and recurring severe symptoms were unaffected. Practitioners in this area deemed that educational approaches were not sufficient in improvement or management of persons with psychiatric disabilities. Merinder (2000) and Zygmunt, et.al. (2002), tended to reach similar conclusions in their research.
According to Atkinson, Coia, Gilmour, Harper, education about mental illness is a necessary and critical factor in family intervention programs (1996). This family education targets how the relatives of the mentally ill can help to manage and collaborate, with regard to potential treatment programs, for those with whom they reside who experience some degree of mental illness. These techniques are meant to overlap and meld with individual illness self-management programs. There appears to be consensus that research on such programs has failed to illuminate any specific results that favor such treatments or interventions and there is no specific mention as to how educational outreach programs favor inmates (Atkinson, et.al., 1996).
Peters, May, and Kearns, have found that persons who attend jail-based substance abuse programs, and also show symptoms for mental illness, had more difficulty in areas of employment, relationship development, and other mental difficulties (1992). Overcoming these issues means developing new leisure activities, recreational pursuits, and employment skills and training within the prison environment.
Blackwell believes that there has been too much adherence to recommended treatments with regard to psychiatry and mental illness (1973). According to Coldham, and Addington, an individuals sensitivity to others efforts to direct or control their behavior as psychological reactance thinks that treatments that are authoritarian in nature can cause non-adherence in persons who are known to be highly psychologically reactant (2002). There is some consensus between Fogarty (1997) and Moore, Sellwood, Sterling, that if there is collaboration in exacting treatment alternatives between psychiatrist and patient there will be more respect for the treatment decision (2000).
Lurigio and Swartz made many attempts to evaluate substance abuse treatment in the Cook county jail located in Chicago, IL (1994). The program being used there was three-pronged in that it began with orientation, then intervention, and aftercare. Sadly, of the 34 who started this program, only 17 of those actually completed it.
Relapse prevention strategies have proven effective outside of the criminal justice setting according to research performed by (Mueser, Corrigan, Hilton, Tanzman, Schaub, Gingrich, Essock, Tarrier, Morey, Vogel-Scibilia, Hertz (2002). These programs varied in duration and comprehensiveness. One such program lasted six weeks and was aimed at bi-polar disorder. This study was proven effective at the end of the two year trial and follow-up sessions. Hertz, Lamberti, Mintz, Scott, ODell, McCartan, Nix, studied schizophrenic patients relapse at weekly meetings held over the course of a year (2000). This program was established to track, recognize, and respond to the early warning signs of relapse while also attempting to help these patients manage their triggers better. The end result of this study was that it did have an effect upon relapses and rehospitalizations (Hertz, et.al, 2000).
Wallace and team conducted research regarding medication management and symptom management. They devised a training manual that can literally be used by anyone, from practitioner to novice. Sixteen programs were implemented as result of this study ranging from residential care facilities to corrections, and psychiatric operations. Their particular program lasted for one year and each of their modules were taught over six month periods of time to a variety of personnel showing marked improvement in social adjustment for their patients. Follow-ups were conducted after two years and showed results were ongoing and positive in this regard (Wallace, Linerman, MacKain, Blackwell, Eckman, (1992). This study was not specific to the correctional facility setting and more information would need to be reaped before adopting this program for the Durham County Jail.
Hogarty and colleagues devised what they termed personal therapy. This was an individualized psychotherapeutic approach targeted at persons suffering from schizophrenic disorder (1995). It was their intention to help patients achieve and maintain stabilization in the clinical sense of the word. Sessions for personal therapy were conducted bi-weekly for the first year and somewhat less often over the duration of the second year this program was implemented (Hogarty, 2002). Personal therapy was divvied up into three segments with exact guidelines as to how the program was to proceed. Step one was a meeting between patient and therapist that developed a treatment plan and created a relationship or connection between the two. Sector two was psychoeducation where the patient learned about their illness and various treatments available to control the effects. Internal coping skills and stress management were taught at this juncture. Lastly, was social skills training and interactions where the patients learned how to avoid situations that might cause them conflict and how to initiate positive interactions with others. Personal therapy was deemed to reduce psychotic relapses for those residing at home, but noted increased relapse rates for those living on their own (Hogarty, 2002).. They attribute this anomaly to conflicts with landlords or additional stress from other unrelated factors. However, at the three year follow-up mark personal therapy noted significant improvement in overall symptoms severity, ability to adjust, and employment opportunities.
Chapter Three
Methodology
As previously mentioned the APIC model is the selected best practices service delivery protocol that will be adopted and tested in the New Jersey criminal justice systems. Archival data will be collected from the APIC protocols at each facility that is part of the New Jersey criminal justice system. It will be administered to a select number of inmates, two to three weeks after admission such that the team performing diagnosis is working from a blind perspective and has not biased any results that may follow. Basic demographic information will be gathered from these inmate charts. There will be attempts to segregate the results according to mental disorder, violent or non-violent offenses, drug-related, or non-specified.
Setting
The setting to be used for implementation of the APIC model is the criminal justice system in New Jersey. Symptom profiles are complex for persons with co-occurring disorders because of their multiple treatment needs. Of the jailed in New Jersey ethnically speaking the vast majority was African American or Hispanic, many were males between the ages of 15 and 25. Since 1995 there had been an increase of over 57 females entering jail compared to 34 males entering jail for the same time frame. Of that population 60 had some mental disorders that required treatment and intervention. There was no further demographic breakdown offered from HYPERLINK httpwww.jailovercrowding.comindexwww.jailovercrowding.comindex.
Teplin (1991) found that 85.5 of the persons with co-occurring disorders in the jail system were diagnosed with schizophrenia and had some alcohol dependencies as well. 72.4 had some drug addiction issues. His studies were conducted in five prisons sites. The ratios he found in this study were compared to institutional studies of persons with schizophrenia in combined communities and the prison data sets were double that of the institutional setting. 88 of those persons were males. No data was offered as to ethnicity or specifically targeting women in jail. Pointing to the fact that more studies need to be conducted to reap meaningful demographic data for this area
Models Used
A blend of models will have been tested and evaluated in order to select the APIC model as best practice service delivery protocol for the criminal justice setting in the state of New Jersey.
Best Practice Model
AIPC, (Assessment, Planning, Identification, and Coordination) has been deemed to be the best practice service delivery protocol to be implemented in the New Jersey jail because it takes the best features of the other plans and models and correlates them to the best possible outcomes for the inmates with mental illnesses in those facilities.
Implementation
The AIPC best practice service delivery protocol is organized to roll out in phases over the coming months in order to allow for practitioners to be adequately trained in the requirements to make this plan a success. The first couple of weeks will entail training, networking, and educational outreach projects coordinated within the community this jail impacts most. A variety of professionals from a diverse pool of specialties will contribute to this educational endeavor and hopefully make it a seamless move into the second portion of this plan. The second part of this plan will be the direct results of this educational quest in that it will be the first direct contact these professionals will have with the inmates in this jail.
This portion will begin with an evaluation phase to determine the degree to which these inmates are impacted by their mental illnesses and to ascertain what, if any, previous treatments and interventions have been employed. Medications will be included in this phase as they relate to each persons specific condition and should lessen any outbursts or other problems for the correctional officers tasked for overseeing them. There will also be discussion about how these inmates can begin to take charge of their illnesses, notice what things trigger their episodes, and rein in the ill effects this has caused on their lives. The crux of this plan is to lessen recidivism rates in this jail, especially for those with mental illness or co-occurring mental disorders.
Symptom management is a top priority in this regard and will be taught in four sessions identification of early warning signs and seeking immediate intervention, developing relapse prevention plans, coping with ongoing and persistent symptoms of their various mental illnesses, and avoiding substance abuse. This portion of the plan will involve twice weekly sessions that last for three to six months and will shift, when necessary according to duration of time to be served, from in jail populations with these mental issues to outpatient facilities for continuum toward achievement of best results.
Chapter Four Implications for Social Work Practice
Even under the best circumstances for diagnosis and screening in identification of offenders with mental health issues, few are noted to receive care beyond basic medications for control of symptoms or separate housing for behavioral problems associated with same. (Beck and Maruschak, 2001 National Institute of Corrections, 2001) Cost is a concern at these facilities. A multi-tiered approach toward this serious issue may come close to addressing these needs for inmates with mental illness according to Messer and MacKain. (2004) Multi-tiered services have been adopted by some states and are usually effectuated in the least restrictive setting. These programs offer in-patient care, residential care for special needs inmates under house arrest or lock-down, daily and intermediate treatments, and outpatient mental health services.
Osher and Drake (1996) believe that negative clinical outcomes in the jail setting are more the rule than the exception. Persons with co-occurring disorders compared to those with single syndrome shook out as follows Co-occurring persons had increased vulnerability for rehospitalizations, exhibited more psychotic symptoms, were noted as having more severe depression and tendencies toward suicide while incarcerated. In addition to that they also had serious issues adapting to their daily lives, were more violent and non-compliant in approach to treatments and interventions, and had higher incidence of HIV.
The implications for implementing the APIC plan should be clear to create a best practice service delivery protocol that can lessen recidivism in the New Jersey jail. Paramount in achieving this goal is early detection of inmates who are mentally ill or show signs of co-occurring mental illness. With appropriate interventions on behalf of skilled professionals it is the express hopes that the persons who fall into the correctional system with these disabilities can be diverted on toward treatment facilities where they can overcome some of the ill effects these illnesses have created for them and be less a burden and challenge for the personnel at this facility.
Overall, if this plan can perform as anticipated it sets the stage for adoption into other correctional facilities within and outside the state of New Jersey. The APIC model can serve as benchmark in aiding practitioners in this challenging field to better weed out persons with mental disabilities or co-occurring symptoms from our overcrowded jail and correctional facilities such that they receive appropriate treatment that can help them return to productive persons within our society.
Chapter Five
Conclusion
Best practices are intended to come about due to extensive research and exhaustive studies that have been tested in a variety of circumstances in order to assure that they are capable of being implemented into the one at the jail in New Jersey. Many models have been considered before selection of the APIC plan. Mental illness, like other lifelong chronic diseases, requires ongoing care and management in order to lessen the disruptive and destructive effects on the patientsinmates daily lives, (Mueser and MacKain, 2005). Through regular monitoring by medical and psychological professionals it is hoped that they these professionals can help these inmates move on to lead perfectly normal lives away from the criminal justice setting.
If these inmates can understand the insidious nature of their mental illnesses and co-occurring mental issues they can begin to make changes in their lifestyle behavioral tailoring andor cognitive restructuring, take charge of their medications, select coping strategies, and make better informed decisions about learning about early warning signs and identification of triggers can go a long way toward relapse prevention when they require emergent medical care or intervention for control or prevention of recurring mental problems. It is worth noting that there are oftentimes cognitive limitations associated that accompany these mental illnesses that may require environmental changes to compensate for same. (Velligan, et.al., 2000)
Statistically, it has been proven that, in the vast majority of the studies, there are significant benefits reduced symptom severity or distress on behalf of the inmates with mental illness or co-occurring mental disabilities that can be derived from implementation of the APIC model into the New Jersey jail. (See empirical studies above) Over the course of the past couple of decades, as result of such studies, a number of new programs have been devised in a variety of settings. Information as it relates to the inmate populations in correctional facilities and mental illness or co-occurring mental disabilities still requires more study and insight into alleviating or lessening the recidivism rates for those persons, but it is our firm belief that the APIC model will help in this regard. New studies need to document interventions in jail diversion programs or mental health courts, jails, prisons, or other correctional facilities in their host setting.
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