Remarks by
A. Kathryn Power, M.Ed.
Director
Center for Mental Health Services
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services
Restoring Hope at the Intersection of the Behavioral Health and Criminal Justice Systems
March 18, 2008
Washington, DC
PowerPoint Version
Attached is the text prepared for delivery; however, some material may have been added or omitted at the time of delivery.
[Slide 1: Title slide]
Thank you Hank for your kind introduction and for the invitation to be with you today. I am always invigorated by joining you once every 2 years because I think of each and every one of you in this room—more than 1,000 strong—as a “transformer.” Many of you may be familiar with the children’s toy that transforms from a rather innocuous looking car or truck into a fearsome robot capable of rooting out and destroying evil. I am looking at the faces of mild-mannered policymakers, treatment providers, law enforcement and corrections officers, judges and court personnel, consumers, and family members. But I know that when you leave here, you will return to your communities to be fearless advocates for the rights of individuals with mental and substance use disorders in the criminal justice system.
Your actions at home, and your very presence here today, speak volumes not only to the need to transform our mental health system to one that is client-driven, recovery-focused, and evidence-based, but also to the fact that it can be done, it is being done, and it MUST be done.
It is no accident that the CMHS National GAINS Center is now part of the SAMHSA CMHS Transformation Center. I can think of no greater example of the commitment, collaboration, and true partnerships required to transform mental health delivery in this country than the work you do at the intersection of the mental health services, substance abuse treatment, and criminal justice systems in this country.
[Slide 2: Pew statistics slide]
And it’s clear that we haven’t a moment to waste. T.S. Eliot has said that “April is the cruelest month,” but cruelty, if measured by the number of Americans in our Nation’s prisons and jails, knows no season. Late last month the Pew Center on the States released a report with the grim statistic that for the first time in our Nation’s history, more than 1 in 100 American adults are behind bars. For minority men, the numbers are even worse: 1 in 9 black men, ages 20 to 34, are serving time, as are 1 in 36 Hispanic men. And incarceration rates for women are rising at an even more rapid pace.
Clearly, this situation is untenable from both a human and a financial perspective. Many of our Nation’s jails are overcrowded, leading to low staff morale and overtime pay. Last year alone, the 50 States spent about $44 billion in tax dollars on corrections, up from nearly $11 billion in 1987. And more than half of released offenders are back in prison within 3 years, either for a new crime or for violating the terms of their release.
[Slide 3: Virginia Governor quote]
Many observers are searching for reasons to explain this rise in incarceration rates that has occurred even as crime rates are falling. For the individuals with mental and substance use disorders we serve, I think the answer all too often is the one given by a former mental health consumer at a SAMHSA-sponsored dialogue between consumers and representatives of the criminal justice system: “Individuals are incarcerated simply because they are sick,” this individual remarked.
We know that individuals with mental and substance use disorders commit serious crimes for which incarceration is the appropriate response. However, it is equally true that, often as a result of circumstances beyond their control, individuals with serious mental illnesses and co-occurring substance use disorders are just as likely to be victimized.
They are also more likely to be arrested; to be detained because they cannot post even very low bail; to be charged with more serious crimes; to have stiffer penalties imposed; to spend two to five times longer in jail; and to be involved in more fights, infractions, and sanctions. Frequently, they cycle in and out of the mental health, substance abuse, homeless services, and criminal justice systems, receiving inadequate treatment or inappropriate treatment, if they receive treatment at all.
Often, individuals who are caught in the “revolving door” of corrections, mental health and substance abuse treatment, and homelessness are thought of as “bad clients” or “treatment resistant,” when in reality, Hank is quick to point out, they are the casualty of “client resistant services.”
That’s why you are here for the next several days to talk about creating more effective services. In the time I have with you this morning, I’d like to discuss three topics that I hope will frame what you hear in the presentations you attend and will help shape your dialogue in informal networking with your colleagues and collaborators:
- First, what do we mean by “creating more effective services?”
- Second, how can we use this knowledge to create trauma-informed services and systems for individuals with mental and substance use disorders who are involved with the criminal justice system?
- And third, how can we meet the needs of returning veterans with mental illnesses, substance use disorders, and trauma experiences who come in contact with the criminal justice system?
Creating More Effective Services
When it comes to creating effective services, we know what works to help individuals with behavioral health disorders recover and lead productive lives in their communities.
We know that Assertive Community Treatment reduces hospitalizations for individuals with serious mental illnesses and, according to some studies, is no more expensive than traditional care.
We know that Supported Employment promotes rehabilitation and return to mainstream employment for individuals with psychiatric disabilities.
And we know that integrated treatment for co-occurring disorders reduces alcohol and drug use, homelessness, and the severity of mental health symptoms.
But we have to put what we know into practice, and this isn’t easy when we are talking about transforming service delivery at the intersection of the mental health and criminal justice systems.
First, some of these interventions may need to be adapted to serve the dual and sometimes competing purposes of individual recovery and public safety. The mental health system is evolving to be recovery-oriented and consumer-driven, but the criminal justice system is a rigid system based on control. These systems are seemingly incompatible and have remained separate for too long.
Second, we need to look at relationships between States and communities, particularly around how services for individuals with mental and substance use disorders are funded. In particular, we need to examine how those policies and practices influence the services that are provided to consumers, particularly those with justice system involvement.
[Slide 4: CSG benefits tools]
Third, we have to ensure that eligible individuals are connected to benefit programs—such as Supplemental Security Income and Medicaid—immediately upon release from jail or prison so they have access to the services they need to recover and remain stable in the community. Without prompt access to community services, including mental health and substance abuse treatment, many individuals are at risk for re-incarceration.
At the Federal level, we recognize that timely receipt of benefits may be delayed because of confusion over eligibility rules for individuals who are or have been incarcerated. To increase awareness of the rules and regulations, CMHS asked the Council of State Governments Justice Center to develop two online tools:
- The first is an interactive chart for case managers working with individuals in jail or prison to compare and contrast key features of various benefit and cash assistance programs.
- The second tool is geared toward corrections administrators interested in developing discharge planning processes and other agreements to improve access to Social Security and Medicaid benefits for eligible individuals upon release from jail or prison.
I’m pleased to announce that both tools are available online for the first time today at www.reentrypolicy.org. You can also view screen shots of the tools at the Justice Center’s booth in the materials room.
Clearly, we must address a host of challenges in creating effective services for individuals with mental and substance use disorders in contact with the criminal justice system. However, the focus on consumer needs that drives the behavioral health care system can also be the motivating force behind collaboration with the criminal justice system. When individuals with serious mental illnesses and co-occurring substance use disorders are diverted from the justice system, provided with comprehensive and appropriate services while incarcerated, and helped to reenter their communities successfully when they leave jail or prison, justice operations, costs, and staff morale improve.
Both systems are serving the same individuals and the extent to which we serve them well is reflected not only in individual outcomes but also in systemic improvements. This is transformation in action!
“Creating more effective services,” therefore, is a mandate to community-based service providers and to criminal justice agencies to address service access, costs, quality, and innovation based on recovery-oriented and consumer-driven principles.
It is also a mandate to surmount barriers and to disseminate practical solutions to those barriers.
[Slide 5: NLF facts]
The National Leadership Forum for Behavioral Health–Criminal Justice Services is a response to this call for creating more effective services for individuals with mental and substance use disorders who are involved with the criminal justice system.
The goal of the National Leadership Forum is to go beyond previous efforts to address diversion and reentry for this population to tackle one of the most common barriers to success—the lack of accessible, quality, and appropriate services that will help individuals remain and succeed in the community.
Currently there is no group in the services arena that parallels what the Council of State Governments has done in the policy arena with the Consensus Report around justice reinvestment.
The Consensus Report had a major influence on policymakers, who were convinced to reallocate State-level funding that was originally earmarked for building new prisons toward funding the provision of treatment services.
The goal of the National Leadership Forum is to do the same thing in the services arena. This group of highly committed top-level leaders met for the first time several weeks ago, and I was pleased to be able to welcome them to their new task. Together, these individuals have the knowledge and power to drive the development and funding of evidence-based services for individuals with mental illnesses and co-occurring substance use disorders in contact with the criminal justice system. This is transformation in action!
The Need for Trauma-Informed Service Systems
The second area I want to highlight this morning is one that I’m certain the National Leadership Forum will attend to and that is the need to address trauma and the development of trauma-informed services and systems for individuals with mental and substance use disorders in contact with the criminal justice system.
[Slide 6: Hemingway quote]
In A Farewell to Arms, Ernest Hemingway wrote, “The world breaks every one and afterward, many are strong at the broken places.”
It is a sad fact of the work we do that many of the consumers we serve have “broken places,” but we need to recognize and celebrate their strength. Data from the cross-site evaluation of the CMHS Treatment Capacity Expansion for Jail Diversion Programs Initiative reveal a 90 percent lifetime prevalence of trauma among jail diversion participants. Prevalence for the past 12 months is roughly 60 percent.
Rates of trauma are also high for individuals with mental illnesses and co-occurring substance use disorders. Recent studies have reported prevalence rates of trauma at 52 to 90 percent for these individuals.
Traumatic events include the personal experience of interpersonal violence, such as sexual abuse, physical abuse, severe neglect, loss, or the witnessing of violence. Many of the consumers we serve are re-traumatized within the mental health system when they are subject to any kind of forced treatment.
For all intents and purposes, we must assume that each and every one of the individuals with whom we come into contact—both men and women—has experienced some type of trauma in his or her life. In fact, I believe this issue—the inextricable link between violence and trauma and both women’s and men’s mental health—is the emerging issue at the crossroads of mental health and criminal justice.
More than 30 years ago, when I was working as a rape crisis counselor, I learned again and again that a woman’s searing exposure to the raw trauma of physical or sexual assault put her overall emotional health at very high risk for both the short and long term. I learned, too, that the power of violent and traumatic events to destabilize individuals had been systematically missed by the mental health field.
[Slide 7: Elements of a trauma-informed system]
To fully address the needs of survivors at the intersection of the mental health and criminal justice service systems, we must adopt a systemic approach, characterized both by trauma-specific diagnostic and treatment services and by a “trauma-informed” environment capable of sustaining these services.
Perhaps most important, we must adopt a public health, community-based approach that stresses the links between health and the physical, psychological, cultural, and social environments in which individuals live, work, and go to school.
In a seminal 1988 report, the Institute of Medicine defined public health as “what society does collectively to assure the conditions for individuals to be healthy.” The fundamental premise of a public health approach to health care is that it is inherently better to promote health and prevent illness before it begins. We know we must address the impact of trauma on both women and men to promote health, prevent illness, and break the cycle of repeated contact with the criminal justice system for individuals whose only crime, all too often, is being sick.
[Slide 8: Women and trauma]
I mentioned earlier that we know what works to help individuals with mental and substance use disorders recover. More specifically, we know what works to help women with co-occurring disorders and histories of violence reclaim their lives as women, as mothers, and as productive members of their communities.
The SAMHSA-sponsored, 5-year Women and Violence Study has provided the most authoritative and comprehensive view to date of what can be accomplished in the public health system for women who have histories of physical and sexual abuse and who are in need of services for both mental and substance use conditions.
This groundbreaking study featured a trauma-integrated counseling approach that addressed the full range of a woman’s behavioral health care needs. Findings at both 6 and 12 months suggest that integrated counseling—for example, group and individual therapy that addresses trauma, mental health, and substance use conditions—was the key element associated with better outcomes.
This is exactly the type of intervention adopted by the Correctional Center of Northwest Ohio or CCNO, a regional jail serving six Ohio counties. CCNO adopted a trauma program for women called TAMAR—which stands for Trauma, Addictions, Mental Health and Recovery—that was developed in Maryland jails as part of the SAMHSA Women and Violence Study.
At CCNO, staff pride themselves on consistency with policy, procedure, and practice, yet a trauma-informed correctional environment requires some flexibility. Initially, officers were concerned that being flexible would be perceived as inconsistent or showing favoritism. They soon found that trauma-informed practices made for smoother operations.
Let me give you an excellent example. A female officer attempted to awaken a female inmate, and when the inmate awoke, she was startled, upset, and ready to fight. The inmate quickly recognized the officer and realized she was okay. She then apologized and explained that when she was a child, her stepfather would stand over her bed, wake her, crawl into her bed, and abuse her.
The corrections officer thanked the inmate for the explanation, and they worked out an accommodation about how to wake her in the future to prevent an aggressive reaction. The corrections officer logged this information to serve as a reference. Six months earlier, the threatening action toward the corrections officer would probably have resulted in segregation or lockdown. Instead, because of the trauma-informed training she received, the officer was able to respond to the inmate’s need for safety while still preserving jail routines.
Trauma-informed staff and systems can help reduce recidivism, reduce the use of seclusion and restraint in correctional facilities, and reduce relapse. In fact, since CCNO adopted the TAMAR program, use of force, acts of self-harm, and suicide attempts have decreased. This is transformation in action!
As wonderful as they are, however, these statistics don’t tell the whole story. When you implement trauma-informed care, you are not just cutting down on reportable incidents—you are giving someone back her life. Listen to what a trauma survivor and consumer advocate said at the SAMHSA dialogue on criminal justice about her work providing services to women who are incarcerated for nonviolent crimes:
“I watch women in our program for the first time experience what it is like to be a parent, to hold their babies and feel worthy of having that child in their arms—and to begin to feel that they deserve something and that they are worthwhile human beings.”
I don’t quite have the words to express how wonderful it is to realize that we have the power to help someone care about herself. That is transformative for her and for us.
Before I leave this topic, I would be remiss in not reminding us that trauma also impacts the men we serve, as well. The Hartford Men’s and Women’s Support Program, a jail diversion program in Hartford, Connecticut, expanded its services to include men with mental illnesses and trauma histories. The program offers trauma-specific services and peer support as part of an individualized, comprehensive service plan. Men are 10 times more likely to be in jail or prison than women, and we cannot transform the way we deliver services without addressing their needs for trauma-informed care, as well.
Returning Veterans
Finally, this morning, I want to talk about a subject that we simply cannot afford to ignore. When we fail to address the mental health and substance abuse treatment needs of returning veterans and their families, we are setting them up for a host of adverse affects that include homelessness, arrest and incarceration, and suicide.
A former colleague of mine once said, “The duties of today’s soldiers can leave footprints on their psyches. We owe veterans more than our gratitude.”
[Slide 9: Traumatic brain injury]
Indeed, we owe them our full support to help heal the wounds of war, including those that are not easy to see. More than 1 million men and women have served in war zones since the terrorist attacks of September 11, 2001, and they are experiencing difficulties particular to the kind of warfare they are encountering.
In Iraq and Afghanistan, for example, the lack of a front line means that soldiers can face danger anywhere—even in supposedly “safe” zones. And medical advances now allow soldiers to survive catastrophic brain injuries, spinal cord injuries, and wounds that once would have been fatal. In fact, traumatic brain injury is sometimes referred to as the “signature wound” of the Iraq War.
Those fighting in Iraq and Afghanistan also differ from those who fought previous wars. Women now constitute 16 percent of the members of the Armed Forces and are assigned to 90 percent of all military occupations.
Further, roughly half of the 150,000 troops in combat are National Guard members and reservists. These “citizen soldiers” are not eligible for some benefits accorded to enlisted soldiers, and some may lose their jobs and have to be re-employed. These are broad-based challenges to a successful life in the community.
In fact, a Department of Defense Task Force on Mental Health found that 38 percent of soldiers and 31 percent of Marines report psychological concerns such as traumatic brain injury and posttraumatic stress disorder (PTSD) after returning from deployment.
Among members of the National Guard, the figure is much higher —49 percent—with numbers expected to grow because of repeated deployments. In fact, veterans with PTSD increased by 42 percent from 1998 to 2003. One fifth of veterans returning from Iraq and Afghanistan are diagnosed with a substance use disorder.
[Slide 10: Women veterans]
We know that exposure to war zone trauma is a risk factor for PTSD. However, we must also confront the realization that sexual trauma in the military is a growing concern. As a woman, a Captain in the U.S. Naval Reserve, and a mental health professional, I find this deeply troubling. And I know our silence on this issue will only make the problem worse.
It should come as no surprise that mental disorders are one of the top three conditions that lead veterans to seek care from the VA. But what is more troubling is that many veterans don’t reach out for help when they need it. This is not unique to veterans.
Despite the availability of effective treatments, fewer than half of all individuals who require mental health services get the help they need. But stigma may be an especially significant barrier for men and women who are taught to “be all they can be.”
When veterans don’t get the treatment they need, the outcomes can be tragic. Mental health officials in the Veterans Health Administration estimate 1,000 suicides per year among veterans receiving care with VHA and as many as 5,000 per year among all living veterans.
[Slide 11: Veterans in prison]
And many of the men and women who fought for their country end up in our Nation’s prisons and jails. According to the Bureau of Justice Statistics, the percentage of veterans among State and Federal prisoners had steadily declined over the past 3 decades. However, in 2004, there were still 140,000 veterans in our Nation’s prisons. In an earlier study, the Bureau found that 31 percent of all incarcerated veterans—225,000 in 1998—were in local jails.
We know that half of incarcerated veterans performed wartime military services, and 1 in 5 reported combat duty. More than half are serving time for a violent offense. Veterans in State prison are more likely than non-veterans to report a recent history of receiving mental health services. They tend to have shorter criminal histories but to spend more time behind bars.
[Slide 12: SAMHSA activities]
SAMHSA has made the behavioral health care needs of returning veterans and their families a top priority. Last March, SAMHSA convened a National Conference on the Behavioral Health Needs of Returning Veterans and Their Families, and our next conference will be held August 11-13. More than 1,000 participants attended the first conference, which produced a set of recommendations to address the behavioral health needs of returning veterans and their families. We are already planning a follow-up conference.
Following last year’s conference, SAMHSA established a Workgroup on Returning Veterans and Their Families. The group’s members have been meeting with the VA and the Department of Defense to determine how we can partner most effectively to meet the mental health and substance abuse treatment needs of returning veterans. As an outgrowth of this work, SAMHSA and the VA collaborated to add a special feature for veterans to the National Suicide Prevention Lifeline. Callers who identify themselves as veterans are connected to VA suicide prevention and mental health professionals.
We’ve also begun making some changes internal to SAMHSA, as well. For example, we have identified veterans as a priority population for many SAMHSA grants and have created a set of resources for returning veterans and their families on the SAMHSA Web site at www.samhsa.gov.
I’m also pleased to announce that on May 9, the GAINS Center, through the CMHS Transformation Center, will convene a meeting called “Combat Veterans, Trauma, and the Criminal Justice System.” The purpose of meeting is to develop an agenda and an action plan to promote the type of cross-systems integration needed to meet the needs of veterans with experiences of trauma who may come in contact with the criminal justice system.
But working effectively with veterans at risk for incarceration and those who are involved in the justice system doesn’t happen at the Federal level—it happens where you sit, in treatment programs, patrol cars, courts, and local jails. Programs for veterans need to be established at the front door of the criminal justice system—in law enforcement training and jail diversion—and at the back door—in transition planning and community corrections programs.
Further, we have to assess what State and local resources need to be in place to address this population. And we have to develop services that integrate the principles of peer support and recovery in providing services for veterans with mental illnesses and substance use disorders involved with the criminal justice system.
Current and former service women and men are essential elements for implementing effective services that meet the needs of veterans involved with the justice system. Veterans helping veterans is the essence of a consumer-driven system of care.
Not long ago I came across an interview with Doonesbury cartoonist Garry Trudeau about the research he did to create the experiences of his character B.D., a Vietnam vet, reservist in the first Gulf War, and now Iraq War amputee. Among the places he visited were Vet Centers, which are staffed by small multidisciplinary teams of dedicated providers, many of whom are combat veterans themselves. There are 207 community-based Vet Centers located in all 50 States, the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands.
I was especially struck by the fact that in one Doonesbury strip, Celeste, a VA receptionist, greets B.D. and all visitors with the words “Welcome home.” She says, “We don’t think vets can hear it often enough.”
Wrap-up and Conclusion
We must welcome home all of the individuals with whom we work, who too often feel displaced, forgotten, and unwelcome among us. In his recent book aptly titled “Strong at the Broken Places,” journalist and multiple sclerosis patient Richard Cohen tells the story of five remarkable individuals living with chronic illness. In the final chapter, he profiles Larry Fricks about his bipolar disorder. Larry Fricks is internationally known for his work designing the first Medicaid-billable certified peer specialists’ program in the United States during his nearly 13 years as director of Georgia’s Office of Consumer Relations and Recovery. But to Cohen, he is just Larry, and he speaks candidly about his struggles not only with the illness itself, but with the negative attitudes of treatment professionals.
“After I was hospitalized,” he told Cohen, “I was dumbstruck by the sense of hopelessness that individuals attach to mental illness and the message that came through to me.” But Larry found a savior during his stay in the hospital, a fellow patient with bipolar disorder who, whenever Larry would enter or leave solitary confinement, extended a hand and told Larry that his experiences were real and could not be taken away from him. “I chose not to be angry or to give up,” Larry said. “Recovery would mean a transformation for me, to realize I could own my life.”
Let me repeat that. “Recovery would mean a transformation for me, to realize I could own my life.” This is why each and every one of you in this room does the challenging and rewarding work you do. You are transformers, modeling the collaboration and cooperation needed not only to transform systems, but also to transform lives. Most of all, you are agents of hope, and hope, Larry Fricks says, “is to the soul what oxygen is to the body.”
You bring hope that a person with a mental illness or substance use disorder at risk of justice system involvement can receive the evidence-based services and supports he or she needs to remain stable in the community.
You bring hope that a woman who has been physically or sexually assaulted and has turned to alcohol or drugs to numb the pain no longer has to be re-traumatized by an unthinking or uninformed behavioral health or criminal justice system.
And you bring hope that we can, indeed, replace antiquated myths, outdated science, and outmoded financing with a system that is client-driven, recovery-focused, and evidence-based.
[Slide 13: Keller quote]
I’d like to leave you with this wonderful quote from Helen Keller, whose life has been an inspiration to so many individuals who endeavor valiantly and with grace to surmount the challenges in their lives. Miss Keller said, “The world is moved along, not only by the mighty shoves of its heroes, but also by the aggregate of tiny pushes of each honest worker.”
You are honest workers in the struggle against discrimination and bias, in the conflict over how to promote recovery and protect public safety, and in the crusade for the needs of individuals with mental illnesses and substance use disorders for evidence-based services that will help them remain stable in the community. Together, you are my heroes.
Thank you for being here today. I’d be happy to take your questions.
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