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
National GAINS Center Conference
Systems Transformation at the Interface of the Criminal Justice and Mental Health Systems
April 6, 2006
Boston, MA
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]
{to the audience}
Thank you for that warm, wonderful welcome.
{to Dr. Steadman}
And t hank you, Dr. Steadman , for those generous remarks.
American author and business management guru Tom Peters has said,
[SLIDE 2. Peters Quote]
“Celebrate what you want to see more of.”
I am here today to celebrate the successes and remarkable progress the GAINS Center has made in support of individuals with co-occurring mental illnesses and substance use disorders within the criminal justice system.
I salute all of you and your efforts to expand interest—exponentially—in jail diversion programs, mental health courts, and Crisis Intervention Teams throughout our States and local communities across the Nation .
I applaud your awareness, over the years, to adapt to and address the evolving needs of States and local communities. From a focus on creating and implementing model s for community response and treatment…to stimulating systemic change and providing support for integrated systems of care…to your current emphasis on science-to-service and the promotion of evidence based practices…you are improving response and outcomes for justice involved individuals with co-occu r ring disorders.
I commend you for taking on the task of assessing evidence-based practices in the treatment of individuals with mental illness and criminal justice involvement and promoting some very effective model programs .
And, I congratulate you for bringing together the largest group of advocates drawing the largest audience in your Center’s history to this 4th annual GAINS Center conference. in your Center’s history Today’s attendees, over 1,000 strong─span ning both the spectrums of the criminal justice and mental health─who are over 1,000 individuals committed to improving the fate of individuals with co-occurring mental and substance use disorders within the justice system. I ’m pleased to see a strong representation from consumers and consumer advocates here at the conference…and participating on panels, where they can make the vitally important contribution of sharing their lived experiences. This is cause to celebrate!
To each of you, in the audience—consumers and family members, those who work in justice, and those affiliated with mental health—I am here to celebrate your collective hard work to fuel transformation…to change the status quo…to improve outcomes for people with mental and substance use disorders caught upon the justice system. I want to thank you for taking time from your extreme ly heavy workloads to attend this conference. I am sure the experiences gained you will gain after attending through this impressive showcase of many of the program sessions over the next few days will become the catalyst for future successes. Your presence here is cause to celebrate!
The GAINS center, and everyone every one of you here, is truly a shining example of transformation in action. When I spoke at t his conference two years ago, I encouraged you to promote transformation…to facilitate the use of best practices that offer recovery for people in contact with the criminal justice system…to share your success so others can have the opportunity for a rewarding life in the community. And you have. Over the past two years, you have never stopped fanning the flames of transformation.
Your commitment to collaboration between criminal justice and m ental health at the State and local levels…is transformation in action. You are demonstrating that collaboration is possible…is happening…and at an increasing pace. You are working in your communities, collaborating to minimize the fragmentation between systems and to facilitate recovery . You are taking steps to ensure that there is continuity of care whether an individual is in the criminal justice or mental health system. You have achieved a delicate alliance in leading transformation to serve mentally ill individuals caught in the criminal justice system...an alliance between criminal justice and m ental health…what some might call unlikely partners .
Yet, history demonstrates that Some very powerful outcomes can result when unlikely partners champion a cause. The cautious al liance between Former President Lyndon Baines Johnson and the Reverend Martin Luther King Jr. is a provide such an historical example. of an unlikely partnership The—a rough talking Texan who had lived through rampant racism in the South and a the southern black visionary who inspired the nation by fighting a nonviolent war. Yet they came to work together to provide the critical leadership that achieved one of the most dramatic social changes in America since the Emancipation Proclamation. Sharing a passion for equality civil rights and to improve the lives, they Johnson and King knew how to work in found complementary ways to overcome differences, to accommodate each other’s political needs and to achieve the common goal of equal voting rights for all Americans. .
A passion for c ivil rights was t he interface between Johnson and King. Webster’s defines interface, “ as a point at which independent systems or diverse groups interact”. The theme of this conference—,Systems Transformation at the I nterface of the Criminal Justice and Mental Health System—, thus, reminds us why those of us in criminal justice and mental health are here together in the same room.
[SLIDE 3 . ATP ]
Transformation is our interface…our call to action…our common pathway to Achieving the Promise—“a future when mental illnesses can be prevented or cured, a future when mental illnesses are detected early, and a future when everyone with a mental illness at any stage of life has access to effective treatment and supports—essentials for living, working, learning, and participating fully in the community.”
The many interfaces of the criminal justice and mental health systems are critical points of opportunity to realize this vision.
The New Freedom Commission on Mental Health Subcommittee on Criminal Justice has provided clarity and focus to help us seize these opportunities. The subcommittee, it its 2004 report, described the need for a range of interventions to offer effective alternatives for the courts, correctional institutions, and people with mental illnesses. The interventions include diversion programs to keep minor offenders with serious mental illnesses out of the criminal justice system where they do not belong … and services in correctional facilities for those with serious mental illnesses whose crimes are serious enough to warrant incarceration .
Just as important, the subcommittee recommended discharge planning, li n king people with serious mental illnesses to community-based services upon discharge from correctional institutions.
The GAINS Center has been advancing the use of these interventions in communities throughout these United States. In doing so… you are leading America ’s journey toward system transformation. I commend you for taking on the task of assessing evidence-based practices in the treatment of individuals with mental illness and criminal justice involvement and promoting some very effective model programs. Through your Evidence-Based Programs (EBP) in the Justice System you have dem on strated an unwavering commitment to the goal of transforming the Nation ’s fragmented mental health system and developing a recovery-oriented, consumer-driven system of care as described in the President ’s New Freedom Commission report. You are providing States and communities with knowledge application and technical assistance strategies to further the implementation of evidence-based programs in the justice system. You are forging unprecedented collaborations among the mental health, substance abuse, and cri m inal justice systems a cross the country.
I’d like to showcase some of the fruits of these success ful collaborative efforts…efforts that can serve as models for all of us who must interface with each other in order to help those consumers entangled in the justice system achieve recovery.
[SLIDE 4. Collaborations-1]
One noteworthy collaboration is in Ohio. I want to recognize Ohio State Supreme Court Justice Evelyn Stratton and two advocates from the Ohio Criminal Justice Coordinating Center of Excellence─ Dr. Mark Munetz and retired Lt. Michael Woody─for their pioneering efforts in promoting both pre- and post-booking jail diversion programs, including police-based Crisis Intervention Teams and Mental Health Courts. Ohio ’s Criminal Justice Coordinating Center of Excellence was created in 2001 through State funding. T hat investment has paid off well. Ohio now has j ail diversion programs successfully implemented in more than 45% of its counties. Ohio’s jail diversion program serves as a n excellent model for other States to follow. This is an example of transformation in action.
[SLIDE 5. Collaborations-2]
Another leading-edge program to watch is in Florida. Miami-Dade County Judge Steven Leifman is the champion behind the first county jail to be built specifically for inmates with chronic and severe mental illness . Judge Leifman has success fully secured a $22 million bond to construct this facility. I applaud Judge Leifman for his fervor, his creativity, and his boldness to help inmates diagnosed with mental illness. His approach is unprecedented. This is transformation in action.
[SLIDE 6. Collaborations-3]
The Howie T. the Harp Peer Advocacy Center in Harlem, NY, is another exemplary program. The Center trains mental health consumers for positions that provide services to their peers. It has 250 graduates who are currently working as peer specialists, service coordinators, case managers, job coaches and case aides. The programs offered by the center are shining examples of ways to help consumers gain employment and financial independence…essentials for living, working, learning, and participating fully in the community. This is transformation in action!
[SLIDE 7. Action Agenda]
As evidenced by these programs, States and communities around the country have harnessed the transformative power of collaboration. I’m pleased to say that w e, a t SAMHSA, are mirroring your efforts. Partnerships are just the beginning. As part of an unparalleled commitment to collaborate, SAMHSA and its Federal partners released the Federal Action Agenda—the roadmap that is guiding our steps as a nation toward the wholesale transformation of our mental health system. Copies of the Action Agenda can be found at the SAMHSA booth . Please read it and share it with your colleagues.
The Action Agenda identifies the first, time-limited, realistic steps that the Federal partners—across all of the key health and human services agencies—are taking to move transformation forward. This document is tangible evidence of how we will move from a vision of transformed mental health care to its reality. It is our pledge to take action. Efforts to build on and expand criminal and juvenile justice and mental health collaboration are among the se first steps.
[SLIDE 8. SIGs ]
One of the most significant actions we have taken was last f all when we awarded the first Mental Health Transformation State Incentive Grants (SIGs) to seven States—Connecticut, Ohio, Oklahoma, Washington, Maryland, New Mexico and Texas. With this $2.7 to 3 million dollar per year investment, over the next five years, these States will begin to make the systemic changes to meet the goals of Achieving the Promise ─including those that addres s criminal justice issues. What these States learn can help speed the pace and extent of transformation by others. The GAINS Center has been working with the SIG States to assure that criminal justice activities are part of their Comprehensive State M ental H ealth P lans. If you are from one of the SIG States, I encourage you to talk to leaders in the mental health system─your State mental health directors, in particular─and ask them how criminal justice issues figure into their plan.
Our justice/mental health partnership at the Federal level is real...and it is strong. Through our part nership with the U.S. Department of Justice, we are leading by example and encourag ing mental health organizations at the State and communit y level to work with leaders in th e criminal justice system. In a few moments, you’ll be hearing from Director Domingo Herraiz from the Bureau of Justice Assistance (BJA) . I can assure you that Domingo and I stand shoulder to shoulder on syste m transformation─the common goal that will help mental health consumers exit the revolving door that too often leads them to jail and, instead, enter into recovery-focused treatment program s that will direct them back into productive and satisfying community life. Together, CMHS and BJA are working toward that goal.
[SLIDE 9.JLI]
The Judges Criminal Justice/Mental Health Leadership Initiative (JLI) is a nother notable example of how our two systems are working together . This leadership initiative is staffed by the GAINS center─CMHS’s technical assistance provider and by the C ouncil of State Governments─BJA’s technical assistance provider.
The JLI brings together judges who are already taking a leadership role in issues at the intersection of criminal justice and mental health. S pear h eaded by two distinguished members of the bench─ Justice Evelyn Stratton and Judge Steven Leifman─this initiative provides judges with the tools and information they need to improve the response to people with mental illnesses involved in the criminal justice system in their communities.
This effort is critical to the success of transformation. Change of this magnitude will requi reresources beyond what SAMHSA can provide. Champions beyond the circle of mental health will be key. Judges are an extraordinary resource for transformation . They are uniquely qualified to convene key stakeholders…to motivate distinct agencies and systems… to see the shared responsibilities they have for transforming mental health and improving outcomes for people with mental illness in the justice system.
Last year’s mee t ing of the JLA was held in con j unction with BJA’s national conference, a collaborative effort of CMHS, BJA and the National Institute of Corrections. For the first time, this conference brought together 400 criminal justice and mental health professionals to gain further insight on how to address the complex issues surrounding offenders with mental illness.
Another very successful mental health/criminal justice collaboration : includes BJA’s Mental Health Court TA Center, The Council of State Governments, and SAMHSA’s TAPA Center for Jail Diversion, which who have been working together very closely. CSG refers mental health court evaluation issues to TAPA. Likewise, TAPA refers criminal justice related issues to CSG…reducing duplication of effort and maximizing efficiencies by making use of both TA centers’ strengths. This is an outstanding example of transformation in action at the federal level!
We have much work ahead of us to fulfill the promise of recovery for persons with mental illnesses. I want to underscore that we cannot...we will not...realize the goals that remain in front of us without the help of leaders in the justice system. Together, we can create real opportunities for change. Together, we can empower adults and juveniles who have come in contact with the criminal justice system to take back their health…their lives…and their futures. Together, we can transform lives!
President Bush and our National Congress have signified their belief that an investment in human lives NOW will pay heavy dividends in the future. Last year, our Government enacted the Mentally Ill Offender Treatment and Crime Reduction Act. This Act supports programs that prevent inappropriate incarceration and that provide re-entry and transitional help for persons with mental illnesses. Both the House and Senate passed the bill unanimously.
Every single voting member of Congress endorsed it. In passing this bill, Congress plainly stated what we already know: the majority of persons with mental and emotional disorders can be treated successfully through integrated community-based treatment, rehabilitation, and support services. Jail diversion programs figure promi n ently in helping consumers get the appropriate treatment they need. Nationally, there are approximately 300 diversion programs offering a wide variety of diversion initiatives.
SAMHSA is supporting the expansion of these kinds of innovative programs with all of the resources at our disposal. We currently fund 26 jail diversion programs nationwide. These are 3-year grant programs. Federal funding will end for 10 of them this year. Federal grants are intended to be catalysts for change, rather than long-term support for any one group. SAMHSA is a small agency with a large mission, so we must use our funding strategically to stimulate transformation as broadly as possible. The value of continuing these programs, however, is clear. Nine of these programs will be sustained through a combination of State and local funds.
[SLIDE 10. TCE Jail Diversion programs-1 ]
One of our Targeted Capacity Expansion jail diversion grantee s that has had excellent results is Nebraska ’s Lancaster County Mental Health Jail Diversion project . This jail diversion program is one of the best in the country and w e are using it as a model program for new grantees . It uses mental health clinicians to assess charges and criminal history and make recommendations to the judge at or post-arr aignment. When an individual is released into the jail diversion program, a case manager helps the individual find hous ing an d employment, access entitlement funds, and medical and psychiatric appointments.
As a result of the Nebraska project, there is less recidivism among participants, decreased use of costly emergency services, and an increased use of less-costly ongoing services. Participants also show improvement in both their attitudes and symptoms. They report a greater ability to control their lives and to deal with cris e is as we ll as less depression and loneliness.
[SLIDE 11. TCE Jail Diversion programs-2]
Another Targeted Capacity Expansion grantee who has an exceptional model program is t he 11 th Judicial Circuit Criminal Mental Health Project Mental Health Jail Diversion Program in Florida. The 11 th judicial circuit recently expanded their its jail diversion activities to incorporate both pre- and post-booking diversion models and a comprehensive array of programs that address the mental health needs of individuals involved in the criminal justice system. The ir project’s mission statemen t appropriately speaks to our purpose, “Diversion and linkage to comprehensive care will make jail the last resort. ”
It is through jail diversion programs like th ese that we know we can keep offenders with serious mental illnesses out of the criminal justice system . We know that when we link citizens with mental illnesses to community-based services upon discharge from correctional facilities, they can…and do…live safely in the community. We know that, with assistance, they can attain employment and become caring and nurturing parents and productive, contributing citizens.
Ray Carver is one of these citizens. For 20 years of his life, Ray had taken medicine…on and off…for schizophrenia. He had been hospitalized several times. Most of the time, though, Ray spent his days drifting up and down the East Coast, sometimes staying in abandoned buildings, often homeless. He was periodically arrested for shoplifting or vagrancy and spent months at a time in jail. At age 45, Ray was arrested for shoplifting in Salisbury, Maryland. Then, everything changed for Ray.
While he was being processed at the county detention center, Ray mentioned that he had been taking medication for schizophrenia. He was referred to a mental health case manager at the detention center and his history was reviewed. He received the proper medication. At the same time, Ray’s case manager began counseling him, and while he was at the detention center, together they developed a treatment plan and after-care plan that included treatment for alcoholism, participation in day treatment programs at a psychiatric center, and a plan to reinstate his Supplemental Security Income benefits.
After his case manager discussed his case with the public defender, the county prosecutor and the judge, Ray pleaded guilty to a misdemeanor, and was sentenced to a year’s probation. Because he was homeless and willing to stop drinking, he was eligible for housing assistance. With the help of his case manager, Ray was released. He moved into an apartment and found a job at the psychiatric day treatment center.
Today Ray attends Alcoholics Anonymous meetings, meets regularly with a psychiatrist and his probation officer, and has started working on his GED. Ray has successfully recovered his life. This is what care will look like for offenders with mental illnesses in a transformed mental health system…the system envisioned by the Commission in Achieving the Promise .
We need more programs like this. Programs like these not only improve identification of inmates with mental illnesses like Ray Carver , they also result i n enhanced communication between mental health and corrections staff and reduced disruptive behavior in the detention centers. And, the impact in human lives saved is immeasurable!
I’d like to turn your attention to another population that often lands in our criminal justice system : individuals with co-occurring mental and substance use disorders often brought on by a severe traumatic experience…in particular, women. An understanding of and appreciation for the impact of trauma is central to our work. This is a critical issue because it affects so many of the people who come into the corrections system…people who don’t respond to tradition al sentencing. Increasingly, both mental health and criminal justice are recognizing the importance pf addressing trauma in the populations we serve. The critical need to improve our approach to helping victims of trauma is evidenced by looking at this conference agenda . There are 18 sessions devoted to trauma during the course of this conference, alone.
Some of you who have heard me speak before know that this is a subject that resonates deeply with me on both a professional and a personal level. I first became aware of the insidious effects of trauma nearly 30 years ago, when I was working as a rape crisis counselor. I saw , then , how physical and sexual abuse could devastate a woman, causing terrible mental anguish. At that time, many women were too guilt-ridden, ashamed, and filled with self-doubt to seek the professional help they needed to deal with their trauma. Many victims of rape and other violence still, today, deny or hide their traumatic experiences, even though trauma may be an important fac tor underlying a mental or substance use disorder, clearly affecting their emotional and behavioral health .
Today, in my position as Director of SAMHSA’s Center for Mental Health S ervices, I continue to champion women’s recovery from the impact of trauma and violence. SAMHSA is taking several strides forward to make States and communities aware of best practices for trauma-informed services.
[SLIDE 12. Women & Trauma]
We recently completed a of women with co-occurring disorders and histories of physical and sexual abuse. During phase 1, we worked with 14 sites across the country to develop fully integrated trauma-informed systems. During phase 2, nine of these sites conducted outcome evaluations for their trauma-informed service models for women. The results of these evaluations are very rewarding: trauma-informed treatment does work, and it is cost-effective.
[SLIDE 13 . Women & Trauma-2]
It is from studies like this that we learn the impact of trauma. We have learned that trauma can no longer be regarde d as an anomalous experience. We have learned that addressing trauma is increasingly recognized as essential for recovery. We have learned that a trauma-informed service system is necessary to deliver appropriate treatment and reduce the spiraling costs that “treatment as usual” for consumers with trauma histories exacts on society .
[SLIDE 14 . Women & Trauma-3]
It is from studies like this that we learn about trauma interventions. We have learned that evidence-based trauma informed models are needed to help victims of violence overcome trauma. We have learned that a trauma-informed service system environment represents a profound cultural shift in w h ich consumers and their conditions are viewed differently. We have learned that we need consumers as “trauma champions” to help shape treatment that is trauma-responsive to a wide range of needs that will lead to recovery.
[SLIDE 15 . Women & Trauma- 4 ]
It is from studies like this that we learn the outcomes of trauma. We have learned that integrated counseling─for example, group and individual therapy that a ddress trauma, mental health, a substance-use conditions─I was the key element associated with better outcomes.
The Action Agenda calls for the development of toolkits that will serve as models and spread what we know about assisting individuals survive trauma.
A number of States and communities are developing model programs that integrat e gender and trauma services within their jail-diversion programs…with measurable success.
[SLIDE 16 . Trauma Programs-1]
In Connecticut, the Women’s Support Program in Hartford and New Briton targeted high-risk repeat offenders…women who judges would ordinarily have been reluctant to return to the community. Upon evaluation, the 128 women who participated in the program showed significant improvements in substance use, employment, arrests, trauma symptoms, and importantly, in hopefulness.
[SLIDE 17 . Trauma Programs-2]
Maryland ’s TAMAR—Trauma, Addictions, Mental Health, and Recovery) Project—treats trauma disorders in incarcerated w omen . The project, originally funded through a SAMHSA grant, has continued to expand across the State well after the Federal funding ended. A second project, TAMAR’s Children, is designed to foster secure mother-infant attachments by allowing incarcerated pregnant or postpartum women with trauma histories who have co-occurring mental and substance use disorders to keep their babies through comprehensive inpatient and community-based supports . States from Ohio to New Hampshire have expressed interest in the TAMAR model.
[SLIDE 18 . Trauma Programs-3]
A post-booking jail diversion program in Hawaii provides another promising example. The State mental health department worked with the TAPA Center to learn about the components of a trauma-informed system, to select a flexible model upon which it could develop trauma-specific services and, then, to train case managers in implementing trauma-specific treatments with consumers who returned to the community under the supervised release program. This successful program now serves as a model for state-funded programs on three other Hawai ian islands .
Each of these examples demonstrates a critical point: To eliminate trauma and reduce its impact, we must expect and anticipate trauma histories in the populations we serve…and we must be prepared to meet their needs with trauma-informed, trauma-specific treatment and services . The GAINS Center has been a leader in developing, testing, and implementing new models of trauma care for women in the criminal justice system. Collaboration between the mental health, substance abuse, and criminal justice system is a key component of that strategy.
The new CMHS Center for Women, Violence, and Trauma. Is also taking deliberate steps toward that same goal. The Center takes a step beyond providing immediate trauma care to orchestrate and support the plan for a Trauma-Informed Mental Health System Transformation Plan. Networks of key leaders across the United States are being developed and v aluable information has been culled about the transformation and change process. It will take all of us to facilitate that change beca use the effects of trauma spill over into our hospitals and our jails and our social welfare system . We know that these organizations, too, must be part of a comprehensive solution.
Transformation of our mental health system hinges on o ur ability to facilitate recovery for every individual . Last December, SAMHSA brought together consumers and other experts to develop an operational meaning of recovery. We examined such topics as recovery across the lifespan and recovery in different cultural contexts. We considered how recovery applied at the individual, family and community, provider, organizational, and systems levels. Our meeting led to this consensus definition of recovery for adults—
[SLIDE 19 . Recovery]
Mental health recovery is a journey of healing and transformation for a person with a mental health problem to be able to live a meaningful life in a community of his or her choice while striving to achieve maximum human potential.
A few words based on a wealth of beliefs! The most unshakable premise is that every individual has a continuous capacity for growth. The process of recovery builds on the strengths of each individual. It is nonlinear and self-directed. It is holistic and person-centered, and it involves personal and community respect, responsibility, and hope. It empowers consumers to make decisions that impact their lives. It recognizes the valued role of consumers in supporting and encouraging others as they continue on their own journey toward recovery.
Recovery is not an end point! Our definition implies a continuum of services…and a breadth of services…that acknowledge the whole person and not just the disorder. The scope of this definition changes our entire perspective on how we should provide care.
Certainly recovery is not a new concept. We’ve talked about it on the community level…and on the State level. But here’s the difference: We are, for the first time, working to reorient the Nation’s entire mental health system toward recovery . Great synergies will result from this collective effort. The GAINS Center has successfully shown us that great synergies come out of collaborations demonstrated that fact. You have demonstrated some very positive outcomes from your collaborations. As we advance transformation, all eyes will be on you.
[SLIDE 20. Einstein Quote]
Albert Einstein tells us that “Setting an example is not the main means of influencing others; it is the only means.”
I urge each of you to use your work as examples to influence others. I urge you to press on...to continue to lead the revolution in mental health called for by the New Freedom Commission on Mental Health. I encourage you to expand your reach…to DO MORE…to keep the wheels of transformation moving forward…with an accelerated pace.
I do caution you, however, not to lose sight of our primary focus…the consumer. The contributions consumers are making to transform America are immeasurable. Let their voices be heard…loud and clear. Listen to their experiences…listen to their needs. Consumers are a critical part of the transformation equation.
All of us here today have embarked on the road to system transformation. We know the road ahead is a long one…with many twists and turns. We know that steering people out of jails and into the appropriate community-based treatment is going to be an ongoing process. That’s why it is so vitally important to find reasons to pause and celebrate our progress along the way.
Today, I celebrate the GAINS Center…and all of you in the audience…for the examples you have set and the wonderful progress you have made toward system transformation.
When I challenged this group at the last conference to do more, I never imagined the number of accomplishments you would make…in such a short time. I look forward to the next time we meet…to our next celebration. I look forward to seeing the results of even more collective energy…to seeing you again exceed expectations to help consumers with mental illnesses and substance use disorders out of the criminal justice system and down the path to recovery. Thank you.
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