1. Addressing a National Crisis:
Too Many People who have Mental Illnesses are in Jails
The National Alliance on Mental Illness: Maryland Annual Conference
Chenise Bonilla, Senior Policy Analyst, The CSG Justice Center
October 20, 2018

2. The Council of State Governments Justice Center
National nonprofit, nonpartisan membership-based association of state government officials that engage members of all three branches of state government
Justice Center provides practical, nonpartisan advice informed by the best available evidence

3. Six Questions Framework
11/12/2014
Overview
The Problem
Stepping Up
Six Questions Framework

4. National Estimates of this Crisis
Of the 11 million people admitted to jail annually…
…about 2 million have serious mental illnesses
Source: Steadman, HJ, Osher, FC, Robbins, PC, Case, B., and Samuels, S.  Prevalence of Serious Mental Illness Among Jail Inmates, Psychiatric Services, 6 (60), , 2009.

5. Jails are the De Facto Mental Health System
Naked, filthy and strapped to a chair for 46 hours: a mentally ill inmate's last days
“The inmate, who suffered from schizophrenia, was left in his own filth, eating and drinking almost nothing…
When he was finally unbound, guards dumped him to the floor of a nearby cell. Within 40 minutes, he had stopped breathing.”
Although counties have made significant progresses, the problem still remains. This crisis is solvable, but it requires a new approach—one that is data-driven, focused on systems-level change, and collaborative in nature.

6. Bottom Line: People who have Mental Illnesses are Overrepresented in Our Jails
General Population
Jail Population 4%
Serious
Mental Illness
17%
Serious
Mental Illness
72%
Co-Occurring
Substance Addiction
A majority of these individuals have additional challenges, like homelessness and chronic medical conditions
Source: Steadman, HJ, Osher, FC, Robbins, PC, Case, B., and Samuels, S.  Prevalence of Serious Mental Illness Among Jail Inmates, Psychiatric Services, 6 (60), , 2009.; Center for Behavioral Health Statistics and Quality, Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health, 2016 (HHS Publication No. SMA , NSDUH Series H-51),   Abram, Karen M., and Linda A. Teplin, “Co-occurring Disorders Among Mentally Ill Jail Detainees,” American Psychologist 46, no. 10 (1991): 1036–1045.

7. Factors Driving the Crisis
Disproportionately higher rates of arrest
Longer stays in jail
Limited access to healthcare
Higher recidivism rates
¾ of SMI meet criteria for co-occurring disorders
Three times more likely to have substance use disorder if you have MI, four times more likely to have substance abuse disorder diagnosis if you have MI.
Can’t discuss reducing the prevalence of mental illnesses without discussing co-occurring disorders.
Rikers study – 217 days versus 37 days – same charges, same sentences
BJS – same charges and sentence – 15 months longer in prison if you have MI
Board Member Comments: Tracy Plouck and Lynda Zeller discuss familiarity and implementation of RNR principles in BH field
Low utilization of evidence-based practices
More criminogenic risk factors

8. Research on Detaining People in the Pretrial Stage
Detaining low-risk defendants, even for just a few days, is strongly correlated with higher rates of new criminal activity both during the pretrial period and years after case disposition
Low-risk defendants had a 40% higher chance of committing new crime before trial when held 2 to 3 days compared to those held one day or less and 51% higher chance of committing a new crime in the next two years when held 8-14 days compared to one day or less
Research Shows that Longer Lengths of Stay for Low-Risk Defendants Increases their Likelihood of Recidivism.
This research is broader than people with SMI
Source: Laura and John Arnold Foundation, The Hidden Costs of Pretrial Detention, November 2013,,

9. Other Challenges that Counties Commonly Face
A Multi-System Problem
Law enforcement lacking alternatives to arrest and options for crisis responses
Courts lack diversion options and information to inform pretrial release
Behavioral health service capacity is scarce, and may not necessarily align with what works to help reduce recidivism
Probation approaches are not always effective for people who have mental illnesses (e.g., high rates of technical violations)
Lack of formal, collaborative governance structures
Insufficient capacity to collect and share data to inform decision making and track progress
Efforts are small-scale and mismatched with need
Lack of appropriate and effective community-based care and services

10. Six Questions Framework
11/12/2014
Overview
The Problem
Stepping Up
Six Questions Framework

11. “Stepping Up is a movement and not a moment in time”
A National Initiative to Reduce the Number of People who have Mental Illnesses in Jails
GOAL: There will be fewer people who have mental illnesses in our jails tomorrow
than there are today
Our goal in Stepping Up, whether it be at the state or county level, is to have fewer people with mental illnesses in our jails. We hear from counties all over the country, as well as from different constituencies like jail administrators, that this is important to them, and yet prevalence remains high.
“Stepping Up is a movement and not a moment in time”

12. Calls for a paradigm shift:
Move beyond programs and pilots to scaled impact and measurable reductions in prevalence
No-nonsense, data-driven public management:
Systematic identification of mental illnesses in jails
Quantification of the problem
Scaled implementation of strategies proven to produce results
Tracking progress and adjusting efforts based on a core set of outcomes

13. Major Partners Rally Around a Common Goal
11/12/2014
Major Partners Rally Around a Common Goal
Lead Partners
Federal Partners
Other Partners
The Council of State Governments (CSG) Justice Center, the National Association of Counties (NACo), and the American Psychiatric Association Foundation (APA Foundation) partnered to create Stepping Up with the purpose of rallying local, state, and national leaders to achieve a measureable reduction in the number of people in jail who have mental illnesses.

14. Since May 2015, 450+ counties across 43 states have passed resolutions

15. Maryland Counties that Passed a Stepping Up Resolution
Montgomery Anne Arundel Prince George’s Calvert Hardford

16. Six Questions Framework
11/12/2014
Overview
The Problem
Stepping Up
Six Questions Framework

17. 1 2 3 4 5 6 Is our leadership committed?
Do we conduct timely screening and assessments? 3
Do we have baseline data? 4
Have we conducted a comprehensive process analysis & inventory of services?
Stepping Up Assists Participating Counties with Adopting & Implementing the Six Questions Framework 5
Have we prioritized policy, practice, and funding improvements? 6
Do we track progress?

18. 4. Reduce recidivism rates for people who have mental illnesses
Systems-Level, Data-Driven Changes Should Focus on Four Key Measures
1. Reduce the number of people who have mental illnesses booked into jails
2. Shorten the length of stay in jails for people who have mental illnesses
3. Increase connection to treatment for people who have mental illnesses
4. Reduce recidivism rates for people who have mental illnesses

19. Goal: Every County Has Accurate, Accessible Data
Having accurate and timely data is critical for counties to know the scale of the problem, develop a strategic action plan that effectively targets scarce resources, and tracks progress
Recommended approach for accurately identifying
people who have SMI in jail:
Establish a shared definition of SMI for your Stepping Up efforts that is used throughout local criminal justice and behavioral health systems
Use a validated mental health screening tool on every person booked into the jail and refer people who screen positive for symptoms of SMI to a follow-up clinical assessment by a licensed mental health professional
Record clinical assessment results and regularly report on this population
This 3-step approach is a high bar, and the SU initiative recognizes that counties may be using proxy measures to estimate the SMI prevalence rate, including counting people who are on psychotropic medication

20. Nine Stepping Up Innovator Counties Recognized for Having Accurate, Accessible Data
Pacific
Hennepin
Polk
Champaign
Calaveras
Franklin
Douglas
Johnson
Verified to have accurate and accessible data
Serve as mentors to current Stepping Up sites   
Recruit additional Stepping Up sites to use three step process and track four key measures
Demonstrate best practices and strategies to achieve improvements along key measures
Miami-Dade
The initiative recognizes that there may be more counties that are using or committed to using the three-step recommended approach to have accurate, accessible baseline data and want them to join this cohort!

21. A County’s Process Analysis for the Arrest/Booking Stage
CIT training of law enforcement is not comprehensive; protocols vary by agency 1 2
Law enforcement is often unable to locate facility with capacity for Arrested Persons (APs) with acute MH needs 3
Lack of standardized policies at the various detention facilities across the county
Automated information system data entry happens at various times 4 5
Medical staff cross check jail booking information with local hospital(s) system to check MH history; info is not shared with county jail

22. Recap of Stepping Up Six Questions Framework6
Key questions county leaders need to ask in order to reduce the prevalence of people with mental illnesses in jails 4
Key measures to identify drivers and track progress overtime 3
Step recommended approach to have accurate, accessible data on the prevalence of people with SMI in jails to know the scale of your county’s problem 1
County plan that addresses your county’s specific challenges within your unique CJ and BH systems

23. Resources Developed in partnership with NAMI
Stepping Up Webinar on ”Engaging People with Mental Illnesses in Your Planning Efforts”
Developed in partnership with NAMI

24. Additional Guides to Implement the Six Questions Framework
Project Coordinator’s Handbook
Online County Self-Assessment
Series of Briefs

25. Stepping Up Resources Toolkit: Webinars, Case Studies, and More!
Quarterly Network Calls for
Rural, Urban, and Mid-Size Stepping Up Counties
One-stop-shop for key resources, webinars, network calls, and more
stepuptogether.org/toolkit

26. Questions for the Audience
What, if anything, resonates with you when seeing the system map on the right?
What systems-level changes would you like to see in the criminal justice and behavioral health systems for people who have SMI in your county?
How, if at all, do you navigate through the systems?
How, if any, experience do you have pre- and post- contact with law enforcement?
How, if any, experience do you have in a jail setting?
What, if any, experience do you have with connection to treatment?
How can we help your voices be better heard in planning efforts?
County Example: System Map

27. THANK YOU For more information, please contact:
Chenise Bonilla, Senior Policy Analyst, The CSG Justice Center –
stepuptogether.org | #StepUp4MentalHealth