Mental Health Collaboration & Holistic

Public DefenseDesiree Fox

Meghan Gill, MAConfederated Salish & Kootenai Tribes

Holistic Defense Program

CSKT Public Defenders• Criminal Defense & Civil Legal Aid• 5 Criminal Attorney/Advocates• Average caseloads of 90-200 cases each– 2011-2012 Defenders represented 721 adults, 231 juveniles

• Development of specialized diversions– Bad checks, Minor theft, Driver’s licenses

• Focus on Holistic Defense– Case Management, Psychological Services, Cultural

Mediations, Collateral Consequences

What is Holistic Defense?4 Pillars defined by Center of Holistic Defense in Bronx, NY:

1. Accessible services meet clients’ legal/social needs 2. Interdisciplinary communication and collaboration 3. Advocates with interdisciplinary skill sets4. Understanding and connection to the community

Help address core issues that bring individuals into the criminal justice system rather than just taking a punitive approach.

Current Funding• 2009 awarded U.S. Department of Justice

Justice & Mental Health Collaboration Project– Individuals who have come in contact with the

criminal justice system with co-occurring mental health & chemical dependency

– Grant expired in 2012, no opportunity offered for expansion that year

• 2013 Kevin Howlett from CSKT THHS allowed our program access to funding for the continuation of the essential elements of the program– P/T Case Manager and Clinical Psychology Trainee

Goals of our Program• Address needs of individuals in the community– Client-identified needs

• Streamline access to mental health services• Develop and foster partnerships between

departments and fields to collaborate for optimal client outcomes – Tribal Health, Tribal Police, Tribal Court

• Engage the community • Propose that this will reduce recidivism

Individuals Served• Approximately 130 individuals received some level of

services

• Members of federally-recognized tribes that have been accused of crimes through the tribal criminal justice system on the Flathead Reservation

• Co-occurring mental health & chemical dependency issues

• Age range of those served is 18-65 years of age– Average age 31 years old– Standard Deviation of 11 years

Services Offered• Housing– Information, Applications, Application follow-up,

Problem-solving• Transportation– DHRD bus system, Bus Passes, Rides, Home-Visits

• Financial– Financial management training, Referrals to OPA,

Application assistance• Employment– Information, Referrals to Voc-Rehab

Services Offered• Educational– Information, GED, Higher Education

• Donations Program– Community donations of clothing, shoes, toiletries

• Incentive Program– Rewards for reaching milestone goals

• Court-ordered conditions– Fine tracking, Community Service Fine-

Replacement, Assessments, Probation

Services Offered

• Cultural Mediation and Mentoring– Community volunteers, Elders

• Psychoeducational Groups– Educational Presentations

• Mental Health/Chemical Dependency– Assessments, Treatment, Referrals for Treatment– Crisis Intervention, Attorney/Advocate Consults

Case Management Services Provided 2009-2012

• 79 total individuals served– 42 males, 37 females

• 67 formal case management clients:

– 45% Housing services

– 27% Transportation services

– 25% Financial services

Recidivism Outcomes2009-2012

• Of the 67 case management clients:– 48% had zero recidivism (no subsequent offenses)• Of those, 37.5% had 10+ tribal criminal offenses

prior to coming into case management (not including juvenile offenses)

– 80.5% had 3 or fewer subsequent offenses

–Only 13% had 0 or 1 offenses prior to referral to case management

Psychology Services Provided 2010-2012

• 50 individuals received psychological services through the Clinical Psychology Trainee

– 6 chemical dependency related

– 4 mental health related

– 20 both chemical dependency and mental health

– 20 other (acute crisis intervention, consultation)

Case Management Data 2013

• 25 total individuals served– 13 males, 12 females

• 13 full case management clients

– 61.5% Housing services

– 61.5% Transportation Services

– 54% Financial Services

• 38% of the 13 had zero recidivism

Psychology Services Data2013

March through June 2013

• 17 individuals received psychological services through the Clinical Psychology Trainee– 4 chemical dependency related

– 2 mental health related

– 4 both chemical dependency and mental health

– 7 other (acute crisis intervention, consultation)

The importance of proactively providing services to those facing multi-generational stress and

current hardship.

How the Holistic Defense Mental Health Program addresses barriers to treatment.

Future directions to develop.

Overview

Historical Trauma and ACE’s

One possible mechanism of how historical trauma may get transmitted is via Adverse Childhood

Experiences (ACE’s).

The higher the number of ACE’s the more risk for illness, addiction, instability and chronic stress in

adulthood.

ACE Score Adult Hardship

Historical Trauma and ACE’s

Examples of ACE’s include early exposure to: substance abuse divorcesocio-economic disadvantage losswitnessing domestic violence family in prisoncaretaker mental illness neglectphysical/sexual abuse

The adult hardships associated with ACE’s (mental/physical illness, addictions, instability and chronic stress) then become the ACE’s for the next

generation.

Why “well-being” services for individuals facing legal hardship?

• Incarceration and legal challenges correlate highly with ethnic minority and low socio-economic status.

• Legal challenges can lead to a sense of entrapment, humiliation or loss of social rank: all powerful risk factors for suicidal behavior and depression.

• Legal challenges create a cascade of stressful events, and rather than serve as a deterrent, they can severely impair a person’s functioning and mental health.

Why “well-being” services for individuals facing legal hardship?

• Psychological, emotional and social support offered in adulthood demonstrates a moderating effect on the impact of ACE’s.

• American Indian health disparities call for a range of responses that are creative and community-based.

Primary among the barriers to getting effective health care is the impact of stress on individuals facing hardship. Stress can disproportionately affect those with ACE’s and/or chronic trauma.

Stress can limit motivation, energy and ability to explore.

The holistic defense program makes it easier to get necessary care.

Why in a defender’s office setting?

Barriers to Treatment

• Economic & transportation challenges• Going to new, unfamiliar place when feeling stigma,

anxiety, shame and/or depression.• Meeting with an unfamiliar person (mistrust)• Disrupted continuity of care (the referrals trail)• Cultural fit issues with the provider and interventions• Initiating care feels overwhelming• Hopelessness about outcome• Access: Waitlists, shortage of services & procedural

delays.

How Holistic Defense Manages Barriers

• Free, sometimes closer, resulting in less transportation hurdles.

• Proactive outreach efforts and marketing of services.

• Referral is usually followed by an immediate introduction.

• Referral association is supportive, client centered and nonjudgmental.

• In the same office where clients receive legal support.

• Flexible approach with complementary services that bridge the gap in continuity of care: travel vouchers, case management, therapy, assessments and advocacy.

• Options for jail visits and assessments to be done in the jail.

• All treatment recommendations coming from assessments are client centered.

How Holistic Defense Manages Barriers

Case Example

Relapse and Inpatient Placement.• Use until incarcerated.• Detox in jail and renew motivation for sobriety

and/or treatment• Leave the jail and try to initiate treatment.• Face barriers.• Relapse due to instability in living situation

and inaccessibility of services.

How Holistic Defense Could Respond

• Post detox, assessment can be conducted in jail.• Part of jail term can be served in in-patient

treatment setting.• Better prepared to manage re-entry into community• Assessment contact allows for an additional source

of social support after returning from treatment.• Case management services can be initiated right

after jail term.

Future Development

• Integration of traditional well being practices– Elder led mediation program–Mentoring Program– Culturally based interventions

• Support services for families and loved ones– The stress and hardship of a family member facing legal

challenges radiates out to the entire social network.

Funding Future DevelopmentExpansion Plans• 2013 JMHCP Expansion Grant Application

– Juvenile services

– Cultural mentoring

– Increased services to those incarcerated

– Full-time case manager

– Data consultant

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