Mental Health Mental Health Court: In Court: In

Concert With Concert With Community Community TreatmentTreatment

Forensic Mental Health Association of Forensic Mental Health Association of CaliforniaCalifornia

March 16, 2006March 16, 2006

Kathleen Connolly, LCSW Kathleen Connolly, LCSW David Fariello, LCSWDavid Fariello, LCSW

Program HistoryProgram History

19801980 Citywide Case Management links high Citywide Case Management links high

users of San Francisco psychiatric users of San Francisco psychiatric inpatient facilities to community inpatient facilities to community servicesservices

1985 1985 Citywide reconfigured as a clinical case Citywide reconfigured as a clinical case

management programmanagement program

19901990 Case manager added to treat Case manager added to treat

severely mentally ill adults being severely mentally ill adults being discharged from jail discharged from jail Increased to 2 FTE with monies from jail Increased to 2 FTE with monies from jail

overcrowding settlementovercrowding settlement

19991999 Citywide becomes part of Sheriff's Citywide becomes part of Sheriff's

Department response to the State Department response to the State Mentally Ill Offender Crime Mentally Ill Offender Crime Reduction GrantReduction Grant Program increases in size and complexityProgram increases in size and complexity

Program History Cont.Program History Cont.

January 2003January 2003 San Francisco’s Behavioral Health San Francisco’s Behavioral Health

Court startsCourt starts July 2004July 2004

MIOCR Grant funding endsMIOCR Grant funding ends Forensic Program funding continuesForensic Program funding continues

Program History Cont.Program History Cont.

Client DemographicsClient Demographics 100 Severely mentally ill adults100 Severely mentally ill adults

18-59 years old18-59 years old 75% Men, 25% Women75% Men, 25% Women

47% African American, 35% White, 12% Latino, 47% African American, 35% White, 12% Latino, 6% Asian6% Asian

83% single never married, 13% Divorced 83% single never married, 13% Divorced or Separated, 4% Married/Living togetheror Separated, 4% Married/Living together

21% High School graduates; 7% some 21% High School graduates; 7% some collegecollege

96% Unemployed96% Unemployed

Diagnosis Diagnosis 73% Schizophrenia/Schizoaffective 73% Schizophrenia/Schizoaffective

DisorderDisorder 16% Personality Disorder16% Personality Disorder 13% Mood Disorders13% Mood Disorders 8% PTSD8% PTSD 5% Paranoid disorder 5% Paranoid disorder

96% Substance Abuse Disorders96% Substance Abuse Disorders Crack-cocaine most commonCrack-cocaine most common Alcohol #2Alcohol #2 Amphetamines and heroinAmphetamines and heroin

Client Demographics Cont.Client Demographics Cont.

Multidisciplinary TeamMultidisciplinary Team

Project DirectorProject Director Clinical SupervisorClinical Supervisor 7 Case Managers7 Case Managers

Social Workers, MFTs, and InternsSocial Workers, MFTs, and Interns Occupational TherapistOccupational Therapist Counseling AssistantCounseling Assistant 2 part-time Psychiatrists2 part-time Psychiatrists Licensed Vocational NurseLicensed Vocational Nurse

Collateral AgenciesCollateral Agencies Jail Psychiatric ServicesJail Psychiatric Services Jail Aftercare ServicesJail Aftercare Services Money Manager On-siteMoney Manager On-site

Lutheran Social ServicesLutheran Social Services Adult Probation Officer On-siteAdult Probation Officer On-site SF Public Defender’s OfficeSF Public Defender’s Office Housing & Urban Health ClinicHousing & Urban Health Clinic Residential Dual Diagnosis ProgramsResidential Dual Diagnosis Programs Hotel ManagersHotel Managers

Provide StructureProvide Structure

Wraparound Services available at clinicWraparound Services available at clinic Group ProgrammingGroup Programming Social OpportunitiesSocial Opportunities Vocational TrainingVocational Training Saturday ProgramSaturday Program On-Call ServiceOn-Call Service Community Building/CelebrationsCommunity Building/Celebrations Community ActivitiesCommunity Activities Daily lunchDaily lunch

FORENSIC CHECK-IN

“HEARING VOICES”

ANGER MANAGMEN

T

STRESS MANAGEMEN

T

HARM REDUCTIO

N

WOMEN

WELLNESS

DBT SKILLS TRAINING

YOUNG ADULTS

CLOZARIL

CHESS

ART

COOKING

SINGING

LGBT SUPPOR

T

WRITING

CREATIVITY

AFRICAN AMERICA

N MEN

GROOMING

CURRENT

EVENTS

DUAL DIAGNOS

IS

CITYWIDE GROUP

PROGRAM

MOVIE

Clinical Case Clinical Case ManagementManagement

Masters Level Masters Level TherapistsTherapists

Individual TherapyIndividual Therapy Family TherapyFamily Therapy Group TherapyGroup Therapy Crisis InterventionCrisis Intervention Assertive OutreachAssertive Outreach AdvocacyAdvocacy Case Management Case Management

BrokerageBrokerage Medication ManagementMedication Management

Teach rather than “do Teach rather than “do for” the clientfor” the client

Outreach/fieldworkOutreach/fieldwork Therapeutic approachTherapeutic approach Long-term Long-term

relationshiprelationship Small Caseloads 13:1Small Caseloads 13:1

Engagement ProcessEngagement Process

Referral from JASReferral from JAS AssessmentAssessment Link with client in custodyLink with client in custody Develop a discharge planDevelop a discharge plan Advocate for client in courtAdvocate for client in court

DischargeDischarge

Welcome client to communityWelcome client to community Assist client in obtaining entitlementsAssist client in obtaining entitlements Provide housing vouchers if neededProvide housing vouchers if needed Psychiatrist and Medical AppointmentsPsychiatrist and Medical Appointments DMV/Muni Bus PassDMV/Muni Bus Pass Provide Miscellaneous ItemsProvide Miscellaneous Items

Alarm clock, cigarettes, bus tokens, Alarm clock, cigarettes, bus tokens, clothing, hygiene products, etc.clothing, hygiene products, etc.

Treatment InterventionsTreatment Interventions

Align with client around goals and Align with client around goals and assist client throughout the court assist client throughout the court processprocess

Develop individualized treatment plan Develop individualized treatment plan based upon client’s functioning levelbased upon client’s functioning level

Use of UAs in treatment of substance Use of UAs in treatment of substance useuse

Use of daily meds/daily checksUse of daily meds/daily checks Incentives and SanctionsIncentives and Sanctions

Role of the Therapist in Role of the Therapist in Relation to the CourtRelation to the Court

Traditionally the criminal justice system Traditionally the criminal justice system does not work in the best interest of a does not work in the best interest of a client’s rehabilitationclient’s rehabilitation

In Mental Health Court, the therapist In Mental Health Court, the therapist helps shift focushelps shift focus Provides advice to the Court on treatment Provides advice to the Court on treatment

interventionsinterventions Becomes educator to the CourtBecomes educator to the Court Serves as client’s advocate and supporterServes as client’s advocate and supporter Manages public safetyManages public safety

Use of the Court as Use of the Court as Treatment InterventionTreatment Intervention

Ability to understand the legal status Ability to understand the legal status of clientsof clients

Creative use of incentives and Creative use of incentives and sanctionssanctions

Utilize the Court as reinforcement of Utilize the Court as reinforcement of treatment options and make client treatment options and make client realize consequences of behaviorrealize consequences of behavior

Better treatment outcomes Better treatment outcomes

Goals of TreatmentGoals of Treatment

Stabilization in communityStabilization in community Adjudication of criminal caseAdjudication of criminal case Attachment to mental health Attachment to mental health

services that continue after legal services that continue after legal obligations endobligations end

Transition client from the legal Transition client from the legal system to the community mental system to the community mental health systemhealth system

Treatment IssuesTreatment Issues

Prevalence of Substance AbusePrevalence of Substance Abuse Residential vs. Outpatient Treatment Residential vs. Outpatient Treatment

programsprograms Long-term nature of the work vs. Long-term nature of the work vs.

economic realities of mental health economic realities of mental health treatmenttreatment

Transference IssuesTransference Issues

Many clients suffer not only from Many clients suffer not only from severe mental illness and chronic severe mental illness and chronic drug use, but from difficult and an drug use, but from difficult and an unstable childhoodunstable childhood Foster care and/or Juvenile Detention is Foster care and/or Juvenile Detention is

a central part of their experiencea central part of their experience Institutions quickly assume the role Institutions quickly assume the role

of an all-powerful, punitive parentof an all-powerful, punitive parent

Clients quickly develop a hostile Clients quickly develop a hostile dependency toward institutionsdependency toward institutions

Survival strategies are developed in Survival strategies are developed in jailjail Demanding, confrontational, threatening Demanding, confrontational, threatening

behaviors which do not allow for feelings behaviors which do not allow for feelings or weakness are the ruleor weakness are the rule

The BHC and connected treatment The BHC and connected treatment inadvertently reinforces the inadvertently reinforces the transferencetransference

Treatment is required and monitoredTreatment is required and monitored The probation officer works at the The probation officer works at the

treatment sitetreatment site

Transference Issues Cont.Transference Issues Cont.

On-site Money management is On-site Money management is often part of treatmentoften part of treatment

Clients can be remanded for Clients can be remanded for treatment non-compliancetreatment non-compliance

Race, gender and class differences Race, gender and class differences between staff and clients reinforce between staff and clients reinforce power differentials power differentials

Transference Issues Cont.Transference Issues Cont.

Counter-TransferenceCounter-Transference

Two clients--the client & the communityTwo clients--the client & the community Staff work hard and are thinly stretchedStaff work hard and are thinly stretched Staff feel responsible if a client fails and Staff feel responsible if a client fails and

returns to jail or is sent to prisonreturns to jail or is sent to prison Staff respond to incessant client Staff respond to incessant client

“demands and “crisis’“demands and “crisis’ Staff and other providers can be split by Staff and other providers can be split by

clientsclients

Behavioral changes are slow Behavioral changes are slow Frequent treatment plan Frequent treatment plan

reconfiguration reconfiguration BHC remanding-sometimes leaves BHC remanding-sometimes leaves

staff dispiritedstaff dispirited Treatment alliance can feel Treatment alliance can feel

strainedstrained Therapists begin to feeling like Therapists begin to feeling like

another probation officer rather than another probation officer rather than an allyan ally

Counter-Transference Cont.Counter-Transference Cont.

Work Through The Work Through The IssuesIssues

Acknowledge circumstances from the Acknowledge circumstances from the beginningbeginning Treatment is not entirely voluntary.Treatment is not entirely voluntary.

Explore and support experiences of Explore and support experiences of racism, disadvantage, powerlessnessracism, disadvantage, powerlessness

What does the client want?What does the client want? Now and in the futureNow and in the future

What does client see as the obstacles to What does client see as the obstacles to achieving goals?achieving goals?

Work from the very beginning to have Work from the very beginning to have clients do clients do withwith you rather than do you rather than do forfor themthem

Set out markers to turn over more Set out markers to turn over more activities to the client activities to the client e.g. How does the client assume e.g. How does the client assume

management of their own funds?management of their own funds? Set limits that the clinician needs to live Set limits that the clinician needs to live

by and avoid “jack-in-the-box” by and avoid “jack-in-the-box” relationshiprelationship

Counter-transference is normal, expected Counter-transference is normal, expected and a valued clue to clinical informationand a valued clue to clinical information Don’t dismiss it!Don’t dismiss it!

Work Through The Issues Cont.Work Through The Issues Cont.

Future of Forensic Case Future of Forensic Case ManagementManagement

Increased vocational skill buildingIncreased vocational skill building Getting better at discharging to a Getting better at discharging to a

lower level of carelower level of care ““Restorative Justice”Restorative Justice” WISH projectWISH project Diversion and Prevention- keeping Diversion and Prevention- keeping

severely mentally ill clients OUT of severely mentally ill clients OUT of the criminal justice systemthe criminal justice system