Transcript mentally ill criminal defendants

SERIOUS MENTAL ILLNESS &
CO-OCCURRING SUBSTANCE
ABUSE DISORDERS
Stephen S. Goss, Judge
Superior Courts of Georgia
Albany, Georgia
Colorado Drug Court Conference
April 26, 2011
Largest mental hospital in U.S.?
Los Angeles County Jail with 3,000 MI inmates every day
Earley, Pete, Crazy: A Father's Search Through America's Mental Health Madness (Putnam, 2006)
Transinstitutionalization
Mentally Ill Inmates
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Lack of community
treatment-ER time police
Jails de facto treatment
centers(i.e.LA & Rikers)
10-15% Inmates on
Mental Health
Rx(APA;DO.Co. Jail)
SSI and funding issues
Human vs. tax
cost:jail,legal,child,ER
Homeless shelters
STIGMA
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Fear- cannot see it; no objective tests
Fear- what is hard to understand
TMI( too much info)-not MH issues
Hushed tones/whispers
“He’s not right”
Olmstead
527 U.S. 581 (1999)
Under ADA Title II, states
are required to provide
community based MH
treatment when
recommended and if
placement can be
reasonably accommodated
SERIOUS MENTAL DISORDERS
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Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition,(DSM-IV), American
Psychiatric Association
Bipolar Disorder (Manic Depression)
Schizophrenia
Mood Disorders
Developmental Disabilities
Organic/Traumatic Brain Injuries
DSM-IV
Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition
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Axis I- clinical disorders: mental
illness ( i.e. schizophrenia; bipolar
disorder) and substance related
disorders
Axis II-Personality Disorders ( ie
antisocial; obsessive-compulsive)
and mental retardation
DSM-IV
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Axis III- General Medical Issues
(diabetes; HIV;hepatitis)
Axis IV-Psychosocial and
Environmental Factors(homeless;
death of spouse)
Axis V- Global Assessment of
Functioning
Challenges with COD Population
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Diverse and complex problems
No one clinical approach “fits all”
Expectation, not exception
Personality disorders, learning
disabilities and health issues impact
treatment plans
“They have been here Mr.
Mulder”
( you deal with the same folks anyway)
Case Scenario
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Returned to Community
Outpatient Treatment and Medicines
Life Stressor(i.e.family or job)
Decompensates- No Rx or Drugs & Alcohol
Public Safety Call
Combative or “mercy booking”
Importance to Judge- Revolving Door Cases
The Headache Analgesic
Symptoms-Cause
WIIFM?
“What is in it for me?”
Better docket management
 Cut down on the frantic calls
from the jail
 “Pay me now or pay me later”
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Compare Drug Courts/MH
Courts
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Similar- high
incidence of cooccurring issues
Self-medication
judicial
reviews/team
approach
Drug testing
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Differences-smoking
cocaine is illegal
Schizophrenia is not
a crime
Incentives
/sanctions have to
be more
individualized with
mh participant
JAILED WITH MENTAL HEALTH
ISSUES
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Homeless
Practically homeless-worn out welcome
Housing, economic and lifestyle instabilitylack of Rx regimen
History of trauma: sexual, domestic violence
JAILED WITH MH ISSUES
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Possible security issues:
decompensated, combative with jailers
Increased suicide risks
Other poorly managed chronic medical
issues (HIV,diabetes, hypertension)
Jail: Treatment Disruption
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Decompensated on
entry
Formulary only: side
effects
Loss SSI
Rx Gap: Leave jail
until Dr. appt.
Sequential Intercepts
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Where /how are you screening?
Challenges of large jurisdictions
CIT
Jail staff/nursing staff
GAINS ( handout page)-Brief MH Jail
Screen
Do not have a separate MH Court
Sequential Intercepts-GAINS
Screening
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Red Flags
Jails routinely screen for other
purposes- security classifications
History of violence, health issues,
suicide risks etc.
Quick Overview/Non-clinical
GAINS “APIC” Model
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Assess- ( clinical and social needs)
Plan- (treatment and services)
Identify- (community programs)
Coordinate-( try to avoid gaps)
Assessments
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Clinicians if available- at times, in context of a
competency evaluation
Look at your program criteria- Axis I;
Developmental Disabilities; Traumatic Brain
Injuries
Criminal Risk assessments; Social Needs
Like a jury- who to exclude vs. who to accept
You are a judge, not a doctor-DO NOT
prescribe from bench
Factors
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Sometimes sobriety “clears the haze”
and the mh symptoms rise to the
surface
History-treatment, special education
classes
Unusual appearance, thoughts, speech
patterns, movements
Hearing voices/seeing images
Factors
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Lethargic/bursts of energy
Sleep pattern disruptions
History of trauma-vets; abuse victims
Integrated Treatment
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Not parallel or sequential
Treat each disorder ( SA and MH)as
primary and seek integrated treatment
FAMILY
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Exhausted-end of rope
Role reversal with adult mentally ill
“child” and elderly parents
Can help with case management
Can try to manipulate when get the
case “out of the ditch”
Frustration
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Mentally ill defendants-sick and tired of
being sick and tired Cf. criminal justice
motivations
Tired of the cyclical pattern of criminal
justice system
Families- Role reversal for elderly/adult
child
All tired of gaps in system
DEVELOP RESOURCES
Plan vs. “grip and rip” ( have a “Hon”
meeting)
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Forensic Services, State Hospital: ACT
Community Services Board
Local Medical Community
Local Disability Groups, particularly on
transportation and housing issues
If more limited program, look into nurse with
MH/SA treatment background for jail
assessments and referrals
DEFINING A “WIN”
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Do not expect perfection-crisis
frequency reduction is a win
Episodic crisis events
It is an illness –manage not cure
Do not cherry pick- lawyer settling too
many cases
QUESTIONS?
Definition of “Insanity”Doing the same thing the same
way over and over again
expecting a better outcome.