Recommendations for Implementation

It is sometimes said that the mental health system has many doors - and all of them are closed. To address this problem of access, some systems have found it most effective to designate a single agency as the "gatekeeper" or controller of entry to the system. Depending on such variables as geography and governmental structure, gatekeepers can take many forms. In some states, for example, a county-based system may be structured so that a single multiservice agency is responsible for all mental health services. By virtue of its "franchise," it becomes responsible for gatekeeping as well as for providing services. In other states, multiple agencies may provide services, but one may be designated as the point of entry, with responsibility for linking each client to those services appropriate to his or her needs. There are many manifestations of this concept, but the organizing idea is to make entrance into the system as user-friendly as possible.

This kind of arrangement encourages service integration, cuts down on conflicts and redundancies, and promotes more efficient use of resources. Most of all, it works to create a pathway through the system that, ideally, delivers to each client the mix of services that best meets his or her needs.

Example:  New York State Office of Mental Health

The New York State Office of Mental Health has asked local governments in the state to establish a single point of entry (SPOE) system covering case management and housing services. Intended to coordinate services for individuals with multiple needs, the SPOE system is intended to allow communities to build on the strengths of their existing systems. In addition to the primary purpose of coordinating and integrating services, SPOE provides a platform from which improved data collection can take place, leading to identification of performance indicators for evaluating system outcomes.

One way many states have limited the potential cost of mental health services is by identifying and defining a priority population for those services and then targeting resources to that population. Only by meeting the priority population definition can one access mental health services in most states. Usually, the priority population has been defined by such characteristics as diagnosis and functional limitation, which in theory translate easily to a hierarchy of need.  Sometimes, however, focusing services on a priority population has a perverse ancillary effect.  The complicated diagnostic picture of many of those who are homeless and/or coming into contact with the criminal justice system at times pushes the boundaries of existing priority population definitions. Where financial or capacity pressures are straining the system, people with complex problems are sometimes screened out in favor of those who "only" have a mental illness that clearly fits within the priority definition.

Policymakers and providers need to address the questions of who falls within the priority service population and what to do for those people with serious problems who do not fit established priority categories. It is important that policymakers recognize not just the growing potential of science, medicine, and rehabilitative services, but also their limits. A thorough understanding of these dynamics is difficult for policymakers to achieve, not the least because this is an area in which change is occurring very rapidly. As science and mental health practices advance, policymakers will need to keep pace so that our systems are not - as they are in so many states today - artifacts of a time when far less was known about mental illness and the treatments available for it.

One way to ensure that resources are available to serve people with complex problems who have typically been overlooked by the mental health system and thus are at risk of involvement with the criminal justice system is simply to identify them as a priority population and place them first in line for services instead of last. To do this would mean targeting resources that do not now go to this population. It is a very complicated task to find funding from a variety of federal and state sources for the comprehensive treatment this population is likely to need. Because practice in many places has been to ignore this population and therefore to avoid grappling with the difficulties involved with treating them, expansion of the priority service definition will need to be closely monitored for effectiveness as well as such unintended consequences as the deprioritizing of other needy groups.

Indeed, the possible consequence of expanding the priority population that most alarms advocates, consumers, and many others with a stake in the system is that services for people with mental illness who are law-abiding, adherent to treatment, and in many ways less obvious to those outside the system will fall in priority or even be supplanted by those for the "criminal justice" population. With mandates to serve more difficult patients and no increase in overall mental health system resources, this is one very possible outcome. It is an outcome to be avoided because this law-abiding population, easier to serve though they may be, has been less apparent precisely because the system has worked effectively for them.

Example:  Maryland Mental Hygiene Administration

In developing services for people with mental illness who have been in county jails, Maryland's Mental Hygiene Administration, the state's public mental health authority, arrived at the assumption that one population was being served, regardless of an individual's history of incarceration. Such issues as treatment for mental illness or substance abuse as well as the need for housing were substantially the same for those who had been jailed as they were for others in the mental health system. By automatically including people with mental illness and histories of jail time in the priority population, Mental Hygiene Administration officials found they were able to deliver services more effectively, while at the same time reducing recidivism to local jails.

People with mental illness do not always seek treatment in the same way someone suffering from acute physical pain might. Sometimes they don't know where to turn for help, or perhaps they don't realize they need it. In fact, sometimes they actively avoid it. For this reason, providers of mental health services must be creative and opportunistic in their approach to some who are in need of treatment.

For many, the mental health system is invisible and unknown. A person who shows signs of a mental illness may have no idea where to call for information or treatment. More shockingly, family doctors and other professionals in the community may be unfamiliar with local mental health agencies. Mental health providers need to maintain and improve community contacts so that finding help is an easily navigated process. Referrals from other agencies - housing and homeless assistance agencies or substance abuse treatment and detox centers, for example - should be welcomed by mental health providers. Rather than apply rigorous screening so that all but a few are excluded from the system, mental health providers should actively seek out cases. To serve a community effectively, public mental health agencies should be as visible and active as any health care resource.

When the affected individual doesn't realize help is needed, a family member or someone else in the community may reach out to a provider agency. In such instances, the agency should be responsive. If the individual will not go to the agency's intake facility, outreach staff from the agency should visit the person wherever he or she is and, if appropriate, they should be able to access acute care hospital beds or crisis intervention services. Similarly, if the person is homeless or without apparent social support, agency staff should make efforts - repeated, if necessary - to engage him or her in a setting where that individual is most comfortable.

For outreach to be effective, it must be done in a culturally appropriate manner. Certainly, an outreach specialist must be able to use the individual's primary language. Yet, as has been increasingly understood throughout the mental health system, cultural competency involves the ability to listen to each individual and pick up cues that are culturally based. By meeting an individual's needs in a culturally sensitive manner, providers significantly increase the likelihood that that person will accept and continue services.

Each individual has needs that are particular to him or her. While the central need may be treatment for serious mental illness, other needs are frequently associated with it, including treatment for alcohol or substance abuse; treatment for HIV/AIDS or other illnesses or disorders; affordable housing; income assistance; and/or employment services. Not all needs are immediately evident, so a full assessment should be undertaken. This may certainly be focused on the need for mental health treatment and services, but it should by no means be limited exclusively to that arena. The use of illicit substances by a person with mental illness markedly increases his or her risk of contact with the criminal justice system and must be assessed.  The presence or absence of various supports in a person's life should always be thoroughly understood by treatment providers who are designing treatment plans. Similarly, as much as possible should be learned about the individual's history of treatment and incarceration. Not only will knowledge of this history be helpful in gaining a broad understanding of a person's condition and status, it could help in forging links with past or even current providers who can offer further insight useful in treatment. In building a person's history, mental health professionals should also try to learn whether or not the subject has been the victim of physical or sexual abuse. Understanding this part of a person's history can help immeasurably in designing effective services for that person.

Mental health treatment interventions are most effective when they are tailored to an individual's particular needs. It is clear that provider agencies must be staffed and organized to provide multiple interrelated services to the individuals they serve. For example, mental health agencies in many places have added staff expertise in the social supports needed by many clients with serious mental illness precisely so that services tailored to meet those needs can be offered. Substance abuse expertise is needed to address the large percentage of persons with co-occurring mental illness and substance abuse disorders.  By providing an array of services that can be tailored to each individual's needs, agencies are more likely to keep clients engaged, enabling many to develop the skills or contacts necessary for them to live successfully in the community.

Ideally, the public mental health system should function as part of a broader public health system that identifies problems in their early stages and takes steps to prevent their exacerbation. To do this effectively, the system must include a full array of services, including linkage with community resources traditionally seen as residing outside the mental health system. A community in which a full range of services is not available will find itself facing preventable problems, evident in the numbers of encounters between people with mental illness and components of the criminal justice system.

When clients find the services they receive to be helpful and meaningful, they are far more likely to continue them. For many people with mental illness, developing this sense of connection is extremely important. Because individually tailored services lead to more sustained engagement in mental health treatment, they are a critical link in preventing inappropriate criminal justice involvement.

A person with mental illness needs to gain access to appropriate services repeatedly.  Services are successful only if they are sustained over time. A provider agency's role, therefore, does not end with identifying services and providing referrals. Success of an intervention often rests on the level of support provided to a person with mental illness who is striving to follow his or her treatment plan. For the difficult-to-engage person who is most at risk for criminal justice involvement, this kind of support can often be quite intensive. Frequently, it means repeated outreach to the individual, often through such treatment models as Assertive Community Treatment (ACT) or intensive case management. For very ill individuals, it can mean access to acute care and inpatient services when needed. And it cannot be emphasized enough that such support must go well beyond purely treatment-related needs to supports such as housing, employment or education assistance, and transportation - supports that will enhance the likelihood of a person living successfully in the community.

Delivery of comprehensive mental health services at the community level requires a significant investment of public resources. Effective community mental health service providers have learned that they must draw from a variety of sources if they are to offer a full spectrum of services. As discussed later in this document, funding for mental health treatment and associated supports in a typical community may come from several different federal agencies, state general fund allocations, and local tax levies.

Resourceful administrators have learned how to use scant state and local funds to leverage money from other sources and to maximize revenues from federal programs such as Medicaid. They look to the U.S. Department of Housing and Urban Development for funds to provide housing for their clients, and they try to join federal block grant funds for mental health and substance abuse treatment with other sources in order to provide integrated services for co-occurring substance abuse and mental disorders. Even the most artful administrators at the provider, county, or state system levels have difficulty matching resources to need. While agencies and systems survive by identifying and tapping a range of sources, the inescapable conclusion is that funding limitations in many communities prevent the public mental health system from making a full range of effective services available.

Broad implementation of the kinds of comprehensive, individualized services briefly described in this section - services that have been successfully implemented in some communities around the country - will result in fewer people with mental illness coming into contact with the criminal justice system. Provision of necessary treatments and supports is the most effective "precontact" diversion from the criminal justice system for people with mental illness.