The challenge there is because of the limited funding for substance abuse and mental health treatments for people who otherwise don’t have health insurance, we aren’t getting to a very high percentage of the population.  On the last estimate that I saw nationally was that drug courts get to about 1% of people on probation. They do very good work with those folks, but we’re not getting to jail.  It’s healthcare reform that gives us an opportunity to take these interventions to scale.

We also look a look at the parole populations.  Obviously, the number of people on parole are significantly smaller, but they are substantial.  In Illinois in 2009, we had about 33,000 people on parole.  In Indiana, it was about 10,000.  In Michigan, 22,000, and Ohio with about 19,000.  Much like for probation, there’s special parole supervision initiatives.  Individual officers make a lot of referrals.  There has also been other interesting initiatives in our region.  Ohio, recently, passed a reform legislation that will focus on putting more people on the street than the community.  Then, there are projects in Illinois where we have in Sheridan, Southwestern Illinois correctional center programs, which is on its way to becoming a jail because they’re a large institution.  There are, in both cases, I think 1,000 inmates, and most are treatment prisons.

So, most are medium-security prisons for people with substance disorders.  They get treatments there, and there are a lot employment programs to that initiative and also, post-release, treatment and case management in the community.  So, those are efforts that have shown benefits and recidivism among the parole population.  Given how expensive it is to put people back in prison, we pay a lot of attention to that here in Illinois, especially the last couple of years.  So, these are the kinds of things that when there is more availability of treatment in the community, they’ll be easier to expand these kinds of positive initiatives.

I’m going to shift now to talking about some of the current challenges and latest thinking on evidence-based practices, and Monica, if we want to take questions about what I presented.  Let’s give the people a chance to raise their hands.  We could do that. On your screen there, you have an option of raising your hand.  Right now I see Jimmy whose hand is up on this line.  Jimmy?



Hi.  My question is more like will this presentation be available after the conclusion.



Yeah.  For those of you would like to have a copy of the webinar, I’m actually recording the webinar, and we’ll be posting the webinar on our website.  I’ll make that announcement.



Will the slides also be available, Monica?



Yeah.  The slides will also be available.



Okay.  Thank you for the question.



Does anyone have any more questions? Are there any more hands raised?  We don’t, but we’ll have another opportunity to ask questions.



Okay.  Alright, good.  So, we’re going to go on to talking about the current challenges in both providing care and funding care for justice populations.  First of all, this slide may be a little bit hard to see on your screen, easier when you have the PowerPoint and you can blow it up much larger.  This is a chart that we use to talk about the criminal justice system and all of its on-ramps and off-ramps and the intervention opportunities that exist along the continuum, and when we’re talking about being able to take the intervention scale, we are really talking about the whole length and breadth of the national justice system.

So, there are opportunities for diversion to community days, mental health and substance abuse treatment and arrest on the mental health site.  The crisis intervention, you can see CIT is an intervention that’s been gaining a lot of popularity, and I definitely encourage people to pay more attention to that in the future.  There are opportunities for similar community-based supervision at the time when people are arraigned, but before I get into that, people who are held in jail and whose charges are dropped or dismissed, there’s an opportunity to do good re-entry services with them as well.  They just have to be short and quick and very effective.  So, there’s some models I’ll talk about a little bit later on that.

In terms of interventions and arraignment or sentencing, there are lots of opportunities to divert people to community-based substance abuse and mental health treatment.  With community supervision with the support of a community-based infrastructure that links support and the community, as well, to tighten up the supervision part of that so the court and the community could have confidence that people are supervised.  What this does is it allows us to have people supervised in the community and going to treatment in the community, which we know is very effective, rather than incarcerated and pulled out of the community for a period of time and, then, just face all of those issues, again, when they come out.

For people on probation, I talked a little bit earlier about specialty courts like mental health courts and drug courts. The opportunities to link people to substance abuse and mental health services once they’re more widely available exists all along throughout probation and parole.  We certainly, in the future after 2014, we should be considering every person in front of us as a person who could potentially be referred to the services that they need.  We’re not able to think that way now.  We’ll talk a little more about the reasons why now.  It is very frustrating, but it is a good thing that it may change.

So, this slide is borrowed from a presentation that Doug Marlow gave.  If you don’t know Doug’s work, he is the research director for the National Association of the Drug Court Professionals and a university professor, and he does very good work on thinking about how you use graduated sanctions in drug court to influence behavior, what the timing is on these kinds of things.

This slide is from a different perspective.  He wrote a great paper called “Evidence-based Sentencing Practices”, and he talked about the continuum of risk and need.  Risk, in this situation, is public safety risk, and need is need for a clinical intervention; so, mental health and substance abuse treatment.  In particular, when you look at people who are in the low risk, low needs in the bottom right box, they aren’t posing much threat to public safety.  They don’t have very high need for formal, structured substance abuse and mental health treatment, but they’re doing some stuff that’s getting them through the attention of the criminal justice system.

So, what do they need?  He talks about that as prevention.  We might, in the substance abuse treatment field, we might talk about it as early as intervention.  So, motivational intervention structured like an expert, screening, brief intervention, and referral to treatment project, which is a strong methodology that’s been demonstrated on the public health side and in the substance abuse treatment side to make a difference, as well as what kind of life skills interventions and good supervision that are offered through community safety officers.

So, then, if we go up to the next, high need, low risk box, this is the classic box for low-level drug offenders who’s continuing involvement with the criminal justice system is driven by their alcohol and drug use.  They have a very high need for good structured intervention, but because they pose low risk to the community, they don’t need a very high level of supervision from probation and parole officers.  They could conceivably be good candidates for diversion programs at the far end of the criminal justice system as well.

Then, when we look at the high risk column, we are really dealing with a different profile of offenders.  Also, if this box represented offenders in the criminal justice system, the high risk column would be much narrower and smaller and the row risk column would be much larger.  The high risk, high need folks are people who, and Doug has come to talk about these folks.  These are the folks that need the resources of a drug court and a mental health court.  They need to be very accountable on short timeline for whom treatment compliance is absolutely essential, and also, a lot of habilitation is needed.

So, when you think about the previous slide of the continuum of intervention, we just don’t want to spend our resources willy-nilly.  We want to prioritize where our somewhat limited resources go, and so, focusing the highest intensity of resources on the high risk, high needs people makes a certain amount of sense.

Then, the last box is the high risk, low need people.  These are people who are less likely to be impacted positively by mental health and substance abuse treatment and for whom accountability and habilitative services are the priority.

So, that’s how he broke out this thinking, and it’s a helpful way.  There’s a lot of talk in probation these days about evidence-based probation strategies, and triaging and spending resources where they’re most needed is obviously a budgetary reality as well as a professional reality.  So, this is the kind of thinking that helps us figure out what to do.

So, just a minute.  For folks who aren’t familiar with mental health and substance abuse treatment, I’m just going to say a few things about what treatment actually is.  High quality treatment is used as evidence-based strategy.  Different kinds of treatment modalities that we know have been proven over the years to actually make a difference in people’s subsequent behavior, their arrest behavior, their work behavior, their continued use or not continuing use, which is the goal.

In substance abuse treatment in particular, behavioral therapies are used.  We use counseling.  We use cognitive therapies like DVT and MRT.  We use psychotherapy as well in various combinations.  You may become more familiar with hearing terms like residential treatment, inpatient treatment, outpatient treatment, and basically, we call those modalities and their levels of intensity and also structure and also determine whether housing is a part of that intervention strategy or not.  What goes on in these settings is the same general activity.  We just relate it to what the setting is in which the person will most benefit.

Physician-prescribed medications are increasingly a part of substance abuse treatment.  Methadone has been around for many years.  There are a number of new medications that have come to prominence in the last decade.  Many of them have been around for a long time but not applied to addiction in this particular way.

There’s buprenorphine, which also goes by the name Suboxone®.  There’s Vivitrol®.  That’s the trade name for a medication that’s been promoted for treating alcoholism as well as opiate addiction.  Buprenorphine is a treatment for opiate addiction, and the good news about all these medications is that they really help people who, otherwise, don’t really stand a great chance of being able to control their own craving and get through the first part of establishing early recovery without some assistance.

What we hear from our treatment partner is folks who are using these kinds of medications actually stay in treatment, and they’re to benefit from the psychosocial rehab and the counseling and the other things that the person has to do to get their life together.  If they’re not able to stay in treatment, they can’t manage their cravings, and they feel overwhelming urgency to go back and use and we’re not getting anywhere.  So, that’s increasingly the value we see in medication-assisted treatment.  Treatment is often a combination of one or more therapies.  They’re not mutually exclusive, and people are stepped up and stepped down in different levels of care based on their progress.

Now, mental health is often organized in a different way, and community mental health centers do a great deal of work around the country.  There’s also a certain amount of this work that’s done in community health centers where physicians are prescribing medications and doing some counseling with people.  In our experience, at least in Illinois, the challenge for the mental health system, even before the budget cuts that have hit since 2008, is that they’re really restricted to working with the most disabled people and a pretty limited number at that because the money will only go so far.

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