May 27, 2013

The Health Foundation of Greater Cincinnati considers its legacy

I have an engraved paperweight from the Health Foundation of Greater Cincinnati, a small token for connecting Catholic Social Services with this philanthropy. It commemorates a puny little grant of $6000, one of the first times our local bishop let the agency accept money with strings attached.

My little prize is dated 1999, the first year of the Foundation’s Substance Use Disorder and Severe Mental Illness in the Criminal Justice Initiative.  From 1999 through 2008, this $12 million initiative funded ACT teams, jail diversion initiatives, mental health courts, crisis intervention teams and other efforts targeting the intersection of criminal justice and behavioral health disorders. The report that kicked off the project is still available online, and now, five years after the 2008 economic collapse put an end to the initiative, the Foundation has published a document saying what it learned.

This report is an interesting read for me, because I witnessed many of these programs as they rolled out across our region. What the Foundation says it has learned often differs from what I have observed about the various projects. The document reflects the point of view of a powerful institution manned by smart, dedicated, well-meaning professional do-gooders. My perspective is more closely aligned with small agencies, family members and service users.

The report starts by identifying why the intersection of behavioral health and criminal justice is important.
[P]eople with behavioral health issues are overrepresented in the juvenile and adult criminal justice systems. And in many cases, individuals’ behavioral health conditions directly influence their participation in crime. Unfortunately, the criminal justice system is ill-equipped to address the needs of these people effectively. Behavioral health services provided in prisons and jails are limited, and many people would be better and more effectively served by behavioral health diversion and reentry programs in the community.
The Health Foundation funded 99 separate projects to address this situation in a 20-county area including and surrounding Greater Cincinnati, a service area that includes urban, rural and suburban communities in Ohio, Kentucky and Indiana, extending even to a small part of Appalachia. The projects mostly included an extended planning process as a step one grant, and implementation as a step two grant.

The planning process was designed to make sure projects were thought through and sustainable. So-called “relevant stakeholders” were brought to projects at the planning grant stage. Unfortunately, the term “stakeholder” usually meant people with political, economic, or organizational clout – not the “client population.” The Foundation seldom promoted competing methodologies that might have suggested clients had a right to “vote with their feet.”

Relationship-building was a key part of the Foundation’s initiative. The Foundation never simply wrote a check. Its staffers stuck with projects, while grantees attended periodic meetings, submitted data, and generated reports.

From my perspective, the most important outcome of the initiative was the way that this relationship-building forced grantees to collaborate across system boundaries. After years of multi-system collaboration, local do-gooders had a chance to see whether organizational silos made sense. As the report notes:
While grantees did not often cite specific examples of changed policies and practices, the funding appears to have led to new and/or strengthened modes of contact between behavioral health and criminal justice system stakeholders.
In other words, the Foundation helped create examples of meta-systems or aggregated systems that replaced silos, the formalistic single-track systems we are usually stuck with. This is the ultimate take-away for me.

These days, when I see a silo, I see deliberate policy choices, funding choices, and mistakes of history playing out in ways that harm people or keep them from making progress. We choose to perpetuate these silos even thirty, forty, fifty years after deinstitutionalization.

Does anyone still believe that single-purpose systems make sense?

A police force stuck in the cops-and-robbers mindset is merely ignorant, not as safe as it should be.

A jail that ignores the treatment needs of prisoners is grossly deficient.

Substance abuse treatment that ignores depression or trauma is manifestly sub-par.

Shouldn’t every court or probation agency have access to relevant mental health expertise?

May 16, 2013

Recovery and re-entry

In many communities, nearly every child has a parent or close relative who has been incarcerated. How can we lessen the impact of this trauma?

There’s no easy way forward. In some institutions it’s almost impossible for security reasons to send a child’s letters, pictures, and art to an incarcerated parent.

And once a parent returns home, new obstacles to rebuilding family relationships emerge.
  • Can childcare centers use parents with criminal records as staff or program volunteers?
  • In your state, can parents help coach baseball if they have a felony conviction?
  • Can you have a school picnic and invite known felons?
  • What is the minimum level of screening and precaution we must support?
  • What safety policies make sense when family reunification is the whole point?
Meanwhile, the returning parent must deal with the mental health effects of incarceration.
  • Thinking has been affected. People lose “executive function,” the ability to make plans or take action when there are no clear guidelines. The only way to get this back is to practice rational thinking: Generate options, then choose. Develop rules to help guide choices. It helps to have someone to help reality-check.
  • Feelings are affected. Shame, fear, depression, anger, trauma. These must be handled and processed, not repressed. People need a support system that helps them regain capacity to be vulnerable and trusting.
  • Relationships are critically important, but need to be rebuilt. This is unavoidable tough work.
  • Information is missing. Time and technology has moved forward while the person has been away.
  • The person must leave the unsafe community, and commit to living in a positive safe world. Prisons and jails are communities. People can miss them, and grieve over relationships and former lives. But they are neither safe nor positive.
What safe, positive places are available and welcoming in your community? What strategies can we recommend for people who return from prison having paid their debt to society?

As a practical matter, I think that the strategy for recovery from prison is exactly the same as the strategy for recovery from any other mental health problem.  People must learn about what they are facing, recruit allies, find resources, plan short term and long term, and follow their plan.

As they develop plans, people should answer four questions:
  • What helps the person make the most of their talents and capacities? 
  • What makes the person less vulnerable? 
  • What helps build capacity to handle stress? 
  • What must the person do to address the risk of something going wrong?