Transitioning from Prison to Nonregulated Community

Peter Salgo, MD: How does inadequate transitioning compromise public safety?

Mauricio Tohen, MD, DrPH, MBA: What is important is to have reintegration centers. Individuals released from prison, into a reintegrate center with the proper follow-up arranged is the ideal system to implement. Unfortunately, these conditions are lifelong—there’s going to be a need to have follow-up for individuals for the rest of their life.

Peter Salgo, MD: We have homelessness, too, which you mentioned, drug abuse and relapse, and suicide. It’s a complex relationship.

Judge Steven Leifman: It’s common.

Mauricio Tohen, MD, DrPH, MBA: More than 50% of mentally ill suffer from substance abuse.

Richard Jackson, MD: Which leads to many of their arrests because it’s a way to fund their substance abuse.

Nneka Jones Tapia Psy.D: Which can contribute to violence as well.

Mauricio Tohen, MD, DrPH, MBA: Absolutely.

Judge Steven Leifman: Crime goes up when they’re on substances. 75% of people in jails with serious mental illnesses have a co-occurring disorder, meaning they have both mental health and substance abuse issues. We have to treat both, which we don’t. However, the good news is it’s fixable. You need multiple approaches to this—a 3-part approach: you need to start early in the school system with a pediatric system to start identifying and screening for trauma.

You then have to construct an elaborate prearrest system so people don’t come into our system and instead, to the crisis care center before they get arrested. Then when they do penetrate the criminal justice system, you have to have a system of diversion. If you get arrested in Miami, Florida, on a misdemeanor and you’re identified as having a serious mental illness, within 3 days we have you out of the jail and sent to one of these crisis systems. They’re on a correctional hold—the 72 hours of our involuntary law does not apply—and we reset the case for 2 weeks, which is what they need—they don’t need long-term hospitalization, but they need some decent hospitalization. Thereafter, we offer an opportunity when they come to receive housing, benefits, medication, clothes and food. We have peers that work with them and have graduated our program—reestablishing relationships—and then getting them back into the community.

Peter Salgo, MD: There is a phrase: “APIC.”

Nneka Jones Tapia Psy.D: Yes.

Peter Salgo, MD: What is APIC? It’s for transitioning?

Nneka Jones Tapia Psy.D: You’re assessing their needs.

Peter Salgo, MD: That’s the A, “assess.”

Nneka Jones Tapia Psy.D: Yes.

Peter Salgo, MD: What else? There’s P, the “plan.” How does that work?

Nneka Jones Tapia Psy.D: You’re planning for their release into the community, so you identify individuals in the community that can meet those needs.

Peter Salgo, MD: Yes, then “identify.”

Judge Steven Leifman: Even before they get released, what we do is conduct a psychosocial and Texas Christian University drug screening evaluation—we do something called the ORAS, Ohio Risk Assessment, to look at their criminogenic risk factors. The ridiculous part of mental illness is that we don’t always find the right treatment for individuals. It’s a one-shoe-fits-all predicament—so we really need to plan properly and figure out what the person needs before they even leave our system.

Peter Salgo, MD: The C in APIC is “coordination,” and that’s what I keep hearing to be a primary component to transitioning.

Judge Steven Leifman: Absolutely.

Peter Salgo, MD: We’ve gotten the “assessment,” the “plan,” and “identifying” the required services, but then somebody has to step in and “coordinate.”

Judge Steven Leifman: We use peer specialists for coordination: people who have serious mental illnesses but have recovered and graduated from our program, who then help individuals navigating these complex systems of care.

Nneka Jones Tapia Psy.D: The problem with jails especially, however, is that you never know when a person is going to leave a jail because they could be bonded out. The sentence could be adjudicated, which makes the planning very difficult. It’s important to note for correctional facilities that you have to start planning at the first moment of encounter with these individuals. That’s one of the guiding principles that most correctional institutions should have.

Judge Steven Leifman: Chicago does this incredibly well. But most jails don’t do a very good job of assessing the person’s illness or diagnosing it at the point of entry. All the assessment tools need to be redone—they need to be validated tools. They’re not doing that. A lot of work needs to be done.

Peter Salgo, MD: In your area, APIC is part of what you started doing?

Judge Steven Leifman: Absolutely.

Peter Salgo, MD: And your experience is that it works?

Judge Steven Leifman: I already told you that our number of arrests dropped from 118,056. Recidivism rates among our misdemeanor population went from 72% to 20%, and our felony diversion program has a recidivism rate of about 20%. It saved the county 68 years of jail bed days.Treatment and coordination work, and helping people get their lives back is the appropriate thing to do.

Mauricio Tohen, MD, DrPH, MBA: And contribute back to society.

Judge Steven Leifman: Yes, contribution—and it improves public safety. It saves money, improves our public safety, and helps people get their lives back. There’s no reason not to do this.

Peter Salgo, MD: The association between adherence to antipsychotic medication and re-incarceration—I’m going to assume there’s an association, yes?

Richard Jackson, MD: Well there often is because, what happens when you’re not taking your medication when you have a severely chronic disease? You get an exacerbation of your illness and you start hearing voices. Instead of these individuals saying, “I better get back on my medicine,” they resort to drugs and alcohol. The combination is a significant increased risk for aggressive or violent behavior, or not being able to function the way they should in the community. They end up back into the correctional facility, typically.

Richard Jackson, MD: It creates a significant amount of anxiety for patients. We don’t get them to verbalize—and as they’re more fearful, they become greater risks.

Judge Steven Leifman: There was a study a couple of years ago at the University of California, where a selection of culturally specific “voices” from around the world were examined. What they found was that people with schizophrenia in the United States heard more violent voices in their head, whereas in Africa, the voices were calmer and quieter. There are some cultural issues about our society that affect this issue. It probably speaks poor volumes about us—it is an issue.

Peter Salgo, MD: I’m hearing unanimous agreement that planning, medication, and conscientious transitioning works—it saves money, jail time, and gives people better lives.

Transcript edited for clarity.