My name is Dr. Deanne Hart. I'm going to serve as your moderator. Thank you for attending our session, Mental Illness Beyond Bars, Psychiatrists as a Contributor and Advocate for Change. We have an exceptional panel of two psychiatric physicians with experience in correction and advocacy, as well as a social worker who will be joining us. He has lived experience within the justice system, and he currently works with system-impacted individuals as he leads the strategic planning and implementation of Bronzeville Community Justice Center's Justice Initiative Youth Program development. And it's probably many of you are aware the United States has 4% of the world's population, yet houses 25% of the world's prisoners. Incarcerated patients have a high burden of chronic health disorders, including severe mental illness, substance use disorders, and trauma. Lockup facilities, local and state jails and prisons, federal prisons, immigration detention centers, and Indian Affairs Centers are the largest mental health providers in the United States. An estimated two in five people who are incarcerated have a history of mental illness, 37% in state and federal prisons and 44% in local jails. These institutions are severely underserved. Jails and prisons have difficulty hiring and retaining mental health professionals. The workforce shortages were exacerbated by the COVID-19 pandemic, which contributes to profound shortages in availability and retention of psychiatrists who can provide psychiatric care and leadership in these settings. Despite the high need and workforce shortages, psychiatric physicians do not regularly receive routine education or clinical training regarding this clinical care setting, despite the fact that most training programs are within four miles of a jail or prison. And I think we'll hear some about some efforts to change that. The lack of training leads to significant missed opportunities to improve the quality of care for this patient population. First, early exposure to care within these facilities increases the likelihood of trainees considering carceral correctional health care as a profession. Second, each year more than 600,000 individuals are released from state and federal prisons. Another nine million cycle through local jails. Therefore, even if the psychiatrists do not choose a career in this field, they must have minimal competency in carceral systems and incarcerated patients to improve the quality of care within and for these individuals receiving both care while in custody and in the community upon release. I plan to introduce each of our panelists as they come to the podium. I'm going to start with Dr. Elizabeth Ford. Dr. Ford is the clinical director of the New York State Psychiatric Institute and chair and co-founder of the Justice Involved Behavioral Work Group in the Columbia University Department of Psychiatry. She specializes in the mental health care of and advocacy for individuals who are incarcerated or formerly incarcerated in the education of multidisciplinary providers about the complex interface between the behavioral health and criminal justice systems. Most of her almost 20-year career has been in direct care and leadership roles at Bellevue Hospital on Rikers Island. Dr. Ford continues to publish in peer-reviewed academic journals, chairs the American Psychiatric Association's work group on the care of individuals in jails and prison, and wrote a critically acclaimed narrative about working on Bellevue's hospital jail psychiatric service. You see our objectives? I won't read those, but we will get right to Dr. Ford. Thank you, Dr. Hart. Good morning, everybody. I'm actually kind of glad we have a nice small group so we can have lots of questions and discussion, and thank you for the introduction. Also, Derek, who will be joining us shortly, is trying to park his car, and I have my phone in case he has trouble getting in, so I may hand that off to you if he calls. I think, and also, I'm gonna get that picture off the slide. So, Dion mentioned the relative lack of education in, well, I think we'll talk specifically about psychiatry today, but in psychiatry training programs about, oh, you can't hear me? Oh, I usually talk too loud. Okay, sorry. Thank you. About, oh, so Dr. Hart was talking about the relative lack of education in psychiatry training programs, about the care of people who are incarcerated or have been incarcerated, despite the massive prevalence of that experience in this country, particularly for marginalized populations, particularly for black men. And today, today is the whole, actually, can I tell them about the whole day? I know not everyone is going, but today there is a site visit that, I don't know if some in the audience have signed up for, but that involves a visit to Rikers Island and to see some of the jails there, and that's a whole day affair with a debrief at the end, and this lecture is designed a little bit as a preamble to that and also as an introduction to the field in general. I will say at the outset that it's, I think, and there's, it's a little bit ethically fraught to think about going and visiting a jail, especially a jail like Rikers Island and many jails in this country where people are caged and where you're coming in as an observer. These visits have at times been called tours, and I think that's misleading and not the most respectful, so we all, we talk about them as site visits, but do want to be thoughtful about the experience of going and seeing people who are people first, and then people with illness second, and then people who are incarcerated way, way down the line. So I think my role here is to just give an overview of carceral psychiatry in general for the audience. I don't know how many, actually maybe, how many people have been to a jail before? Okay, okay, and how many people have worked in a jail before? Okay, all right, so there's about half, have some, well, some of this will probably be a little bit repetitive and basic, but hopefully we'll spur some thoughts, and then when Derek arrives, he can give you the perspective about some of the things I'm saying from someone who's been through the system. Okay, so first up, we're going to talk about what jails are. So they're, in this country, they're about 3,200, how many now? 3,100. So the number of jails are sort of dropping in this country. About a decade ago, there were approximately 3,500, and jails are designed specifically for people who are, have either been accused of and convicted of a misdemeanor, which is considered a low-level crime and for which someone will not serve more than a year. So petty larceny, for example, or trespassing, those typically are considered misdemeanors. That's about a tenth to a quarter of people who are in jail. The vast majority of people who are in jail are people who have been charged with something and have not been convicted of anything and are awaiting some kind of disposition in their case. So either the case is dismissed or they're convicted or they take a plea, those kinds of things. For the most part, these days, and in New York City, Danielle will talk a little bit more about the specifics of New York City, increasingly people are being detained in jail for felony charges, which, if you think about the purpose of a jail, is probably in a better direction than people being detained in jails on misdemeanors, but we still have high rates, about 10 million people a year who are booked into jail. There are also a small percentage of people who are booked into jail because they have violated parole, and parole is only for people who have been released from prison. New York State violates the most people in this country on parole, and so sends the most people in this country to jail who have been on parole. This is, that's the island right there. New York City's had some decarceration efforts since COVID, and so now all, is this right, Danielle, all the jails? Yeah, so now all of the jails in the New York City jail system are on Rikers Island. There used to be five jails throughout the rest of the city, and then the picture below is Twin Towers in Los Angeles. You just look at the, what they look like. Those are two very different looking facilities. Oh, sorry, when I, oh let me go back. Rikers is on a very secluded island. You can only get to it from that bridge, and Twin Towers is right in downtown LA. So there, it's also important to think about the geography of jails when you're thinking about also training opportunities, and can people get access to those jails. Prisons, on the other hand, are specifically for people convicted of a felony. Felony is considered a more serious charge, so people serving a sentence of less, of more than a year. Sometimes people will go into prison, they've already served most of their time in the jail, so they may touch down in the prison very briefly and then come back, but they have been convicted for something that, for which the punishment is more than a year, and there are about 16, a little more than 1,600 in the United States. Prisons are designated as state. The vast majority of prisons are state, state run or federal, and Dr. Hart works in the federal system. They operate very differently. So one thing to think about with, I would conceptualize jails as the short-stay acute facilities, even though they're typically not short-stay anymore, and then prisons as the more chronic facilities, and that's important when you think about providing care in each of those settings. We'll skip through this, but this, Dion mentioned already the high rate of incarceration here, and you can look to see about, it's 531 per 100,000. It's pretty high. This also, by the way, includes on the, on the far, what is this, your right, people who are detained in, in spaces that are not jails and prisons, so immigration detention facilities, which technically are jails and prisons, but it's categorized slightly differently. Also people who are committed under sex offender involuntary commitment statutes, and people who are detained in juvenile detention. The United States puts a lot of people in places by force. So in terms of how frequently this happens in the United States, there's one arrest every three seconds, and the vast majority of people are arrested for low level offenses. In New York, people in a study that, it's relatively old, a couple of decades, but unfortunately there's actually not a whole lot of data that's reliable about this kind of work. The, almost, about 93% of people who had a serious mental illness and were arrested, had been arrested on a low level charge. One in 48 adults is under correctional supervision in this country, so that means either incarcerated or on probation or parole. One in 48, that's like almost one of us in this room. Lots of admissions to jail each year, and then I'm hoping for this audience it's not new information that the United States disproportionately incarcerates people of color, particularly black people and men. This is just a quick graphic to, on the bottom you can see the rate of prison incarceration per 100,000 based on someone's race, race or ethnicity, and just to note that because a lot of this data is, is relatively old, the way people are described and classified and the way they're checked off on surveys is a little bit behind the times, but you can see here that for African American men who drop out of high school, that's the purple dotted line, the risk of imprisonment by the time they're age between 30 and 34 is drastically higher than the rest of the group. And the rest of the group includes white men who completed high school, white men of all education, and then black men of all education. This is also a note about the importance of education. Also in incarcerated populations, high, high rates of, actually, in terms of individuals who are trans women and individuals, particularly black trans people, high, high rates of incarceration among that population. Now, while they don't make up a huge percentage of people who are incarcerated, when you think about the representation of them in the general population and the representation in carceral settings, it's pretty striking. And they are, these populations are the ones who typically are the most at risk for victimization while incarcerated. Okay, rates of mental disorders. Don't worry, you don't have to read this. Dion mentioned a statistic about roughly 40% of people have had serious mental illness, mental illness. Also, just a note that serious mental illness and mental illness are a little complicated and they're defined all sorts of ways. And each jail and each prison typically define them differently also. But the point of this slide and this slide, which, again, you don't necessarily need to see, is that we really don't know the answer to the percentage of people who actually have a range of mental illnesses in jails and prisons because the carceral environment is so incredibly destabilizing and traumatic that it elicits in people behaviors that one might consider to be mental illness. It gets very challenging. Also, there are real complications with self-report of symptoms in a setting like that. So there's high, high incentive not to share information, to over-report, to under-report. There's great incentive for providers to over-pathologize and under-pathologize. And there's a lot of incentive to weaponize diagnoses. So it's fair. And I know this audience, you guys have some experience working in these settings. So hopefully some of that is ringing true with you. The truth is we just really don't know. And the DSM does not really adequately fit into these settings. The DSM didn't design any of those diagnoses based on people who've been incarcerated, who are incarcerated. Fair to say, however, that lots of people have a lot of mental distress in these settings. And Danielle may talk about this some more, but it's also not just the people who are incarcerated. It's a highly stressful work environment as well. So a note about substance use disorders, which I include in the broad range of mental health disorders, but I can appreciate that some think of it as a separate field. But to note that during incarceration, for people who are incarcerated, opioid overdoses account for about 75% of all drug overdoses. So the opioid epidemic is inside the jails and prisons also. It is a myth that people cannot have access to those either prescribed or smuggled in drugs. And as of 2019, about a third of the jails surveyed had provided an, oh, sorry, hold on one second. This is Derek. You wanna, okay, great, thanks so much. He's probably outside. I'm hoping. Only about a third of the jails surveyed provided any kind of medication for opioid use disorder. The most common is naltrexone, which this is only my opinion, I believe has the least evidence in terms of actually long-term support for people with opioid use disorders. And the most common thing to do is to continue people who have been on the medication on the outside. But again, this is only in a third of the jails that were surveyed. Most prison systems, and it's barely a most, offer methadone, but almost half of those who do just for pregnant women or those who are in chronic pain. So we're really at a point where so many people who have opioid use disorders are arrested and incarcerated, and it's very difficult in general to get care. Now New York City is incredibly different in that regard. Danielle will talk about that a little bit more, but New York City and Rikers has the oldest and largest methadone program in the country. And you can get whatever kind of medication you need and be initiated on it as well. And then to note that after incarceration, individuals have a 40 times higher relative risk of death from a drug overdose in the first two weeks of release compared to people in the community. And almost all of post-incarceration deaths are a result of drug use. So it's a significant challenge. Okay, so the, hey Derrick. So the impact of incarceration is profound, and you'll hear more about this from Derrick, from the perspective of taking care of people in this setting. From the perspective of taking care of individuals in this setting and providing care. These are made up words, suicidogenic and aggressogenic, but the environment itself can, as I mentioned before, impart an individual's emotions and behaviors that they may not feel or demonstrate when they're not incarcerated. There's a state of hypervigilance and persistent fear, like chronic fear all the time. And sometimes it sort of fluctuates, high intensity, low intensity, but doesn't really ever go away. That's not helpful for a person's mental status. There's strong regression to early styles, so childlike behavior. So you're in a set, this is not unlike actually inpatient units. If you work on inpatient units, you'll notice too that adults who are involuntarily confined will sometimes start to behave more like children and rely on those kinds of defense mechanisms. There's a loss of trust all around, so it's very hard to know who to trust, when to trust, how to trust. A sense of learned helplessness develops, particularly, so for people who've been incarcerated for a long time and have not made decisions on their own about many things, it can be incredibly challenging to return to a state of full autonomy when you get released. High, high rates of illness, including, so people who are coming in have high rates of illness, and the environment itself certainly contributes to that. People who are incarcerated, studies have shown for each year of incarceration, they have a two year lower life expectancy. And then there's, because of all of the barriers and challenges to getting help, and the stigma that exists in these spaces as well as outside, there's a reduced ability and interest in seeking help. And some of these things also apply to staff who work there. Hello. Okay, so a little, I think this will, I'm gonna go through a little bit about how this, let me, just a little bit about the evolution of kind of how we got to the point we are now, where so many people are either being, with mental illness, are being arrested and incarcerated, or are incarcerated now. Just a reminder, and it's probably not a reminder, none of us were around for this time, but before hospitals were, before Pennsylvania Hospital, people with mental illness were jailed. And they were shackled, and they were imprisoned. That was the treatment for them, and they were certainly not called patients. And then Pennsylvania Hospital started in 1752, and actually, that was the, they admitted the first psychiatric patients. Bellevue Hospital was really the first public hospital in this country, but they didn't start having an official psychiatric unit until a little bit later than the Pennsylvania Hospital one. And psych hospitalization was initially just for the basic necessities, keeping someone alive, and therapeutic interventions continued to be relatively barbaric. And then later on, we have innovations from Philippe Pinel in France, and then Dorothea Dix in this country, who really strongly advocated for hospitalization over incarceration. Then we have admission rates to psychiatric hospitals growing. Very few people, at least from reports, and not sure how reliable, but from reports in the late 1800s, very few people who had illness were incarcerated. I don't know if that was true or not, but that's what the census report reported. And then you have the Community Mental Health Act, which probably you've all heard about, and deinstitutionalization. I think there's a common narrative that deinstitutionalization became transinstitutionalization and people just shifted from the hospitals to the jails. I would argue that, in fact, it was the drug law policies that made it much easier to get into jail for drug crimes, and as this was happening, civil commitment laws were changing, so it became much harder to get into hospital. So harder to hospital, easier to jail, and the comorbidity between substance use and mental health, again, is so strong. I think that's likely what contributed more. And so then by 2000, we have the state that we're kind of in now, which is not enough access to psychiatric beds. And in the interest of time, just wanna note some things that have happened in the organizational structure. Henry Weinstein, who just passed away not too long ago, developed the Bellevue Hospital, psychiatric service for men at Rikers Island who need psychiatric care, and you'll learn about the evolution of his service a little bit more from Dr. Kushner. The American Academy of Psychiatry and the Law has started to develop, formed in 1969. It has not fully embraced the care of and study of people who are incarcerated as part of their mission. I think they're trying to do it, but it has historically been an organization devoted specifically to the forensic evaluation of individuals. Then we have Forensic Psychiatry Fellowships, which started in the early 90s. Again, their focus is really on the forensic evaluation work and less about the treatment work. And then we do have now a committee on correctional psychiatry that American Psychiatric Association does, which we're changing its name. But that started in the 1990s and has started to push more APA position statements and resource documents related to the importance of this kind of work. And then the woman below is Stephanie Lammel. She's the Director of the Public Psychiatry Fellowship at Columbia and has been a strong advocate of ensuring that the care of people who are incarcerated is considered public psychiatry, because it really is. It's much more public psychiatry than it is forensic psychiatry. Dion's giving me the one minute mark, so I don't know if I can do that. Let me go through, if you're interested in these slides, we'll get these slides. These are some legal cases that describe the rights that individuals who are incarcerated have to medical and psychiatric care. So unlike all of us in this room, people who are incarcerated have a right to that kind of treatment. It doesn't mean a right to good treatment, but they do have a right because their freedoms have been taken away for the state or the federal government to provide healthcare for them. This, I think, is the most probably important thing when you think about the ethics of this work. So jails and prisons, their healthcare staffing models vary. There are private institutions, there are public institutions, there are mixed institutions. They're locally run, state run, federally run. There are all sorts of mechanisms that play into role there. Most of them are not regulated by any kind of particular accreditation agency. The Joint Commission and the National Commission of Correctional Healthcare do offer accreditation for these programs, but you have to pay for that, and many jails and prisons choose not to do that. It also comes with all the regulations and monitoring that you're probably familiar with. So in this first bubble, correctional agency and healthcare staff, so that's when the healthcare staff are part of the correctional agency. So I'm curious if anybody can think of a challenge that might present to somebody who's a healthcare provider. If your boss is a correctional. Sorry that I didn't. I guess one difficulty that I can anticipate is maybe perhaps what your boss wants as a correctional facility versus what's best for the patient. Exactly. Totally. Yep. And that's you've just named one of the key challenges of working in this kind of field. Even if the health care staff are not kind of part of the agency but contracted by the agency. Even if they're totally separate in the way they are in New York City but they have to work together. There are, it's called dual loyalty, but very strong challenges when for example it costs too much for the agency to get the medication you want or they think providing methadone is coddling addicts and so they're not going to provide it. Or they want somebody to stay in solitary confinement for punishment reasons and you're like no way that's making their mental health worse. And when you as a health provider go up against a correctional agency it can be incredibly difficult. Same kinds of tensions exist and when you're working with the police as well. So it's in terms of advocacy I feel like these these roles require a lot of diplomacy and a lot of education and persistence in terms of getting what's best for the patient. Okay in terms of mental health care in these settings typically there's screening, there's mental health assessment, there's treatment, and there's discharge planning. Some jails and prisons have almost none of this and some have all of it and it varies across the specific settings. Some of the challenges that we just talked about in terms of dual loyalty. So the custody management might want things to be very efficient. Security assessments typically have higher priority over health care assessments. And then what you decide about a patient in terms of for example their diagnosis and their treatment can often inform where they're housed and who they're with and sometimes even the type of punishment they may get down the line. There are tons of access to care issues. We've mentioned a few of them including the formulary. Most jails do not have access to hospitals. New York City does and prisons typically have some level of higher care but also they may not have access to a hospital in the way that we all know it. Lots of access to information challenges including as we mentioned from the patient their issues around consent. I think a lot of people feel like if you go to jail or prison HIPAA doesn't apply there which is not true but there actually are some carve-outs that make it easier to share information in an emergency. And as we talked about before there's really very little organizational educational or research guidance about this care. Okay thank you. Thanks for tolerating that somewhat lengthy explanation. Hopefully there's some questions around there. I'm going to turn it over to Derek. Would you like to introduce Derek? Yes and he'll give you the true expert opinion about this. Thank you Dr. Ford. Dr. Ford well covered two of our objectives to provide information about the unmet needs of carceral populations and talk about the early exposure to mental health care within correctional facilities and how we as psychiatric physicians can advocate for those patients to make sure that those unmet needs are covered. Our next presenter Mr. Derek Stroud will discuss the critically necessary integration of people with lived experience in this population and in this setting and discuss the perspective from a mental health provider as well. I'm going to tell you a little bit about his work. In his current position he supports system impacted individuals as he leads the strategic planning implementation of Bronzeville Community Justice Center's justice initiatives, youth program development, anti-violence organizing, social work supportive services, and placemaking initiatives. He also worked with the Justice Center's project director to build and maintain relationships with city agencies, local service providers, and program partners including law enforcement, faith leaders, and other stakeholders and community-based organizations. He seeks to identify neighborhood resources and troubleshoot issues. Derek previously served as a director for Exodus Transitional Community Brooklyn supervised release program and as a trauma therapist for Exodus Transitional Community Center for Trauma Innovation. Derek received his Bachelor of Arts in Social Science from Bard College and his Master of Social Work from Hunter College in 2019. He currently works as a licensed social worker and is a doctoral candidate of social work at Long Island University with an anticipated metric. Did you already graduate? Oh he graduates in five days. Yes. May 2024. I'm like that's now. Yes. So please join me in welcoming Mr. Strahl to the podium. Good morning everyone. So today some things that I'm talking to a psychiatrist but I'm a social worker soon to graduate with a doctorate in social work. Okay my voice is a little deep but here we go. So I said this morning I'm speaking to a psychiatrist but I'm a social worker soon to graduate with a doctorate of social work. And so the conversations around prisoners or some people call them inmates but I like to think of them as that people that's just been incarcerated right. Regular humans and some of the things that we can do to sort of offset the systems impact. So first I'll just share a little bit. Dr. Ford asked me to share a little bit. So I did serve 25 years in prison and one of the things that happened is that when we talk about person-centered work and person-centered language. I was in prison in the time when they had took the schools out of prison and then Bard Prison Initiative or Bard College came in and offered us the opportunity to access education and led to me getting a BA. And getting this BA allowed me to feel human again. Getting a BA allowed me to feel human again because prior to that there was just a lot of wreck and stuff that you do in jail and so when you are treated like a human oftentimes you start feeling like a human and then you start behaving like a human. So that's where the intersection comes in at. A lot of the work that happens in prison settings people aren't using this stuff that they learned in school. So there's these challenges because there's a lot of correction staff around and the correction staff has a duty to create security to make sure that things are secure and people who are here to service people in psychiatry or mental health are there to sort of do something else. And we often, at least from the perspective of the prisoner, we often feel slighted when we're working with people who look to us different or in the same way as the correction staff. So when you're coming in sort of doing the work we expect psychiatrists or somebody doing mental health to give us an opportunity to sort of express, to have a safe space to express some of the things that we're going through because to be honest with you a lot of it isn't mental health. A lot of it is trauma that people are bringing with them to prison. So it's missed, can be misdiagnosed, it can be underdiagnosed or cannot be diagnosed at all. It depends on what happens in reception. So if you come into a prison setting and there's something else going on, say in the back of the prison, you may get a quick assessment and you may not get diagnosed or you may have something on your record that has a diagnosis because you've already been receiving services and you're part of some sort of city agency has that record and what happens that's a misdiagnosis. And I think that's what Dr. Ford was talking about. Depending on the assessment that's done and depending on the diagnosis is how they sort of order your stay in prison moving forward. So if someone has a violent, they have a trauma response in the moment and it's sort of violent and then someone comes in and says that they're aggressive and they have an anti-personality disorder and that goes on your record, moving forward that's how people will treat you. So there's never this idea that, not never, excuse me, there's never a never, but there's this idea that you may not be getting client-centered work. So this is where the social work aspect, and I'm not a psychiatrist, right, but this is where I think the social workers kind of get it right because we look at the person in the environment. So if I'm coming from a space, I work with a lot of systems-impacted youth. To be honest, I work with a lot of young men with gun charges in Brownsville right now. A lot of gang, active gang members in Brownsville with gun charges. And so if you come from Brownsville, which is like 1.26 miles and you got 17 housing developments and over 170,000 people and it's poverty, lack of education, lack of resources, you would sort of feel traumatized and isolated. And perhaps your response would look like mental health, but it may just be a trauma response. And so as you're getting arrested and you may already be charged because you feel that the police are sort of over-policing. I think Dr. Ford also talked about that inside and outside, this hyper-policing of the black male body. What happens is that you may get a diagnosis in a moment that has nothing to do with what's really happening inside. But if you do serve time, if you do go on to serve time, that diagnosis is hardly ever going to get changed. So every time something happens, police are already—we talked about this idea of HIPAA. My experience as someone who did 25 years, there's no real HIPAA in prison. The police will share your information or the staff will share your—hospital staff will share your information with police and police share your information back and forth. So now you're not only isolated in prison, but you're isolated by a diagnosis that may be incorrect. And so the rest of that time in prison can look like a lot of SHU time, which is Special Housing Unit. So I know that a lot of people in this audience probably fought for the idea that the limit on SHU time, but SHU is the space that they use to put people who are unruly. So all these things in sort of toe-toe brings about this idea that—and I don't want to think of us, the health providers, as a savior. That's not our job. We don't go in to save people. In fact, I preach and teach that we can't save people. But what I do believe is that when we in correctional institutions, we are sort of a safe way. We can be a safe way, but we have to have a voice. And generally, my experience has been when you got ten correction officers and a captain telling you what to do, and generally people in our profession, in our line of work, succumb to the captains and the sergeants and police staff. It's very hard to push back from both angles, from a profession who now practices, and I go to court with people every week, and also from a prisoner who served 25 years. I've witnessed that it's very hard to push back because you work with people, and as you work with people, you form sort of a comradery. And you don't want to be the one person that's always saying, we need to do something different. But that poses a problem. It really does pose a problem for people inside a prison because oftentimes those same people are struggling with issues related to stuff that doesn't even have anything to do with prison. It's just compounded by being in prison. Again, I work with a lot of young people, and we don't do mental health where I work. We do trauma work, we do group work, we do peer facilitation, but we don't do mental health. We refer mental health. But even in the community-based organizations, I have to go around and find spaces that can work with these young people because they have criminal justice impact, because they show up different. And that difference is not a mental health. It's not a mental health. It couldn't be a mental health diagnosis, but it's not generally a mental health diagnosis that's happening in the moment. It's generally a trauma response, and they look the same. I'm sure I'm preaching to the choir. They can look the same, but they actually are two different things. I'm having experience based on the stuff that I've been experiencing, and I'm hypersensitive and hyper-aroused in the moment. So if I see a police officer, it looks, if I'm accosted in a certain way by officers who may be questioning me within the line of their duty, I'm not saying that the officers is wrong. This is not what I'm trying to say. I'm saying how we have to be able to look at things in the moment. We can't just, at least I believe, the thing is not to sort of just go along with diagnosis. I also practice in a community-based mental health organization for four years, three years, and what happened is every young black guy from the age of say nine to twelve who had problems with his teacher got an ADHD diagnosis. Now I'm not the smartest guy, but I know that had to be wrong. Every young black guy in school who couldn't sit still had an ADHD diagnosis, but when they work with me one-on-one, these guys was geniuses. I learned the game called roadblocks from these young guys, seven and older, and they told me how they built up towns, they had to put clothes on people, they had to go shopping and design all this stuff, which would make them an engineer on my book, if not an interior decorator or something else, but all of them had ADHD diagnosis. Something was wrong. It wasn't the young people. It may have been the space that they were in, so again I look at it from a social work perspective, person in an environment. So these young men, ADHD diagnosis, multitude of suspensions, you see how this thing contract, so now you don't go, you don't finish high school because of the suspensions, prison two years, school two prison pipeline. That's kind of sort of a lot of times what we're seeing in prisons in New York City. I didn't know that until I got to prison that a lot of the guys I had grew up with weren't able to read and write, didn't have GEDs. I was lucky, right, I had a GED going in. I didn't, I couldn't read and write. My mother prioritized education. I didn't know a lot of my friends didn't have that. So when we get inside of prison, it's more frustrating because now I can't maneuver systems neither. In the street I can talk and get things done, but in prison it's smaller and you have to be able to read. You have to read mail, you have to read your law, you have to read the correspondence back and forth from your lawyer, and so I'm frustrated most days, and I had to figure this out, right, so I'm frustrated most days, I'm talking about general population, and so when I'm frustrated and there's a bunch of frustrated people all living in the same space, you can imagine the chaos that happens. So yes, security is a big issue, or by all means there has to be security. There has to be this way that people are managed, but we also have to look at the conditions, and I think that's what some of the jobs that we come in at, helping the people who manage security to manage expectations based on real-time person and environment. So a lot of the other, and I see up here they got some stuff that, sort of, another part of this is that going back and forth the court, not knowing what's happening, having a family outside, right, and sort of, so I've witnessed a lot of men believe that if they forcibly got a diagnosis, it would somehow also help with their case, which never is the case. New York doesn't have, like, in its truest sense, this idea that you can get away with a crime just because you have a mental health disease. So a lot of guys, though, coming in, think that if I play crazy and I take these medications, what can happen is I may get some sort of lessening of my time. What they don't understand, and what I witnessed later on after staying in jail for a couple of decades, is that that forced diagnosis that they played to get sticks with them throughout the rest of the incarceration. It hinders where they can, and what they can do, and where they can be placed at also. Generally, you have, now you have, when I was leaving prison, you have SNU in the state prisons with special need unit, and you have SHU. Prior to 2010, most people, when you act, when you acted disaccordingly, you went to SHU, which is a Penalty Punitive Housing Unit. Around 2010, they started taking a lot of the people out of SHU and putting them into special needs unit, which meant that they didn't have to stay in their cells 23 hours a day. They had some other activities, some pro-social activities. They had some engagement with staffing who wasn't correctional staff, and that was meant to ease sort of the experiences they were having with prison. But even then, there was this sort of, there's these, when you have a, when you have a mental health diagnosis, this is stigma in prison, that the prisoners sort of ostracize you as well. So now it's not only staff who sees you as different, prisoners see you as different as well. So a lot of people who do need help, who really do have mental health diagnosis, wouldn't go get help because there's this line, and on that medication line, and that's across mostly every prison I've been in, there's this medication line around 4 o'clock right after dinner, which is the mental health meds. And if you get caught going on that line, right, there's, now you're twice ostracized. You're in prison three times because you're in prison, staff is ostracizing you, and now the prisoners will ostracize you as well. So a lot of that, right, it happens and then people don't seek help. Another reason why people don't seek help is because people don't believe that us service providers will really be there to help them. And that's based on a lot of experience. So some of what we do, some of what we can do, some of how we can offset some of these things that I've talked about is be more client-centered. See the person in front of you, not a diagnosis. Generally, I don't even like to read diagnosis prior to working with someone. It's there, it's on the desk, I'm not saying we forget it, but I want to see the person because you would know the environment that they're in in a moment. So I want to see you and talk to you. And then we can talk about what the diagnosis is and what's the treatment and create a treatment plan because it's a collaborative ride. The healing journey is supposed to be a collaborative ride. But oftentimes when I was in prison, I witnessed a lot of doctors. I didn't do a lot of mental health in prison because it's a stigma, right? So it's almost ostracized to ever ask to see a mental health provider. In fact, if I said I needed to see a mental health provider, the officer probably on the company would have said, hey, Stroud wants to go see a mental health provider out loud. So it's generally, that's not something that you do. However, it's like, yeah, if you're getting what I mean, if I had a real serious issue, and I did 13 years in a box, so I probably do have, did have a real, and do probably have a real serious issue, there was no one that I felt safe to speak to. And that's not the correction staffs doing, that's the people who are doing the services. Because despite the space that we own, we're still dealing with humans. And the idea is when you're dealing with humans, you treat them as such. Again, I'm not a psychologist, I'm a social worker, so we look at the world kind of as a person and environment thing. And then looking at the world as a person and environment, I always check what's happening in the space that people are in before I start trying to give them a diagnosis, because they're people before their mental health or their diagnosis and all the other things that may happen. I just want to make sure I'm covering everything. So, doctor, covered that. So, I want to say a little bit more about trauma in this way. I want to say a little bit more about this in this way. If we took off, I saw the professional room just for one second and thought about humans, just as a human-to-human connection. And thinking about being in prison, and that's an experience that you have to have the experience to really understand. My fiancee tells me she was a correctional officer for 15 years and she always said, oh, I did time in prison, too. Oh, no, you didn't. You came and you did a job and you're laughing. You thought that you was experiencing the same thing I was experiencing. You never did at all. So, if we can come in and sort of use that empathy that we was taught in school. You know, a lot of stuff that they use in school is really like progressive in the way that we use it. And talk about empathy, right, having empathy for the people that we're seeing. And we came in with empathy and we look at a person in a client-centered way and we sort of put ourselves in that space just for a moment. Not that we're not professional, but we're sort of moving away our professional lens just for a moment to see the person that we're dealing with and we create some real, real, real bonds, some real therapeutic alliance, some real alliance with this person. Then perhaps we can get the story of the person and then we can get to what diagnosing is really about, helping people. But if I don't do all that, if I got to, and generally I'm going to have a long list. So, it's like a long list of people I need to see every day and a bunch of other work that needs to happen. And if I just have people running in and out of my office and I'm not really hearing them and I'm saying, well, this is what the diagnosis is saying, here's what the meds is and I'll repeat your meds the next every 30 days, you need to come back. What happens is I miss a point of connection. And I think that's kind of the most important part in the work that we do, the connection part. And I start off by saying I work with a bunch of, I manage about eight groups of system-impacted people, but my tribe, the people I work with the closest, is a group of young men between, like now it's 14, I had to bring the groups down. It was 15 to 21, I had to bring them down last week to 14 to 24. And all of them have been arrested in the use of carrying of guns. So, a lot of them are out now on ankle braces because youth facilities, youth detention facilities are kind of crowded and so they were sleeping in the hallways and in different spaces so they're letting them out on ankle monitors. And they're geniuses. Do they struggle with a lot of stuff? Yes, they struggle with substance use, they struggle with a lot of anger issues, they struggle with a lot of hyper-vigilance, they struggle with a lot of hyper-sensual, you know, they always sort of on, as they said, they always on time and they always on go. Always ready to go. But it's a protective measurement. It's an adaptability piece. So yeah, we don't do mental health there but I'm sending some of them to other spaces to get some trauma work done. And I'm sure that some of them shared that they have IEPs and some of them shared some of the traumas that happened in their life. So I'm sure that there's some mental health amongst them but I don't look at it like that. I look at them as little, not little, because they've grown, right, in the sense that they're already outside and they've probably been outside for a long time. But I look at them as little young men who are struggling to find a space. And then I look at them with the adolescent brain as well. So a lot of times the adolescent, we just know that the brain is still challenging, still going through its process of developing. And the whole of this stuff that they talk about, adolescents, they challenge authority, they don't wanna listen, all those things are happening as well as the trauma that is imposed because they live in Brownsville or they on Rikers Island or they in Crossroads or they in Horizon or any of the other juvenile facilities. So all of that, you're putting all of that into a mix, into this pot and we're sort of boiling it down. And again, it may come that some of them do need some medical assistance. They may need meds to manage some of the mental health issues that are later on diagnosed. That very well may be true but I don't just write them off. I just can't write them off. I can't say these guys are, and that's because that's as they did with all these young men. In fact, I'm gonna say with five young men between the ages of seven and 12 when I was doing therapy in a community-based organization and it just struck me weird that all of them had the same diagnosis. And then when I went around the clinic, all the young black guys and Spanish guys who were between those ages, pre-adolescence had ADHD diagnosis and it struck me weird and nobody else in the clinic could see that. And then they told me about how they would act up in their individual sessions. And then it reminded me of being in prison, being in a box and hearing some of the stuff that I heard coming out those doors when the cells was locked. And it mirrored, it kind of mirrored. So I'm asking, are we setting people up? Early diagnosis, ADHD, is this a setup for later on people that we'll see in Rikers Island in state prisons? I'm not saying that's true. I'm just saying that being on both sides of the aisle, I found it to be sort of, I found it to be sort of the gateway, I thought of it as a gateway. I thought that people were being set up, not deliberately, I thought it was a laziness quota. Instead of going through and managing and really figuring out what's going on, it's easy to sometimes give a diagnosis when something is already known. So I like to, I know I don't got that much time, but I want to end whatever I'm saying with this. If we become more curious, not about the work, because we all know the work. I graduate in five days, I know a lot of the stuff about social work, I know some stuff about mental health and medications and all that, but if we become more curious about the people we're working with in the moment, right in front of us, right there, just curious, we probably would go on to do greater work because the people respond to authenticity and being heard. That's what people respond to. You know, when I came into offices, personally, when I came into offices and had this so much time in a box and I was noted as being a problem, I didn't have to ever say a word because the record was there and everybody already knew, here's the problem. Then I got to a space in Eastern and counselor, correction counselor said, I don't care about this paperwork. I don't care nothing about none of that. They got college here, I want you to find a way to get into this college and I want you to put some stuff together and I think you can do well. The stuff that I see on the paperwork says you're a leader. So she changed the narrative a little bit for me, something I wasn't able to do in the moment because I was caught up in the narrative. And then when I finally got into Bard, there was this idea that I wouldn't be able to manage because I couldn't stay in the school building, not because I couldn't do the work, because they had me sort of diagnosed that I would be a troublemaker and wouldn't be able to be in the school building. You see the story, people start believing in me and told me, this is what they're saying about you. Let's prove them wrong. I bought into that narrative. We can also change narratives. We get the power to diagnose. We get the power to talk to people one-on-one all the time. We can change the narrative. The journey, the healing journey, the one that we collaborate with, the one that we walk people through, we can help them. CBT talks about changing or challenging automatic thinking. I'm gonna challenge all those thoughts that you had, Derek. You ain't tough, you smart. You can do this work. And I graduated Bard in 3.79 or something to that effect. Then they challenged me, when you come home, you'll get a PhD and you'll be the first one who'll have a PhD coming out of prison in Bard. Well, I disappointed them. I didn't get the PhD because I didn't have six years to go back to school. But I did get the master's and now the doctorate in five days. So what I'm saying is that when we're working with people, it's part of our job is to guide them along. Whatever they in. If it is a mental health issue, it's still a part of our job. But some of it, trust me, just from experience speaking, some of that is trauma. Some of that's fear. Some of that's the inability to access information and understand it in time. And some of that is the jobs that we can do when we're dealing with people one-on-one. And so for that, I wanna thank you and just stay curious. I think that we stay curious that all the people that we see in the dyad, all the people we work with in the dyad will sort of benefit immensely. Thank you, everybody. Thank you. Thank you, Mr. Shaw, for those powerful words. I think that message of needing to be more curious about the people we're working with in the moment, the authenticity, being heard, being seen, are all challenges that we can take call to action when we leave and continue to do this work. So thank you. I'm gonna put on my hat as being a member of the Scientific Planning Committee. I think what we just witnessed was a very powerful message. So I'm gonna ask that you follow the social media sites for the APA and that you tweet, share, post your experiences about this session. The AMA's annual meeting hashtag is APAAM24. Again, APAAM24. And for this session, it's SMI is not a crime. So we wanna make sure that those messages are spread and amplified. So again, thank you, Mr. Shaw, for your powerful message. Our next presenter is going to continue to review the needs, standards, and limitations of providing and receiving mental health care in correctional settings. Our next presenter is Dr. Danielle Kushner. She is a Clinical Associate Professor of Psychiatry at NYU's Grossman School of Medicine and is board certified in general and forensic psychiatry. She is currently Assistant Chief of Mental Health at H&H Correctional Health Services in New York City and Associate Program Director for NYU Forensic Psychiatry Fellowship. She is past president of the New York County Psychiatric Society and is currently a corresponding member of the APA Council on Psychiatry and the Law and APAL, which is American Academy of Psychiatry and the Law, representative to the APA Assembly, which is our policy-making body. Her academic interests include health care delivery, hospital violence, psychiatric education in the jail setting, among others. Please join me in welcoming Dr. Kushner. Thank you. Thank you very much for the warm welcome, Dr. Hart and Mr. Stroud, for your powerful statements. My role in the end of this presentation is to introduce the group to the site visit that we will be doing later this morning over to Rikers Island and the clinical facilities. Hopefully, there's a fair amount of you here that will be going on that journey with us, but even so, this is an introduction to our system here and those experiences. I wanna provide a little bit more background that Dr. Ford had talked about of where these visits have come from and especially for me. As I've gone through my training, I really didn't have an experience of jail and prison work or visits until I moved to New York City and the health care system here. And I think this exposure to understanding the jail and prison system, the patients, and what they experience is very important to practice psychiatry in the United States, especially just given the high rates of our population and minority populations that are incarcerated. One of my missions and passions is to educate the younger students and residents and additionally, people like myself in practice that haven't experienced this so they can treat patients better, understand where they're coming from, and understand their communities. So that will be one of these experiences today. And I wanna let everybody or have them keep in mind, like Dr. Ford said, this is not like you're going to another place or an amusement park or a visit, but remember you're going to somebody that, or a place where people are living and going through the challenges that they are and you're a guest in their place just like you are a guest at the House of Security of DOC as well. People also ask, how do you do this work? How do you get through each day? It is very challenging. Cultural and systems work, especially when you see people stigmatized and challenged can be hard to face, especially during the COVID pandemic. I think there was a lot of challenges going on and when I think back at it, some of the trauma that I experienced. But I think the thing that keeps me going and the thing that I want to share with people that may be doubtful about coming into this field and experiencing it is what would happen if we weren't there and how would these people fare in terms of treatment and in terms of their access to care. And keep that in mind when you have those challenging days of the role and why we're doing this work. So on that note, I just want to briefly go through as an introduction to the New York County Jails or the New York City Jail System and provide that overview of what we're doing there in terms of work, how structure and of the mental health system is. So you have a sense of some of the good work and things that we work through each day. So first, looking at this map of New York City, it shows Manhattan and just the large scape of the city and Rikers Island that holds most of the jail population is there in the center, isolated in a sense of just putting those patients and people in a separate area. And that can be a challenge for individuals to get visits and even for staff to get there. So an overview of our system and like other cities and smaller places in the country, we are a conglomeration of eight jail facilities on Rikers Island. Rikers Island itself is not a jail but it's made up of these jail facilities. In the 80s during the jail or during the drug academics, there were more populations and more filled jail buildings there but currently we just have eight open. One that's a female jail and the rest in the male population. And each one of these has different populations and medical and mental health areas of focus in each of these buildings. So for you guys that are going on the visit today, there will be three, we'll break up into three groups and we will be going to buildings that have more of a mental health focus with both general population and mental health housing and those will be the women's jail and OBCC and GRVC. I mentioned the borough jails here. We also used to have jails in each of the boroughs in Manhattan, Brooklyn, Bronx, et cetera. And those were closed and right now we're working with just the jail facilities on the island. There is a big initiative to decentralize Rikers Island and go back to the borough-based jails within the next few years. But it's still a work in progress and something that we hope we're moving, continuing to move forward towards. And luckily in our system we also have two jail units in the city hospitals. They aren't affiliated directly with CHS, the Correctional Health Services at Rikers but we work closely together with them and that's at Bellevue Hospital and Elmhurst Hospital. Elmhurst Hospital unit, it was closed during the pandemic but luckily it finally has reopened in January to provide that much needed care for the women. So just a picture to see an overview of the island. The bridge that you go over from Queens to get there and it just shows the largeness of it, the complexes of each of these buildings that I was talking about, its own city within itself, just with power and food and transportation overall. Just some basic numbers of our jail population. Compared to some small cities, this is a very large amount of people put together and they're all, and imagine just that they're all incarcerated and going through the system. Throughout a year, we have 23,000 people coming in and out and being re-incarcerated and these are new intakes, new admissions, new processing, the mental health history. And on an average day, right now, we're at about 6,000 population. 91% of them are male. As we said, most people incarcerated in this country are male and minority black or Hispanic men, especially in New York City. Young men, 35 is your average age and 90% are pretrial. The population has kind of shifted a little bit over time. It was definitely very, as we said, during the 80s and 90s, much higher than this. But this graph here shows in the last few years the overall New York City daily population. So in 2019, we were actually at one of our highs. And then with COVID coming down, there was a big exodus of people getting out that weren't felony charges. Parole people, we also tried to get out of the jail population and so you really saw a decrease down to about 4,000. Technically, for the borough-based jail plan, you need, the population should be around four to 5,000, which we were around during 2020, but the population has crept up, given some of the safety concerns and initiatives that have been going on recently in the city, and we're closer now, as I said, to the, where is it, at the 5,800 mark. And here, we have the average daily population in the red line at the top. So just an introduction to different types of housing areas that you may see when we visit the mental health housing areas. We will see the clinics and where people deliver care and understanding that, but also, on the mental health housing areas, we do provide services on the unit. This is a general dorm area where people with lesser security clearances will live, and you see that it is close proximity to each other, and the little space that you have that is your own and privacy and collecting all of your belongings that you have with you in these plastic bins. And then, this is a cell unit, actually, of OBCC, and shows a little bit more space and just the individual area that you have for yourself. These are more, usually, higher security individuals and some of our mental health housing. And this is a picture of an individual cell, just a little snapshot of it, where you have your sink, your toilet is behind the wall, a little desk, and for the bed with your mattress, which is definitely not, as you can see, either one of these, very comfortable, welcoming, or homey. So, just a little background of our service and just the richness and things that we do try to provide equal or more improved care than the community. We provide mental health services from medical intake when people first touch down at the jail through release, and we take referrals throughout that time. And we work on a team structure, both with psychiatrists, social workers, creative arts therapists together, and we focus our teamwork based on the housing area and the levels of care that people require. We provide both a rich array of psychopharmacology, I think being affiliated with health and hospitals and not necessarily being part of the jail facility gives us a lot of aspects to provide high quality care in terms of medications and other quality improvement measures, et cetera. And then we do have the access to the hospitalization as well. So, this is the wide range of services that I was saying in different disciplines. And related to the mental health service as well are some very key aspects to medical help and medical treatment. We have a wide range of substance use treatment, which right now is under more of the medical umbrella. But like Dr. Ford said, it is one of the oldest and largest methadone treatment programs in jails. We provide both detox when people first come in, in addition to maintenance treatment with the wide range of everything, methadone, suboxone, et cetera. And we're also distributing in the housing areas NARCAN both to individuals that are incarcerated themselves, the DOC officers and staff, due to the risk and an increasing risk of overdose. We have a strong re-entry for transitioning people from leaving the jail setting, in addition to court advocacy to help with anything that we can do with letter writing for people with serious mental illness or other challenges. Another aspect is the court clinics for court evaluations for competency are also under our services. And we also have an EPAS service, which is a pre-arraignment screening service prior to coming to the jails to see if they can be diverted from the system and provide any advocacy. So we are a rich group at Correctional Health Services of New York City, really providing the services for this needed population. A couple other things to think about is serious mental illness and how that is flagged in our system. It is something that needs to be tracked. As Dr. Ford said, there is a slippery slope and it all kind of blends together in terms of serious mental illness and trauma and other disorders that we're treating and monitoring. But we really do wanna flag the people that have serious schizophrenia, schizoaffective and bipolar, so they don't fall through the cracks in the system. Overall, with us, it's about 20% of the overall jail population, but of everybody that we follow in the mental health service, it's about 37%. And our definition are those with psychotic disorders, whether it's just substance-induced psychosis or schizophrenia, and then 16% have bipolar disorder and lesser amount with depressive disorders or general PTSD. We strive very hard to match or exceed community standards, and that's dictated by the general Board of Corrections of New York, Brad H., a previous legal case and CHS policies. And we exceed over the NCCHC guidelines as well. We strive to continue to provide the services and what are needed. Sometimes there are things that may be considered out of direct control, whether people are going to court or things in housing area. You can't get transport or something with DOC, but we still factor in to try to make people get their treatment in the guidelines that are expected. I won't go too much into detail here. This is something we'll hit more in the tour and some talks there today, but just how people walk through our system in terms of medical intake is the first place to be flagged. There's a lot of research and different ways to make sure that people are picked up and what questions to ask at medical intake. And we have referrals from other sources overall, legal aid, family, 311, outpatient treatment teams. And then after doing that evaluation, we refer them to the housing area and the clinical care that they best need, whether that's general population clinic or a mental health therapeutic unit. And we have two levels. We have a general mental observation unit and our enhanced services, which are called the PACE units. And so general population, you come down like you're an outpatient. You see your people in the clinic and you go back to your housing area. MO and PACE, we provide the services on the unit similar to hospital level of care. And there's more groups, programming and supports. And it really is a treatment environment. PACE is something that was created by Dr. Ford when she was at CHS, really modeling the level of care at Bellevue Hospital. We have nurses on the unit there as well that help encourage medication compliance, lab work. And we have increased monitoring such as behavioral health techs on that unit as well. So there's a lot of resources, a lot of things that we try to do to provide care. It's not a replacement. We don't want our people to be incarcerated or be in this setting, but given where they are, we still want to provide to them and help them get the support and treatment to transition out of the community. Lastly, just as a final note, I just put a summary of the article from the PACE outcomes of Dr. Ford in 2020 that really showed with this initiative just the increased care of medication compliance, decreased uses of force, and even so with self-harm with this increased monitoring in our housing areas through PACE. So there's a lot of initiatives and drive to really provide that care. So we're welcome to those that are coming on the tour. I thank you for taking that time to understand this population and thank you for coming with us today. And I will hand it over back to Dr. Hart. Thank you. Thank you again, Dr. Kushner, for highlighting some of what we will see today and really, again, a call to action to make sure that you are accessing patients for mental health disorders when they arrive in correctional facilities and that there is a continuity of care when individuals in custody release. As people start to come to the mic, hopefully to ask questions or give comments, I do want to state one thing that I think is important, that trauma, it can be direct or vicarious and people who work in corrections do also have high instances of trauma, higher rates of PTSD, anxiety disorders, substance use disorders, suicide greater than the community standards, and also that even, like I work in federal, people are often deceased 18 months after they retire. So while we certainly do not experience the same type of trauma, there definitely is an experience where people in correctional officers and other providers in that setting are at risk. So just to make sure I highlight that, but we do welcome your questions and feedback. If you would like to come to the microphone in the center to make sure that the audience on demand or can also hear your question or comment. Hello. Good morning. Thank you for the presentation. Can you add one more to the tour? We wish we could. Unfortunately, we have to do the background and security clearance well in advance, couple weeks in advance. But that's on the record that there was more injuries, so we'll make sure that when we come back to New York that we do our best to include this again. Thank you. Please. Thanks. I'm here from Toronto. I'm sure the mental health laws here are different than where I am. A lot of the population about whom you're speaking have SMI, which you've defined as psychosis mainly. Those clients, patients can receive all the TLC in the world. If they don't get their meds, they're gonna be sick. So my question really, or questions are about having the capability to make consent decisions. Are there substitute decision makers? Once the clientele leave being incarcerated, how do you maintain their medication if they have no insight, which the majority of patients with psychosis don't have insight, often forever? How do you keep them in treatment? And from the other end, are a lot of these people incarcerated because they weren't taking or receiving treatment, and were they not receiving it because they were refusing it due to lack of insight, and the laws here not allowing to keep them in treatment against their will? Or do they? How difficult is it to keep people who have no insight in treatment? Jafar, do you wanna start? Sure. Lots of questions in there. I'm not gonna be able to adequately do justice to those. Maybe we'll push back a little bit. In my experience, the majority of people I've taken care of with schizophrenia do have some level of insight. And if they don't, it's oftentimes not germane to them not taking medication specifically. But at least, and also, so civil commitment laws, the laws that govern forcing people into spaces vary across the United States in each different state. In New York State, there are three main ways to do it, and the one I think that's most relevant for your question relates to people having an involuntary commitment, which is you have to have a lack of capacity. So you have to, to your point, a little like a lack of insight and an ability to make the decisions about your healthcare and to have some kind of ongoing or acute dangerousness and to have a mental illness. So it does factor into civil commitment. When someone gets incarcerated, oh, and then the other piece is treatment over objection, which I think is what you were referring to in terms of having people take medication who really need it. In the jail system in New York City, we have actually, there's no law that restricts forcing people to take medication that's on the books, but there's never been a case that has tested that on the legal perspective. In the prison system in the United States, people can be forced to take medication pursuant to administrative hearing, and the U.S. Supreme Court has weighed in on that in a case called Washington v. Harper, but that's been extended to jail systems only rarely and not in New York City, and actually, intentionally not, because the PACE units that Danielle was referencing, use a non-coercive model to help people engage with their medications, and that demonstrated adherence rates in line with people who've been forced to take their medications. So we're trying, and I don't, you can talk more specifically now. I left the system a few years ago, but the goal is to engage patients more in their treatment, and so there's that, and then there was one other part to your question that I, oh, the transition to the community. Yeah, I mean, that's a question for people leaving hospitals, people leaving jails, people leaving prisons, people leaving nursing homes, people leaving any kind of confinement setting. I think maybe we probably don't have time to go into that here, but it's a challenge that faces people leaving institutional care, and I would say New York City has a long ways to go in terms of community resources that can really adequately help there. So one of my roles is being the American Medical Association's representative to the National Commission on Correctional Health Care. So this discussion about reentry and making sure people have their medications and access to treatment, like giving warm handoffs as a priority for the commission. So there's currently a position statement in the works to improve transition of care. And to your question for the federal government, a person who is in custody and living with a mental health disorder, you cannot have a substitute decision maker for mental health treatment or a guardian while you're in federal custody, but as Dr. Ford mentioned, we have Harper hearings, so it's like a due process to involuntarily treat people if they are imminently at risk for hurting themselves or others or gravely disabled, so not taking care of their basic needs. Sir? Yeah, two quick questions. Number one, how is the CHS funded? Great question. So currently CHS in 2015 is now under the New York City Health and Hospitals Corporation, which provides the city treatment throughout the five boroughs. So we are an aspect of that system, which I think has helped some of the background to provide the adequate formulary medication and some of the hospital infrastructure and quality improvement measures, recruitment, et cetera, compared to other ways that jails and prisons can be staffed. Other models that Dr. Ford had talked about have been incorporated in New York City before. We were a contracted agency prior to health and hospitals coming in, so there has been a difference, which I was not under that system, so Dr. Ford can talk about it a little bit more. City taxpayer dollars funded, basically, is the answer. I'm sorry for interrupting. No, no, that's just so that you know. So the next question is, I come from a state, Oklahoma, that is not as forward-thinking as New York is. Do you talk about this at conferences around the country to help encourage others to, our state does not fund corrections in the mental health as much as New York does. Is there an effort to help spread this model nationwide? We had a presentation yesterday with CHS as well, and there was a similar question, how would you encourage your local area to have more, they were talking more resources, academic, the educational aspects, and I think having more presentations like this and education, I'm definitely on that camp that this will spread the word. We'll reach out to organizations. We can do our part, but additionally, you guys taking back this information and advocating for education, partnering with your local institutions to get more residents and fellows rotating through these areas and being exposed, I think, is the first step. In my experience, these institutions see it as recruitment, and recruitment is the way to kind of find that ticket in as the more you educate, the more you have an ongoing workforce, and I think that is important. So definitely encourage you all, and we are working on an educational guide and training for residency programs to get more people exposed and continuing new innovative ways to spread the word. I'm sorry, just real quickly, the other catch is cost savings, which, so Nebraska, Ohio, Indiana, I've been talking there around, so these models reduce violence and self-harm, and that means reducing trips to the hospital, reducing the costs of medical care, reducing transport and all. So I would love to say that the incentive would be great patient care. That's typically not the best first message for some of these agencies that really care about the money. So again, I would encourage you to follow APA's social media sites, hashtag SMIIsNotACrime to share your thoughts about it, and APAAM24 if you want to see more sessions focused on people who are in custody, adults incarcerated, juveniles, so that we can begin to talk about it until our patients are not receiving most of their care and corrections. This should be a priority for the APA, but we need members to encourage that. So you take one final question. Thank you, I thought you were out of time. I appreciate it. Thank you so much for the presentation. My question is about PTSD. You know when you listed the SMI percentages, I thought that maybe, I'm wondering if the numbers are coming from diagnosis that were given, or whether if you were to actually screen the population, do you think you might pick up a lot more PTSD than 9% or something like that? Yes, and that was a shortened slide from one that we presented yesterday, in that full diagnosis of PTSD is more narrow, and our catch-all term, more of our people, even 30%, fall under other specified trauma, which is more of our complex PTSD. And as we all know, that's very hard to diagnose, and is something that is definitely underrepresented in the numbers. So I want to thank each of our panelists for sharing their experience and knowledge with us today.

mental illness

psychiatrists

correctional system

incarcerated individuals

mental health care

staffing shortages

COVID-19 pandemic

carceral psychiatry

ethical considerations

community reintegration

trauma responses

client-centered care

systemic issues