Protocol for a quasi-experimental, 950 county study examining implementation outcomes and mechanisms of Stepping Up, a national policy effort to improve mental health and substance use services for justice-involved individuals

Implementing a Treatment for People with Serious Mental Illness in Jail: A Mixed-Methods Study of Stakeholder Perspectives on Feasibility and Acceptability

People with mental illness are over-represented in the U.S. criminal legal system. Jail presents an optimal opportunity to provide needed mental health care as the entry point to corrections. However, there is a lack of programming available in jails, which may be partly due to limited understanding of how to successfully implement interventions in this complex setting. We implemented a nine-session psychotherapeutic intervention for people with serious mental illness in a county jail. As part of a larger implementation-effectiveness hybrid study, we gathered mixed-methods data from stakeholders (treatment recipients and jail administrators) on the feasibility and acceptability of the intervention's implementation. In focus group discussions and qualitative interviews, treatment recipients (n = 29) provided qualitative and quantitative data on their perceptions of the implementation's feasibility and acceptability. Jail administrators (n = 6) completed two quantitative self-report measures on their perceptions of the treatment's feasibility and acceptability. Qualitative analyses were conducted by two coders using inductive thematic template analysis; seven global themes relating to treatment recipients' perceptions of the assets and hindrances to feasibility and acceptability were developed and are presented with supporting quotations. Quantitatively, all treatment recipients endorsed the intervention's feasibility (100%), and nearly all (97%) endorsed its acceptability. On both self-report measures, jail administrators' mean scores fell above a-priori thresholds indicating feasibility and acceptability. We found qualitative and quantitative support for the use of this intervention in jail from both sets of stakeholders. These results have implications for clinical service and policy in jail, where service providers struggle to meet the considerable demand for mental health services.

Recommended Mental Health Practices for Individuals Interacting With U.S. Police, Court, Jail, Probation, and Parole Systems

OBJECTIVE

Tens of millions of individuals with mental health problems interact with the U.S. criminal legal system (including 911, police, jail detention and sentences, courts, and probation and parole) each year. The authors sought to identify recommended mental health practices for criminal legal system-involved individuals and report the percentages of U.S. counties and of the U.S. population living in counties in which each recommended practice is present.

METHODS

Recommended practices for criminal legal-involved individuals with mental health problems were identified from meta-analyses, reviews, and best practice recommendations. Up to four respondents per county (i.e., jail, probation, community mental health, and community substance use treatment administrators) from 950 counties were asked whether each recommended practice was present for criminal legal-involved individuals. Weighted percentages of U.S. counties using recommended practices and of the U.S. population living in counties with each recommended practice are reported.

RESULTS

Fifty-nine recommended practices, including general mental health approaches (e.g., permanent supportive housing, Medicaid continuity) and diagnosis-specific mental health treatments (including medications and psychotherapies), were identified. Weighted data from respondents (N=791 from 519 counties) indicated that each recommended practice was present for criminal legal-involved individuals in only 21.9%-43.0% of U.S. counties.

CONCLUSIONS

These results inform implementation efforts by indicating the presence of recommended care practices for criminal legal-involved individuals with mental health problems in counties nationwide. Because supportive housing, access to Medicaid reactivation in jails, and psychosocial interventions for physical pain have low presence but high importance for recovery, implementation efforts might first target these approaches.

Assessing County-Level Behavioral Health and Justice Systems with the Sequential Intercept Model Practices, Leadership, and Expertise Scorecard

The Sequential Intercept Model has helped conceptualize interventions for people with serious mental illness in the criminal/legal system. This paper operationalizes the Sequential Intercept Model into a 35-item scorecard of behavioral health and legal practices. Using interviews, survey, and observational methods, the scorecard assesses an exploratory sample of 19 counties over 27 independent data collections. A series of ordinary least squares regression models assessed the predictor scores on four jail outcomes: prevalence of serious mental illness, length of stay, connections to treatment, and recidivism. Increases in pre-booking scores showed significant decreases in jail prevalence of serious mental illness at the p < 0.05 level, and post-booking scores and overall scores showed significant positive associations with connections to treatment at the p < 0.05 level, though these were non-significant after correcting for multiple comparisons. Preliminary findings suggest a combination of practices across the Sequential Intercept Model could have synergistic impacts on key jail diversion outcomes.

Applying the Stress Process Theory to Assess Correlates of Suicide Ideation-to-Action Among Persons on Parole in the United States

There is limited knowledge regarding precipitating factors associated with suicidality among persons on parole. Pairing the suicide ideation-to-action framework and stress process theory, the present study aimed to characterize sources of major stress (drug use, physical health, and mental health) and their associations to suicide ideation, planning, and attempt among a national sample of persons on parole. This study included a subsample of persons on parole (N = 1725) using pooled national data from the National Survey on Drug Use and Health (2015-2019). A series of logistic regression results indicate that various drug use, physical health, and mental health factors significantly influenced all three suicidality measures. Due to this population's unique experiences and numerous barriers following release from prison, it is essential to personalize interventions geared toward this population to meet their specific needs and address suicidality based on where they fall on this continuum.

The relationship between community public health, behavioral health service accessibility, and mass incarceration

Background

The relationship between healthcare service accessibility in the community and incarceration is an important, yet not widely understood, phenomenon. Community behavioral health and the criminal legal systems are treated separately, which creates a competing demand to confront mass incarceration and expand available services. As a result, the relationship between behavioral health services, demographics and community factors, and incarceration rate has not been well addressed. Understanding potential drivers of incarceration, including access to community-based services, is necessary to reduce entry into the legal system and decrease recidivism. This study identifies county-level demographic, socioeconomic, healthcare services availability/accessibility, and criminal legal characteristics that predict per capita jail population across the U.S. More than 10 million individuals pass through U.S. jails each year, increasing the urgency of addressing this challenge.

Methods

The selection of variables for our model proceeded in stages. The study commenced by identifying potential descriptors and then using machine learning techniques to select non-collinear variables to predict county jail population per capita. Beta regression was then applied to nationally available data from all 3,141 U.S. counties to identify factors predicting county jail population size. Data sources include the Vera Institute’s incarceration database, Robert Wood Johnson Foundation’s County Health Rankings and Roadmaps, Uniform Crime Report, and the U.S. Census.

Results

Fewer per capita psychiatrists (z-score = -2.16; p = .031), lower percent of drug treatment paid by Medicaid (-3.66; p < .001), higher per capita healthcare costs (5.71; p < .001), higher number of physically unhealthy days in a month (8.6; p < .001), lower high school graduation rate (-4.05; p < .001), smaller county size (-2.66, p = .008; -2.71, p = .007; medium and large versus small counties, respectively), and more police officers per capita (8.74; p < .001) were associated with higher per capita jail population. Controlling for other factors, violent crime rate did not predict incarceration rate.

Conclusions

Counties with smaller populations, larger percentages of individuals that did not graduate high school, that have more health-related issues, and provide fewer community treatment services are more likely to have higher jail population per capita. Increasing access to services, including mental health providers, and improving the affordability of drug treatment and healthcare may help reduce incarceration rates.