Psychotherapy Bulletin

Psychotherapy Bulletin

Clinical Impact Statement: This article looks at the need for change in the intertwined criminal justice and mental health systems, through the personal lens of the author’s training and career. Suggestions for approaching systemic change as mental health providers and advocates are included.

I have approached life and my career with a genuine enthusiasm for adventure. I have also found my richest experiences in life to come from learning to be comfortable with the uncomfortable. Being asked to write about my career turning points as a relatively new psychologist evoked this uncomfortable feeling. Do I really have something to write about that others care to read? My desire to end human suffering and promote values of equality and justice is a widely shared goal among many in the field. However, I am grateful for this opportunity to share my thoughts on the need for larger systemic change within criminal justice and behavioral health settings.

Thus far, my most significant career turning point was matching for pre-doctoral internship at NYU Bellevue Hospital as part of the Forensic Track. It was one of the best training years of my life, and I was fortunate to be surrounded by arguably one of the top intern cohorts Bellevue has ever seen. Obviously, I am a bit biased, but the rigorous training year was somehow muffled by the laughter and support. Unlike many of my colleagues, I chose to apply for jobs after internship rather than a postdoc. I was fortunate and accepted the position as the Team Leader for the Brooklyn Forensic Assertive Community Treatment (FACT) team at the Center for Alternative Sentencing and Employment Services (CASES). This mobile-based mental health team was designed to help individuals with severe mental illness and criminal justice involvement live sustainable lives in the community. Our clients were some of the Brooklyn’s most vulnerable and marginalized members. Each one of them had seen the inside of a psychiatric hospital, emergency room, prison cell and/or courtroom far too many times. Many struggled with primary psychotic illnesses with co-occurring substance abuse disorders. Their lives were laden with trauma, ruptured relationships, and homelessness. As you can imagine, it was a steep learning curve- overnight I went from an intern to a manager, administrator, and clinical supervisor. Fortunately, I was starting with a strong foundation of training and experience coming from Bellevue and the University of Denver’s Graduate School of Professional Psychology.

Like many things in this world, my first job was a mix of privilege, timing, and luck. I mention privilege given my ability to train at Bellevue and live in New York City with the support of family, despite large student loan debt. An internship at Bellevue Hospital afforded me exceptional clinical training and an expanded network of clinicians and mentors. Timing in sense of right place, right time. New York City wanted to build five borough specific FACT teams and a former Bellevue graduate was looking for eager psychologists to staff the teams. Lastly, I say luck because I will always believe in non-scientific based things such as luck or karma. Yes, there were years of hard work and perseverance leading up to it, but in that moment, luck, karma, or something bigger showed up and helped me get my first job as a clinical psychologist.

The Need for Change

As the Team Leader for the first Brooklyn Forensic ACT team, I felt connected to something much greater than just my team, our clients, or CASES. I felt connected to the movement in New York City to end mass incarceration, to stop the rotating door between psychiatric hospitals and correctional facilities, and to increase access to mental health treatment for marginalized community members. It was life changing- challenging, of course, but the type of challenging that motivated me to do better, work harder, and learn more. I worked alongside deeply inspiring, passionate people from all disciplines and backgrounds. Together we were fighting for a solution, determined to see change within the system. However, it did not take long to feel hindered by the slow bureaucratic issues that made change feel almost impossible.

In order to lead a group of eager and relatively new social workers, I had to first bring my attention to the here and now- distract my mind from wandering to the aspirational intersection of mental health and criminal justice. As a team, we needed to work together to get through each day. We encouraged each other to take joy in every win, no matter how small or seemingly insignificant. We focused on supporting one another, creating a place where people’s strengths were utilized, and searching for ways to improve how we delivered treatment to our clients. We did the best we could with what we were given. We stressed the importance of self-care and work/life balance, as part of our job entailed living and reliving the traumas endured by many of our clients. In order to continue showing up for them, we needed to first show up for ourselves. It was our job to meet our clients where they were at in their recovery with hope, compassion, and enthusiasm.

From working this population, I have developed some strong opinions. To me, it is pretty simple: People managing mental health issues get better in the community, not in jail or prison. It is a widely known that for years our criminal justice system has functioned as a series of ill-equipped psychiatric treatment centers- not designed to treat and heal, but rather to punish and supposedly deter. Our criminal justice system is disproportionally harsh on communities of color, especially those with mental illness, substance abuse, and lower socioeconomic backgrounds. For many, there are traumas associated with incarceration and extreme psychological difficulties when reentering the community. Within the bubble I choose to live, psychologists, social workers, psychiatrists, and those passionate about this topic are well-versed in the layers of systemic atrocities– numbed, outraged, and deeply saddened, though not surprised, when horrific stories like Kalief Browder are brought forth in the news.

From my experience working in New York City, change is happening. The movement for mental health treatment behind locked doors and barbed wire is improving, but the rate of victimization within the criminal justice system is still too high. Many of our clients shared the traumas they endured while awaiting sentencing at Rikers Island or serving time upstate. These are stories filled with violence and abuse. The number of young Black men who endured their first psychotic break while in segregation was far too many. I heard about the experiences of men who would never wear the color green [one of the prison jumpsuit colors] because it brought back vivid memories of events they would prefer to forget forever. I listened to the experiences of women who endured physical, psychological, and emotional trauma while losing their children to the system, uncertain if they would ever be able to hold them again. People’s lives were forever changed by incarceration, which exacerbated their mental illnesses and made reentry into life in the community much more difficult.

What Can We Do?

As a nation, we need to intervene sooner, strengthen our diversion programs, and increase access to mental health for all community members. We need to expand our mental health, drug, and specialty courts systems and give juveniles and adults an opportunity for recovery sooner. I will never forget the day I witnessed our first mental health court client be un-handcuffed and released to our program. I was fortunate to bear witness to this many times, and for those who were able to manage life in the community with their available supports, it was remarkable to see their progress and positive interaction with the legal system. They felt the judge cared about them and their lives. They also felt pride and a sense of accomplishment once they finished. After observing the different mental health court systems in New York City, I became aware of the politics and the dance that occurred in and outside of the courtroom, between courtroom players, advocates, and judges. There were politics behind the cases that were accepted, the cases that were rejected, and conditions for sentencing. There were also strong opposing viewpoints and variable levels of understanding about mental health among legal professionals. To me, this intersection is the perfect place for psychology to influence change, if we are willing to develop the necessary skills. We need to learn to speak the language and participate in the dance. We need to learn to articulate the challenges and overlap between mental illness, criminogenic risk, and risk assessment. We need to learn to explain dynamic and static risk factors through a clinical lens, the role of strengths and protective factors, and how risk can be mitigated through appropriate community based intervention. Simply, we need to continue educating our court systems and legal professionals on mental health and community-based treatment.

On a united front, we need to increase access to all mental health services for our community members. Intervention needs to happen as soon as possible and we need to be creative and dynamic in our approach. This requires qualified, trauma informed professionals in these positions to change an individual’s first experience with the mental health system. Our clients had years of negative experiences with mental health, and it was our job to change that. We were given service dollars and told to be imaginative. We viewed our clients through a person-centered lens and met them where they were at in their recovery. Assertive Community Treatment (ACT) changes the walls of treatment and awards individuals a different experience with mental health. Why does it take repeated hospitalizations, patterns of not taking psychiatric medications, and criminal justice involvement to get a FACT team? Might some people need a mobile team from the beginning? I wonder: Can we identify the needs of our community members and develop treatment around those points, rather than having people mold to the model of mental health we most commonly know?

We need to open more discussions between corrections and mental health and push through the resistant barriers to change through platforms, discussions, and trainings. We need to improve how we communicate with and understand one another. The movement is alive and well, and change is slowly happening but we must keep talking. On our team, we witnessed insignificant parole violations with short-term incarceration jeopardize a client’s place of residence, after years of living in the shelter system and working toward stable housing. We observed parole officers who were understanding and compassionate towards the ebb and flow of stability, and those who were not. If you have never been to a New York City shelter, pay a visit to one, and try to put yourself in the resident’s shoes. How are individuals with severe, complex trauma backgrounds, managing severe mental illness and substance abuse, supposed to see hope in treatment if they don’t have a safe environment in which to live? How are they able to meet every demand the criminal justice systems puts on them while living in the community in such conditions?

Developing peer support models. Additionally, we need to grow the peer movement. Peers are individuals who share background experience of mental health, substance abuse, or criminal justice involvement with the people they serve. They are able to provide support, validation, and empowerment through a different lens than medical personnel, psychologists, or social workers. Peers bring a valuable perspective to the discussion, one that I believe needs to be heard more often. I will never forget when my team was grappling with the thought of a client returning to jail due to a parole violation related to smoking marijuana. The parole officer agreed to substance abuse treatment; however, our client wanted to serve time. We as a team had blinders on, only focused on the re-traumatization that might occur by returning to jail. My staff searched, advocated, and fought for a place to accept our client, believing he would change his mind. It wasn’t until the peer specialist on our team shared his perceptive that we understood how this choice could be empowering. How at some point you are simply exhausted from running and you just want the chase to be over. Within this movement, we also need to learn how to best support our peers, through supervision and workload expectations. I watched too many peers come through our team, struggling to manage their own hardships, while giving a large part of themselves to others.

Working effectively with other support systems. We need to continue the conversation between hospitals and community based treatment. To be honest, I was struck by my own learning curve, and how much I did not know until I ran the Brooklyn FACT team. I want to challenge hospitals to reevaluate their approach to medication and think about what happens after a client leaves those hospital walls.  Discharging a homeless patient from a psychiatric hospital with a bag of oral medication, required to be taken multiple times a day, without discussing the option of injectable medication seems ineffective and potentially harmful. I have spoken to psychiatrists about this particular concern. They reassure me that these conversations are happening, and the case I am referencing is an outlier. Injectable medication not only decreases risk for the client, but also for the community. I believe that one’s approach and choice of words can empower an individual in making a decision about a medication regimen that works for them. It is also important to see what might be lost in the dialogue. For example, I had a client who required a translator during our sessions. Despite my experience working with translators and attempts to explain this concept, I was flabbergasted when I realized he was refusing injectable medication because he believed he would be stuck with a needle every day. I could have sworn I did a good job explaining it— clearly something was being missed.

The challenges that accompany hospital systems are complex, and I recognize I have only been exposed to few. However, I see the importance of more discussion on complex topics such as medicating substance abuse, traumatic brain injury, and trauma with antipsychotics and mood stabilizers, occurrences that were far too common among our clients.

Conclusion

Now more than ever, strong leadership within behavioral health, criminal justice, and state government is paramount in this movement for change. I want to challenge reformers to understand the issues of front line staff and stakeholders by bringing them to the discussion before developing and implementing programs. Ask questions, listen, then ask some more. They are filled with knowledge and a unique perspective. It is one thing to develop a program that sounds good on paper, and another to do it by knowing what works and what does not. By excluding these voices from the discussion, I believe we do a disservice to our community, wasting time, money, and effort in the process. At every level we can be working for change, but our leaders sent the tone. Long-term change occurs from the top and works its way down.

Lastly, we need to shift the culture within mental health to one which prioritizes staff wellbeing. By valuing staff, we are taking better care of our institutions, agencies, and clients. Culture within public mental health needs to support both productivity and wellness. Let’s face it; I don’t think there will ever be a time when the workload will evenly match the allotted timeframe. The culture needs to value the individual employee and promote growth, similar to how Assertive Community Treatment (ACT) takes a person-centered approach. Within this culture, we need to increase lines of communication, acknowledge individual efforts, and offer employee programs that promote a healthy work/life balance, from physical to mental health, to social, financial, and spiritual wellbeing. I witnessed how burnout and compassion fatigue at every level can lead staff to look for a different job. It eventually got the best of me. I recently left my job as the Brooklyn FACT Team Leader for some time to reflect on my next steps … Time to figure out how I can reenter the system in a way that supports larger change in alignment with my viewpoints.

Cite This Article

Vogel, R. (2018). A personal perspective on systemic change. Psychotherapy Bulletin, 53(2), 23-27.

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