central new york psychiatric center: an approach to the treatment of co-occurring disorders in the...

Behavioral Sciences and the Law

Behav. Sci. Law 20: 523–534 (2002)

Published online 17 June 2002 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/bsl.488

Central New York PsychiatricCenter: An Approach to theTreatment of Co-OccurringDisorders in the New YorkState Correctional MentalHealth System

Hal Smith,* Donald A. Sawyer, Ph.D., M.B.A.,y

and Bruce B. Way, Ph.D.y

Central New York Psychiatric Center operates a maxi-

mum security inpatient treatment hospital and outpatient

mental health services for all of the 72 New York State

prisons. In this article prevalence data, patient character-

istics, and interventions offered to inmates diagnosed

with co-occurring mental illness and substance abuse dis-

orders in the New York State prison system are reviewed

and discussed. Available interventions have resulted from

the close collaboration of the State Department of

Correctional Services and State Office of Mental Health.

Aspects of current programs and plans for future service

developments are discussed along with implications for the

treatment of an offender population diagnosed with a

co-occurring disorder. Copyright # 2002 John Wiley &

Sons, Ltd.

Prior to 1977, the New York State Department of Correctional Services (DOCS)

was responsible for the provision of security, medical, and mental health services for

all inmates in the state correctional system. In 1977, jurisdiction for the mental

health treatment of inmates in the state correctional system was transferred from

DOCS to the New York State Office of Mental Health (OMH). In response, the

Central New York Psychiatric Center (CNYPC) organization was established.

CNYPC has statutory responsibility for providing a comprehensive range of mental

health services to inmates in DOCS, as well as forensic evaluation and treatment

Copyright # 2002 John Wiley & Sons, Ltd.

*Correspondence to: Hal Smith, Executive Director, Central New York Psychiatric Center, Box 300,Marcy, NY 13403, U.S.A. E-mail: [email protected] New York Psychiatric Center.

services for pre-trial jail detainees in a 36 county catchment area. However, the

primary population at risk is the 70 000 inmates in DOCS.

During the last ten years the New York State prison population year-end census

has increased from about 50,000 inmates to 70,000, approximately a 40% increase.

During the same period, the number of state prison inmates on the mental health

caseload has had an even greater percentage increase. While the number of inpatient

beds (about 200) has remained unchanged over the period, the outpatient mental

health caseload expanded from about 4,600 to 7,400 patients, approximately a 60%

increase. While over the last 10 years the number of annual admissions to state

prison has remained fairly constant at approximately 30 000 individuals, a greater

proportion of these admissions have been assessed and identified as in need of

mental health services. A recent study at one of the four New York State reception

centers, where inmates enter the state prison system, found that between 1991 and

1998 the percentage of inmates identified as requiring mental health services

increased dramatically (Hill, 2001).

The mental health service delivery system provided by CNYPC for state prison

inmates includes the operation of a 206 bed maximum security forensic hospital, 12

Mental Health Satellite Units located in select state maximum security correctional

facilities, and 11 Mental Health Units located in medium security correctional

facilities. For calendar year 2001, inpatient hospital totaled 850 annual admissions

with a median length of stay of 42 days. As of December 31 2001, the Satellite and

Mental Health Units (referred to as CNYPC’s outpatient services) had an active

patient case load of 7,400 inmates receiving mental health services. The treatment

strategy for this service delivery system has been the development of prison-based

community services and programs (staffing increased by 30% in 2000–2001), while

keeping inpatient hospitalization to a minimum.

During the two and a half decades of CNYPC’s operation, a strong partnership

has been forged between the OMH/CNYPC and DOCS. An interagency agree-

ment, detailing the respective agencies’ interactions and responsibilities, is articu-

lated in a formal Memorandum of Understanding, which is reviewed annually by the

OMH and DOCS Commissioners. At the annual meeting, joint agency initiatives

and potential budget submissions are proposed and discussed. One measurable

outcome of the success of this collaboration is CNYPC’s attainment of full

accreditation by the Joint Commission on Accreditation of Healthcare Organiza-

tions (JCAHO). While the inpatient hospital has been JCAHO accredited since its

inception, the outpatient Satellite Units were not included in the survey process

until 1995. In 1995, 1998, and again in October of 2001, the CNYPC organization

(inpatient and outpatient/prison based services) were fully accredited by JCAHO.

According to JCAHO, CNYPC is the only fully accredited, statewide correctional

mental health system in the United States. It should also be noted that all DOCS

facilities housing Mental Health Units are also fully accredited by the American

Correctional Association (ACA).

What follows is discussion concerning the prevalence of those with a co-occurring

disorder in both the general population and those who are incarcerated in prison. In

addition, data gathered by DOCS and CNYPC on mental illness and substance

abuse will be presented. Later discussion includes specific services and programs

available to those diagnosed with a co-occurring mental illness and substance abuse

disorder in state prisons.

524 H. Smith et al.

Copyright # 2002 John Wiley & Sons, Ltd. Behav. Sci. Law 20: 523–534 (2002)

PREVALENCE OF CO-OCCURRING DISORDERS

IN PRISON

The impact of substance abuse over the past four decades has been well chronicled

in the popular press. For the past 20 years, professional concern and commentary as

to how best serve individuals with co-occurring mental illness and substance abuse

disorders in the community has increased (Drake, Mercer-McFadden, & Mueser,

1998; Minkoff, 1991; Osher, 2001). More recently, approaches for treating indi-

viduals with co-occurring disorders in prison environments have emerged. Edens,

Peters, and Hills (1997) review seven new dual diagnosis treatment programs being

tried in prison settings. Therapeutic community, cognitive restructuring, psycho-

education, relapse prevention, and transition to the community were common

elements. Treatment approaches in New York State for inmates with co-occurring

disorders are discussed later in this article. It is estimated that in the United States,

up to ten million individuals meet the diagnostic criteria for a co-occurring disorder

within any given year (CMHS, 1997). More on point, it is estimated that between 3

and 11% of prison inmates nationally meet the diagnostic criteria for co-occurring

Axis 1 mental illness and substance abuse disorder (Peters & Hills, 1993). Similarly,

the National GAINS (gather, assess, interpret, network, stimulate change) Center

for People with Co-Occurring Disorders in the Justice System estimates that 13% of

prison inmates have both a serious mental illness and a substance abuse disorder

(National GAINS Center, 1999). Further, the GAINS Center estimates that among

prison inmates with schizophrenia, major affective, or antisocial personality

disorders, the prevalence of co-occurring substance abuse disorder is 90%. Cote

and Hodgins (1990) estimate that about 26% of substance abusers in prison have a

lifetime history of bipolar disorder or major depression and 9% have a history of

schizophrenia. Separate estimates for prison populations based on Ecological Catch-

ment Area data for serious mental illness and substance abuse without considering

co-occurrence are alcohol abuse—26%, drug abuse—56%, schizophrenia—7%,

major depression—9%, and bipolar disorder—5% (Peters & Hills, 1993).

In New York, each individual inmate’s history of drug and alcohol abuse is

recorded upon their reception into the prison system. According to DOCS reports,

71% of the inmates under custody on December 31 2000 had either an alcohol or

drug abuse problem or both (New York State DOCS, 2001). Accordingly, of the

70,000 inmates under custody, 71% would equate to almost 50,000 with substance

abuse histories. In the reception and classification process, alcohol abuse is

determined by the Michigan Alcoholism Screening Test (MAST) whereas drug

abuse is determined via inmate self-report. It was noted that the percentage of

inmates with substance abuse was higher for women, with 87% having a substance

abuse problem, as compared with 70% for men. With respect to abuse patterns,

47% used drugs only, 35% used both alcohol and drugs, and 19% used only alcohol.

According to the DOCS report cocaine was the mostly widely used drug aside from

alcohol.

Data used to develop the above estimates were obtained during the DOCS

reception process which did not include assessment by trained mental health

professionals, which comes later. It is unknown as to what portion of the 50,000

substance abusing state prison inmates in New York would meet the formal

Treatment of co-occurring disorders 525


diagnostic criteria for a substance abuse disorder. Self-reported drug abuse is likely

less reliable than formal diagnostic criteria. However, if one were to combine the

50,000 estimate with the 9% history of schizophrenia as reported by Cote and

Hodgins (1990), there may exist an estimated 4500 individuals in prison with a

history of schizophrenia and substance abuse. Using the 3–11% national estimates

of co-occurring serious mental illness and DOCS substance abuse disorder

produces estimates of between 2,100 (3% of 70,000) and 9,100 (13%) inmates.

Based upon available DOCS reports and national prevalence data, it is

reasonable to conclude that co-occurring disorders present significant treatment

issues for inmates in New York State prisons. This treatment challenge will be

further considered with a presentation of the caseload characteristics of those

currently being served on the CNYPC active mental health caseload.

CASELOAD CHARACTERISTICS OF THE CNYPC

PATIENT POPULATION

As of August 1 2001, CNYPC’s caseload consisted of 159 inpatients and 7,383

outpatients (see Table 1). Thirty-three % (n¼ 53) of the inpatient population at

CNYPC had a primary or secondary substance abuse (SA) diagnosis. For the

CNYPC outpatients being served in prison, 28% (2,031) had a SA diagnosis. Most

of the CNYPC patients with SA also had an additional major mental illness

(diagnosis of schizophrenia or mood disorder), but significant diagnostic differences

between the CNYPC inpatient and outpatient settings were reported. Most (66.0%)

of the inpatients with an SA diagnosis also had a schizophrenia diagnosis, whereas

Table 1. Active CNYPC patients as of August 1 2001

Inpatients Outpatients

SA Non-SA SA Non-SA

Diagnosis 33.3 66.7 27.5 72.5(n¼ 53) (n¼106) (n¼2031) (n¼5352)

AccompanyingMajor mental illnessDiagnosis

Schizophrenia 66.0 68.9 25.7* 22.9Mood disorder 17.0 18.9 46.2* 42.9

GenderMale 86.8 88.7 80.6* 89.6

EthnicityWhite 37.7 27.4 29.3 28.8Black 43.4 53.8 43.5 45.8Hispanic 17.0 18.9 25.7 23.2Other 1.9 0.0 1.5 2.2

Age (mean) 37.5 34.7 36.8* 35.9Inpatient admissions

in 5 year period 2.3 2.5 0.17 0.20Inpatient days

in 5 year period 277.8 260.3 15.2 15.7

*p<0.05.

526 H. Smith et al.


among the outpatients with SA only 25.7% had an accompanying schizophrenia

diagnosis. Seventeen % of SA inpatients also had a mood disorder, while 46.2% of

the SA outpatients also had a mood disorder. Among the outpatients, patients with

SA were significantly more likely to have an accompanying schizophrenia or a mood

diagnosis than persons without SA. Therefore, CNYPC has 557 inmates on the

active caseload that are identified and have both a schizophrenia and SA diagnosis.

Adding mood disorder increases the co-occurring serious mental illness figure of

patients being served to 1,544.

We should note our belief that the available data under-reports the prevalence of

these co-occurring disorders. This is attributable to the fact that the computerized

diagnostic profiling system in use at CNYPC allows for entry of only one Axis I, and

only one Axis II diagnosis. Due to the frequent presence of a strong, competing

Axis II diagnosis (e.g. personality disorder) it is clear that not all patients with SA

were identified.

As mentioned above, this 1544 is an under-estimate of the true number of co-

disordered patients on the caseload due to a computer system limitation, and a study

is planned to more fully explore the multiple disorders that patients have. Further,

while case-finding of inmates with mental health disorders has been much improved

in the last ten years there are still a significant number of inmates who refuse mental

health services. This is for a variety of reasons including stigma and inmate

perception that psychiatric medications impede their ability to negotiate in a

predatory prison environment. Refusal to participate is particularly true of inmates

in Special Housing Units (SHUs) (disciplinary housing). New programs are being

implemented by CNYPC to encourage participation in treatment and a study is

underway to examine the prevalence of mental illness and substance abuse among

the 4,500 inmates in SHU, 1,000 of whom are on the mental health caseload.

Similar percentages of patients with and without an SA diagnosis were male in the

inpatient hospital, while in the outpatient setting patients with SA were more likely

to be female. It was noted that there were no significant difference between the

groups concerning ethnicity. Outpatients with an SA diagnosis were significantly

older (mean 36.8) than individuals without SA (35.9). The inpatients with SA were

also older, but due to sample size the difference was not statistically significant.

INTERVENTIONS AND SERVICES OFFERED TO

INDIVIDUALS WITH CO-OCCURRING DISORDERS

CNYPC and DOCS offer a continuum of care for those mentally ill inmates who

require treatment interventions to help manage with both serious mental illness and

substance abuse problems. As noted above, services provided include outpatient

(prison based) and inpatient (psychiatric center setting) interventions. The mission

of the CNYPC continuum of care is to promote recovery for inmates with

psychiatric disabilities in the correctional system and to ensure continuity of mental

health services upon their release. To ensure continuity of care, CNYPC works

diligently to effect appropriate and comprehensive discharge planning so that the

individuals’ chance for success, upon return to their ‘‘community’’ (either within a

prison setting or, if being released from incarceration to the ‘‘outside’’), is max-



imized. This article will next consider the specific services and programs provided to

state prison inmates.

Reception and Classification

Assessment of an inmate’s mental health needs begins immediately upon entry into

the state prison system. Newly admitted inmates are directed to one of New York

State’s four ‘‘Reception Centers’’, where an initial, comprehensive evaluation

occurs. The initial mental health evaluation includes an extensive review of the

inmates’ mental health history, including information regarding prior New York

State inpatient and outpatient treatment interventions. There is at least one, and

typically several, face-to-face sessions with a non-medical clinician and psychiatrist.

During these sessions, a thorough understanding of each inmate’s mental health

needs is developed, including, when appropriate, the diagnosis of the existence of a

‘‘co-occurring disorder’’.

Based upon the reception evaluation, an inmate may be admitted to the mental

health active patient caseload where an initial treatment plan is developed, which

may include a medication intervention, and individual and/or group counseling

provided, and referred to a specialized treatment setting within the state correctional

system. At this point, the inmate is identified as ‘‘inmate/patient’’ with mental health

needs, and receives ongoing services from appropriate CNYPC staff. A critical

aspect of the reception process is that each inmate/patient receives a designation or

code which indicates the category of state correctional facility they must be

incarcerated in to meet their mental health needs (note: each inmate also receives

a code which designates the required correctional facility security and medical level).

Accordingly, inmates who are designated ‘‘Mental Health Level 1’’ are deter-

mined to require placement in a correctional facility which has a Satellite Unit

providing on-site clinic and crisis services, seven days per week. Clinic staffing

includes psychiatrists, psychologists, social workers, psychiatric nurses, and reha-

bilitation/recreation workers. In addition, in each ‘‘Level 1’’ facility, there is a

sequestered, supportive living/treatment program, called the ‘‘Intermediate Care

Program’’, which provides individuals with serious and persistent mental illness in

the prison setting with 24 hour care and custody. The Intermediate Care Programs

(ICPs) are jointly operated by DOCS and CNYPC and 565 ICP beds are available

system-wide. Those inmate/patients with less need for mental health services are

assessed and determined for placement in a Level 2, 3, or 4 facility. The intensity

and availability of services increases as one moves ‘‘up’’ the continuum to Level 1. It

should be noted that a Mental Health Level is frequently changed by clinicians as

the inmate’s mental health condition and needs change over time.

Specific services in a Level 1 facility for those diagnosed as having both a

substance abuse problem and mental illness include all services listed above as

well as access to specialized individual counseling and treatment groups that target

the substance abuse problem. In addition to the services offered by mental health

staff to this group of inmate/patients, when inmates are within two years of the

possibility of release from prison (either conditional release upon parole, or

unsupervised release when they reach the maximum expiration date of their

sentence) they can access DOCS programs which target individuals with alcohol

528 H. Smith et al.


and/or chemical abuse problems. Many of the 7,400 mental health caseload inmates

participate in DOCS substance abuse treatment programs (developed in collabora-

tion with the New York State Office of Alcoholism and Substance Abuse Services—

OASAS), to which CNYPC provides clinical support. These specialized programs,

described below, receive ongoing support from mental health staff. The goal of both

DOCS and CNYPC is to offer an integrated program whenever possible.

Collaborative Programs

Alcohol and Substance Abuse Treatment (ASAT)

ASAT is a competency-based continuum of care treatment program emphasizing

information, insight, and skills necessary to address addiction problems and to begin

the recovery process. Completion of the program is based on an inmate’s ability to

demonstrate to ASAT staff that he/she has a functional understanding of the process

of addiction and the process of recovery. Participation and completion of the ASAT

requires approximately six months. ASAT services are provided in all medium and

most maximum security DOCS facilities. On an average day, there are approxi-

mately 7,600 male and female participants in the ASAT program, many of whom

receive adjunct mental health services.

Comprehensive Alcohol and Substance Abuse Treatment (CASAT)

CASAT consists of three phases designed to provide a continuum of treatment

services. Phase 1 involves participation in an in-prison therapeutic community

separated from other inmates and lasting approximately six months (treatment

annexes at medium security correctional facilities). Phase 2 is community reintegra-

tion, which involves placing the participant in a work release facility and possible

assignment to a contracted community reintegration service provider. In phase 3,

participants are released to parole supervision, where they receive close supervision

and are encouraged to continue their treatment efforts in a community. CASAT

facilities contract with community substance abuse treatment providers such as

Phoenix House.

Residential Substance Abuse Treatment (RSAT)

RSAT is a federally funded program located at 14 correctional facilities. The

program is six months in length and follows the DOCS competency-based treat-

ment approach outlined above. Inmates participating in the RSAT Program must

live and participate in programs separately from other inmates. The treatment

program, content, and philosophy of RSAT is similar to the ASAT Program

operation. A total of 1,400 male and female participants receives RSAT program-

ming. RSAT teams are currently being established at three additional maximum

security facilities which will include services for special needs populations. These

populations include inmates infected with hepatitis C, the physically handicapped,



and mentally ill chemically addicted. A goal of DOCS is to expand the RSAT

program in all maximum security facilities.

Current and Future Directions

The ASAT, CASAT, and RSAT treatment models currently include inmates who

are on CNYPC’s active outpatient caseload. As noted above, these individuals

receive a full range of mental health services and mental health staff regularly consult

with ASAT, CASAT, and RSAT, staff regarding the needs of individual inmates. In

addition, mental health staff provide groups and other interventions to these

programs. Currently under way is development of a program to formally designate

dedicated beds in CASAT or RSAT programs for inmates with co-occurring

disorder, or to ‘‘carve out’’ one or more select CASAT or RSAT facilities to provide

services exclusively to inmates with co-occurring disorders.

For example, DOCS contracts with New York Therapeutic Communities, Inc.,

which operates the program ‘‘Stayin’’ Out’ at the Arthurkill Correctional Facility on

Staten Island and the Bayview Correctional Facility in New York City. The Stayin’

Out Program (approximately 180 male beds) has one-third or more of its program

participants on the active patient caseload of the Arthurkill Level 2 Mental Health

Unit. The Bayview Program (40 female beds) also currently has active mental health

caseload participants. These intensive therapeutic community programs last

approximately nine months and the proposal is to formally develop a dual diagnosis

modified track for programming of mental health caseload inmates and develop

community placement transitional housing and modified therapeutic community

for availability upon parole and/or release. The DOCS also operates Shock

Incarceration Camps and the Willard Drug Treatment Program, which are based

on a six month (boot camp) model emphasizing discipline, academic education,

substance abuse education, and treatment. The Willard program provides a 90 day

intensive drug treatment program for non-violent offenders who violate parole

conditions or are sentenced to an indeterminate term of prison but are immediately

placed on parole. Following successful completion of the program, participants are

released to community supervision and possible additional treatment under parole

supervision. There are approximately 850 participants in this program.

Case reviews conducted by CNYPC and DOCS clearly indicate that most

individuals suffering from serious mental illness do not adjust well to the intense

environment of shock incarceration or the Willard model. While this does not

preclude program participation for some inmates who are relatively stable, the

intense experience has been the occasion of a number of inmates with co-occurring

disorders having to voluntarily or involuntarily be discontinued from participation in

these programs.

Inpatient Services

When determined to pose a danger to ‘‘self or others’’ due to an existing psychiatric

condition, the inmate/patient is court committed to inpatient treatment at CNYPC.

All inpatient admissions are ‘‘involuntary’’ and the patient must be assessed by two

530 H. Smith et al.


psychiatrists as appropriate for inpatient care and then confirmed by judicial order.

In addition, referrals for inpatient care are screened by either the CNYPC Clinical

Director or Director of Psychiatry prior to hospitalization, and a final assessment is

made by the ‘‘on-call physician’’, who authorizes an admission upon arrival of the

patient at the inpatient hospital.

After admission to inpatient services, a patient is oriented to their treatment

environment and introduced to their treatment team, which consists of a psychia-

trist, psychologist, social worker, psychiatric nurses, security hospital treatment

assistants (direct care staff ), recreation therapist, occupational therapists, rehabili-

tation specialists, and other adjunct staff (for example nutrition services). All new

admissions receive a variety of assessments by several key disciplines including

mental status examination (psychiatrist), psychological assessment (psychologist),

core history (social worker), nursing assessment (registered nurse), nutritional

assessment (dietician), educational assessment (teacher), and trauma assessment

(trauma specialist). Using a strength-based approach, an individualized treatment

plan is developed within five days and, in agreement with the patient, implemented.

Various interventions are available to those with co-occurring disorders, that are

both ‘‘generic’’ and also targeted specifically to those with substance abuse prob-

lems. Available interventions include, but are not limited to, those appearing below.

Medication Therapy

Psychiatric staff receive ongoing training in the assessment and treatment of patients

with a variety of psychiatric illnesses, including those with co-occurring disorders.

This is emphasized in the training of CNYPC Forensic Resident Fellows, an

ACGME-accredited Forensic Fellowship program in affiliation with SUNY Upstate

Department of Psychiatry and Syracuse University College of Law. Medications

and medication education are targeted so as not to facilitate drug seeking behaviors

and dependence, but to reduce symptoms to the extent required to assist the

individual in being accessible to, and able to benefit from the other interventions

offered in the inpatient setting. There are frequent sessions (several times per week)

where the psychiatrist, psychiatric nurse, and patient review these issues on an

ongoing basis.

Treatment Mall

CNYPC has developed an innovative approach to inpatient treatment for this

forensic patient population. The CNYPC Treatment Mall offers an individualized,

but structured, approach to patient care. Each patient is programmed on the Mall

four days per week and receives group therapy and instruction in a variety of ‘‘areas’’

including, but not limited to, ‘‘self-help skill development’’, ‘‘understanding my

illness’’, ‘‘anger management’’, ‘‘time management skills’’, ‘‘effective social inter-

actions’’, ‘‘conflict resolution’’, and ‘‘cognitive skill building’’. The Treatment

Mall’s goal is to assist the patient to build a usable group of ‘‘core competencies’’

that, when sufficiently developed, transfer to other settings and provide the

individual with the skills necessary to function more successfully back in the

correctional setting, or in the community after release.



While these groups or ‘‘modules’’ do not specifically address the substance abuse

issue, they have a proven effectiveness in assisting with the treatment of the more

‘‘traditional’’ aspects of major mental illnesses. However, certain modules such as

those targeting cognitive training, conflict resolution, and anger management all

address skill deficiencies that are also targeted through more traditional interven-

tions for those with substance abuse problems and addictions (for example,

Alcoholics Anonymous and Narcotics Anonymous groups). Treatment Mall inter-

ventions have been consistently judged to be quite helpful by patients via patient

satisfaction/perception surveys, with the typical 12 week module cycle being rated as

‘‘helpful’’ or ‘‘very helpful’’ by more than 80% of those patients attending.

A variety of rewards are provided to ensure, and enhance, patient participation.

In this regard, patients receive ‘‘certificates of participation and completion’’ if they

achieve required objectives. In addition, a modest patient monetary allowance is

directly tied to key variables, judged to be under a patient’s control when attending a

group module, including attendance and session participation. Session leaders/

instructors rate patients on these variables, and points are awarded based upon

established performance criteria, well known to patients. Allowances are provided

weekly, based upon a ‘‘formula’’ that is also well known to all patients. Allowances

can be used to purchase personally relevant items (e.g., snacks, personal hygiene

items, stamps, cards, small gifts). Initial evaluation of the incentive package has led

to the conclusion that it is highly effective in ensuring active patient participation in

the group modules listed above.

Therapeutic Group Work

Patients with co-occurring disorders have access to a variety of therapeutic groups

including those targeted to relaxation, and groups sponsored by Alcoholics Anon-

ymous and/or Narcotics Anonymous. For these two latter groups, group leaders

come into the hospital as volunteers from the surrounding community and an effort

is made to identify and recruit, as group leaders, patients who have had a personal

history of substance abuse that led to incarceration, so that they can better provide

an appropriate experience for this population.

Discharge Planning

Whether a patient is returning to a correctional facility or is being discharged to the

community with conditions of parole or as maximum expiration release, extensive

discharge planning is conducted as a part of the overall inpatient/outpatient

treatment process. Discharge planning is relatively ‘‘traditional’’ in that the treat-

ment team, in conjunction with the patient, attempts to find the best available

placement and services that meet the individual’s needs. However, when patients

are returning to the outside community from a state correctional facility and are

diagnosed with a mental illness, placement and service coordination is immensely

complicated. If in addition, the inmate/patient also has a co-occurring disorder,

discharge planning becomes even more difficult.

To assist in this process, CNYPC has specially trained ‘‘Pre Release Coordina-

tors’’ in all Level 1 units, and at the inpatient hospital. These individuals follow a

532 H. Smith et al.


carefully scripted approach to discharge planning (Pre Release Manual) that

provides reasonable guidance on where within the state designated services are

available. However, Coordinators are also frequently called upon to ‘‘improvise’’ in

order to completely meet the individuals’ treatment needs and to ensure, to the

extent possible, public safety.

Discharge planning begins several months prior to a patient’s release. The Pre-

Release Coordinator meets with the patient and primary therapist and identifies

what living arrangements, supports, and treatment interventions are necessary for

the patient to successfully transition from prison to the community. The Pre-

Release Coordinator then works to establish necessary appointments and living

arrangements. Each inmate/patient leaves prison with a supply of medication (if

receiving medication), a place to live and an appointment with a mental health

provider scheduled within two weeks of his/her release.

Assisted Outpatient Treatment

One additional program sponsored by legislative mandate under New York’s

‘‘Kendra’s Law’’ is available to help specific inmate/patients make a successful

return to community living. Assisted Outpatient Treatment (AOT) is targeted to

those who are returning to the community, but who, due to their current level of

illness and past behavior, have evidenced a significant resistence to or inability to

engage in outpatient treatment. In these relatively few but high risk cases, CNYPC

can, in conjunction with the county where the individual will eventually reside,

choose to pursue an Assisted Outpatient Treatment application through New York

State Supreme Court. In cases where an AOT application is successful, a treatment

plan is established during the court hearing process and the patient is expected to

cooperate fully with the course of treatment identified in the plan. If cooperation is

not evident, the individual can be assessed and hospitalized for treatment for a

period on an inpatient basis.

CONCLUSION

Evidence from several recent studies, summarized by Drake et al. (1998), demon-

strates that comprehensive, integrated treatment efforts assist individuals with a co-

occurring disorder to reduce substance abuse and maintain remission. They report

that integrated approaches are also associated with less frequent inpatient psychia-

tric care and other negative outcomes. Recognizing the evidence base associated

with this approach, CNYPC and DOCS are committed to continue efforts to more

closely collaborate and integrate programs for the inmate/patient with co-occurring

disorders. There are significant treatment challenges to providing effective services

for this subpopulation. Our experience has demonstrated that trying to treat mental

illness and substance abuse separately can lead to fragmented services and fre-

quently to competition for resources, and can create treatment dilemmas for the

patient. Well integrated programs with staff cross trained to recognize the purpose

and value of substance abuse and mental health treatment technologies is key to

providing effective services to forensic patients with co-occurring disorders.



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