Judge, Butler County Common Pleas Court, Butler County, Ohio

Position:Butler County SAMI Court: A Unique Approach To Treating Felons With Cooccurring Disorders

I. Introduction: Prison: A Warehouse For The Mentally Ill II. A Solution: Integrated Treatment III. The Substance Abuse And Mental Illness (SAMI) Program: An Integrated Treatment Alternative A. The History of SAMI B. The SAMI Team: The Client's Support System C. The Individual Team Members and Their Roles in SAMI: 1. The Judge 2. The Probation Officer 3. The Case Managers 4. The Program Nurse ... (see full summary)


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Judge, Butler County Common Pleas Court, Butler County, Ohio.

Law Student, Georgetown University Law Center.

Magistrate, Butler County Common Pleas Court, Butler, County, Ohio.

I Introduction: Prison: A Warehouse For The Mentally Ill

Schizophrenia, mania, and major depression are all serious mental disorders that require intensive treatment. An individual suffering from schizophrenia, mania, or major depression, and who struggles with a substance abuse disorder, requires treatment for not only his or her mental illness, but also his or her substance abuse problem. Shockingly, the majority of those who suffer mental illnesses or substance abuse disorders receive treatment only through the criminal justice system, not hospitals or rehabilitation centers.

"Prisons and jails are becoming places not only for punishment, but also for treatment and rehabilitation."1 Due to the dwindling numbers of mental hospitals, the criminal justice system has, in effect, become the "custodial warehouse for people with mental illness."2 Approximately 1.9 million individuals, a 76.8% increase from 1990, are incarcerated in our nation's jails and prisons.3 Of these 1.9 million, approximately 60% have a mental illness or substance abuse disorder.4 It has been estimated that between 5% and 13% of individuals confined in correctional settings have co-occurring disorders.5 A co-occurring disorder is defined by the Substance Abuse and Mental Health Services Administration (SAMHSA) as a mental disorder in addition to an alcohol or drug use disorder, where at least one disorder of each type can be diagnosed independently of the Page 952 other.6 Co-occurring disorders may include any combination of two or more substance abuse disorders and mental disorders identified in the Diagnostic and Statistical Manual of Mental Disorders - IV (DSM-IV).7 "There are no specific combinations of substance abuse disorders and mental disorders that are defined uniquely as co-occurring disorders."8

Approximately, ten to twelve million Americans suffer from cooccurring disorders.9 Those with co-occurring disorders are very hard to stereotype because the only linking factor that many of the individuals have is their multiple disorders. Those with co-occurring disorders may be extremely educated and successful, or they may be destitute and homeless.10 However, because of the nature of both diseases and the interaction between the diseases, regardless of their educational or financial status, it is hard for those with co-occurring disorders to fit into society. Thus, a large number of individuals with co-occurring disorders spend time in correctional institutions.

"Among detainees with a severe mental disorder, 72% have a cooccurring substance abuse disorder."11 "Approximately one million offenders with both a mental health and substance abuse disorder reside in correctional institutions."12 In prison, they do not receive the treatment they need to be rehabilitated. Bluntly put, prisons merely warehouse these individuals and serve as revolving doors for prisoners with mental illnesses. Typically, individuals with co-occurring disorders are simply locked away, and then returned to society with the same problems, likely returning to the criminal justice system time and time again.

Because of the large number of people suffering from these diseases in prison, the fact that the prison system is unable to adequately treat people Page 953 with such problems is especially disturbing. Moreover, studies strongly suggest that prison often exacerbates psychiatric disabilities.13 Hence, not only are prisons not treating these people, they are making their mental illness and substance abuse problems worse. In sum, prisons and jails are ill equipped to treat mentally ill prisoners, especially those with substance abuse disorders.

II A Solution: Integrated Treatment

In a recent study, of those suffering from both a serious mental illness and a substance abuse problem for at least a year, not one received treatment for both problems, and only 49% received any treatment at all.14 Because of the interactions between the disorders, the only treatments that have been proven to be successful treat both diseases at the same time.15 This "integrated" treatment is very seldom available in jails or prisons, and is not even available in most places throughout the country.16 The majority of treatment programs, whether prison-related or not, focuses on either the mental illness or the substance abuse problem and fail to wholly treat the individual.17

III The Substance Abuse And Mental Illness (SAMI) Program: An Integrated Treatment Alternative

The Substance Abuse and Mental Illness (SAMI) Court program in Butler County, Ohio, was designed to provide integrated treatment to individuals who suffer co-occurring disorders in the criminal justice system. Butler County's SAMI program employs the New Hampshire- Dartmouth Dual Disorder Integrated Treatment (DDIT) model.18

A The History of SAMI

The SAMI program in Butler County has been active since July 1999.19 It was created in response to the need displayed in the community for such a treatment program to deal with those suffering from co- Page 954 occurring disorders. As of 1997, Butler County had approximately 8,001 individuals, or approximately 2.5% of the population, suffering from such problems.20 The SAMI program was designed to deal with the "most difficult patients" who other programs would not and could not help.21

It was originally funded from 1999 through 2001 by block grants from the Ohio Department of Mental Health (ODMH) and the Ohio Department of Alcohol and Drug Addiction Services (ODADAS). In 1999, ODMH granted nine block grants to SAMI centers across the state of Ohio.22 After its first three years, the remainder of the funding has come from ODADAS. As of March 2002, the Butler County Mental Health Board has also contributed funds for psychiatric services and medicines, but their contribution ended after June 2003.23

The Butler County SAMI program was and still is the only SAMI program that involves a court program. The SAMI program has an average capacity of twenty-five clients at any one time.24 The average time that a client spends in the program is fifteen months before they "graduate" or "transition" to other, less intensive forms of treatment. Thus far, nineteen consumers have successfully transitioned from the SAMI program.25

B The SAMI Team: The Client's Support System

The key to the SAMI program is the committed team members. Each team member contributes to the treatment of the patient, who is generally referred to as a "client" or "consumer." Each member has a certain role in the program, and together, they meet the different needs of the client.

The SAMI team generally meets as a whole, first with each other, and then with each client every two to three weeks, depending on the particular needs of that individual client.26 Before meeting with the client, the team discusses each client, where they are in their treatment, their drug test results, and other relevant information in order to keep the entire team Page 955 informed of each client's entire situation.27 The team then is joined by the client.

During the meetings, which take place in a courtroom, the team members surround the client, symbolizing to the client his or her support system. Each team member provides oral reviews to the client regarding his or her progress in the program that week. The client also has the opportunity to address the team members during the meeting. These meetings not only allow the team to monitor the client's progress, but also serve as opportunities to praise the client if he or she has done well, or chastise the client if he or she has not followed the SAMI directives. Either way, the client receives feedback to address all of his or her problems. In other words, the meeting gives the judge a chance to direct the treatment and decide if any measures need to be taken to help catalyze advancement in the client's treatment.

C The Individual Team Members and Their Roles in SAMI:
1. The Judge

The judge performs an integral role in the SAMI Court program and does far more than simply sentence clients into the program. He participates in the weekly team member meetings to make sure the client is progressing in his or her treatment, and also in the meetings in the courtroom with each client every two to three weeks. While meeting with the client, the judge wears his robe and sits on the bench, reminding the client that SAMI is a court program. If the client is not progressing, the judge has the flexibility and the tools available to impose other sanctions, or even temporarily suspend the treatment in the program by sending the...

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