North Carolina Department of Public Safety, Division of Adult Correction and Juvenile
The North Carolina Department of Public Safety (NCDPS), Division of Adult Correction and Juvenile Justice has experienced a steady increase of the percentage of incarcerated individuals with a diagnosed mental health disorder in our prison system. In 2007, 9.8 percent of the total prison population was receiving behavioral health services (not including primary substance use disorder treatment services). In the following ten years, that percentage grew significantly to 17 percent by December 2017. Part of this increase involved more individuals with a mental illness being placed in restrictive housing units. A population sample from the first quarter of 2015 revealed that 8.1 percent of our total behavioral health population was housed in a restrictive housing unit.
In order to reduce the use of long-term restrictive housing for individuals with mental illness, the department created diversionary treatment units as an alternative for this population. Therapeutic diversion units (TDU) provide an evidence-based multidisciplinary approach with a treatment curriculum focused on psychological and emotional health, physical well-being, relationship building, and social skills development.
The TDU assists individuals with a diagnosed mental illness and serious behavioral disturbances in developing effective emotional regulation and self-management skills, understanding their symptom presentation and patterns, and helping them prepare for reentry into a less restrictive environment within the prison and ultimately into a successful transition to the community.
With the implementation of these units, the percentage of individuals with a diagnosed mental illness in restrictive housing has decreased from 8.1 percent of the total behavioral health population in 2015 to 3.9 percent in 2017.
- Enhance the care and custody of individuals who have a diagnosed mental illness
- Improve the quality of life for this vulnerable population
- Decrease incidents involving violence and/or self-harm
- Decrease the need for placement in a restrictive housing setting
- Reduce the number of individuals with mental illness being placed in restrictive housing
- Decrease the amount of time in restrictive housing
- Prepare individuals who have spent significant time in restrictive housing to be reintegrated back to the general population
- Reduce the practice of releasing individuals directly to the community straight from restrictive housing
- Provide access to programming and treatment for these individuals
The North Carolina Department of Public Safety joins the Vera Institute of Justice, American Correctional Association and other human rights advocacy groups in acknowledging the mandate for alternatives to the use of long-term restrictive housing for people with a mental illness.
Individuals whose movements are constrained in restrictive housing units may develop symptoms of acute anxiety or other mental problems. The longer an individual with serious mental illness remains acutely symptomatic, the poorer the long-term prognosis. Yet, for individuals with a mental illness, it can be very difficult to achieve sufficient periods of good behavior in order to secure release from segregation, thus exacerbating the negative mental health impact that restrictive housing has on these individuals. Furthermore, restrictive housing units do not offer an optimal environment to provide effective behavioral health therapy.
To address these problems, a standardized evidence-based therapeutic (EBT) curriculum and program structure was developed. The program development process included:
- securing funding;
- developing the program and curriculum;
- identifying staffing patterns and needs;
- developing an implementation strategy;
- identifying locations for the programming;
- developing policy;
- training staff; and
- identifying and securing materials required to implement the program, such as journals and testing
In 2016 four Therapeutic Diversion Units (TDU) were activated to provide a standardized evidence-based therapeutic curriculum and programming for individuals with mental illness who were assigned to long-term restrictive housing. The initial unit was activated at Central Prison with a 24-bed capacity, followed by Maury Correctional Institution with 32 beds, North Carolina Correctional Institution for Women with 24 beds, and Polk Correctional Institution with 32 beds. Additional units were activated in 2017: Central Prison with a 24-bed capacity, Alexander Correctional Institution with 32 beds, and Foothills Correctional Institution with 20 beds.
Standard TDU staffing includes a psychological services coordinator who provides clinical oversight to treatment staff. Additionally, each TDU is staffed with a lead nurse, LPNs, psychiatry support, a staff psychologist, and two to five behavioral specialists. An integral TDU staffing component is the correctional officer. In addition to coordinating and facilitating movement of incarcerated individuals, the TDU correctional officer is a member of the treatment team. Correctional officers assigned to the TDU occupy a ”non-pull” post, which is critical for guaranteeing that out-of-cell structured and unstructured activity is accommodated.
TDU team members and managers complete ACA Correctional Behavioral Health Certification in addition to Crisis Intervention Team training.
During initial program implementation, the target population was individuals with a serious and persistent mental illness (such as Schizophrenia, Bipolar Disorder with psychotic features or severe manic episodes, or Major Depressive Disorder, Severe) in which they primarily receive infractions due to their mental illness rather than other factors, such as antisocial character traits. As program implementation progressed, individuals with mental illness who also demonstrated behavioral disturbances related to criminality and antisocial character traits (as opposed to their mental illness} were integrated into the TDU programs. Behavioral health staff, in collaboration with custody staff, assess an individual’s appropriateness for participation in the program by taking into consideration the potential threat that they pose to the safety or security of the institution based on current rules infraction and past behavior.
The curriculum chosen for this program is a cognitive-behavioral, interactive, journal evidence-based treatment. The program focuses on reducing criminal behaviors and developing more appropriate and acceptable behaviors to avoid further criminal activity. In addition, this program teaches participants about mental illness, how to develop positive coping skills, and how to make informed decisions about mental illness as it relates to them. Participants will learn these skills through journaling, counseling, and therapy. Participants will advance through different phases of the program by completing interactive journals and activities, exhibiting pro-social behaviors and showing improvements on their goals.
As participants in the program demonstrate new ways of thinking and acting, successfully complete assignments, and show consistent improvement on treatment goals, they will be able to earn incentives, with increasing incentives as they progress through the program. Participants must follow established rules to maintain eligibility for participation in the TDU program.
The TDU model remains in the early stages of development. Assimilating evidence-based programs into a prison culture can be a multi-year process. The first several years have been dedicated to implementation and cultural orientation, with program adjustments being driven by initial outcome data. Some adjustments that have already been made include the unit’s physical location and its treatment focus. Reliable statistical findings will require more time for data collection and analysis.
During the first 24 months of the program, over 450 individuals with a diagnosed mental illness have been diverted from long-term restrictive housing into a TDU. Approximately 58 percent of those entering the program have experienced a positive outcome, as indicated by completing all phases of programming or being released from prison. A total 57 participants have been released directly from a TDU back to the community. Preliminary findings have shown an approximate reduction in the number of inpatient admissions by 48 percent from six months prior to six months post therapeutic diversion programming. Additionally, preliminary findings suggest that people who participate in the program see a decrease in the number of infractions, serious self-injurious behaviors, and admissions to behavioral health inpatient treatment both during and immediately after completion of the program. However, there is a gradual increase in these outcomes over time following program completion.
A related measure of program success is the number of individuals with an extensive history of serious infractions and negative behaviors who are willing—and even requesting participation in—the program. Similarly, testimonial letters received from program participants after completion is anecdotal evidence of positive program impact.
Evidence-based program development across multiple high-security facilities has been a massive undertaking, requiring close collaboration among health services, correctional services, and prison administration. Multiple obstacles have presented themselves during the 24 months of TDU operation, with some anticipated and some unforeseen.
Individuals participating in the TDU program often share a common history of poor familial support and negative environmental interactions contributing to existing poor coping skills, lack of emotional regulation, and behavioral impulsivity. This constellation of personality and behavioral factors understandably requires an intensive treatment regimen in order to accomplish sustained behavioral change. Therefore, several TDUs have extended the program length from 6 months to 9 to 12 months. Extending program duration will not only increase the likelihood of sustained behavior change but will also allow for more effective management of this population due to reduced infractions and mental health crises as reflected by initial outcome data.
The impact of correctional officer vacancies has been particularly problematic as an obstacle to successful treatment delivery. During early phases of the TDU, participants are moved from their cells in restraints. This function is extremely labor intensive—requiring a minimum of two correctional officers.
In many instances, correctional officer vacancies on the TDU reduced out-of-cell treatment activities for participants. Vacancies have also interfered with expansion of the TDU at one facility and resulted in TDU services being suspended at another.
During 2016 and into the middle of 2017, TDUs significantly impacted a reduction in the number of mentally ill individuals housed in long-term restrictive housing. Tragic events during 2017 within North Carolina state prisons resulted in a reversal of this trend. It is anticipated that with time, this pattern will stabilize before the number of people with mental illnesses in restrictive housing again begins to decline.
During the implementation process and into treatment programming, it become evident that a large proportion of the target population demonstrated behavioral disturbances that are not directly related to their mental health symptomatology. This population also includes individuals who are gang-involved and/or demonstrate antisocial character traits. Allowing these people to participate in TDU services continues to pose potential safety risks that require close review on a case-by-case basis. Considering that many individuals with mental illnesses are vulnerable and will request protective custody, maintaining a safe environment is essential for TDU success.