Three-year process of mapping potential changes nears an end, but work still remains
By Aimee Rothman, Granite State News Collaborative
Across the Granite State, jails and prisons have become overcrowded and overstaffed, in part due to the rising rate of incarceration, intensified by recidivism that the state has experienced over the last several decades.
Since 2020, New Hampshire’s jail population has grown 23%, while the state prison population has grown 7%. But, measured since the 1970s and 1980s, the jail population has grown 448% and the prison population in New Hampshire has grown 432%.
To address that growth in the jail and prison populations — and since a substantial number of those incarcerated are living with a mental illness or substance abuse issues — the N.H. Judicial Branch is looking at how to improve both its and the community’s response to people with mental illness. (A 2008 National Alliance on Mental Illness-NH report found that 40% of incarcerated males and 70% of incarcerated females were living with a mental illness.)
For the past three years, a mental health team formed by the judicial system has been holding workshops county by county using the System Intercept Model, or SIM, to track each interaction or intersection between people experiencing mental illness or substance abuse and the judicial system. The goal is to use the data to bring about community-based changes in the system.
The idea of community-based change in the treatment of people struggling with behavioral and mental health problems is not a new one.
In 1963, President John F. Kennedy signed his final piece of legislation, the Community Mental Health Act, a monumental law that spearheaded a change in the country’s response to behavioral and mental health issues. With it, the United States made a shift toward community-based care rather than the institutionalization of people struggling with mental health and behavioral health issues.
Elaine Michaud of the Manchester Health Department helps facilitate a SIM workshop at Elliot Hospital on Jan. 17, 2024. (Courtesy N.H. Judicial Branch)
The new legislation was paired with the establishment of community mental health centers across the nation.
Today, over 2,500 of these centers exist in the United States, including 10 in New Hampshire. Even so, the country and the state still report a high rate of institutionalization of people struggling with these issues. But they are not institutionalized at state-sanctioned asylums anymore; instead, they are often placed in jail and prison cells.
The National Alliance of Mental Illness reports that nearly two in five people who are placed in jail have reported a history of mental illness. Nationally, NAMI reports that 37% of incarcerated people in federal prisons report a history of mental illness, and the number is about 44% in local jails.
As more and more incarcerated people are struggling with mental health and behavioral health issues, NAMI has found that jails and prisons have effectively become “de facto mental health facilities.”
That understanding has become widespread. A 2022 poll for the American Psychiatric Association found that only 20% of people being held in U.S. prisons and jails were getting the mental health care they need. Rebecca W. Brendel, president of the psychiatric association, said at the time that “Americans are recognizing the longstanding reality that our jails and prisons have become the largest mental health provider in the country and that people in the criminal justice system need treatment and support.”
Addressing institutionalization
While it has been over 60 years since Kennedy signed the Community Health Act, there is still work to be done, according to Susan Stearns, executive director of NAMI-NH. “The vision for community-based services was not realized and the investment in community-based care was not continued,” she said.
“The act was intended to bring people out of institutions,” she said, with the goal of “providing those community-based services locally so they could live a full life within their community without needing to be institutionalized.” But, she said, the number of people with mental health issues being placed in jails or prisons is “very similar to the number of folks being institutionalized back then.”
The Sequential Intercept Model is made up of six intercepts where people with mental health or substance abuse issues may come into contact with the judicial system. (Courtesy N.H. Judicial Branch)
“We do indeed know that we have a significant number of people who are in our corrections facilities who have mental health and substance disorders,” Stearns said. And, after their release, “it can be very challenging to access treatment services, let alone in a very quick turnaround,” within their communities.
So, too often, “their symptoms or their treatment would lapse, whether it be mental health treatment or substance abuse treatment, and they would once again become involved in the justice system,” Stearns said.
In 2022, N.H. Supreme Court Chief Justice Gordon J. MacDonald and Dianne Martin, director of the Administrative Office of the Courts, assembled a multidisciplinary mental health team focused on tracking the intersection of mental health and the judicial system.
That team established three goals: to hold a statewide mental health summit, to survey judicial branch employees about the treatment of people with mental health or substance abuse issues that may come into the judicial system, and to conduct SIM mapping workshops of each of the state’s 10 counties.
That SIM mapping, according to the federal Substance Abuse and Mental Health Services Administration, “details how individuals with mental and substance use disorders come into contact with and move through the criminal justice system.” It also “helps communities identify resources and gaps in services at each intercept and develop local strategic action plans.”
The idea, the agency said, is to bring together leaders, agencies and systems “to work together to identify strategies to divert people with mental and substance use disorders away from the justice system into treatment.”
The SIM model notes six points, or intercepts, at which people with mental health or substance abuse issues may come into contact with the judicial system:
Community services, such as crisis helplines.
Law enforcement.
Initial detention and/or initial court hearings.
Jail and/or courts, including specialty courts such as mental health courts.
Reentry after release from jail.
Community corrections, such as parole or probation. E
While the 1963 Community Health Act aimed to deinstitutionalize people with behavioral and mental health issues, says Susan Stearns, executive director of NAMI-NH, the number of people with mental health issues who are being placed in jails or prisons is “very similar to the number of folks being institutionalized back then.” (Courtesy photo)
Essentially, the model follows each step of the judicial system, looking at how changes could be made at each step to better serve people with mental health or substance abuse issues.
By studying each intercept, the state can identify “gaps” in the judicial system, where there is room to add new resources and improve existing ones. By improving interactions at each intersection, the state hopes to reduce the number of people incarcerated.
SIM workshops
The state held its first SIM workshop in Merrimack County in April 2023, with a forum led by Chief Justice MacDonald and Martin.
At the gathering, Martin spoke to the importance of the initiative, highlighting the need for mental health awareness and resources.
“Every one of us is touched in some way by mental illness — in a friend, a family member, a colleague, or ourselves,” she said. “Those working in the court system are touched by individuals experiencing mental illness, people in crisis, and people experiencing trauma, who come into our courts every day. We all recognize we need to do better for them. But we cannot do it alone. This change requires education, training, access to treatment and, most importantly, collaboration across the state.”
Since then, SIM workshops have been held in all 10 of the state’s counties, said Rachael Azotea-Bolstridge, mental health and wellness coordinator of the judicial branch. After each workshop, Azotea-Bolstridge publishes a report highlighting the findings. The results for two counties — Sullivan and Rockingham counties — have not yet been published, but Azotea-Bolstridge expects that to happen by April.
The reports, such as the one from Belknap County, highlight gaps and potential areas of growth in the community, and include a list of resources available in the community. For instance, the Belknap County report noted that the county has no mental health court, which was identified as a “gap.” The county also identified a need for transitional housing for people being released from jail, and additional resources for them.
At each workshop, participants highlighted “achievable goals which could happen in the near future” and formed breakout groups that focused on ways to achieve that goal, Azotea-Bolstridge said. The most common goal recognized among all of the breakout groups was addressing a shortage of behavioral workers.
The workshops launched a continuing process, as each breakout group worked toward achieving its goals. Azotea-Bolstridge holds a three-month check-in session with the entire group so each focus group can report on its progress and the whole group can collaborate on other ideas.
Supreme Court Chief Justice Gordon MacDonald chairs the N.H. Judicial Branch’s mental health team. (Courtesy photo)
Azotea-Bolstridge continues to host the check-ins, which she sees as an “opportunity for people to refocus and report out. She plans to keep them going “until they are no longer needed.”
So far, only one county, Cheshire County, has concluded its check-in sessions.
Bringing the groups back together
Azotea-Bolstridge plans to host a virtual session in April, at which each county can share details of its work, trade ideas with other counties, and keep each other on track with their overall goals.
A big question from a lot of people attending the workshops has been:”How are other towns doing it?” she said.
If the April session goes well, “we’ll probably do it for the other large commonly shared issues,” Azotea-Bolstridge said.
As preliminary data from the workshops comes in, however, one thing is clear: The greater community must be involved to bring about changes in the judicial system.
“I think the biggest impact [of the SIM workshops] is going to be legislative change, whether that’s on the state level or more of the community level,” Azotea-Bolstridge said.
In the end, the breakout groups are working to create solutions tailored to each county. “Every community comes up with different ways to resolve problems in their community,” Azotea-Bolstridge said.
Looking to the future of the judicial system in New Hampshire, Stearns said the road ahead is still long. “We have laid some really good foundations with the SIM mapping,” she said, “but where do we take that work?”
These articles are being shared by partners in the Granite State News Collaborative. For more information, visitcollaborativenh.org.