The Prosecutor, May-June 2008, Volume 38, No. 3

Mental health treatment and treatment providers

2008
The second of two articles meant for prosecutors on mental health issues

In the last issue of this journal, a primer on basic terms and diagnoses regarding mental health issues was published. In this follow-up piece, we’ll learn about treatment providers and options. By understanding the basics, prosecutors will be in a better position to communicate with mental health professionals when evaluating cases and making recommendations for community supervision.

Treatment providers

Many types of mental health issues are successfully treated with a variety of providers. For instance, a woman who has been a victim of domestic violence and now suffers from depression and post-traumatic stress disorder may receive medication from a psychiatrist, counseling from a licensed clinical social worker, and support from a group lead by a person with a bachelor’s degree in psychology. A man with an alcohol addiction who suffers from depression and anxiety and has relationship issues with his partner may receive medication from a psychiatrist, seek counseling with a licensed marriage and family therapist, and attend Alcoholics Anonymous meetings.

One cannot practice medicine or law without an education and a license, but one can practice some types of mental health treatment without one. Without training or a license, a person can charge money for words of wisdom and even call himself a psychotherapist or a life coach. Unlicensed individuals provide many good mental health services. They often have bachelor’s degrees, experience, and training. However, these people cannot call themselves a counselor, psychologist, or a social worker because those are licensed professions.

Just because someone has a license doesn’t mean he is qualified to treat every type of mental health problem, that he’s a suitable fit for every client, or that he’s any good at his job. Having a license protects the profession because people without proper credentials can’t practice in licensed professions. A license also protects the public: It means that the professional has met the requirements (i.e., education, internship, supervision, and passing a test) for his profession and can be held accountable if he does something wrong. Insurance companies are more likely to pay for services provided by a licensed professional.

Professionals who can give a mental health diagnosis are limited to licensed clinical social workers, licensed professional counselors, licensed marriage and family therapists, advanced practice nurses, psychologists, physician assistants and physicians. According to the Texas Code of Criminal Procedure, only qualified psychologists and MDs are allowed to testify about competency and sanity. Licensed Chemical Dependency Counselors are only allowed to diagnose substance abuse related disorders.

Unlicensed providers. Unlicensed individuals (ex. caseworkers, life coaches and advocates) provide many good mental health services. They often have bachelor’s degrees and/or experience and training. For example, someone who teaches a parenting class for a community social service agency may have a bachelor’s degree in psychology and have gone through a training program.

Ministers and chaplains. There is a wide variety of counseling skills and orientation among religious staff.  They are often the person who is sought after when someone has a problem and they provide advice, support, and intervention to individuals.  They may or may not have a counseling license.

Licensed Chemical Dependency Counselor (LCDC). LCDCs are required to have an associate’s degree, supervised hours of training, and to pass a licensing exam. They are only allowed to diagnose substance abuse disorders and provide treatment around substance abuse disorders.  The Texas Administrative Code states: “LCDCs are not qualified to treat individuals with a mental health disorder or provide family counseling to individuals whose presenting problems do not include chemical dependency.”

Licensed Bachelor Level Social Worker (LBSW), Licensed Master Level Social Worker (LMSW). LBSWs and LMSWs are licensed social workers. LBSWs have bachelor’s degrees in social work and LMSWs have master’s degrees in social work; both are required to pass licensing exams. They cannot diagnose mental illness and unless they have an independent practice license, they cannot practice independently (in other words, they have to be connected to an agency). They can provide education and counseling, but are limited to the scope of their licenses.

Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Licensed Marriage and Family Therapist (LMFT). LCSWs, LPCs, and LMFTs are required to have a master’s degree, supervised clinical hours, and have passed a licensing exam. They are allowed to diagnose mental illness and provide treatment, which generally means counseling. They can operate independently and are generally reimbursed by insurance.

Psychologists. Psychologists have PhDs or doctoral degrees, have had supervised clinical hours, and have passed licensing exams. They can diagnose and treat mental illness. They cannot prescribe medication in Texas; however, they are increasingly allowed to prescribe medication in other states if they receive additional training. If properly qualified, they can testify about competency and sanity in criminal court. Psychologists use a variety of testing instruments to measure behavioral and psychological characteristics including memory, intelligence, personality disorders, psychosis, depression, ADHD, trauma exposure, aptitude for work, etc.

Licensed Psychological Associates (LPAs). These professionals are required to have at least a master’s degree and provide a range of psychological services, including assessment and counseling. LPAs must work under the supervision of a licensed psychologist and cannot practice independently. They are often employed at government mental health agencies.

Registered Nurses, Advanced Practice Nurses, Physician’s Assistants, and Physicians. Registered nurses can provide mental health treatment, such as administering medication, but they cannot diagnose mental illness. Advanced practice nurses (with appropriate training), physician assistants and physicians can all diagnose and treat mental illness, including prescribing medication. Properly qualified psychiatrists can evaluate and testify about competency and sanity. Psychiatrists are physicians who specialize in psychiatric disorders. Neurologists specialize in brain disorders, but generally refer to psychiatrists for psychiatric disorders (such as bipolar disorder). Many general practice physicians or pediatricians also prescribe psychotropic medication.
 

See the chart attached to this webpage for a list of treatment providers and what they are qualified to do.

Education and support

Education. Educational programs are designed to give information about a specific subject, are generally not regulated, and do not require special credentials for the instructor. The class may be held once or over several sessions. For instance, a person who commits his first DWI may be sent to a class to learn about substance abuse behaviors and symptoms; a person who commits criminal mischief might be sent to an anger management class. Educational programs are not treatment. For example a parenting class may teach participants strategies for dealing with children, child development issues, and coping skills. In treatment (i.e., professional counseling), parents meet with a therapist who uses clinical techniques to change the parents’ thoughts, beliefs, and actions towards their children.
Peer support group. A peer support group is comprised of individuals with a similar issue who meet to provide each other with support and advice. An example is Alcoholics or Narcotics Anonymous or a domestic violence survivors group. An advantage of peer support is that it is usually free, but while it enhances treatment, it is not treatment.
Life skills training. Young adults, juveniles or people with cognitive issues (such as low IQ or neurological damage) can benefit from life skills training. A caseworker might teach people basic life skills, such as home management, grocery shopping, basic self-care, or basic financial skills.

Treatment

Substance abuse treatment.12 Substance abuse intervention ranges from a DWI class to inpatient treatment, and many options in between. Some addictions, such as prescription drug abuse, might require medical management. Treatment programs should have an aftercare component, which is follow-up support for people who have completed the program. If someone is required to attend Alcoholics Anonymous, she could be required to secure a sponsor with several years of sobriety.
Counseling and therapy. Counseling or therapy should be provided by an appropriately licensed mental health professional—generally, a licensed clinical social worker (LCSW), psychologist, licensed professional counselor (LPC), or licensed marriage and family therapist (LMFT). This professional meets with clients over a period of time to resolve emotional or behavioral issues.

Someone may call herself a “psychotherapist,” but there is no license associated with this term. Licensed chemical dependency counselors (LCDCs) may provide counseling relating only to substance abuse issues. Most psychiatrists don’t provide therapy. They usually meet with the client long enough to prescribe and monitor medication.
Specialized programs. Community supervision departments have special caseloads and programs, some of which are regulated for purposes of community supervision. Examples are substance abuse programs, domestic violence programs (also called BIPPs [Batterer’s Intervention and Prevention Program, discussed below]), and sex offender treatment.
Batterer’s Invention and Prevention Program (BIPP). BIPP is intervention and education for domestic violence perpetrators. It is different from anger management in that it explores and challenges the basis of battering, which is one person exercising power and control over his partner. It is a standardized program agreed upon by domestic violence service providers, the Texas Department of Criminal Justice (TDCJ), and the Texas Council on Family Violence (TCFV). Specific guidelines can be found at the TCFV website (www .tcfv.org). The goal is to achieve victims’ safety, offenders’ accountability, and opportunities for batterers to change their beliefs and behaviors relating to their partners.

Effective September 1, 2009, as a condition of community supervision, judges can only send batterers to TDCJ-accredited BIPPs. More information can be found in the Texas Code of Criminal Procedure, Chapter 42. Currently, the accreditation process is underway. There is no requirement that the treatment provider have any type of professional mental health license (unlike sex offender treatment providers), only that they complete the required training.
Sex offender treatment.13 The Texas Administrative Code specifically defines who can provide sex offender treatment and treatment guidelines (Title 22, Part 36, Chapter 810); treatment providers are limited to those licensed in Texas to practice as a physician, psychiatrist, licensed professional counselor, licensed marriage and family therapist, licensed clinical social worker, or advanced nurse practitioner [with additional requirements]. Licensed Sex Offender Treatment Providers (LSOTP) must also undergo hours of clinical supervision and training.
In-custody programs. Various programs are available for in-custody treatment. Here in Harris County, we have in-custody programs for substance abuse treatment and mental health. We might consider an in-custody program for a repeat offender who has a particularly difficult addiction problem. Some people with chronic mental health problems receive the most consistent mental health treatment when they are in jail.
Hospitalization. Hospitalization or partial hospitalization programs provide intensive treatment for people with active suicidal thoughts or plans or severe psychosis or those who need intensive medication management. Partial hospitalization is an alternative where the client may spend several hours or all day at a treatment center but go home at night. Such treatment might be used, for example, when someone has been recently suicidal but is now stable. The person might choose partial hospitalization for five days, then step down to twice-weekly counseling sessions, and ultimately end with weekly sessions until treatment is completed.
Involuntary commitment. A person can be involuntarily committed if he exhibits signs of a mental illness and poses a serious, imminent danger to himself or others. It isn’t enough to merely be “out of one’s mind” or actively psychotic (hearing voices, being paranoid, etc). A police officer is authorized to take someone into custody and to a mental health facility (or to a jail if one is not suitable) only if he believes that person is mentally ill and a serious danger.14

An adult (who doesn’t have to be relative) can swear out a mental health warrant through the local probate court. When a person is picked up on a mental health warrant, he is held up to 72 hours. If there is cause to hold him longer, there is another legal procedure to follow. The longer a person is held involuntarily, the more stringent the law is for keeping him.15

There is a tension between individual rights, proper treatment, and cost. Under the old system, a person could be sent to a sanitarium and left for years, but on the other end of the spectrum, mentally ill people are released after a very short time, usually only having been stabilized on medication; after that, it is difficult to justify reasons to keep people hospitalized involuntarily. Once they are released, there is no way to ensure that they keep taking their medication, and long-term treatment can be very expensive. Middle ground surely exists, but our criminal justice system hasn’t found it yet. Prosecutors might be tempted to dismiss charges against someone with a chronic mental illness; however, with our current system, there is no guarantee that that person will receive consistent and appropriate treatment. In some cases, the best way to ensure treatment is through the criminal justice system.16

Psychotropic medication

Many mental illnesses, such as schizophrenia or bi-polar disorder, require medication to control symptoms. It is often when people “go off their meds” that we see them in the criminal justice system, sometimes after committing “nuisance crimes” such as criminal trespass. If a person is placed on community supervision, he can be ordered to take medication as recommended by a physician.

Following is a description of common types of medication and their uses.17 It is a short list as it is beyond the scope of this article to describe psychotropic medication in detail.18 It should be noted that just because a person is taking a certain medication, it does not mean she has a certain diagnosis. For instance, sometimes anti-psychotic or anti-depressant medication is given to people with ADHD to control aggressive or impulsive behavior.
Anti-depressants and SSRIs (selective serotonin reuptake inhibitors). These medications relieve symptoms of depression and anxiety. Common brand names are Prozac, Wellbutrin, Zoloft, Paxil, Celexa, and Effexor. Strattera is an anti-depressant prescribed for ADHD.
Hypnotics and anti-anxiety medications. Some of the most common anti-anxiety medications are benzodiazepines, which include Valium, Klonopin, and Xanax. Some non-benzodiazepine hypnotics induce sleep; Ambien and Benadryl are two common ones. Note that these medications have high potential for abuse.
Anti-psychotics. The primary function of these medications is to eliminate or reduce psychotic symptoms (i.e., delusions and hallucinations). A second-line application is the reduction of aggression. Examples are Seroquel, Risperdal, Zyprexa, and Abilify.
Mood stabilizers and anti-manics. Medications such as lithium, Tegretol, or Depakote stabilize mood and control mania associated with bi-polar disorder.
Psycho-stimulants. These are medications given for ADHD. It is believed they work on dopamine to increase attention. Examples are methylphenidate (Ritalin or Concerta) or amphetamines (Adderall or Dexedrine).

Sample treatment plan and diagnosis

Julia, a 24-year-old Hispanic female accountant, presents as a voluntary patient in a psych hospital.  She has been sleeping 16 hours a day, not taking care of basic hygiene, and feeling hopeless, sad, and overwhelmed. She was quiet and appeared timid and unsure of herself.  Her affect was somewhat blunted. She did not display any psychotic symptoms and was oriented to time and place.  She reports she was sexually assaulted for several years as a child.  She recently left her home because her boyfriend was violent with her. She has used cocaine three times during the past year and has a charge pending for cocaine possession. She has diabetes and was treated in the past for major depression, but stopped taking her medication because she didn’t like the sexual side effects.  She has had thoughts of suicide recently, but no specific plan or intention. Julia’s strengths include a desire to make her life better, a willingness to seek help, having a decent job with health insurance, and a small, but very supportive group of friends.

Axis I        296.3x Major Depressive Episode, Recurrent
309.81 Post Traumatic Stress Disorder, Chronic
305.60 Cocaine Abuse
Axis II        Deferred
Axis III    Diabetes
Axis IV    Legal problems, facing criminal charges,
Previous sexual abuse, domestic violence
Axis V     GAF – Current 45 – Highest during past year – 70 

Helpful programs

Community supervision departments establish relationships with treatment providers. However, some prosecutors may want (or have) to take a more active role in finding programs. Following are some thoughts to consider in ascertaining the effectiveness and quality of treatment:
•    A good place to start is with the local United Way or MHMR (Mental Health and Mental Retardation Authority). Other good places are a local Mental Health Association (www .nmha.org) or through the National Alliance for Mental Illness (www .nami.org).
•    Establish relationships with local mental health providers through local professional associations, such as the National Association of Social Workers (www.naswtx.org).
•    Find out if there are licensed mental health experts at your local Community Supervision Department. They can assist in determining appropriate conditions of community supervision.
•    Larger offices can hire a licensed mental health professional on your staff. Not only will she will be able to help evaluate programs, she can also assist prosecutors with reading and interpreting mental health reports and evaluating other types of mental health issues.
•    For smaller offices, contract with a mental health professional when necessary and develop relationships with mental health professionals at public agencies who can answer general questions.
•    Ask the provider what types of programs (education, assessment, therapy) they have.
•    Who is providing the services? Do they have a license? What type? Are they operating within the scope of their license?
•    How long have they been in business?
•    Do they keep stats on how many of their clients complete their programs?
•    Do they keep stats on how they measure the efficacy of their programs?
•    Does research support the effectiveness of their program?
•    Do they have a written curriculum? If so, ask to see it, and ask questions about it.
•    Do the number of treatment programs suit the number of staff members? D

Endnotes

1 Tex. Code Crim. Proc., Chapter 46.
2 Texas Administrative Code. Title 25, Part 1, Chapter 450.
3 Texas Department of State Health Services. Texas Occupations Code Ch. 505.
4 Licensed Professional Counselor Act, Texas Administrative Code, Title 22, Part 30, Ch. 681, subchapter B; Occupations Code, Ch. 503.
5 Texas Administrative Code, Title 22, Part 35, Ch. 801, subchapter F.
6 Texas Occupations Code, Subtitle I, Ch. 501.
7 Texas Administrative Code, Title 22, Part 11, Ch. 217.
8 Texas Occupations Code Ch. 204.
9 Accreditation Review Commission on Education for the Physician Assistant.
10 Texas Occupations Code, Subtitle B, Ch. 151, Subchapter A.
11 Psychiatrists are physicians who specialize in psychiatric disorders. While neurologists specialize in brain disorders, they generally refer to psychiatrists for psychiatric illnesses, such as bipolar disorder. Many general practice physicians or pediatricians also prescribe psychotropic medication.
12 Texas Administrative Code, Title 25, Health Services, Chapter 453, Offender Education Programs; Texas Code of Criminal Procedure. Chapter 42.12.
13 Texas Administrative Code. Title 22. Part 36. Chapter 810. Subchapter A.
14 See Texas Mental Health Code, §573.001.
15 See Texas Health and Safety Code Ch. 574.
16 For a real-life account, I recommend Crazy: A Father’s Search Through Mental Health Madness by Pete Earley. It is a heart-breaking but informative book about a young man who is ultimately diagnosed with bi-polar disorder, his involvement with the criminal justice and mental health systems, and his family’s struggle to help him.
17 Information from National Institute of Mental Health.
18 For a downloadable cheat sheet on psychotropic medication, go to www .psychceu.com/Preston/quickreference.doc.html.
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