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APA Achievement Awards   |    
Significant Achievement Awards: The Nathaniel Project—An Effective Alternative to Incarceration
Psychiatric Services 2002; doi: 10.1176/appi.ps.53.10.1314
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People with mental illness who are incarcerated receive limited—and in many cases inappropriate—psychiatric care. Frequently, their illness sets them apart from other inmates and makes them particularly vulnerable to violence and abuse. When released from jail or prison, these individuals tend to be denied access to housing and treatment in the community, because they are viewed as potentially disruptive to service systems. As a result, they are often caught up in a cycle of arrest, incarceration, release, and reincarceration.

The Nathaniel Project, a relatively young program that became fully operational in November 1999, is an alternative-to-incarceration program for people with serious mental illness who are charged with felony offenses in New York City. Named for a homeless man with schizophrenia whose illness went untreated during some 15 years of repeated incarcerations, the Nathaniel Project is a program of the Center for Alternative Sentencing and Employment Services (CASES), New York City's oldest and largest alternative-to-incarceration agency. The Nathaniel Project aims to stabilize offenders with serious mental illness in the community by providing treatment through the health care system rather than punishment through the criminal justice system. It offers intensive case management and court advocacy, links participants to mental health treatment and housing, and monitors participants' engagement with community-based treatment and rehabilitative service providers. By demonstrating that its clients can succeed in the community, can engage in treatment, and can lead law-abiding lives, the program helps participants build a new track record.

To participate in the Nathaniel Project, clients must both be prison bound and have an axis I diagnosis. Clients typically have had little or no treatment experience, have chosen to leave treatment in the past, and enter the program with little hope that treatment will help them. They tend to be homeless and suffer from co-occurring substance use disorders along with a host of related chronic medical conditions, such as AIDS, heart problems, hypertension, and asthma.

Potential clients are referred to the Nathaniel Project before final sentencing by lawyers or judges who suspect a psychiatric problem. Staff often begin an intake with no information other than that provided during the telephone call from the lawyer or judge. After the intake assessment, the individual enters treatment for a two-year period, and sentencing is deferred pending the outcome of treatment. In most cases, the treatment plan involves a supervised residential program. Regular reports must be made to the courts in order for a case to be adjudicated without the client's serving jail time. Clients who do not meet their treatment plan goals may be subject to arrest and incarceration.

Over the past two and a half years, the Nathaniel Project has served 53 individuals. The project's staff work with participants to overcome negative perceptions of mental health treatment by emphasizing that it is only through a commitment to treatment that they will avoid further contact with the criminal justice system. The project helps participants to see the connection between their symptoms and their offending behavior and, in turn, the connection between psychiatric treatment and reduction of symptoms.

Staff accompany participants to their mental health appointments and during family visits or interviews and provide practical advice and direct treatment as needed to ensure continuity of care during the transition to new providers. Staff members also teach basic community living skills, such as money management, and provide participants with a subsistence allowance for medications and basic needs such as clothing, food, and temporary housing to cover any gaps in benefits.

The consulting psychiatrist is an integral member of the project's staff. He has expertise in working with high-risk populations with criminal histories and is available 24 hours a day, seven days a week. The team also includes four forensic clinical coordinators, each of whom is a master's-level professional in mental health and psychiatric rehabilitation and carries a caseload of ten to 12 clients at any given time. The clinical coordinators are supervised by the project's deputy director, who holds a master's degree in social work and who is responsible for reviewing and approving all court reports and for securing participants' access to a variety of community-based treatments and services.

To supplement the efforts of the staff, it is envisioned that participants who complete the program will serve as mentors to clients who are new to the program. Thus consumers are directly involved in their own care, and the development of the program incorporates their experience.

The project has a number of quality assurance measures in place, including soliciting and documenting the judiciary's impression of the program's effectiveness, referring participants only to practitioners who are licensed and experienced, and regularly overseeing participants' care. Quality improvement is measured by tracking the success of individual participants in terms of factors such as the participant's reconnection with the psychiatric treatment provider, access to housing, and reintegration into the community.

Locating appropriate treatment services in the community has been a challenge, both because of a general lack of services—particularly residential ones—in New York City and because of the resistance many providers express toward working with clients who have serious involvement with the criminal justice system or histories of violence. Funding and a lack of housing also present ongoing challenges, particularly given that this is a program in which 92 percent of participants are homeless at intake. The program has a good history of getting its clients into housing: so far 94 percent of its clients have been placed in short-term housing at the time of release, and 79 percent have been placed in long-term supportive housing after a year. The project has secured funding to develop its own supervised transitional housing, which is scheduled to open in 2005.

The project has had tremendous success in retaining participants: 98 percent of enrollees at 30 days after intake, 91 percent at four months, and 85 percent at 12 months, with an overall retention rate of 81 percent. Participants in the Nathaniel Project demonstrate a dramatic decrease in arrest rates. The number of arrests dropped from 101 (35 misdemeanor and 66 felony) in the year before entry into the program, including the arrest that brought them to the program, to seven (five misdemeanor and two felony) in the year since intake. All participants are currently engaged in mental health and substance abuse treatment programs, and all are receiving benefits such as Medicaid or Supplemental Security Income. The project has demonstrated that the yearly cost of providing services to a participant ($14,578) is significantly less than the cost of a year in a state prison ($29,678) or a city jail ($53,224).

The project has played an important role in promoting a dialogue between the criminal justice system and the mental health system—creating a dynamic and fluid connection between two systems that have not traditionally worked in partnership. The project's staff has had to confront the criminal justice system's widely held perception that mental health treatment is a "soft" and inadequate alternative to traditional incarceration. The courts trust the Nathaniel Project to monitor and supervise participants in the community, which is an indicator of their appreciation of the strong positive relationship between the provision of mental health treatment and public safety.

The project has received funding support from both mental health funders and criminal justice agencies. Funding for the Nathaniel Project for fiscal year 2001 came from the New York City Council ($300,000), Van Ameringen Foundation ($100,000 as part of a three-year grant), the New York Community Trust ($100,000 as part of a two-year grant), United Way ($75,000), the Frances L. and Edwin L. Cummings Memorial Fund ($50,000 as part of a three-year grant), and the Schnurmacker Foundation ($15,000). The project was recently awarded funding from the New York State Division of Probation and Correctional Alternatives.

The Nathaniel Project has served as a best-practices model at the national level for other jurisdictions and policy makers who are confronting the problem of how to serve mentally ill offenders. The project has been awarded the 2002 American Probation and Parole Association's President's Award and the Thomas M. Wernert Award for Innovation in Community Behavioral Healthcare. CASES staff served on the mental health advisory board for the Mental Health and Criminal Justice Consensus Project, a national initiative sponsored by the Council of State Governments. The New York State Department of Probation and Correctional Alternatives has invited CASES to produce an instructional CD-ROM and video to train staff from the courts and the criminal justice system in the early identification of mental illness. In addition, mental health staff from the Bureau of Forensic Services presented the Nathaniel Project as a model program at a statewide best-practices conference in Brooklyn last year. Finally, the Bazelon Center for Mental Health Law has promoted the project as a best-practices model for serving people with mental illness in the criminal justice system.

By using an integrated approach that addresses the complex interaction of mental illness, substance use, and homelessness, the Nathaniel Project successfully balances the mental health needs of the individual on one hand and accountability to the court on the other.

For more information, contact Yves Ades, M.D., Director of Mental Health Programs, CASES, 346 Broadway, Third Floor, New York, New York 10013; phone 212-533-6314; fax 212-533-6300; e-mail, yades@cases.org; Internet, www.cases.org.

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