Jeffrey Draine

The good-enough science-and-politics of anthropological collaboration with evidence-based clinical research: Four ethnographic case studies

The apolitical legitimacy of evidence-based medicine offers a practical means for ethnography and critical social-science-and-humanities-of-health theory to transfer survival resources to structurally vulnerable populations and to engage policy and services audiences with urgent political problems imposed on the urban poor in the United States that harm health: most notably, homelessness, hyperincarceration, social service cut-backs and the War on Drugs. We present four examples of collaborations between ethnography and clinical research projects that demonstrate the potentials and limits of promoting institutional reform, political debate and action through distinct strategies of cross-methodological dialogxa0with epidemiological and clinical services research. Ethnographic methods alone, however, are simply a technocratic add-on. They must be informed by critical theory to contribute effectively and transformatively to applied health initiatives. Ironically, technocratic, neoliberal logics of cost-effectiveness can sometimes render radical service and policy reform initiatives institutionally credible, fundable and capable of generating wider political support, even though the rhetoric of economic efficacy is a double-edged sword. To extend the impact of ethnography and interdisciplinary theories of political-economic, cultural and disciplinary power relations into applied clinical and public health research, anthropologists - and their fellow travelers - have to be able to strategically, but respectfully learn to see through the positivist logics of clinical services research as well as epidemiological epistemology in order to help clinicians achieve - and extend - their applied priorities. In retrospect, these four very differently-structured collaborations suggest the potential for good-enough humble scientific and political strategies to work for, and with, structurally vulnerable populations in a punitive neoliberal era of rising social inequality, cutbacks of survival services, and hyperincarceration of the poor.

“You Don't Get No Help”: The Role of Community Context in Effectiveness of Evidence-Based Treatments for People with Mental Illness Leaving Prison for High Risk Environments

Community reentry interventions for persons with serious mental illness leaving prison have operated under the tenet that linkage to mental health services is a paramount priority to achieving successful reentry. However, these interventions have produced mixed outcomes, especially related to psychiatric or criminal recidivism. As mental health evidence–based treatments are applied to this population, other environmental or community-level factors such as social disadvantage and poverty may enable or suppress the effectiveness of such intervention models. Such factors need to be considered as possible impediments to the effectiveness of these interventions as perhaps demonstrated in trials with other populations. Explicitly addressing these factors may help improve outcomes in some cases. In others, the impact of the risk environment may be stronger than what could be overcome with clinically focused intervention.

Engagement processes in model programs for community reentry from prison for people with serious mental illness

Linking prisoners with mental illness with treatment following release is critical to preventing recidivism, but little research exists to inform efforts to engage them effectively. This presentation compares the engagement process in two model programs, each representing an evidence-based practice for mental health which has been adapted to the context of prison reentry. One model, Forensic Assertive Community Treatment (FACT), emphasizes a long-term wrap-around approach that seeks to maximize continuity of care by concentrating all services within one interdisciplinary team; the other, Critical Time Intervention (CTI), is a time-limited intervention that promotes linkages to outside services and bolsters natural support systems. To compare engagement practices, we analyze data from two qualitative studies, each conducted in a newly developed treatment program serving prisoners with mental illness being discharged from prisons to urban communities. Findings show that the working relationship in reentry services exhibits unique features and is furthered in both programs by the use of practitioner strategies of engagement, including tangible assistance, methods of interacting with consumers, and encouragement of service use via third parties such as families and parole officers. Nevertheless, each program exhibited distinct cultures and rituals of reentry that were associated with fundamental differences in philosophy and differences in resources available to each program.

Examining the Impact of Mental Illness and Substance Use on Time till Re-incarceration in a County Jail

This paper examines the role that substance use and serious mental illness play in criminal justice recidivism by examining the time to return to jail for a cohort of people admitted to jail in 2003 (Nxa0=xa016,434). These analyses found that people with serious mental illness alone experienced the longest time in the community before returning to jail and were found to have a risk of re-incarceration that did not differ significantly from individuals with no psychiatric or substance use diagnoses. People with co-occurring disorders had a risk of re-incarceration that was over 40xa0% higher than that of individuals with no diagnosis.

I'm not sure that I can figure out how to do that: Pursuit of work among people with mental illnesses leaving jail.

Restoring people with mental illnesses to community life after detention in jail is fraught with significant challenges. Many of these challenges mirror those faced by anyone else who has been detained in jail. Among these is the particular challenge of seeking gainful employment and financial support for day-to-day life. This challenge is intensified when individuals return from jail to impoverished communities where employment prospects are already limited for residents and where either a criminal record or a mental illness creates still additional barriers to work. To understand these barriers more fully, this study examined the process of seeking employment among people with mental illness leaving jail. Seventeen individuals with a history of mental health problems and with recent jail incarceration were recruited from either a community based employment program or a mental health service setting. The informants were interviewed using life history interview techniques. Results show that connections to the paid workforce were tenuous at best for these respondents, both before and after their jail detention. Although psychiatric symptoms, addiction, and the lack of productive social connections were individual-level factors that affected employment, the most pernicious impediments were rooted in policy, community structures, stigma, and other social and economic realities. If employment interventions are to have any traction at all in these settings, interventionists need to dig for innovative ways to address these factors, which are not complications, but bedrock realities that undergird all else.

Understanding how police officers think about mental/emotional disturbance calls

Police officers frequently respond to calls involving persons with mental illnesses and in doing so, they are key gatekeepers of access to mental health treatment as well as entry into the criminal justice system. Programs such as Crisis Intervention Teams (CIT) are being implemented across the United States and elsewhere to train officers to respond more effectively and facilitate access to mental health services when appropriate. These programs would benefit from a thorough understanding of these encounters from the perspective of police officers. We take as a premise that officers develop frames of reference or schema for understanding and responding to these encounters that are shaped by socialization, training, and their experience as police officers. In this study, we examine police officer schema of mental/emotional disturbance (M/EDP) calls. Qualitative interviews provided the foundation to develop the Needs on the Street Interview (NOSI) to tap officer schema of four types of M/EDP scenarios. The NOSI was administered to 147 officers in Chicago and Philadelphia. Latent Class Analysis (LCA) was conducted separately for each scenario to examine groups of officers with different schema as well as predictors of schema group. For three of the four scenarios, officers were classified into a two category or schema model, for the fourth (crime reported) a three category model was supported. Schema groups tended to be differentiated by ratings of level of resistance/threat and substance use. Contrary to our expectations, CIT and law enforcement experience did not predict officer schema group. While the CIT model emphasizes de-escalation skills to reduce resistance and the need for officers to use force, CIT and other training programs may want to consider increasing content related to factors such as co-occurring substance use and managing resistance.

Mental Health, Mental Illnesses, Poverty, Justice, and Social Justice

In 2002, my colleagues and I at the then Center for Mental Health Policy and Services Research at the University of Pennsylvania published a paper in Psychiatric Services on the role of social disadvantage in explaining mental illness and mental health status (Draine, Salzer, Culhane, & Hadley, 2002). In the paper, we argued that the mechanisms of social disadvantage were underappreciated in research on the lives of people with mental illness living in communities. We asserted that mental illness was being overly blamed for some social conditions such as homelessness, unemployment, and criminal justice involvement, when, in many cases, the causal order for poor mental health status (however defined) could be easily argued the other way around—that endemic social distress and exclusion was making recovery from mental illness more challenging that it otherwise would be. This is no mere echo of the debates concerning social selection or social drift in the previous eras of psychiatric epidemiology (Dohrenwend, 1967). This is, rather, an invitation to look deeper into the lives of people with mental illness as they confront the impact of low socioeconomic status and social exclusion in their

Reincarceration Risk Among Men with Mental Illnesses Leaving Prison: A Risk Environment Analysis

Reentry interventions for persons with mental illness leaving prison have consisted primarily of linkage to mental health services and have produced mixed results on psychiatric and criminal recidivism. These interventions primarily focus on intra-individual risk factors. However, social and environmental factors may also increase risk of reincarceration by constraining choices and pro-social opportunities for community reintegration upon release from prison. In order to add to the knowledge base on understanding reincarceration risk for men with mental illnesses leaving prison, we examined interpersonal and environmental factors that exposed men to heightened risk for reincarceration. As part of a larger study examining the effectiveness of Critical Time Intervention for men with mental illness leaving prison, in-depth interviews were conducted with 28 men within 6xa0months of release from prison. Policies and practices at local and state levels, community conditions, and interpersonal obligation and conflict were identified as increasing risk for reincarceration.

Influences of Economic, Social and Cultural Marginalization on the Association Between Alcohol Use and Sexual Risk Among Formerly Incarcerated Latino Men

Formerly incarcerated Latino men (FILM) have been significantly impacted by the HIV/AIDS and alcohol abuse epidemics in the United States. In this analysis, we examine the role of social, economic and cultural marginalization in the likelihood of alcohol-related sexual risk taking behavior among FILM. We recruited a non-random sample of FILM, ages 18–49 (nu2009=u2009259). We performed logistic regression modeling to test four hypotheses examining the direct and moderating effects of socio-cultural factors. Drinking before sex was strongly associated with high likelihood of condomless intercourse (adjusted odds ratio, AORu2009=u20092.93; 95% CI 1.74, 4.94). Low acculturation and social marginalization factors were significant moderators of the association between high-risk alcohol use and sexual risk behavior among FILM. Our data suggest that risk reduction initiatives geared towards reducing alcohol-related sexual risk taking among FILM should target FILM with low levels of acculturation, and those with high levels loneliness, anxiety, and/or depression.

The crisis intervention team (CIT) model: An evidence-based policing practice?

As academic researchers, we are often asked to opine on whether the Crisis Intervention Team model (CIT) is an evidence-based practice (EBP) or evidence-based policing. Our answer is that it depends on how you define evidence-based practice and what outcome you are interested in. In this commentary, we briefly describe the CIT model, examine definitions of evidence-based practice and evidence-based policing, and then summarize the existing research on what is known about the effectiveness of CIT to date. We conclude that CIT can be designated an EBP for officer-level cognitive and attitudinal outcomes, but more research is needed to determine if CIT can be designated an EBP for other outcomes. Using an evidence-based practice process approach, CIT may also be a justified strategy for many communities. Future directions to inform the field are discussed.