Developing decision support tools for high-risk women and healthcare providers to increase chemoprevention informed choice and uptake: A retrospective translational science case study.

Retrospective case studies are one approach to help identify processes underlying the translation of successful health interventions. This case study investigates the development of RealRisks and Breast Cancer Risk Navigation (BNAV), decision support tools for breast cancer risk assessment, and risk-stratified prevention. Following a recently developed protocol for retrospective translational science case studies, we examined the career trajectory of Dr Katherine Crew as she expanded from basic science to interdisciplinary, patient-oriented research in oncology and began collaboration with Dr Rita Kukafka, a public health informatician focused on communicating risk. Data collection methods included key informant interviews and examination of peer-reviewed publications, funded grants, and news articles associated with the research. Data were analyzed to identify key milestones in the development of RealRisks and BNAV and to elucidate facilitators and barriers to the translational process. Facilitators to translation included funding and infrastructure provided by a Clinical and Translational Science Award (CTSA), the creation of an interdisciplinary team, and broad support from stakeholders including patient advocacy groups. Barriers to translation included limited mid-career support, ongoing costs for technology, and the time required to establish interdisciplinary, team science efforts. The findings reported here can be used to inform ongoing efforts to develop a more robust science of translation.

Technology for advancing behavioral health integration: implications for behavioral health practice and policy.

Behavioral health integration (BHI) encompasses the integration of general health, mental health, and substance use care. BHI has promise for healthcare improvement, yet several challenges limit its uptake and successful implementation. Translational Behavioral Medicine published the Continuum-Based Framework by Goldman et al., 2020 to create comprehensive guidance for BHI within primary care settings. Technology can help advance BHI and provide evidence to support it. This commentary describes challenges and illustrative use cases in which technology solutions help organizations achieve BHI through the Continuum-Based Framework domains. Two rounds of semi-structured interviews with field leaders, practice sites, and technology stakeholders identified key barriers in BHI amenable to technology solutions, applications of technologies, and how they facilitate BHI. Findings showed that technology can facilitate the implementation and scaling of BHI by reducing care fragmentation and improving patient engagement, accountability and financial sustainability, provider experience and support, and equitable access to culturally competent care. Continued efforts by stakeholders to address legacy policy and implementation issues (e.g. incentives, investment, privacy, and workforce) are needed to optimize the impact of technology on BHI.

Behavioral health integration (BHI) combines physical, mental, and substance use care to enhance overall well-being. While BHI offers benefits, it faces challenges. Researchers developed the Continuum-Based Framework to aid primary healthcare centers in implementing BHI. Technology is key to supporting BHI effectiveness. Researchers examined how technology can assist with BHI by interviewing experts and analyzing real-world examples. They found that technology helps healthcare centers address BHI challenges by ensuring comprehensive and equitable care delivery, promoting patient engagement, and supporting healthcare providers. Technology can improve BHI practices over time, but policy, investment, and privacy changes are necessary for optimal integration.

Barriers and Facilitators to Staff Recruitment and Retention for ACT Teams: Perspectives of Staff and Participants.

The behavioral health workforce has been experiencing deepening problems with recruitment and retention, particularly in publicly funded settings serving individuals with serious mental illnesses. This quality improvement project gathered Assertive Community Treatment (ACT) participant (service user) and provider perspectives on workforce challenges. The authors conducted 8 interviews with ACT participants and 9 focus groups with ACT current staff, team leaders, and former staff. Interviewees discussed barriers to recruitment and retention, including inadequate compensation, work becoming more task-oriented during periods of short staffing, a lack of understanding of what ACT work entails, and elements of the team-based model of care; and facilitators of recruitment and retention, including other aspects of the team-based model of care, connections with colleagues and ACT participants, and flexibility. ACT participants had variable experiences regarding availability of their teams. Recommendations from focus groups and interviews include increasing flexibility, improving awareness of ACT work, optimizing team functioning, addressing staff wellness, and attending to risk. Findings include key insights that may help address the critical workforce shortages in public behavioral health settings.

Community-Based Mental Health Crisis Response: An Overview of Models and Workforce Implications.

Communities across the United States are working to improve community-based mental health crisis response, with 1 goal being to reduce criminal legal system involvement among individuals with mental illnesses, behavioral disorders, or mental health crises. Existing and recently developed models can generally be divided into non-law enforcement-based response models and law enforcement-based response models. Wide variation exists in terms of staffing, how response teams are called out or dispatched, hours of operation and immediacy of response, and approaches to crisis resolution.

Qualitative Evaluation of Acceptability and Feasibility of a Behavioral Intervention to Reduce Violence Among Young Adults with Early Psychosis.

Young adults with early psychosis are at higher risk of violent behavior, but no studies have explored using CBT-based interventions to reduce violence in specialized early intervention services (EIS) settings. This study describes formative research about the acceptability and feasibility of the Psychological Intervention for Complex PTSD and Schizophrenia-Spectrum disorder (PICASSO) to reduce violence, using interviews with EIS participants and staff. Generated themes regarding acceptability included negative experiences of violence and the desire to control and minimize violence. Themes regarding feasibility raised concerns about time constraints, consistency of participation in the intervention, and implementation issues in the context of stigma related to both psychosis and perpetration of violence. Findings from this study suggest there is a need for an intervention addressing violence risk. If adequate resources are devoted to addressing implementation issues, a CBT intervention for violence like PICASSO appears both acceptable and feasible for EIS participants and staff.

Predictors of Criminal Sentiments Scale-Modified Scores in Outpatients with Legal System Involvement.

The Criminal Sentiments Scale-Modified (CSS-M) has been widely used as a measure of criminal attitudes. This analysis examined CSS-M scores in a large sample of outpatients with serious mental illnesses and a criminal legal system history. We compared total and subscale scores in our sample to scores from two other previously published U.S. studies in which the CSS-M was used, and evaluated associations between total CSS-M score and nine variables (age, educational attainment, gender, race, marital status, employment status, diagnostic category, substance use disorder comorbidity, and adverse childhood experiences (ACE) score). Scores were higher than in two prior U.S. studies involving other types of samples. Independently significant predictors of higher CSS-M scores included being younger (P < .001), having a higher ACE score (P < .001), being male (P = 03), not identifying as White (P < 001), not having a psychotic disorder (P < 001), and having a comorbid substance use disorder (P = 002). Future research should test the hypothesis that these factors increase risk for arrest and that arrest events, and subsequent criminal legal system involvement, are characterized by negative experiences and perceptions of poor procedural justice, which in turn underpin the negative opinions referred to as "criminal sentiments" or criminal attitudes.

A Group-Based, Six-Lesson Healthy Eating Curriculum for Individuals With Serious Mental Illnesses: Development and Implementation.

As part of an intervention tailored to individuals with serious mental illnesses in residential settings that aimed to increase dietary intake of fresh vegetables and fruits, we developed and implemented a nutrition and cooking curriculum. To develop the curriculum, we assembled a Workgroup that consisted of professionals from multiple fields. The Workgroup held weekly discussions before drafting what would become the Workbook. Residential staff at partnering housing agencies taught the curriculum to residents. The curriculum Workbook contains six lessons, which are organized around two field trips to a mobile farmers market and a grocery store, and four cooking methods. The Workbook also includes instructions on using FreshConnect Checks at mobile farmers markets. The new curriculum distinguishes itself from other nutrition and culinary literacy curricula in that it delivers knowledge about fresh produce and skills in preparing fruits and vegetables in a way that is tailored to individuals with serious mental illnesses.

An open pilot trial of a behavioural intervention to reduce violence by young adults with early psychosis receiving treatment in an early intervention services setting: A protocol.

AIMS: Despite the public health impact of violence among young adults with psychosis, behavioural interventions to reduce the risk of engaging in violence remain rare. For young adults with early psychosis, cognitive behavioural therapy (CBT)-based psychotherapy has efficacy in reducing impairment and improving functioning. However, no CBT-based intervention to reduce violence has been formally adapted for young adults with early psychosis. This protocol outlines the first clinical trial of a behavioural intervention to reduce violence for young adults with early psychosis. This study is set in an early intervention services (EIS) setting and seeks to adapt and pilot Psychological Intervention for Complex PTSD and Schizophrenia-Spectrum Disorder (PICASSO), a CBT-based intervention, through an iterative process utilizing mixed-methods assessments. METHODS: All research will occur at OnTrackNY, the largest EIS program in the United States. This study will consist of an open pilot trial, with four EIS clinicians delivering the intervention to one to two EIS participants per round. In this mixed-methods study, both quantitative measures (acceptability, feasibility and hypothesized mediators of target outcome collected on a weekly basis) and qualitative interviews (with EIS clinicians at weeks 4, 8 and 12) will be conducted. Transcripts will be analyzed using thematic content analysis. Two to three rounds of iterative modifications are anticipated (n = 10-16 EIS participants total). RESULTS: Recruitment began in February 2024 and is expected to continue over a 9-12-month period. CONCLUSIONS: Because violent behaviour causes interpersonal disruptions such as incarceration and increased caregiver burden, an innovative intervention to reduce violence risk could have broader health impact for this vulnerable population. Adapting the PICASSO intervention to the EIS setting will optimize its acceptability and feasibility by the intended target population.

Comparing brief video interventions to reduce public and self-stigma: Randomized control trial.

AIM: Stigma is a major mental healthcare barrier. This study compares the efficacy of two types of brief video interventions, targeting public and self-stigma, in reducing public stigma towards people living with psychosis. We hypothesized both interventions would similarly reduce public stigma and outperform the control group. As a secondary analysis, we explored the effect of familiarity with a person living with serious mental illness (SMI). METHODS: Participants (N = 1215) aged 18-35 recruited through crowdsourcing were assessed pre- and post-intervention and at 30-day follow-up regarding five public stigma domains: social distance, stereotyping, separateness, social restriction and perceived recovery. Both videos present individual narratives using different approaches: the self-stigma video was created through focus groups, while the public stigma video portrays a single person's journey. RESULTS: A 3 × 3 analysis of variance (ANOVA) revealed a significant group-by-time interaction across all five stigma-related domains (p's < .001). Effect sizes (Cohen's d) ranged from 0.29 to 0.52 (baseline to post-intervention), and 0.18 to 0.45 (baseline to 30-day follow-up). The two video interventions did not significantly differ. Linear mixed modelling showed a significant difference between participants familiar and unfamiliar with people living with SMI for the public stigma video, with greater stigma reductions for unfamiliar participants. CONCLUSIONS: This study corroborates previous findings on the positive influence of social contact-based interventions on youth mental health perceptions. Results provide insights into the relationship between public and self-stigma and the impact that familiarity with SMI may have on the efficacy of stigma reduction efforts further validation in diverse groups is needed.

Randomized Controlled Trial of a Brief Video Intervention to Reduce Self-Stigma of Mental Illness.

Objective: Self-stigma, a phenomenon wherein individuals internalize self-directed negative stereotypes about mental illness, is associated with negative outcomes related to recovery. This randomized controlled study assessed the efficacy of a brief social contact-based video intervention in reducing self-stigma in a large sample of individuals ages 18-35 endorsing an ongoing mental health condition. We hypothesized that the brief video would reduce self-stigma.Methods: In January and February 2023, we recruited and assigned 1,214 participants to a brief video-based intervention depicting a young individual living with mental illness sharing his personal story or to a non-intervention control. In the 2-minute video, informed by focus groups, a young individual described struggles with mental illness symptoms; this was balanced with descriptions of living a meaningful and productive life. Self-stigma assessments (Stereotype Endorsement, Alienation, Stigma Resistance, Perceived Devaluation Discrimination, Secrecy, and Recovery Assessment Scale) were conducted pre- and post-intervention and at 30-day follow-up.Results: A 2 ✕ 3 group-by-time analysis of variance showed that mean self-stigma scores decreased in the intervention arm relative to control across 5 of 6 self-stigma domains: Stereotype Endorsement (P = .006), Alienation (P < .001), Stigma Resistance (P = .004), Secrecy (P < .001), and Recovery Assessment Scale (P < .001). Cohen d effect sizes ranged from 0.22 to 0.46 for baseline to post-intervention changes. Baseline and 30-day follow-up assessments did not significantly differ.Conclusions: A 2-minute social contact-based video intervention effectively yielded an immediate but not a lasting decrease in self-stigma among young individuals with ongoing mental health conditions. This is the first study to examine the effect of a video intervention on self-stigma. Future trials of self-stigma treatment interventions should explore whether combining existing interventions with brief videos enhances intervention effects.Trial Registration: NCT05878470.

Making Decisions About Calling 988 Versus 911: Understanding End-User Views Before the Launch of 988.

OBJECTIVE: The 988 telephone number was implemented in July 2022 as an easily accessible way to reach the National Suicide Prevention Lifeline and has been envisioned as one step in building a more robust crisis care continuum in the United States. This study aimed to describe how various stakeholders anticipated using 988 compared with the most widely known crisis line: 911. METHODS: Focus groups (N=15, with 76 total participants) were conducted in three counties in New York State between October and November 2021, before the launch of 988. Five stakeholder groups were included: mental health services consumers, family members of consumers, community members, mental health providers, and crisis call takers. Thematic analysis was used to code and analyze all focus group transcripts. RESULTS: Participants anticipated that key uses for 988 would be accessing support during a crisis, obtaining connections to local resources and services, and receiving alternatives to law enforcement response. However, participants continued to articulate uses for 911 during a mental health crisis, especially for situations involving "safety concerns." CONCLUSIONS: The broad expectations for 988 suggest that the line must be flexible and responsive to a range of needs and that communities should clearly define what is available through 988. More implementation research is needed to ensure a detailed understanding of those whom 988 is serving, how the line meets callers' needs, and the line's potential for connecting people to needed services.

Identifying Individuals With Early Psychosis in Jail: Lessons Learned for Coordinated Specialty Care Services.

OBJECTIVE: This study sought to establish the feasibility of a two-component intervention embedded within a jail setting that would detect detainees with early psychosis and connect them to coordinated specialty care (CSC) in the community upon release. METHODS: The two components of the intervention were a targeted educational campaign for correction officers and a specialized early engagement support service to facilitate jail discharge planning. Jail detainees with early psychosis were referred to the project and assessed for positive and negative symptoms, substance use, and duration of untreated psychosis (DUP). During a 24-month period, 25 individuals were referred, of whom eight were eligible and interviewed. RESULTS: The sociodemographic and clinical characteristics of the jail detainees were similar to those of individuals in hospital settings. The median DUP was 36 weeks. One of the eight detainees with early psychosis was successfully referred to CSC; for the other detainees, social or criminal legal factors precluded referral. CONCLUSIONS: A targeted educational campaign for correction officers and a specialized early engagement support service can be implemented in a jail setting, and referrals can be facilitated. Success of the campaign may depend on having dedicated liaisons within the jail setting (e.g., among correctional health staff) as well as liaisons in local CSC programs and leadership. Changes in the law and policy environments (e.g., criminal legal system reform) and changes in organizational practices and processes for corrections, correctional health, and local CSC programs (such as those made during the COVID-19 pandemic) require ongoing collaborations.

Introducing the Staff-Administered Meal Independence Rating Scale for Use Among Patients With Serious Mental Illnesses.

ABSTRACT: For individuals living with serious mental illnesses (SMIs), inadequate meal preparation skills can hinder the ability to live independently; yet rating scales tailored for this population are lacking. We describe development, item analysis, and initial reliability and validity of the Staff-Administered Meal Independence Rating Scale (SAMIRS). After item development involving expert consultation, two rounds of pilot testing ( n = 188, n = 293) were conducted in inpatient and residential settings (transitional living residences [TLRs] and community residences [CRs]). For initial testing of convergent validity, Pearson correlations with Specific Levels of Functioning (SLOF) scale items were computed. Exploratory factor analysis revealed a single factor; Cronbach's alpha was high (0.98). The mean SAMIRS score varied by setting: CR residents scored higher than those in TLRs or inpatient units. Scores were highly correlated with SLOF items measuring community living skills. Although further study is warranted, the SAMIRS could be a useful tool in rating functional needs pertaining to meal independence among individuals with SMI.

Using focus groups to inform a brief video intervention to reduce public stigma toward Black youth living with psychosis.

Objective: Black individuals living with psychosis are at risk for stigma and marginalization due to systematic discrimination and barriers to receiving treatment. Social contact-based interventions have the potential to reduce stigma; however, interventions with elements specific to the experiences of Black youth are limited. Therefore, we aimed to gather input from Black youth living with psychosis to develop a social contact-based, brief video intervention to reduce public stigma toward Black youth with psychosis. Methods: Two 90-min focus groups were conducted with seven young Black individuals ages 18-30 with First Episode Psychosis from OnTrackNY. Participants were asked about their experiences of stigma and racial discrimination, and their perspectives on a video intervention. Focus group transcripts were analyzed using thematic content analysis. Results: Themes that emerged included: the salience of stigma and racial experiences for some participants and not others; the linking of religiosity and symptoms in Black communities; the importance of taking responsibility for recovery as a coping strategy to counteract stigma; and mixed views on creating a video intervention specific to Black youth. Conclusion: Meaningful and empowering involvement of individuals with lived experience of psychosis is essential to create stigma reducing interventions. Input from Black youth living with psychosis assisted in developing a culturally tailored brief video-based intervention to reduce public stigma toward Black youth with psychosis that included information about the protagonist's experience of race and mental illness, specifically family, religious, and community-based experiences.

Self-stigma among people with serious mental illnesses: The use of focus groups to inform the development of a brief video intervention.

OBJECTIVE: People with mental illnesses may avoid or delay treatment due to a fear of labeling and discrimination, a phenomenon known as self-stigma. Self-stigma is a major barrier to care and creates obstacles to pursuing employment, independent living, and a fulfilling social life. We aimed to gather input from people with lived experience of mental illness to develop a social-contact-based, brief video-based intervention to reduce self-stigma. METHOD: Two (n = 12) focus groups were conducted to inform video content and led to the creation of a script and brief video using a professional actor, who described a story of living with schizophrenia while focusing on symptoms, personal struggles, and recovery. Two (n = 9) additional focus groups were held after video development to gather feedback and suggested edits. Focus group transcripts were analyzed using thematic content analysis. RESULTS: Themes emerging in prevideo development included the negative effects of being diagnosed with severe mental illnesses, being stereotyped, the value of relatable recovery stories and seeing the person as a whole, and the utility of focusing on symptoms and experiences rather than diagnosis-specific language. Feedback in the postvideo focus groups was mainly favorable and resulted in edits related to language about "responsibility" and a disclaimer about using a professional actor. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: While participants' experiences of stigma are consistent with extant literature, this is the first study to elicit the perspectives of people living with mental illnesses in developing a video intervention to reduce self-stigma. Studies are needed to examine the efficacy of these videos in reducing self/public stigma. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Crisis Response Model Preferences of Mental Health Care Clients With Prior Misdemeanor Arrests and of Their Family and Friends.

The overrepresentation of people with serious mental illnesses in the criminal legal system has spurred the development of crisis response models to improve or reduce police response to a mental health crisis. However, limited research has explored preferences for crisis response, and no research in the United States has examined the responses desired by mental health care clients or their family members. This study aimed to understand the experiences of people with serious mental illnesses interacting with police and to learn about their preferences for crisis response models. The authors interviewed 50 clients with serious mental illnesses and a history of arrest who were enrolled in a randomized controlled trial of a police-mental health linkage system, as well as 18 of their family members and friends. Data were coded with deductive and inductive approaches and were grouped into larger themes. Clients and family or friends described needing a calm environment and empathy during a crisis. They selected a nonpolice response as their first choice and response from a crisis intervention team as their last choice among four options, highlighting the importance of trained responders and past negative interactions with police. However, they also noted concerns about safety and the shortcomings of a nonpolice response. These findings build understanding about clients' and family members' preferences for crisis response and highlight concerns that are relevant for policy makers.

Contexts shaping misdemeanor system interventions among people with mental illnesses: qualitative findings from a multi-site system mapping exercise.

BACKGROUND: People with mental illnesses are disproportionately entangled in the criminal legal system. Historically, this involvement has resulted from minor offending, often accompanied by misdemeanor charges. In recent years, policymakers have worked to reduce the footprint of the criminal legal system. This paper seeks to better understand how misdemeanor systems intervene in the lives of people with mental illnesses. METHODS: System mapping exercises were conducted with misdemeanor system stakeholders from the jurisdictions of Atlanta, Chicago, Manhattan, and Philadelphia. Narrative detail on decision-making and case processing, both generally and in relation to specific types of behavior, including trespassing, retail theft/shoplifting, and simple assault, were coded and analyzed for thematic patterns. Based on the qualitative analysis, this paper offers a conceptual diagram of contexts shaping misdemeanor system interventions among people with mental illnesses. RESULTS: All four sites have been engaged in efforts to reduce the use of misdemeanor charges both generally and in relation to people with mental illnesses. Decision-makers across all sites experience contexts that shape how, when, and where they intervene, which are: (1) law and policy environments; (2) location of the behavior; (3) expectations of stakeholders; (4) knowledge of mental illnesses; and (5) access to community resources. Law and policy environments expand or constrain opportunities for diversion. The location of offending is relevant to who has a stake in the behavior, and what demands they have. Clinical, experiential, and system-level knowledge of mental illnesses inform a chain of decisions about what to do. The capacity to address mental health needs is contingent on access to social services, including housing. CONCLUSION: People making decisions along the criminal legal continuum are critical to illuminating the dynamic, inter-related contexts that facilitate and frustrate attempts to address defendants' mental health needs while balancing considerations of public safety. Multi-sector, scenario-based or case study exercises could help identify concrete ways of improving each of the contexts that surround whole-of-system decisions.

Improving Nutrition Security for Individuals With Serious Mental Illnesses: A Partnership of Public and Nonprofit Agencies.

In conjunction with multiple partners (state agencies, nonprofits, a university, and key stakeholders and content experts), the authors are implementing and evaluating an intervention intended to enable individuals with serious mental illnesses living in community residences (i.e., group homes) and supportive housing apartments to-with support from residential staff-access, purchase, prepare, and enjoy healthy, local produce. The three-component intervention makes fresh produce more accessible; improves its affordability; and conveys knowledge and skills related to purchasing, preparing, and eating healthy foods, especially vegetables. The intervention is being evaluated in preparation for possible larger-scale implementation and potential dissemination to other populations experiencing nutrition insecurity.

Opening Doors to Recovery: A Randomized Controlled Trial of a Recovery-Oriented Community Navigation Service for Individuals With Serious Mental Illnesses and Repeated Hospitalizations.

Objective: Opening Doors to Recovery (ODR) is a community navigation and recovery support model created in southeast Georgia by diverse, collaborative stakeholders. Following promising results from a quasi-experimental study, this randomized controlled trial hypothesized that, among patients with serious mental illnesses being discharged from inpatient psychiatric settings, compared to those randomized to traditional case management (CM) services, those randomized to ODR would have (1) lower likelihood of hospitalization, fewer hospitalizations, and fewer inpatient days; (2) lower likelihood of arrest, fewer arrests, and longer time to arrest; and, secondarily, (3) greater housing satisfaction and housing stability; and (4) higher scores on several scales measuring recovery-related constructs.Methods: 240 individuals with Structured Clinical Interview for DSM-5 Disorders-based psychotic or mood disorders, functional impairment, and repeated hospitalizations were randomized (December 2014 to June 2018) to ODR or CM. Hospitalization and arrest data were collected from State agencies after 12 months, and housing- and recovery-related measures were collected in person, longitudinally at 4, 8, and 12 months. Intention-to-treat analyses were conducted. Effects of dropout were accounted for, and sensitivity analyses were run.Results: ODR was associated with fewer days hospitalized (RR = 0.86, P = .001), a lower incidence of arrests (OR = 0.35, P < .0005), and longer time to arrest (HR = 0.42, P = .001). In addition, measures of housing satisfaction (Cohen d = 0.45) and recovery (Cohen d = 0.33) were significantly more improved in ODR patients compared to CM patients.Conclusions: The ODR model appears to have advantages over more traditional CM services and could fill a gap in the service array. Studying the mediators of success, cost benefit, dissemination, fidelity, and financing of the model is warranted.Trial Registration: ClinicalTrials.gov identifier: NCT04612777.

Competing Concerns in Efforts to Reduce Criminal Legal Contact Among People with Serious Mental Illnesses: Findings from a Multi-City Study on Misdemeanor Arrests.

People with serious mental illnesses are disproportionately involved in the criminal legal system, often for low-level, non-violent misdemeanors. This paper examines how decision-makers at different stages of the criminal legal system articulate unique visions of the "best approach" for addressing this problem of over-representation. Focus groups and in-depth interviews were conducted with 94 stakeholders from Atlanta, Chicago, New York City, and Philadelphia to understand how decision-makers from different agencies use and process specific misdemeanor charges in relation to people with serious mental illnesses. Data were analyzed using a thematic approach. The data reveal a series of tensions regarding how criminal legal system stakeholders process people with serious mental illnesses through the misdemeanor system. Three key themes emerged from analysis. The first characterizes the shared commitment across agencies to reducing system contact among people with mental illnesses. The second explores how agencies differ on how to make good on that commitment because of the distinct values and goals they bring to the table. The final theme explores the limits of current approaches to reducing system contact for people with mental illnesses. Findings are discussed in the context of literature on "loose coupling" and the focal concerns framework and demonstrate that decisions about how and when to intervene with people with mental illnesses in the criminal legal system are influenced by the varying orientations, goals, and values of stakeholder agencies. Understanding these core differences is a critical step toward value alignment in strategies to reduce system involvement among people with mental illnesses.