Maximizing impact amid scarce resources: Aligning people with programs Jennifer L. Skeem, Ph.D. February 2011 BalHmore, MD
“Were Jared Loughner’s crimes a preventable tragedy?"
2011
2010 2006
Skeem, Manchak, & Peterson, in press, Law & Human Behavior
What do we mean by “evidence-‐based pracHce”? • Applying the best research to inform pracHce that improves outcomes – Fewer new crimes & new vicHms
• The real world ($$) – “opHmal intervenHon. . . the least extensive, intensive, intrusive, and costly intervenHon capable of successfully addressing the presenHng problem”
+ How to make a difference 1. Statement of the problem 2. Contemporary aZempts to solve the problem 3. Moving beyond a one-‐dimensional focus to truly reduce recidivism 4. ImplicaHons for pracHce
People with serious mental illness are overrepresented in U.S. criminal jusHce system 25
20
%
Community men
15
Incarcerated men Community women Incarcerated women
10
Steadman, Osher, et al. (2009): 14% men and 31% women
5
0 Depression
Schizophrenia
Source: Teplin, 1990; Teplin, Abram, & McClelland, 1996
Bipolar
Any
Most have co-‐occurring substance abuse disorders % Without Co-‐Occurring Substance Use Disorders 28%
% With Co-‐Occurring Substance Use Disorders 72%
Source: The Na8onal GAINS Center, 2004
Most are supervised in the community… and ohen “fail” 4500000
ProbaHon
4000000
3500000
3000000
2500000
2000000
Prison
1500000
Parole
1000000
500000
Jail
0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Sources: Bureau of JusHce StaHsHcs (2007); Skeem, Emke-‐Francis, et al. (2006)
“The current situaHon not only exacts a significant toll on the lives of people with mental illness, their families, and the community in general, it also threatens to overwhelm the criminal jusHce system.”
-‐Council of State Governments Criminal Jus;ce/ Mental Health Consensus Project (2002)
+ Making a difference 1. Statement of the problem 2. Contemporary aZempts to solve the problem 3. Moving beyond a one-‐dimensional focus to truly reduce recidivism 4. ImplicaHons for pracHce
The perceived root of the problem “People on the front lines every day believe too many people with mental illness become involved in the criminal jusHce system because the mental health system has somehow failed. They believe that if many of the people with mental illness received the services they needed, they would not end up under arrest, in jail, or facing charges in court”
The implicit model of “what works” for offenders with mental disorder Sentence to treatment and/ or specialty program Psychiatric treatment-‐ Symptom reducHon Reduced recidivism
Research suggests that the problem-‐ and soluHons – are more complex • Even “state of the art” psychiatric services ohen do not translate into reduced recidivism – ACT -‐ Clark, RickeZs, & McHugo, 1999 – IDDT -‐ Caslyn et al., 2005
• Forensic adaptaHons someHmes reduce recidivism… but not for the simple reason we assume – FACT – Cusack, Morrissey, et al., 2010; cf. Morrissey, Meyer & Cudeback 2009
– MHCs – McNiel & Binder, 2007; cf. Christy et al., 2005 – Specialty mental health probaHon – Skeem et al., 2010
Symptom reducHon ohen does not translate into reduced recidivism
Same as in mulH-‐site jail Not revoked Revoked diversion & m ental h ealth court M= -‐1.29, sd= .60 M=-‐1.23, sd= .80 evaluaHons Steadman & Naples (2005); Steadman et al. (2009)
Skeem et al. (2009)
Mental illness is a criminogenic need for only a small subgroup
Junginger, Claypoole, Laygo, & CrisHna (2006); see also Peterson, Skeem, et al. (2009)
+ Making a difference 1. Stepping back: Statement of the problem 2. Contemporary aZempts to solve the problem 3. Moving beyond a one-‐dimensional focus to truly reduce recidivism 4. ImplicaHons for pracHce
IntegraHng alternaHve views • Some people with serious mental illness may “engage in offending and other forms of deviant behavior not because they have a mental disorder, but because they are poor. Their poverty situates them socially and geographically, and places them at risk of engaging in many of the same behaviors displayed by persons without mental illness who are similarly situated” – Fisher et al. (2006), p. 553
Offenders with mental illness have significantly more “central 8” risk factors for crime 60 58 56 54
**
52 50
PMI
48
Non-‐PMI
46 44 42 40 LS/CMI Tot
….and these predict recidivism more strongly than risk factors unique to mental illness (e.g., diagnosis, symptoms, treatment compliance) Source: Skeem, Nicholson, & Kregg (2008)
“Central eight” for criminal behavior (Andrews, 2006)
Risk Factor
Need
History of criminal behavior
Build alternaHve behaviors
AnHsocial personality paZern***
Problem solving skills, anger management
AnHsocial cogniHon*
Develop less risky thinking
AnHsocial peers
Reduce associaHon with criminal others
Family and/or marital discord**
Reduce conflict, build posiHve relaHonships
Poor school and/or work performance*
Enhance performance, rewards
Few leisure or recreaHon acHviHes
Enhance outside involvement
Substance abuse
Reduce use ***p <.001, **p <.01, *p <.05, PMI > Non-‐PMI, Skeem, Nicholson, & Kregg (2008)
Toward a valid model of “what works” to reduce criminal behavior Sentence: Mandated treatment
Mental Health Treatment e.g., ACT, IDDT, others shown to affect psychiatric outcomes
Small subgroup
EBP in Correc8ons e.g., RNR, firm but fair relaHonships, others shown to affect recidivism
Everyone else Fewer new crimes and new vic8ms
Evidence-‐based psychiatric services Target: symptoms & funcHoning • hZp://mentalhealth.samhsa.gov/ cmhs/CommunitySupport/toolkits/ about.asp – Integrated dual diagnosis treatment (IDDT) – Supported employment
• hZp://consensusproject.org/ updates/features/GAINS-‐EBP-‐ factsheets – Supported housing – Trauma intervenHons
Evidence-‐based correcHons Target: criminal behavior • Focus resources on high RISK cases • Target criminogenic NEEDS like anger, substance abuse, anHsocial awtudes, and criminogenic peers (Andrews et al., 1990) • RESPONSIVITY -‐ use cogniHve behavioral techniques like relapse prevenHon (Pearson, Lipton, Cleland, & Yee, 2002) – Consider packaged programs like “Reasoning and RehabilitaHon” (Young and Ross, 2007)
• Ensure implementaHon (Gendreau, Goggin, & Smith, 2001)
Case in point • If symptom reducHon doesn’t reduce recidivism, why do programs someHmes work on criminal jusHce outcomes? • Hints from studies of probaHon and parole 1. Implicitly targeHng criminogenic needs 2. Reducing sancHon threats 3. Establishing strong dual role relaHonships 4. Reducing sHgma-‐based decision-‐making
ProbaHon Outcome Study • Sites selected based on naHonal survey – Specialty: Dallas, TX – TradiHonal: Los Angeles, CA – Matched on jurisdicHon size, ethnic distribuHon & mental health resources
• Matched trial: 180 probaHoners per site • ProspecHve design (2+ years)
Specialty vs. TradiHonal Supervision -‐24 mo
-‐18 mo
-‐12 mo
-‐6 mo
6 mo
✗
Baseline Interview
✗
Officer Survey #1
Record ✗ review
12 mo
Follow-‐Up Interview Officer Survey #2
✗ ✗
Record ✗ review
18 mo
✗
Follow-‐Up Interview
✗
Officer Survey #3
RetenHon=85-‐90%
Record ✗ review
Mental Health Services ViolaHons & RevocaHon Jail Bookings Arrests, Prison Stays
24 mo
ProbaHoners • N=359 (≈ 180 per site) • Eligibility – 18-‐65 years old, English-‐speaking, pass consent test – On acHve supervision, completed > 1 iniHal meeHng with officer, > 1 year remaining on term – Serious mental disorder • Specialty: MIMR placement (modal chart dx: bipolar, 48%) • TradiHonal: Officer referral + screen (modal chart dx: scz/psychosis, 48%)
• Matched – Age, gender, ethnicity, offense (person vs. other), and total Hme on probaHon (over/under 1 year)
Propensity Scores • Condense covariates into one propensity score that predicts probability of specialty treatment • Determine that treatment assignment process is ignorable, given propensity score • CondiHon treatment esHmate on propensity scores
Any Arrest
(FBI records, N=354) Any re-‐arrest within two years of placement 100 90 80 70 60 % 50 40 30 20 10 0
Five year “survival” without any re-‐arrest
**
Context: FBI/UCR arrest rates higher at specialty (6.6%) than tradiHonal (3.4%) site
Specialty
TradiHonal
**p = .001, OR=2.44 controlling for propensity scores
***p <.001, OR= 1.94 controlling for propensity scores
ViolaHon reports sent to the court 70 ***
60 50
**
40 Specialty
30
TradiHonal
20 10 0 VR Yr1
VR Yr 2
** p < .01 & OR= 2.3; ***p = .001 & OR=2.7, controlling for propensity
Effects not explained by symptom reducHon Range: 14-‐70; M= 32 (12) 45 40 35 30
Same paZern with beZer measure of symptoms (PAI) and with funcHoning (GAF): No specialty program effect Disability screen
25 20 Baseline
Six months
Twelve Months
Site unrelated to i or s: X2 (5) = 6.12, ns; CFI =1.0, RMSEA=.03 CondiHonal model, with site and propensity as covariates
Both Sites
…or substance abuse reducHon • Baseline & 12 months • Latent change score – Whole sample: “no change” model fits – Subgroups: esHmated change score not significant for either specialty or tradiHonal (alcohol problems shown below)
Alcohol problems 50.27*** -‐1.33, ns tradiHonal 0.00, ns, specialty
…or boundary spanning Boundary Spanning
In this study
• “seek to bridge communicaHon, understanding, and service gaps and translate the workings of one enHty into the language of another.” • “link two or more systems whose goals and expectaHons are likely to be at least parHally conflicHng” • “advocrat”
• Scale (Steadman, McCarty, & Morrissey, 1989) – Knowledge of other systems – Helpfulness in service linkage – Advocacy • Relates to service access but not CJ outcomes (Manchak, 2010)
– PeZus & Severson, 2006; Miles, 1980; Wertheimer, 2001, respecHvely
1. Implicitly targeHng (some) criminogenic needs Criminogenic PotenHal
AntTraits Ant/Pro-‐Peers AntAwtudes SubAbuse Employ/School AccomodaHon Family/Marital Financial MentalHealth 0
20
40
60
% MeeHngs Discussed Eno Louden, Skeem, et al. (2010)
80
100
Target criminogenic needs • Lewng go of mental illness as the default “master status” • Spend less Hme monitoring, more Hme discussing criminogenic needs
2. Relying less on sancHon threats Consider “Mike” Tradi8onal
Not Tradi8onal
– Bark at him…chew him up one side – …talk with him to iden;fy any obstacles to compliance (like and down the other...you basically transporta;on problems), remove lie to them, “You’re looking at those obstacles, and agree on a prison” compliance plan.
• The “big bluff”-‐ threats and reminders
• Problem-‐solving strategies
TradiHonal
Non-‐ tradiHonal
Compliance strategies
NegaHve pressure predicts failure over 12 months (bad is stronger than good) 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0
**
** Yes No
Arrested
**p<.01, ***p <.001: Manchak, Skeem, et al., 2008
Revoked
NegaHve pressure is featured more heavily in tradiHonal supervision 1.25
Specialty TradiHonal
1 0.75 0.5 0.25 0 Probsolv/+
SancHons/-‐ p <.001, aher controlling for propensity scores
3. Establishing strong dual role relaHonships • RelaHonship quality in mandated treatment – TherapeuHc role – Surveillance role
Controlling
Caring
Skeem, Eno Louden, Polaschek, & Camp (2007); Skeem & Manchak (2008); Kennealy, Skeem, et al. (2009)
RelaHonship quality Colors every interacHon and affects outcomes Authoritarian •
•
•
“The first ;me I met this par;cular proba;on officer, he let me know that he owns me…” “The first ;me I met him, he threatened to put me in prison…I got so damned scared, okay? And I didn’t do anything” “He is chuckling to the other one…and nods his head over towards me and says, ‘You can tell when he’s lying cause his lips are moving.’”
Rela8onal •
•
•
“Actually the first ques;on he asks when I step into his office is, ‘How are you doing?’ And he really wants to know…” “For me, we all need encouragement some;mes to do the right thing – and it’s okay with me as long as it’s done in the right way…talk to me first of all…if you think that I’m going in a direc;on that you feel is going to be harmful to me” “She talks to me the right way”
Dual Role RelaHonship Inventory Toughness
Caring, Fairness & Trust
• I feel that ____ is looking to punish me… • …puts me down when I’ve done something wrong • …makes unreasonable demands of me. • …expects me to do all the work alone and doesn’t… • …talks down to me.
• I know that ____ truly wants to help me. • …treats me fairly. • …considers my views. • …takes my needs into account. • …encourages me to work with him/her. • If I’m going in a bad direcHon, ___ will talk with me… • …is someone I trust.
Skeem, Eno Louden, Polaschek, & Camp (2007). Assessing relaHonship quality in mandated community treatment: Blending care with control. Psychological Assessment, 19, 397-‐410.
Dual role relaHonship quality • Is not the same as the therapeuHc alliance (e.g., WAI) or “liking” • Relates to within-‐meeHng behavior (e.g., confrontaHon & resistance) • Predicts recidivism for those with-‐ and without-‐ mental illness • Does so aher controlling for offenders’ risk of recidivism
Skeem, Eno Louden, Polaschek, & Camp (2007); Skeem & Manchak (2008); Kennealy, Skeem, et al. (2009)
Firm but fair relaHonships help protect against failure over 12 months 7 6.5 6 5.5 5 4.5 4 3.5 3 2.5 2 1.5 1
***
Yes No
Arrested *p<.05; **p<.01
***
Revoked
Firm but fair relaHonships established more ohen in specialty than tradiHonal supervision Specialty
TradiHonal
7 6 5 4 3 2 1 Fair/Care
Trust
Tough
All differences, p<.001, remain significant aher controlling for propensity scores
Total
RelaHonship quality explains effecHveness of specialty probaHon Dual Role RQ (intercept) .25***
.50***
Specialty Supervision
RevocaHon c’= .11, ns c= .23**
4. Reducing sHgma-‐driven decision-‐making Reduced Thresholds/Officer SHgma
“If there’s a nutso on my caseload and he’s just taking up too much of my ;me, when there’s an opportunity to transfer him to another officer, I’ll transfer him.” (from Skeem, Encandela, & Eno Louden (2003)
Mental Illness
“Recidivism” with no new crime
Reduced thresholds: Eno Louden & Skeem (in press); Porporino & MoHuk (1995); Skeem, Nicholson et al. (2009)
There’s more than one way to fail community supervision…
+
65 60 55 50
%
45 40
+
35
EOP
30
CCCMS
*
25
Non-‐PMI
20 15 10 5 0 Arrest
RevocaHon for Technical
RTC * p <.05, + p <.10. Skeem, Nicholson et al., 2009
+ Toward smarter sentencing for offenders with mental illness 1. Stepping back: Statement of the problem 2. Contemporary aZempts to solve the problem 3. Moving beyond a one-‐dimensional focus to truly reduce recidivism 4. ImplicaHons for pracHce
Take home: Avoid bad pracHces • Low thresholds for revocaHon – think “equity”
• Reliance on sancHon threats – think “problem solving”
• Authoritarian relaHonships – think “firm but fair”
• Exclusive focus on monitoring and/or mental health – think “criminogenic needs”
A broader model….
1. Assess illness & recidivism risk • IdenHfy offenders with mental illnesses, using a validated screening tool – BJMHS, for adults:
hZp://gainscenter.samhsa.gov/HTML/resources/MHscreen.asp – MAYSI, for youth hZp://www.maysiware.com/MAYSI2Research.htm
• Assess risk of recidivism, using a validated tool – LS/CMI (includes youth version)
Example: Good supervision + IDDT
Clinical Needs/Risk
High: Increase 2. Tailor supervision to emphasis on EBP for illness severity mental health AND recidivism risk
Low
Example: RNR supervision + IDDT Criminogenic Risk
Example: RNR supervision + good treatment
Good supervision + good treatment Low
High: Increase emphasis on EBP for correc>ons
hZp://consensusproject.org/downloads/community.correcHons.research.guide.pdf  Â
+ skeem@uci.edu
Thanks
MacArthur Research Network Council of State Governments Criminal JusHce and Mental Health Lab ProbaHoners, officers, and supervisor parHcipants