Selecting the Right People for the Right Interventions
Fred Osher, M.D. Director, Health Systems and Services Policy
Today’s Presentation
An Overview of Mental Illnesses in the Criminal Justice System
R-N-R and the Behavioral Health Framework
Application of the Framework within your JMHCA grant
Council of State Governments Justice Center
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An Expanding Population under Correctional Supervision
Source: Pew Center on the States, “One in 31: The Long Reach of American Corrections” (2009)
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5% of Worlds Population 23% of Worlds Prisoners
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Recent Decline in State Prison Population
First decline in state prison populations in 38 years
Source: The Pew Center on the States; Public Safety Performance Project
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Substantially Higher Rates across Demographic Lines
Source: Pew Center on the States, “One in 31: The Long Reach of American Corrections” (2009)
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Substantial Increase in the Number of Women in Federal and State Prisons (1980-2010)
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Rising Number of People in Prisons and Jails for Drug Offenses (1980 & 2010)
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Alcohol and Drug Use Disorders: Household vs. Jail vs. State Prison 60 54 %
Percent of Population
50
47 %
53 % 44 % Alcohol use disorder (Includes alcohol abuse and dependence)
40 30
Drug use disorder (Includes drug abuse and dependence)
20 10
8% 2%
0
Household
Jail
State Prison
Source: Abrams & Teplin (2010)
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Prevalence of Serious Mental Illness and CoOccurring Disorders in Jail Populations General Population
Jail Population
95%
83% 5%
28%
17% 72%
Serious Mental Illness
Serious Mental Illness
Co-Occurring Substance Use Disorder
No Serious Mental Illness
No Serious Mental Illness
No Co-Occurring Substance Use Disorder
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Pressure on State Budgets Continues
Center for Budget and Policy Priorities (2013) Council of State Governments Justice Center
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Cuts to Mental Health Services: 2010-2011
Source: Chart courtesy Ted Lutterman, NASMHPD Research Institute, Inc. (NRI), Oct. 12, 2010 as published in National Alliance on Mental Illness, State Mental Health Cuts: A National Crisis
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The Problem: Overrepresentation of Persons with Behavioral Disorders in Criminal Justice Settings. Why? }
Arrested at disproportionately higher rates } }
} } } } }
Co-occurrence of substance use disorders Homelessness
Limited access to health care Low utilization of evidence-based practices Longer stays in jail and prison High recidivism rates More criminogenic risk factors Council of State Governments Justice Center
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What Accounts for the Problem? Limited Access to Health Care
}
Poor health status
}
Poor health access
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What Accounts for the Problem: Limited Access to Health Care: Stigma “Crazy” “Drug-addicted” “Criminal”
} } } } } } } }
Bias Distrust Prejudice Fear Avoidance Distress Anger Stereotyping
•
Reduced Access: • Housing • Employment • Treatment • Other services
•
Perception of violence risk Discrimination
•
Source: Surgeon General’s Report on Mental Health (1999)
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What Accounts for the Problem? Low utilization of EBPs Past Year Mental Health Care and Treatment for Adults Aged 18 or Older with Both Serious Mental Illness and Substance Use Disorder
Source: NSDUH (2008)
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What Accounts for the Problem? Longer Stays in Jail and Prison
112
M Indicator N=10,213
No M Indicator
NYC Riker’s Island, 2008
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N= 37,805
0 *M Indicator at discharge.
20
40
Days 60
80
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120
What Accounts for the Problem? High Recidivism Rates on Reentry
Screened 2,934 probationers for mental illness: • 13% identified as mentally ill • Followed for average of two years
No more likely to be arrested … … but 1.38 times more likely to be revoked Source: Vidal, Manchak, et al. (2009); see also: Eno Louden & Skeem (2009); Porporino & Motiuk (1995)
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Incarceration is Not Always a Direct Product of Mental Illness Raters code 113 post-booking jail diversion cases: How likely is it that the inmates’ offenses were a result of serious mental illness (SMI) or substance abuse (SA)? 4%
4%
19%
Direct Effect of SMI Indirect Effect of SMI Direct Effect of SA Indirect Effect of SA
7%
Other Factors
66%
Source: Junginger, Claypoole, Laygo, & Cristina (2006); Slide developed by Dr. Jennifer Skeem, University of California-Irvine
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Those with Mental Illness Have Significantly More “Central 8” Dynamic Risk Factors 60 58 56 54 52 50 48 46 44 42 40
**
Persons with mental illnesses Persons without mental illnesses
LS/CMI Tot
….and these predict recidivism more strongly than mental illness Source: Skeem, Nicholson, & Kregg (2008)
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The Mental Health – Criminal Justice Problem Statement in Summary Our localities face significant budgetary pressures . . . } Individuals with MI don’t get access to adequate behavioral health care… } They are arrested more often . . . } They stay incarcerated longer . . . } They are more likely to “fail” upon release. . }
…. so what can the JMHCP grantees do to address these matters? Council of State Governments Justice Center
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Today’s Presentation
An Overview of Mental Illnesses in the Criminal Justice System
R-N-R and the Behavioral Health Framework
Application of the Framework within your JMHCA grant
Council of State Governments Justice Center
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Recidivism Is Not Simply a Product of Mental Illness: Criminogenic Risk Risk: } } } } }
≠ Crime type ≠ Dangerousness ≠ Failure to appear ≠ Sentence or disposition ≠ Custody or security classification level
Risk = How likely is a person to commit a crime or violate the conditions of supervision?
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What Do We Measure to Determine Criminogenic Risk? Conditions of an individual’s behavior that are associated with the risk of committing a crime. Static factors – Unchanging conditions
Dynamic factors – Conditions that change over time and are amenable to treatment interventions Council of State Governments Justice Center
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Static Risk Factors }
Criminal history } number
of arrests } number of convictions } type of offenses
Current charges } Age at first arrest } Current age } Gender }
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Dynamic Risk Factors 1. 2. 3. 4. 5. 6. 7. 8.
Antisocial attitudes Antisocial friends and peers Antisocial personality pattern Substance abuse Family and/or marital factors Lack of education Poor employment history Lack of pro-social leisure activities
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Addressing Criminogenic Risk Factors as Part of Sentencing and Supervision Individual Risk Factors for Criminal Recidivism Risk Factor
Need
History of antisocial behavior
Build alternative behaviors
Antisocial personality pattern
Problem solving skills, anger management
Antisocial cognition
Develop less risky thinking
Antisocial attitudes
Reduce association with criminal others
Family and/or marital discord
Reduce conflict, build positive relationships
Poor school and/or work performance
Enhance performance, rewards
Few leisure or recreation activities
Enhance outside involvement
Substance abuse
Reduce use through integrated treatment Source: Andrews (2006) Council of State Governments Justice Center
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How has Behavioral Health Addressed Dynamic Risk Factors? Static Risk Factors Criminal history number of arrests number of convictions type of offenses Current charges Age at first arrest Current age Gender
Dynamic Risk Factors Anti-social attitudes Anti-social friends and peers Anti-social personality pattern Substance abuse Family and/or marital factors Lack of education Poor employment history Lack of pro-social leisure activities
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Risk-Need-Responsivity Model as a Guide to Best Practices •
Focus resources on high RISK cases
•
Target criminogenic NEEDS, such as antisocial behavior, substance abuse, antisocial attitudes, and criminogenic peers
•
RESPONSIVITY – Tailor the intervention to the learning style, motivation, culture, demographics, and abilities of the offender. Address the issues that affect responsivity (e.g., mental illnesses)
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Differential Program Impact by Risk Average Difference in Recidivism by Risk for Ohio Halfway House Offenders
Low Risk
3
+ % Moderate Risk
6
-‐ %
High Risk -‐
14 %
*Presentation by Latessa, “What Works and What Doesn’t in Reducing Recidivism: Applying the Principles of Effective Intervention to Offender Reentry”
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Risk-Need-Responsivity Model as a Guide to Best Practices •
RISK PRINCIPLE: Match the intensity of individual’s intervention to their risk of reoffending
•
NEEDS PRINCIPLE: Target criminogenic needs, such as antisocial behavior, substance abuse, antisocial attitudes, and criminogenic peers
•
RESPONSIVITY PRINCIPLE: Tailor the intervention to the learning style, motivation, culture, demographics, and abilities of the offender. Address the issues that affect responsivity (e.g., mental illnesses) Council of State Governments Justice Center
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Addressing Criminogenic Risk Factors as Part of Sentencing and Supervision Individual Risk Factors for Criminal Recidivism
Risk Factor
Need
History of antisocial behavior
Build alternative behaviors
Antisocial personality pattern
Problem solving skills, anger management
Antisocial cognition
Develop less risky thinking
Antisocial attitudes
Reduce association with criminal others
Family and/or marital discord
Reduce conflict, build positive relationships
Poor school and/or work performance
Enhance performance, rewards
Few leisure or recreation activities
Enhance outside involvement
Substance abuse
Reduce use through integrated treatment
Source: Andrews (2006)
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Recidivism Reductions as a Function of Targeting Multiple Criminogenic vs. Non-Criminogenic Needs* Better outcomes 60%
(Andrews, Dowden, & Gendreau, 1999; Dowden, 1998)
50% 40% 30% 20% 10% 0% -10% -20% Poorer outcomes
6
5
4
3
2
1
0
-1
More criminogenic than noncriminogenic Council of State Governments Justice Center needs
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-3 More noncriminogenic than criminogenic needs
Risk-Need-Responsivity Model as a Guide to Best Practices •
Focus resources on high RISK cases
•
Target criminogenic NEEDS, such as antisocial behavior, substance abuse, antisocial attitudes, and criminogenic peers
•
RESPONSIVITY – Tailor the intervention to the learning style, motivation, culture, demographics, and abilities of the offender. Address the issues that affect responsivity (e.g., mental illnesses)
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Not all Mental Illnesses are Alike: Mental Illness in the General Population Diagnosable mental disorders 16%
Serious mental disorders 5% Severe mental disorders 2.5%
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Not all Substance Use Disorders are Alike
Dependence
Abstention
The Substance Abuse Continuum Council of State Governments Justice Center
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Responsivity: You can’t address dynamic risk factors without attending to mental illness Antisocial Attitudes Antisocial Personality Pattern
Lack of Education
Poor Employment History
Lack of Prosocial Leisure Activities
Mental Illness
Antisocial Friends and Peers
Substance Abuse Family and/ or Marital Factors
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NIC Commissions Framework
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Creating Cross-System Collaboration What Works in Mental Health Treatment What Works in Substance Abuse Treatment
What Works in Recidivism Reduction Behavioral Health Framework
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Framework for Addressing Population with Co-occurring Disorders (NASMHPD-NASADAD, 2002)
Alcohol and other drug abuse
High severity
Low severity
IV
III
State hospitals, Substance abuse Jails/prisons, system Emergency Rooms, etc.
I Primary health Care settings
II Mental health system High severity
Mental Illness Council of State Governments Justice Center
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Framework for Addressing CJ Populations with Behavioral Disorders
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A Framework for Prioritizing Target Population
Low Criminogenic Risk
Medium to High Criminogenic Risk
(low)
(med/high)
Low Severity of Substance Abuse
Substance Dependence (med/high)
(low)
Low Severity of Mental Illness (low)
Serious Mental Illness
Serious Mental Illness
(med/high)
Low Severity of Mental Illness (low)
Group 1 I–L CR: low SA: low MI: low
Group 2 II – L CR: low SA: low MI: med/high
Group 3 III – L CR: low SA: med/high MI: low
Low Severity of Substance Abuse
Substance Dependence (med/high)
(low)
Serious Mental Illness
(med/high)
Low Severity of Mental Illness (low)
(med/high)
Low Severity of Mental Illness (low)
Group 4 IV – L CR: low SA: med/high MI: med/high
Group 5 I–H CR: med/high SA: low MI: low
Group 6 II – H CR: med/high SA: low MI: med/high
Group 7 III – H CR: med/high SA: med/high MI: low
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Serious Mental Illness (med/high)
Group 8 IV – H CR: med/high SA: med/high MI: med/high
Today’s Presentation
An Overview of Mental Illnesses in the Criminal Justice System
R-N-R and the Behavioral Health Framework
Application of the Framework within your JMHCA grant
Council of State Governments Justice Center
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Screening for Behavioral Disorders }
A formal process of testing to determine whether a client does or does not warrant further attention at the current time in regard to a particular condition or disorder.
}
Screening for co-occurring disorders (COD) seeks to answer a yes or no question: Does the substance abuse [or mental health] client being screened show signs of a possible mental health [or substance abuse] problem?
}
Note that the screening process does not necessarily identify what kind of problem the person might have, or how serious it might be, but determines whether or not further assessment is warranted. Council of State Governments Justice Center
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Features of Screening Instruments
} High
sensitivity (but not high specificity)
} Brief } Low
cost } Minimal staff training required } Consumer friendly
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Some Recommended Screening Instruments for MI and SA Mental Health Screening Form – III } Simple Screening Instrument for Substance Abuse (SSI-SA) } Dartmouth Assessment of Lifestyle Inventory (DALI) } Co-Occurring Disorder Screening Instrument (CODSI) } Corrections Specific Instruments }
} }
Brief Jail Mental Health Screen Texas Christian University Drug Screen - II Council of State Governments Justice Center
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The Goal: Universal Screening }
All individuals presenting for treatment of a substance use disorder should be routinely screened for any cooccurring mental disorders.
}
All individuals presenting for treatment of a mental disorder should be screened routinely for any cooccurring substance use disorders.
}
All individuals booked into jails should be screened for both mental and substance use disorders. Council of State Governments Justice Center
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Assessment for Behavioral Disorders } Goals
of a Basic Behavioral Health Assessment
Gathering key information } Enable the counselor/therapist to understand the client } Determine readiness for change } Discover problem areas } Determine COD diagnosis }
}
Identify disabilities, and strengths.
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Assessment for Behavioral Disorders } Clinical
examination of the client } Includes a number of tests and written and oral exercises } COD diagnoses are established by referral to a psychiatrist or clinical psychologist. }
Assessment of the COD client is an ongoing process conducted over time to capture the changing nature of the client s status Council of State Governments Justice Center
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Domains of Assessment } Acute
Safety Needs } Diagnosis } Disability } Quadrant Assignment } Level of Care
} Strengths
and Skills } Recovery Support } Cultural Context } Problem Domains } Phase of Recovery/ Stage of Change
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The
Best
Assessment Tool
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Assessment for Criminogenic Risk ‌.. the goal of risk assessment is not simply to predict the likelihood of recidivism, but, ultimately, to reduce the risk of recidivism. To do so, the information derived during the risk assessment process must be used to guide risk management and rehabilitation efforts. Desmarais et al, 2013
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Risk Assessment Tools: Few In Practice +!" *!" )!" (!" '!" &!" %!" $!" #!" !"
Dr Tx Prison
Generic Prison
% NO Risk Tool
%use LSI-R
Jail
Community Corrections %use WRN
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Two Critical Components
Target Population
Comprehensive Effective Communitybased Services
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Developing Effective Interventions for Each Subgroup
}
It is assumed these responses will:
Incorporate EBPs and promising approaches } Be implemented with high fidelity to the model } Undergo ongoing testing/evaluation }
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Framework Implementation Challenges Assessing risk and behavioral health needs soon after someone is charged with a crime } Packaging assessment results for decisionmakers and sharing this information appropriately } Using information to inform services and supervision provided } Encouraging treatment providers and supervising agents to serve “high risk” populations } Ensuring treatment system has capacity/skills to serve populations they would not otherwise see as a priority population }
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Implementation Opportunities… }
New commitment to the need for collaboration between health and corrections systems
}
Renewed interest in rehabilitiation and “evidence based” criminal justice programs.
}
Risk-Need-Responsivity model helps drive effective collaboration
}
Shared vision for moving forward
Care and Respect
“One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.” - Francis W. Peabody, MD 1925
Thank you
Fred Osher, M.D. Director Health Systems and Service Policy Council of State Governments Justice Center fosher@csg.org
www.consensusproject.org
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