Principles of Mental Health and Drug Abuse Treatment for Criminal Justice Populations Association of Paroling Authorities International Audio Conference Training March 8, 2007 Fred C. Osher, MD Director of Health Systems and Services Policy Objectives of Presentation Overview of Issues and Common Definitions Principles of Effective Treatment for Criminal Justice Populations Case Study Challenges and Opportunities Open Discussion
Skyrocketing Criminal Justice Populations Bureau of Justice Statistics, 2005 What is the Problem ? People with mental illnesses, substance use disorders, and cooccurring disorders are significantly over-represented in the criminal justice system Substance Abuse A maladaptive pattern of substance use leading to clinically significant impairment or distress failure to fulfill obligations at work, school or
home use in situations in which it is physically hazardous use-related legal problems persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance Substance Dependence A maladaptive pattern of substance use leading to clinically significant impairment or distress
tolerance withdrawal taken in larger amounts or over a longer period than was intended persistent desire or unsuccessful efforts to cut down/control use spending a great deal of time obtaining, using, or recovering important social, occupational or recreational activities abandoned or reduce because of substance use continued use despite persistent /recurrent physical or psychological problem substance is likely to cause or exacerbate Mental Disorders
Clinically significant emotional, behavioral or psychological syndrome or pattern A diagnosable mental, behavioral, or emotional disorder from the DSM-IV-R Results in functional impairment that interferes with at least one major life activity Distinction between problems, serious mental illnesses and severe mental illnesses. Co-Occurring Disorders
One or more mental disorder[s] AND one or more disorder[s] relating to alcohol and/or other drug use Must be established independently of each other Very prevalent in specific environments Clinical settings Homeless settings Criminal Justice settings Drug Addiction and Mental Illnesses are brain diseases that affect behavior
(NIDA, 2006) Source: EJ Nestler, MOLECULAR BASIS OF LONG-TERM PLASTICITY UNDERLYING ADDICTION, Nature Reviews Neuroscience 2, 119-128 (2001) Drug Related Offenses Drugs Related Offenses (Bureau of Justice Statistics, 2005) Substance Use Disorders Among Jail Admissions 60 50 40
30 20 10 0 53.3 43.6 29.1 19.1 15.3 Jail - Males 22.1 Jail - Females
Alcohol Abuse/Dependence Drug Abuse/Dependence Either Substance Use Disorder Serious Mental Disorders Among General Population & J ail Admissions 14 12 10 8 6 4 2 0 12.2
10.5 6.4 0.1 0.9 1 1.8 General Population Males 1.4 3.9 2.7
1.4 2 Jail - Males Jail - Females Mania Major Depression Schizophrenia Any Serious Disorder Principles of Effective Treatment 1. Systematic and Comprehensive Screening and Assessment is Essential
(NIDA, 2006) Screening 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 disorder. The screening process for behavioral disorders seeks to answer a yes or no question: Might the offender have a mental illness, a substance use disorder, or both. 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. Assessment
An assessment for behavioral disorders consists of gathering key information and engaging in a process with the offender that enables the counselor to understand the clients readiness for change, problem areas, mental health and substance use diagnoses, disabilities, strengths, and risks. An assessment typically involves a clinical examination of the functioning and well-being of the offender, a record review, and includes a number of written and oral tests. Assessment of the offenders behavioral disorders is an ongoing process that should be repeated over time to capture the changing nature of the offenders status. Principles of Effective Treatment 2. Placement in treatment must be individualized based on assessment
Clinical need Motivation for Treatment Risk Assessments Availability of Treatment Timing of Intervention (NIDA, 2006) Principles of Effective Treatment Screening for Need Objective and Comprehensive
Assessment Secure Residential Residential Day Treatment Intensive Outpatient Outpatient (NIDA, 2006)
Efficient Use of Scarce Resources Principles of Effective Treatment 3. Provide evidence based practices whenever possible, evidence based thinking after that (NIDA, 2006) Evidence Based Practices The use of current and best research evidence in making clinical and programmatic decisions about the care of the offender. Pyramid
Evidence Based Practice of Pyramid Research Evidence 8 7 6 5 4 3 Expert Panel Review of Research Evidence
Meta-Anal ytic Studies Clinical Trial Replications erent Populations With Diff Literature Reviews Analyzing Studies d Clinical Trial Single Study/Controllem ental Studies Multiple Quasi-Experi gle Group Design Sin , ite i-S
Large Scale, Mult Quasi-Experimental 2 1 Single Group Pre/Post Pilot Studies Case Studies (COCE, 2006) Fidelity to Evidence Based Practices (McHugo et al, 1999)
60 *** If current & subsequent points = 1 then the current score = 1 Figure 1. Percent of Participants for High-Fidelity Assessment Points Baseline 6 mo. 12 mo.in Stable 18 mo. Remission 24 mo. 30
mo. 36 mo. Hi-Fidelity 19.67 26.23 29.51 37.7 42.62 55.74 Programs ( E ; 0n=61) vs. Low-Fidelity ACT Programs (G; n=26). Low-Fidelity 0 3.85 3.85
7.69 7.69 15.38 15.38 ACT 50 40 30 20 10
0 Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo. Principles of Effective Treatment
4. When co-occurring mental and addictive disorders exist, integrated treatment strategies are to be used. (NIDA, 2006) Integrated treatment strategies Traditional models of treatment for persons with dual disorders results in poor outcomes Integrated treatment associated with better outcomes Supported by integrated systems of care Need to bring in housing, health, and other service arenas Integrated Dual Disorders Treatment is an evidence based practice Past Year Treatment among Adults Aged 18 or Older with Co-Occurring SMI and a
Substance Use Disorder: 2003 (NSDUH) Treatment for Both Mental Health and Substance Use Problems Treatment Only for Mental Health Problems 39.8% 7.5% 3.7% Substance Use Treatment Only
49.0% No Treatment 4.2 Million Adults with Co-Occurring SMI and Substance Use Disorder Principles of Effective Treatment 5. For the offender with behavioral disorders, supervision + treatment is more effective than either one alone. (NIDA, 2006) i s M
a j o r C o n c Principles of Effective Treatment 6. Coerced Treatment Can be Effective 7. Offenders Need Treatment that Includes Cognitive Behavioral Therapies 8. No One Shot Solution: Treatment Must be Continuous Over Time & Across Systems 9. Sticks + Carrots Are More Effective than
Either Alone What Specific Intervention Works for Offenders? (Faye Taxman, 2006) Assertive Community Treatment Modified Therapeutic Communities Access to Medications Kansas Probation Revocation Analysis: Methodology Target Population: People admitted to prison in Kansas for probation revocations (93% Technical) Extrapolated from sample of consecutive violators Screens utilized
Substance Abuse Screen (TCUDS II) Mental Health Screen (NCCHC) Kansas Probation Revocation Analysis: Estimated Annual Service Demand Probation Revocations N = 2,168 Substance Abuse or Mental Health Treatment Need? No Yes 42% N = 907
58% N = 1,261 Kansas Probation Revocation Analysis: Substance Abuse Substance Abuse Treatment Need N = 777 (508 SA Only) Co-Occurring 269=High SA / Low MH 144=Low SA / High MH Mental Health Treatment Need N = 483 (339 MH Only) High Level of Need
Moderate Level of Need N = 467 N = 310 Residential Intensive Outpatient Outpatient Residential w/ Integrated MH Intensive Outpatient
w/ Integrated MH Outpatient w/ Integrated MH Kansas Probation Revocation Analysis: Mental Health Substance Abuse Treatment Need N = 777 (508 SA Only) Co-Occurring 269=High SA / Low MH 144=Low SA / High MH Mental Health Treatment Need N = 483 (339 MH Only)
High Level of Need Moderate Level of Need N = 386 N = 97 Residential Intensive Case Management Outpatient Residential
w/ Integrated SA Intensive Case Management w/ Integrated SA Outpatient w/ Integrated SA * 50% of high need and 25% of moderate need meet state definition for priority population and services will be reimbursed Challenges Conducting Accurate Assessments Agreement on Matching Offenders to Appropriate Placement Balancing Treatment in Custody vs. Treatment in Community
Accessing Evidence Based Treatment Challenges Workforce Development and Collaboration Expanding Capacity Without Displacing NonCJ Population Treatment Completion Rates are Typically Low Development of Performance Measures and Evaluating Outcomes Opportunities Increased interest in addressing jail and prison overcrowding through combined supervision and treatment efforts Increased recognition that collaboration across systems is required to achieve common objectives Mental Health and Substance Abuse Systems, then Behavioral Health and Criminal Justice Systems
Increased cross-system dialogue (e.g. this audio conference!) THANK YOU ! Contact Information: Fred C. Osher, M.D. [email protected] Council of State Governments Justice Center www.justicecenter.csg.org
