J uvenile R ehabilitation A dministration

1. An Overview of the Continuum of Care and Integrated Treatment Model Presented by Kelly Dahl North Sound Systems of Care Training Institute Western Washington University August 25, 2010 JuvenileRehabilitationAdministration

2. Presentation Overview • Juvenile Justice in Washington State • An Overview of JRA Organizational Structure Facts and Figures • JRA’s Integrated Treatment Model Residential and Community Applications CBT/FFP Basic Principles

3. Juvenile Justice in Washington State • Juvenile Justice in Washington State is governed by Title 13 of the Revised Code of Washington (RCW) • The Juvenile Justice Act of 1977 (RCW 13.40) – Intent and Purpose • Make the juvenile offender accountable for his or her criminal behavior • Provide due process for juveniles alleged to have committed an offense • Provide necessary treatment, supervision, and custody for juvenile offenders • Provide for the handling of juvenile offenders by communities whenever consistent with public safety • Develop effective standards and goals for the operation, funding, and evaluation of all components of the juvenile justice system and related services at the state and local levels • Encourage the parents, guardian, or custodian of the juvenile to actively participate in the juvenile justice process

4. Continued: Juvenile Justice in Washington State • Determinate Sentencing and Sentencing Guidelines - court sets minimum and maximum sentence determined by offense seriousness and criminal history • “The goal of a determinate sentencing system is to ensure that offenders whose offenses and criminal histories are similar receive substantially similar sentences.” (Juvenile Disposition Manual 2006) • Manifest Injustice sentences – mitigating and aggravating factors may result in sentencing outside of a standard range • “When a court finds that a presumptive sanction would amount to an excessive penalty or would impose a serious and clear danger to society, it may impose a disposition that departs from the standard range.” • (Juvenile Disposition Manual 2006)

6. Continued: Juvenile Justice in Washington State • The Community Juvenile Accountability Act of 1997 • CJAA is enacted into law “to provide a continuum of community-based programs that emphasize the juvenile offender's accountability for his or her actions while assisting him or her in the development of skills necessary to function effectively and positively in the community in a manner consistent with public safety.” (RCW 13.40.500) • This established Evidence Based Practices funding for: • Functional Family Therapy (FFT) • Aggression Replacement Training (ART) • Multi Systemic Therapy (MST) • Coordination of Services (COS)

7. Evidence Based Practices Outcome Evaluations • Legislatively required evaluation was conducted to see if their investment in Evidence Based Practices was effective. • Washington State Institute for Public Policy (WSIPP) conducted the study • August 2002 interim outcome evaluation completed • Competence in and adherence to an Evidence Based Practice is critical to the effectiveness of the intervention • $7.50 of cost benefit* • 30% recidivism reduction *Cost Benefit = the savings from avoided crime costs for each tax dollar spent on the program.

8. DSHS Mission Improve the safety and health of individuals, families and communities by providing leadership and establishing and participating in partnerships.

9. JRA Mission • Protect the public, hold juvenile offenders accountable, and reduce criminal behavior through a continuum of preventative, rehabilitative, and transition programs in residential and community settings • JRA’s overall goal is to enhance public safety by preparing delinquent youth to become confident, competent, responsible adults

10. JRA Organizational Structure • Institution Programs • Oversees 4 institutions and 1 basic training camp. • Community Programs • Manages parole services, six community residential facilities (group homes), and two contracted community programs . • Operations Support Services • Provides fiscal oversight and operational support to the JRA divisions of Community Programs, Institution Services, and Treatment and Intergovernmental Programs. • Treatment and Intergovernmental Programs • Responsible for developing treatment program policies and standards. Oversees the Interstate Compact Program.

11. JRA Youth Profile Youth committed to JRA custody by local juvenile courts have typically: • Committed a serious violent offense, or • Committed a series of minor offenses over time and exhausted local sanctions and interventions, and • Have an average sentence of 40 weeks

12. JRA Youth Profile (7/8/10) • 3% of youth arrested in WA end up in JRA • Male:Female 11:1 (2004) • Ethnic Breakdown: JRAState (0-17) • White/Non-Hispanic: 45% 73% • African American: 19% 5% • Hispanic: 20% 13% • Native American: 3% 2% • Asian: 4% 7% • Age range of incarcerated: 8-20 • 40% (261) are 16 or younger • 52% (343) are 17 and 18 years old

13. Residential Population Characteristics* • Mental Health: 62% • Chemical Dependency: 55% • Cognitive Impairment: 43% • Sex Offender/Misconduct: 27% • Medically Fragile: 3% • Two Issues: 46% • Tri-Issue: 38% • Quad-Issue: 5% *January 26, 2010 Snapshot Data

14. Residential Offense Profile Youth in JRA care are at the very deep end of the juvenile justice system. Their service and intervention needs are both acute and complex. 61% are Violent Offenders 18% have 8 or more prior offenses Types of Current Offenses: # % Robbery 154 23.3 Assault 142 21.5 Burglary 113 17.1 Other Sex Offense 60 9.1 Rape/Rape of a Child 46 7.0 Other Offense 26 3.9 Murder/Manslaughter 20 3.0 Theft 20 3.0 Motor Vehicle Theft 20 3.0 Weapon Offense 19 2.9 Drug Offense 19 2.9 Arson 9 1.4 Parole Revocation 6 0.9 Malicious Mischief 5 0.8 Poss. Stolen Prop. 3 0.5 Kidnapping 2 0.3 Escape 1 0.2 Forgery 1 0.2 Criminal Trespass 0 0.0 n=660 July 8, 2010

15. JRA Facilities and Programs Institutions (598 Beds – actual pop. = 570, 7/8/10) Green Hill School, Chehalis Naselle Youth Camp, Naselle Maple Lane School, Centralia Camp Outlook, Connell Echo Glen Children’s Center, Snoqualmie State Community Facilities (92 Beds – actual pop. = 83, 7/8/10) Canyon View, Wenatchee Oakridge, Tacoma Parke Creek, Ellensburg Ridgeview, Yakima (female) Twin Rivers, Richland Woodinville, Woodinville Contracted Programs (9 Beds – actual pop. = 7, 7/8/10) Residential Treatment & Care, Spokane (6) Benton/Franklin STTP (Short Term Transition Program) (3) Functional Family Parole Services (433 Youth, 7/8/10) Region 1, Spokane Region 4, Seattle Region 2, Yakima Region 5, Tacoma, Bremerton Region 3, Everett, Mount Vernon Region 6, Olympia, Vancouver

17. JRA Continuum of Care Residential Care: 669 youth (7/8/10) Average Length of Stay: 44 Weeks (2010) Institutions and Basic Training Camp Community Facilities Parole: 433 Youth (7/8/10) Range = 4 to 6 months Sex Offense = 24-36 months

18. JRA Placement and Treatment Continuum County Juvenile Courts: Youth w/ Criminal offenses committed to JRA Residential Placement in JRA JRA Parole No Longer Under JRA Jurisdiction Screening, assessment, & testing for placement, treatment planning & service delivery (Diagnostic, Chemical Dependency/Abuse, Client History, GAIN-SS, Suicide & Self-Harm Screen, Aggression/Vulnerability) Community Connections / Resources MHTP: RSN's: Medicaid Eligible Private Insurance No Insurance— Private pay or are unserved Residential Services Integrated Treatment Model: Dialectical Behavior Therapy (DBT/CBT) Aggression Replacement Training ( ART) Moral Reconation Therapy (MRT) Residential Treatment and Care Program (RTCP); aka Multidimensional Treatment Foster Care (MTFC) Family Integrated Transitions (FIT) Individual and Group Therapy Psychiatric & Psychological Services Medication & Med. Management Education/Vocational Training Chemical Dependency/Abuse Treatment Sex Offender Treatment Recreation Cultural Programs Parole Services Integrated Treatment Model Functional Family Parole Functional Family Therapy Family Integrated Transitions Connected to MH services Medicaid Eligibility Limited contracted MH Transitional Services Sex Offender Treatment DASA CD Services DDD Coordination Aggression Replacement Training (ART) MentoringCommunity Connections

19. Framework for working with youth and their family • Committed to JRA/Placement Determined • Diagnostic Process • Institution • Youth Camp • Basic Training Camp • Community Facility Youth Discharged from JRA • Functional Family Parole • Engage & Motivate • Support and Monitor Services • Generalize Skills • Whole Family Involved • JRA Residential Services • Screening / Assessment • School / Vocational • CBT/DBT skills training and coaching • Medical services • Specialized treatment OUTCOMES • 45 Days before release—Transition meeting w/Family: • Parole or No Parole • Living arrangements • Service Connections

20. JRA Integrated Treatment Model (ITM) JRA implemented the Integrated Treatment Model(ITM) in 2003 to address the acute and complex treatment needs of youth committed to JRA care. The ITM incorporates best-practice and evidence-based interventions to address the needs of youth and their families from the point of admission through completion of parole aftercare. Lessons Learned • Failure to adhere to and competently deliver evidence-based intervention models can, in fact, be counter productive • Success requires strict model adherence with supporting quality assurance and consultation • Environment is critically important to achieving positive outcomes. JRA is working hard to establish residential environments that make possible and support therapeutic intervention

21. JRA INTEGRATED TREATMENT MODELThe 5 Critical Functions of Treatment

22. JRA Treatment Services • EVIDENCE BASED SERVICES: Dialectical Behavioral Therapy Functional Family Parole Cognitive Behavioral Therapy Functional Family Therapy Aggression Replacement Training Mentoring Family Integrative Transitions (FIT) • MODES OF TREATMENT Individual Counseling Group Skills Training Milieu Treatment • SPECIALIZED TREATMENT OTHER SERVICES Mental Health Psychiatric Substance Abuse Medical/Dental Sex Offender Education Vocational Training Recreation

23. What the ITM Creates • A uniform set of skills • Behavioral targets that are clearly identified and addressed in a systematic fashion • Addresses youth and family issues in the context in which they occur • Identifies the role of staff across the continuum-of-care • Treatment approaches that vary based on the youth and family needs • Treatment plans are individualized • Multidisciplinary Team approach across continuum

24. ITM CBT/DBT FFP Parole Residential Family Focus Youth Focus Emphasis on Engagement & Motivation Validation Reframing Connecting Treatment to Goals Reducing Blame & Negativity Functions of Behavior are Examined Relational & Hierarchical Assessment Behavior Chain Analysis Skill Generalization is the Ultimate Goal

25. Principles – teaching, shaping, coaching, and reinforcing positive behavior Developing skills for socially responsible living Institutions: Assess treatment needs Begin process of adaptive skill development Community Residential Facilities: Transition youth and practice skills in a community setting Parole Aftercare: Support for generalization and maintenance of skills Engagement of families in youth rehabilitation JRA Integrated Treatment Model

26. Finding Treatment Priorities T R E A T M E N T H I E R A R C H Y • Recent (or Historic) Parasuicidal Ideation, Threats, or Behavior. • Recent (or Historic) Aggressive Ideation, Threats, or Behavior. • Recent (or Historic) Escape Ideation, Threats, or Behavior. • Recent or Current Treatment-InterferingBehaviors. • Significant Quality of Life issues. MentalHealth Substance Abuse Offense (Robbery) FamilyIssues

27. Analyze the chain of eventsmoment-to-moment over time (Behavior Chain Analysis) VULNERABILITIES TARGET BEHAVIOR INITIAL CUE • LINKS CONSEQUENCES

28. Vulnerabilities B C A Cue Function and Other Drivers Links Target Behavior Outcomes Understanding the Problem Substance Abuse

29. CBT/DBT Skill Modules • Mindfulness or Observing Youth who are impulsive, Excessively judgmental, Easily distracted, Rigid thinkers, Youth who have difficulty solving problems • Interpersonal Effectiveness Unstable relationships, History of loss and grief issues, Poor peer selection, Lack of respect, and Lack of social skills • Emotion Regulation Intense anger, Intense shame, Emotional instability, and Low tolerance to frustration • Distress Tolerance Egregious suicide behavior, Acts of aggression, Impulsive self destructive behavior, Substance abuse or addiction, and Compulsive criminal behavior • Problem Solving Anger, Aggression, and Social skills

30. T R E A T M E N T H I E R A R C H Y Mental Health Vulnerabilities B C A Cue Substance Abuse Function and Other Drivers Links Substance Abuse Target Behavior Outcomes State the Target Describe the Function Pick Skills with Similar Function Identify Steps to Block Outcomes Identify Steps to Increase Skillful Behavior Identify Cue Management Plan ITP Family Issues Treatment Planning Summary Robbery

31. Determine Content for Integrated Treatment Plan Treatment Focus Skill Selection Intervention Plan Drives Content & Structure of Our Daily Interactions with our Clients Linked Processes Client History Review& Behavior Chain Analysis Flow should be visible

32. Functional Family Parole CORE PRINCIPLES • Working Alliance • Relational (Family) Focus • Strength Based • Respect • Matching

33. Advantages of Family Focus • Issues arise through family and can begin to be solved there • With the family involved, changes can happen quicker... IF we can engage and motivate them • Family can support youth more effectively than youth on his/her own • Involvement is the first step toward persuasion…

34. MATCHING is a fundamental requisite for effectively engaging and changing families • Match to the phaseof your responsibility - Do the right thing at the right time. • Match outcome goals to the family – Identify and strategize steps to become functional and positive within their own culture, communities, realities, etc. • Match to the clients- Do what it takes for them to feel you are working hard to respect and understand them, their language, norms, etc. mismatch results in “resistance”

35. ENGAGEMENT and MOTIVATION GOALS Engagement Motivation • Address and Reduce Negativity, Blame and Hopelessness • Create a Relational Focus • Maintain Balanced Alliance with all Participants • Help the Family see Different and More Productive Solutions

36. FFP Skills • Change Focus – from individual to relational • Relationship building – humor, curiosity, acknowledgement, strength based statements • Point processing • Sequencing • Interrupting/Diverting • Change Meaning – from blame and negativity to noble but misguided intent • Re-label • Reframe • Themes

37. What is Reframing? Reframing is an Interpersonal Processin which the you take the lead in suggesting that a problem behavior may not necessarily only have a malevolent motive; instead it could also include a more positive (but very misguided) intent.

38. How to do it… 1. Validate/ Acknowledge The people involved and “the problem” Validate the emotion/pain the “bad behavior” produced 2. Reframe motive, intention, goal, underlying emotional state—it’s not giving reasons or excusing behavior 3. Assess acceptability/fit 4. Change/continue

39. Moving from Engagement and Motivation to Support and Monitor If we’ve consistently matched to, established a balanced alliance, created a relational focus, decreased negativity and blaming and created a sense of hope… We will also have created a motivational and informational base, which results in having the necessary credibility to match the youth/family to a program or offer recommendations that will help them make or continue necessary changes

40. Support and Monitor goals/activities • Goals: • Move to less active role • Support family and change agent • Ensure program has effective • change process and element • Eliminate barriers • Activities: • Monitor and support change • Structure supportive activities • Encourage and reinforce family members (and providers?) • Be an advocate of effective • services/programs

41. Support and Monitor Service and Activity Plans Support Activities • Employment • Spiritual Related • Youth oriented recreation/leisure • Family oriented recreation/leisure • Any significant, regularly occurring activity that impacts risk/protective factors Monitor Services • Education • Treatment Mental health, YSO, Drug/Alcohol, FFT, FIT, MST, ART • Mentoring • Employment Training

42. Generalization Phasegoals/activities/focus • Goals: • become active again • reinforce positive change • help generalize change • Activities: • use the community • maintain community contacts • family case manager role • target generalization change based on relational assessment • Focus: • relationships between the family and community • using assessment knowledge

43. Linking to Change Program Linking skills learned in facility to community context POS I T I VE TERMI NAT I ON Generalize PRERELEASE PREP Maintain Facility Treatment Plan (no additional services) Link to… Gen’lization Engage & Motivate Support & Monitor Link to… Gen’lization Evidence-Based or other Change Program Support and Monitor Program and Fit of Skills to Community Context

44. Relapse Prevention 1. Identify situations where problem may occur 2. Identify strategies to use when problem reoccurs 3. Predict the problem to reoccur (The best predictor of future behavior is past behavior) 4. Repetitive skill use and reinforcement helps build expectation that new skills will work in similar/different situations over time

45. The Outcomes Cognitive Behavioral Therapy in Residential Care Since implementing the Integrated Treatment Model, JRA has seen a 60% reduction in assaultive behavior in institutions and similar reductions in calls from living units for security staff assistance, also reductions in self-harm behavior Dialectical Behavioral Therapy(DBT) and it’s related skill sets is the primary cognitive-behavioral intervention used with youth in JRA residential care. A 2002 WSIPP study of JRA youth involved in a DBT pilot-program at Echo Glen Children’s Center shows a 15% reduction in 18 month felony recidivism. However, a future study with a larger sample size is needed to determine conclusively if DBT reduces recidivism Family Integrative Therapy (FIT) is an intervention for youth with co-occurring mental health and substance abuse disorders that uses a combination of evidence-based approaches involving youth and their families. The program begins in residential care and continues when youth are released to parole supervision. A 2004 WSIPP study shows a 33.5% reduction in felony recidivism for youth involved in FIT and future cost savings of $3.15 for each dollar spent Functional Family Parole (FFP) In a recent study conducted by the University of Indiana, 30 percent of youth who received FFP from highly adherent counselors were convicted of a new felony within 12-months of release compared with 35 percent of the matched control group. An 18 month post release study is being finalized

46. SPECIAL THANKS TO… DAN SCHAUB, JRA Mental Health Program Administrator LAURIE HART, JRA FFP Program Administrator PAMALA SACKS-LAWLAR, JRA Substance Abuse Administrator LISA MCALLISTER, JRA FFT Quality Assurance Administrator DR. HENRY SCHMIDT, Former JRA Clinical Director …FOR THEIR HELP AND INPUT INTO THIS PRESENTATION