RNR-Based Assessment and Rehabilitation in Corrections: Severe Mental Illness, Substance Abuse, and Trauma

1. RNR-Based Assessment and Rehabilitation in Corrections:  Severe Mental Illness, Substance Abuse, and Trauma Kirk Heilbrun, Ph.D. David DeMatteo, JD, PhD Kirk.heilbrun@drexel.edu David.DeMatteo@drexel.edu

2. Presented for the Pennsylvania DOC and Sponsored by Community Education Centers DOC Training Academy Elizabethtown, PA April 2011

3. Agenda Overview of RNR:  Evidence and Implications (Heilbrun) RNR-Based Assessment & Treatment of Individuals w/ Substance Abuse (DeMatteo) Severe Mental Illness (Heilbrun) Trauma Histories (DeMatteo) Small group exercise

4. Details • Electronic version of handout available (RNR_ DOC_CEC_4_28_11) • Electronic version of slides available (RNR_DOC_CEC_slides_4_28_11) • See (http://www.drexel.edu/psychology/research/ labs/heilbrun/publications/)

5. RNR Overview • What is risk-need-responsivity? • Model of correctional intervention based on the factors of risk, need, and responsivity • Risk factor • Risk principle • Need factor • Need principle • Responsivity factor • General and specific responsivity

6. RNR Overview • Is there research supporting this model? • Evidence that adherence to the model results in a 35% reduction in recidivism • Meta-analyses • RNR for adult, juvenile, violent, female, and sex offenders • Risk principle

7. RNR Overview • Other research support on • RNR for different populations/programs • Community-based electronic monitoring • Substance abusing populations • Drug court • Prison-based programs • Benefits of targeting high risk offenders • Potential iatrogenic effects of interventions for low-risk offenders

8. RNR Overview • How well are we doing with RNR? • Studies of individual program adherence to RNR show limited adherence in applied settings • Inconsistencies in the research • RNR more effective with certain populations (e.g., less supported among violent offenders in meta-analysis) • Some studies have failed to find significant effects

9. RNR Overview • Gaps in the research • Lack of research examining RNR on an individual level • Studies have started to look at the risk principle, and generally find support for matching service intensity to risk level

10. RNR Overview • Gaps in the research (cont.) • Little research on “treatment fit,” or matching to interventions based on needs • Little research on specific responsivity • There is value in assessing individual factors that may influence how treatment succeeds, such as IQ, mental illness, culture, motivation, and gender

11. RNR Overview • Problems in implementing RNR • Not using up-to-date assessment tools • Failure to base interventions on assessment results • Lack of any risk/needs tools in intervention process • When risk/need information is available, it is commonly not used effectively

12. RNR Overview • Guidelines for evidence-based RNR • Administer a good risk/needs tool to identify risk level and criminogenic needs • Match offender into programs based on the present needs • Consider specific responsivity concerns, such as gender, mental illness, trauma history

13. RNR Overview • RNR and Serious Mental Illness • Offenders with serious mental illness generally have the same risk factors as other offenders • Evidence that providing mental health treatment does not reduce recidivism • Should focus on risk, need, responsivity factors

14. Substance Abuse Overview Scope of the Problem • High rates of drug-involved criminal offenders • Arrestees (Mdn: 67% of males & 68% of females) • Inmates (80%) • Probationers (67%) • Parolees (80%) • Strong relationship between drug use & crime

15. Substance Abuse Overview Scope of the Problem • 80% of offenders report prior drug use • 50% of state inmates meet criteria for drug abuse/dependence (Karberg & James, 2005) • But only 40% participate in drug treatment while incarcerated (Mumola & Karberg, 2006) 6/4/2014 15

16. Substance Abuse Overview Relapse & Recidivism • 95% relapse rate within 3 years of release • 50% recidivism rate within 1 year of release • Within 3 years of release – • 68% re-arrested • 47% re-convicted • 25% re-sentenced for new crime • 25% return to prison for testing drug-positive 6/4/2014 16

17. Substance Abuse Overview Public Safety vs. Public Health • Public Safety • In-prison treatment • Intermediate sanctions • Civil commitment • Public Health • Initiation • Attrition 6/4/2014 17

18. Substance Abuse Assessment Assessment Considerations • Brief screen vs. in-depth assessment • Psychometrically sound • Assessment of individual risks & needs • Assessment of multiple domains

19. Substance Abuse Assessment Assessment Considerations Ongoing assessment Administration time Interpretation by nonclinical staff 6/4/2014 19

20. Substance Abuse Assessment Assessment Tools TCU Drug Screen Level of Service/Case Management Inventory Addiction Severity Index Global Assessment of Individual Needs 6/4/2014 20

21. Substance Abuse Assessment Assessment Tools Substance Abuse Screening Instrument Offender Profile Index Substance Abuse Subtle Screening Inventory 6/4/2014 21

22. Substance Abuse Treatment Intervention Considerations Client’s recognition of drug problem Motivation vs. coercion Matching services to needs High-risk vs. low-risk Recognizing diversity 6/4/2014 22

23. Substance Abuse Treatment Intervention Considerations Comprehensive & evidence-based practices Medical care & medication Adaptive interventions Service integration & continuity of care Resources 6/4/2014 23

24. Substance Abuse Treatment Correctional-based Interventions Increasing motivation Cognitive-behavioral therapy Substitution treatment Contingency management 6/4/2014 24

25. Substance Abuse Treatment Correctional-based Interventions Case management Therapeutic communities Aftercare planning 6/4/2014 25

26. Substance Abuse Treatment Community-based Interventions Restrictive Intermediate Punishment (RIP) Outpatient, halfway house, short-term residential/detox, & long-term residential House offenders & monitor program compliance Diversion Programs Examples: drug courts, mental health courts, veterans courts, re-entry courts 6/4/2014 26

27. Gender Differences in Substance Abuse Treatment • Increasing numbers of women are incarcerated • From 1995-2005, female inmate population increased 57% • Since 1980, female inmate population has increased 336% • Most growth in inmate population is due to drug-related offenses

28. Gender Differences in Substance Abuse Treatment Female vs. Male Offenders • Higher rates of (hard) drug use • More physical health problems • Higher rates of mental health problems • History of victimization/abuse/trauma 6/4/2014 28

29. Gender Differences in Substance Abuse Treatment Female vs. Male Offenders • Lower rates of employment • Higher rates of financial difficulty • Unhealthy social relationships 6/4/2014 29

30. Factors Influencing Re-arrest • Predictors of re-arrest within 1 year • Younger age • Fewer total days in aftercare • Longer lifetime incarceration • Co-occurring psychiatric disorder • Lower levels of education • Unemployment (males) • Parental responsibilities (females)

31. Severe Mental Illness: Assessment • Assessment of mental health problems • Assessment of risk of violent and general reoffending

32. Mental Health Assessment • Screen for mental health problems generally • Specifically, screen for psychiatric symptoms, substance abuse, and suicidality • Incorporate information from a combination of records review, interview, and self-report inventories

33. Risk Assessment • Major predictors of general and violent recidivism comparable for mentally disordered and nondisordered offenders • Psychopathology important in managing mentally disordered offenders, but • In terms of risk assessment, these clinical factors are overshadowed by the more general factors identified in the criminological research (Bonta, Law, and Hanson, 1998)

34. Risk Assessment • A few specialized risk assessment tools have been tested with mentally ill offenders, and perform well enough to be used with this population • Some of the tools are prediction-only tools (do not identify targets for intervention); others are risk-need tools (do identify intervention targets)

35. Risk Assessment • Psychopathy Checklist (PCL) • measures psychopathy, but performs well in a risk assessment capacity (prediction only) • Violence Risk Appraisal Guide (VRAG) • prediction only

36. Risk Assessment • Level of Service (LS) inventories • Risk-need • Actuarial • Historical, Clinical, Risk Management (HCR-20) • Risk-need • Structured professional judgment

37. Risk Assessment • PCL, VRAG, and HCR-20 perform comparably with mentally disordered offenders (prediction) • LS/CMI likely performs well with mentally ill offenders (earlier LS tools have been found to do so)

38. Severe Mental Illness: Tx • Evidence-based Interventions • Cognitive Behavioral Therapy • Dialectical Behavior Therapy • Schema-focused Therapy • Group Psychotherapy • Suicide Risk Factors • Critical Time Intervention • Forensic Assertive Community Treatment

39. Cognitive Behavioral Therapy • CBT is structured approach focused on symptoms, behavior and criminogenic needs • Offenders w/SMI have criminogenic needs associated with values, beliefs, thinking styles, and cognitive emotional states • Identifying , disputing automatic thoughts that generate symptoms (e.g., anxiety, depression) results in improvement

40. CBT Examples • Thinking for a Change – problem-solving approach using introspection, cognitive restructuring, and social skills training • Lifestyle Change – teaches cost-benefit analysis of choices and consequences; focuses on thinking styles associated with criminal activity • Reasoning & Rehabilitation – targets cognitive processing and pro-criminal thinking

41. CBT • CBT reduced odds of recidivism by 1.5 in 12 months after intervention (Landerbergery & Lipsey, 2005) • Important factors in reducing recidivism: • Initial risk level • How well treatment implemented • Inclusion of anger control and interpersonal problem-solving

42. Dialectical Behavior Therapy • Effective with behavioral dyscontrol (e.g., self-harm, violence, poor impulse control) • Goals: • Improve emotional modulation • Increase awareness of consequences to others • Skills training may emphasize emotional regulation and distress tolerance

43. Schema-Focused Therapy • SFT focuses on maladaptive schemas (fixed patterns of thoughts, feelings, and behaviors from negative childhood experiences that continue into adulthood) • Implemented in forensic settings for those with severe APD and/or psychopathy (Bernstein, 2007)

44. Group Psychotherapy • May result in improvements in institutional adjustment, anger, anxiety, depression, interpersonal relations, and self esteem • Incorporation of cognitive and behavioral approaches enhances results • Improvements may not depend on whether inmates were mandated or self-referred

45. Suicide Risk Factors • Environmental • Being in isolation or segregation cells • Shifts with reduced staffing • Distal • Poor social and family support • Prior suicidal behavior (esp within last 1-2 years) • Hx of psychiatric illness, emotional problems

46. Suicide Risk Factors (cont.) • Proximal • Hopelessness • Narrowing of future prospects • Loss of options for coping • Feeling of being bullied • Suicidal intent or plans

47. Critical Time Intervention • Two main components: • Strengthen long-term ties to community and family/friends • Provide emotional and practical support and advocacy during critical time of transition

48. Critical Time Intervention (cont) • Core elements • small caseloads, individualized case management • community outreach • psychosocial skills building, motivational coaching • Context of reentry: • Social ties (e.g., housing, employment, education) • Makes use of existing social connections

49. FACT • FACT (“Forensic ACT Team”) focuses on keeping those with SMI out of jails/prisons • Team of professionals provide services based on consumer needs

50. FACT • Elements • Goal : preventing (re)arrest and (re)incarceration • Those on team of service-providers may have criminal justice histories • Majority of referrals from justice agencies • Supervised residential tx component for high-risk consumers, esp those with substance-use disorders