Stepping Up the Right Way:

Transcription

1 Stepping Up the Right Way: Best Practices in the Treatment of Persons with Serious Mental Illness who have Contact with the Criminal Justice System Wednesday, July 19, 2017, 2-3:30pm EST Dr. Keelin Garvey, Director of Forensic Psychiatry InnovaTel Telepsychiatry

2 Welcome! Chuck Ingoglia, MSW Senior Vice President, Policy & Practice Improvement National Council for Behavioral Health Lea Simms Project Coordinator, Policy & Practice Improvement National Council for Behavioral Health

3 Housekeeping How to join the webinar? GoToWebinar INSTRUCTIONS: Join the webinar: Call in using your telephone:+1 (914) Access Code: Audio PIN: Shown after joining the meeting To ask a question: Type it into the Q&A pod on the right side of your screen. Technical difficulties? Call Citrix Tech Support at

4 Welcome & Housekeeping Agenda Housekeeping items (mute yourself unless speaking) Who is on the line? Polling questions! Setting the stage: Who are we? Why treat this population? Best Practices in the Treatment of Persons with Serious Mental Illness who have Contact with the Criminal Justice System Brief overview of jail diversion Review options for community treatment for SMI with criminal justice involvement Discuss the Risk-Need-Responsivity model of assessing and treating offenders, with focus on criminogenic risk factors Highlight importance of substance abuse treatment and availability of Medication- Assisted Treatment Question & Answer

5 Who is on the line? Please take a moment to answer two polling questions the questions will pop up on your screen in a moment. #1: Please select the category that best describes your profession: a) Psychiatrist or Psychiatric NP or PA b) Psychologist or Mental health clinician (e.g. LICSW, LMHC) c) Substance abuse counselor d) Healthcare administration e) Other #2: Are you currently working with criminally-involved individuals: Yes- in correctional setting Yes- in community setting No

6 National Council for Behavioral Health ,000 3,000 members Employing 750,000 staff Serving 10 million adults, children and families living with mental illnesses and addictions

7 Founded in 2014 to address the need of a shortage of psychiatrists in community mental health settings Rural areas that have difficulty in recruiting and retaining qualified psychiatrists

8 Why this topic? Local jails in the U.S serve an estimated 2 million people with serious mental illnesses each year. 3out of 4 incarcerated individuals also suffer from a substance use disorder. Once incarcerated, individuals with behavioral health conditions tend to stay in jail longer and are at a higher risk of recidivism. So what can you do? What works?

9 Guest Speaker Keelin Garvey, MD Director of Forensic Psychiatry, InnovaTel Telepsychiatry Previously: Forensic Psychiatrist, Old Colony Correctional Center in Bridgewater, MA Deputy Medical Director and Statewide Psychiatric Medical Director, Massachusetts Partnership for Correctional Healthcare Chair of the Gender Dysphoria Treatment Committee, Massachusetts Department of Correction

10 Jail Diversion Pre-booking Post-booking

11 Jail Diversion Interventions to prevent criminal recidivism in the seriously mentally ill: Mental health court Specialty probation/parole Pretrial diversion Conditional release Legal leverage treatment adherence

12 Jail Diversion: Pre-booking Incarceration Treatment Police-based CIT Co-responder model Mobile mental health crisis teams

13 Police Crisis Intervention Teams (CITs) Specially-trained police officers liaison with mental health system

14 Police-based specialized mental health response programs Mental health providers provide on-site and telephone consultations to officers

15 Mental health-based response programs Community-based mobile crisis teams respond to requests from officers

16 Jail Diversion: Post-booking Jail-based Court-based Specialized mental health courts

17 Role of Mental Health Professionals Participate in co-responder teams Consult to police departments Mobile treatment teams Emergency Department assessments Jail psychiatric evaluations Courts: provide opinion about suitability for diversion Consult with forensic psychiatrist or psychologist On-site Telecommunication

18 Outcomes Sirotich, 2009: Diversity of programs and lack of scientific rigor limited empirical evidence Pre-booking: best evidence for police-based specialized police response model in decreasing total time in custody (not recidivism) Jail-based: low-level misdemeanants Court-based: incidence/prevalence of recidivism in SMI not reduced May reduce lengthy and prevalence of incarceration

19 Reentry & Recidivism

20 Recidivism: Statistics 400,000+ inmates released in % arrested within 3 years (49.7% returned to prison) 76.6% arrested within 5 years (55.1% returned to prison) > 1/3 of these arrests happened in first 6 months + > ½ within first year

21 Nothing works Martinson, 1974 The Effectiveness of Correctional Treatment: A Survey of Treatment Evaluation Studies Led to greater emphasis on punishment and incapacitation Fails to take into account the intensity and integrity of treatment programs

22 What doesn t work Fear tactics Scared Straight Shock probation Relying solely on surveillance and punishment Talk therapy Non-directive client-centered approaches Drug/alcohol education

23 Recidivism: SMI Mental illness in general is not associated with criminality Peterson et al, 2014: 18% of crimes by SMI were directly motivated by mental illness Major predictors of recidivism were the same for mentally-disordered and non-mentallydisordered individuals Bonta, Law, and Hanson, 1998 Criminal factors >> Clinical factors

24 Treatment Models for Criminally-Involved SMI ACT FACT AOT

25 Assertive Community Treatment Multidisciplinary treatment teams providing: Medication management/administration Mental health & substance abuse counseling Case management/social support May not meet criminal needs of SMI involved in correctional system

26 Forensic Assertive Community Treatment Incorporates elements aimed at preventing recidivism Heterogeneous (Morrissey, 2007) Point of contact (jail diversion, mental health center, probation, reentry) Staffing (more correctional vs. mental health staff) +/- collaboration with probation officers More outcome data is needed

27 Assisted Outpatient Treatment Civil legal proceeding allowing judge to order an individual with SMI to follow a courtordered treatment plan Goal = improve access and adherence 46 states and D.C.; exceptions: Massachusetts Connecticut Maryland Tennessee

28 AOT Supporters Based on principle of beneficence Prevents further decompensation Allows for less restrictive environment Effective if associated with adequate community resources Court order is not a substitute for effective treatment

29 AOT Opponents Unethical to force treatment for nonemergency conditions Violates autonomy and self-determination: AOT = euphemism Involuntary Outpatient Commitment (IOC) Lacks teeth Diverts funds from voluntary service recipients

30 AOT Outcomes for Criminally-Involved Swartz et al, 2001: 1 year study, 331 participants with SMI in NC (RCT) Subgroup: multiple hospitalizations and prior arrests and/or violent behavior 47% control group vs 12% extended outpatient commitment SMI patients whose arrests are associated with illness relapse

31 AOT Outcomes for Criminally-Involved Gilbert, 2010: AOT recipients in NY (not RCT) 2/3 lower odds of arrest for AOT recipients compared with no AOT or voluntary service agreement Voluntary agreement no statistically significant difference

32 APA Position Statement 2016 AOT is ethical when used appropriately AOT can be effective with: Adequate resources Intensive, individualized outpatient treatment Duration >180 days Outcomes: positive only under certain conditions: Systematic implementation Availability of intensive community-based services Adequate duration

33 Rochester FACT Model Developed to address variability in FACT program structure, operations and treatment populations 4 components: High-fidelity ACT Identification/targeting of criminogenic risk factors Legal leverage Mental health-criminal justice collaboration

34 Rochester FACT: Results Decreased: Criminal convictions Days in jail Use of inpatient psychiatric services No change: ED visits Arrests Incarcerations 1/3 were due to judicial sanctions for noncompliance

35 What works Risk-Need-Responsivity approach Treatment >> Punishment Behavioral interventions Cognitive-Behavioral Therapy Well-designed, well-implemented programs

36 Risk-Need-Responsivity Risk= Who Level of intervention matched to risk level Need= What Change negative behavior by focusing on the criminogenic needs met by that behavior Responsivity= How General: Cognitive social learning interventions Specific: Personality factors and personal strengths

37 Criminogenic Risk Factors Antisocial behavior Antisocial personality Antisocial cognition Criminal companions Substance abuse Family/marital problems Work/school problems Lack of healthy leisure/ recreational activities

38 Risk-Need Assessment Instruments Over 60 instruments used Commonly used: Level of Service Inventory- Revised (LSI-R) and Level of Service/Case Management Inventory (LS-CMI) Wisconsin Risk and Needs (WRN)+ Client Management Classification (CMC) Correctional Assessment and Intervention System (CAIS) Offender Screening Tool (OST) Static Risk and Offender Needs Guide (STRONG) Correctional Offender Management Profiling for Alternative Sanctions (COMPAS)

39 EPICS Model Effective Practices in Community Supervision Teaches probation officers to use social learning theory and CBT methods Translates RNR into practice

40 Criminogenic Risk Factor: Antisocial Behavior Indicators: Early and ongoing involvement in criminal acts in a variety of settings: DYS history Multiple arrests/ incarceration Needs/Response: Identify high-risk situations Develop alternative pro-social behaviors in high-risk situations

41 Criminogenic Risk Factor: Antisocial Personality Indicators: Impulsivity Aggression Thrill-seeking Hedonistic Irritable Needs/Response: Problem-solving skills Anger management Coping skills/selfregulation

42 Criminogenic Risk Factor: Antisocial Cognition Indicators: Negative statements about the law Difficulty with rules and authority Doubt about ability to succeed through conventional means Lack of empathy Needs/Response: Building and practicing less risky thoughts Challenge thought distortions that favor crime Externalizing blame Rationalizing criminal behavior Rejecting authority

43 Cognitive Behavioral Therapy Thinking for a Change (T4C) Aggression Replacement Therapy (ART) Criminal Conduct and Substance Abuse Treatment-Strategies for Self-Improvement and Change (SST) Moral Reconation Therapy (MRT) Reasoning and Rehabilitation (R&R) Relapse Prevention Therapy (RPT)

44 Criminogenic Risk Factor: Criminal Companions Indicators: Peer group involved in antisocial activity Few non-criminal associates Needs/Response: Increase desire to avoid antisocial peers Motivational Interviewing Increase involvement in activities that involve pro-social peer group Clubs, sports

45 Criminogenic Risk Factor: Substance Abuse Indicators: Alcohol and drug use Substance-related crimes Drug charges Robbery/Armed robbery Violent crime while intoxicated Needs/Response: Substance abuse treatment programs Acute detoxification Residential Intensive outpatient Medication Assisted Treatment

46 Medication Assisted Treatment (MAT) Substance abuse intervention combining behavioral therapies and medication Naltrexone/Vivitrol Methadone Buprenorphine

47 Medication Assisted Treatment Re-entry Initiative Prison-based treatment and community referral Education provided in residential and nonresidential substance abuse treatment programs Recovery Support Navigator MATRI

48 Prescription Drug Abuse Scheduled drugs: Opioids Benzodiazepines Stimulants Unscheduled drugs: Bupropion Gabapentin Quetiapine

49 Criminogenic Risk Factor: Family/Marital Problems Indicators: Marital/partner conflict Absentee parent Poor discipline skills Needs/Response: Family therapy Help development of appropriate parenting skills Consequences Rewards

50 Criminogenic Risk Factor: Work/School Problems Indicators: Poor performance in school/drop-out Lack of consistent employment Disciplinary problems at work Poor work satisfaction Needs/Response: Identify strengths Identify deficits and available accommodations Role-play social skills for work Response to supervision Appropriate management of conflict

51 Reintegration of Ex-Offenders Program RExO: Employment-focused reentry Mentoring Employment services Case management 3 year impact study: No effect on recidivism? Lack of resources for other sources of recidivism Substance abuse treatment Physical health limitations for work Housing

52 Criminogenic Risk Factor: Lack of Healthy Recreational Activities Indicators: Lack of non-criminal leisure activities Former inmates & probationers who report fewer recreational activities are more likely to recidivate Needs/Response: Motivational Interviewing to enhance participation in pro-social hobbies/activities Teach skills needed for involvement in pro-social activities No known outcome studies on changing recreational patterns

53 Mental Health & Criminal Justice Collaboration Inform clients what information will be shared Offer choices Use relationship skills (respect, empathy, nonjudgment) to enhance motivation Mental health: Discuss available treatments and services Criminal justice: Discuss legal stipulations Joint meetings with clients therapeutic alliance Firm, fair and caring Lamberti, 2016

54 Reentry Funding Opportunities Second Chance Act 2008 State/federal agencies Native American tribes Nonprofit organizations US DOJ- OJP pportunities.htm

55 Second Chance Act

56 Summary Mental health professionals can play a role with criminally-involved SMI at any stage Criminogenic risk factors, not mental illness, drive recidivism Collaboration is needed between mental health and criminal justice professionals More standardization and research (RCT) needed

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58 Other Resources: Mental Health First Aid International Association of Chiefs of Police (IACP) s One Mind Campaign

59 IACP s One Mind Pledge Establish a clearly defined and sustainable partnership with one or more community mental health organization(s) Develop and implement a model policy addressing police response to persons affected by mental illness Train and certify 100 percent of your agency s sworn officers (and selected non-sworn staff, such as dispatchers) in Mental Health First Aid for Public Safety Provide Crisis Intervention Team training to a minimum of 20 percent of your agency s sworn officers (and selected non-sworn staff, such as dispatchers)

60 Questions? Please type your questions into your Q&A pod on the right hand side of your screen.

61 Thank you! Questions? Contact Lea Simms at