Evidence-based interventions in forensic mental health and correctional settings

Transcription

1 Evidence-based interventions in forensic mental health and correctional settings Liam E Marshall, PhD Research & Academics Division and Provincial Forensics Waypoint Centre for Mental Health Care

2 Introduction Rationale Administrative Components Therapeutic features Evaluation Future Directions

3 INTRODUCTION Goals Provide evidence-based psychological treatments to reduce problems associated with mental illness Provide evidence-based psychological treatments to reduce risk and criminogenic needs Objectives to meet these goals in empirically supported ways which are respectful toward the client and promote positive patient-staff relations

4 Rationale: RNR RISK: Treating mental illness only, does not reduce risk for future offending Client s risk for future offending and risk to cause harm to self and others, needs to be considered NEEDS: Mentally ill offenders can profit from addressing empirically identified criminogenic needs RESPONSIVITY: There is typically less motivation for treatment in mentally ill offenders than in clients who seek treatment Skilled & supported facilitators are more effective 3/25/2015 4

5 Challenges Choice of interventions Choice of therapeutic style/model of intervention Staff to run interventions Assessment procedures Content and process Over reliance on manuals Infrastructure Facility support 3/25/2015 5

6 Considerations Number of patients suitable for psychotherapy Range and skill of staff: choice of training Other responsibilities of treatment staff Who is the customer?

7 CDCP: Replicating Effective Programs (REP) project Systematic and effective strategies to prepare HIV interventions for dissemination Four phases: Pre-conditions (e.g., identifying need, target population, and suitable intervention) Pre-implementation (e.g., intervention packaging and community input) Implementation (e.g., package dissemination, training, technical assistance, and evaluation) Maintenance and evolution (e.g., preparing the intervention for sustainability) 7

8 How to Successfully Implement Evidence-Based Social Programs: A Brief Overview for Policymakers and Program Providers. (Gorman-Smith, 2006) Step 1: Select an appropriate evidence-based intervention Step 2: Identify resources that can help with successful implementation Step 3: Identify appropriate implementation sites Step 4: Identify key features of the intervention that must be closely adhered to and monitored Step 5: Implement a system to ensure close adherence to these key features 8

9 Example of an Implementation Strategy in Forensic & Correctional Settings March 25,

10 Suggestions for Implementation Oversight: intervention committee & 3 sub-committees Required core interventions Criminogenic: emotional self-regulation & substance abuse (sexual self-regulation, prosocial cognition, domestic violence, relaxation/mindfulness, leisure awareness and skills, self-esteem) Others: illness related interventions (e.g., medication & symptom management, CBT for psychosis DBT for BPD) Assessments for interventions: only on issues actually addressed in interventions 3/25/

11 Suggestions for Implementation 1 staff member (psychologist) as over-seer of interventions Allocate according to interest and expertise Empirical, collaborative, reflexive, approach to program development Ongoing support through weekly or bi-weekly clinic meetings with each team and as a unit Opportunities for immediate debrief when needed

12 Recommended initial approach for groups Closed format move to open format when comfortable with material and process Minimum two facilitators Primary & Secondary Small groups (4+ participants) Separate groups or individual counseling appropriate for functioning level of clients (average, low, very low) Number of sessions/week (min 2, max 3) dependent on risk and needs Length (# hours) of sessions dependent of client functioning level; i.e., shorter for lower functioning. Completion criteria: Dependent on goals and objectives Evaluation: Dependent on goals and objectives

13 Components of Intervention Implementation 1. Assessment & Triage Choice of assessment tools Assignment to intervention 2. Interventions & Reporting Criminogenic & Mental Health needs Therapist support & effective reporting 3. Tracking & Evaluation Completions, dropouts, refusers Targets of treatment, recidivism, client perspective 3/25/

14 ASSESSMENTS RATIONALE: Need to identify each client s personal Risk, Needs, & Responsivity, issues Need to be trauma-informed Provides tracking of significant treatment-related trends Informs treatment decisions Allows for measurement of treatment-related progress All of which, informs the improvement of clinical services

15 Example Intake Assessments All incoming patients: Psychology: HCR-20, PCL-R, VRAG, Self-report STAXI-II, URICA, SSEI, MAST, DAST, Shipley, PTSD- CL-R, others Social Work: Psychosocial history Rec., O.T., Nursing, other Specialized Any patient with an index offence of, or a history of, Sexual Offending: STATIC-99R, STABLE-2007, and ACUTE-2007 Any patient with an index offence of, or a history of, Domestic Violence: ODARA or SARA

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17 2. Intervention & Reporting Intervention design and implementation Theoretical orientation Manuals Training for facilitators Supervision maintaining treatment focus and integrity Depth & type of supervision Reporting results of interventions Outcome of intervention Consider stakeholders needs Structure and length of reports 17

18 1) TARGETS DEGREE OF MANUALIZATION No direction Guide Highly detailed manual Lack of specification of targets 2) PROCEDURES FOR EACH TARGET IMPLICATIONS OF THIS CHOICE Choice of targets Fixed and specific targets None specified Choice Single and specified 3) NUMBER OF TREATMENT SESSIONS 4) STRUCTURE Unspecified Fully unstructured 5) TREATMENT STYLE Dependent on each client s needs Treatment targets repeatedly addressed Fixed number Fully modularized Idiosyncratic Psychotherapeutic Psychoeducational 6) CLIENT INVOLVEMENT Client choice only Collaboration Therapist choice only 18

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20 3. Tracking & Evaluation Successful completions, refusers, dropouts Pre & Post testing Client satisfaction Recidivism 20

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22 Sample Outcomes March 25,

23 Example outcomes: Facility A Pre Few programs running, no structure, no oversight, outdated approach, conflict between medical and allied health staff Low staff morale and difficulty recruiting Strategy: provide training to interested staff members, implement one intervention, then expand 23

24 Example outcomes: Facility A Post Every Allied Health team member running at least one criminogenic need-related group intervention with evaluation and reporting processes in place Medical staff (physicians & nurses) also running groups Clients perspectives canvassed Achievement of targets of treatment 24

25 Nursing run self-esteem program Social Self-Esteem Inventory (Lawson, Marshall, & McGrath, 1979) N M SD Pretreatment Posttreatment t (23) = 2.34, p <.03, Norm Mean = 132, SD = 21 25

26 Old Program Results: STAXI-II (N = 34) STAXI-II M SD %ile M SD %ile Diff t p. State Anger th th Trait Anger th th Anger Expression - Out th th Anger Expression In th th Anger Control Out th th Anger Control In th th Anger Index th th

27 Old Program versus New Program Old New Program STAXI-II M SD %ile M SD %ile t p. State Anger th th Trait Anger th th Anger Expression - Out Anger Expression - In Anger Control - Out Anger Control - In th th th th th th th th Anger Index th th

28 STAXI-II RESULTS: NEW PROGRAM STAXI-II M SD %ile M SD %ile t p State Anger th th 2.7 <.01 Trait Anger th th 3.0 <.01 Anger Expression - Out th th 2.9 <.01 Anger Expression - In th th 2.3 <.05 Anger Control - Out th th -2.6 <.01 Anger Control - In th th -3.1 <.01 Anger Index th th 3.7 <

29 Results: Stage of Change (URICA) Number of Participants Pre-Contemplation Contemplation Action Baseline After Treatment 29

30 Clients Perspectives: Domestic Violence group (Group Evaluation Form-Revised, Marshall, Serran, & Cameron, 2010) Scale Scale Alpha Possible Range Mean SD Range % Facilitator % Group % Overall Facilitator Total % Overall Group Na % Na % Would you recommend this group to others? = 97% said Yes. Factor Analysis of whole scale: 1 factor accounting for 59% of variance 30

31 Therapist Post-Treatment Ratings - Domestic Violence Group TRS-2 * Intellectual Understanding Mid Treatment (3.07) Post Treatment t Sig (3.58) 7.11 <.001 Acceptance / Demonstration (2.86) (3.78) 5.33 <.001 Total Score (5.59) (7.15) 6.67 <.001 *Marshall & Marshall,

32 Outcome for Rockwood Psychological Services Sexual Offender Program Reoffence Treated* (N = 535) Expected** Sexual 3.2% 16.8% General 13.6% 40.0% *Mean follow-up = 5.4 years **Based on Static-99 and S.I.R. 32

33 Summary Interventions for mentally ill and other offenders can be effective Proposed structure meets needs of clients, justice system, and other stakeholders Provides treatment needed to move through system Helps to reduce reoffending Efficient use of resources 33

34 Evidence-based interventions in forensic mental health and correctional settings Liam E Marshall, PhD Research & Academics Division and Provincial Forensics Division Waypoint Centre for Mental Health Care 34