Ask the Doctor Webinar Series:

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1 Ask the Doctor Webinar Series: Evidence Based Practices - Myths and Realities Dr. Fred Osher Director of Health Systems and Services Policy Council of State Governments Justice Center

2 Today s Presentation Overview of EBPs What Works to Reduce Recidivism Challenges in Using EBPs Questions & Answers Council of State Governments Justice Center 2

3 Evidence-Based Practice. the integration of the best research evidence with clinical expertise and patient values. Source: Institute of Medicine, 2000 Council of State Governments Justice Center 3

4 Pyramid of Research Evidence Expert Panel Review of Research Evidence Meta-Analytic Studies Clinical Trial Replications With Different Populations Literature Reviews Analyzing Studies Single Study/Controlled Clinical Trial Multiple Quasi-Experimental Studies Large Scale, Multi-Site, Single Group Design Quasi-Experimental Single Group Pre/Post Pilot Studies Case Studies Source: SAMHSA, 2005 Council of State Governments Justice Center 4

5 Research Limitations Lack of specificity of the intervention Programs vs. Techniques Types vs. Brands Lack of generalizability From severity and types of disorders and types of offenses studied From non justice-involved-cod samples Justice involved singly dx samples Non-justice involved COD samples Lack of research period Council of State Governments Justice Center 5

6 What Works Programs Specialized Police-Based Responses Specialty Courts Integrated Treatment and Supervision: Probation Integrated Treatment and Supervision: Parole Arrest & Jail Court Community Corrections Prison & Supervision Council of State Governments Justice Center 6

7 Diversion Logic Model Stage 1 Stage 2 Stage 3 Diversion Identify and Enroll People in Target Group Linkage Improved Mental Health /Individual Outcomes Comprehensive/ Appropriate Community- Based Services Improved Public Safety Outcomes Source: Steadman et al., 2007 Council of State Governments Justice Center 7

8 Diversion Logic Model Stage 1 Stage 2 Stage 3 Diversion Identify and Enroll People in Target Group Linkage Comprehensive/ Effective Community- Based Services Improved Mental Health /Individual Outcomes Improved Public Safety Outcomes Source: Steadman et al., 2007 Council of State Governments Justice Center 8

What Works: Services EBP Expert Panel Meetings Assertive Community Treatment Joseph Morrissey, Ph.D. Trauma Bonnie Veysey, Ph.D. Housing Caterina Roman, Ph.D. Supported Employment William Anthony, Ph.

9 What Works: Services EBP Expert Panel Meetings Assertive Community Treatment Joseph Morrissey, Ph.D. Trauma Bonnie Veysey, Ph.D. Housing Caterina Roman, Ph.D. Supported Employment William Anthony, Ph.D. Illness Management Kim Mueser, Ph.D. Integrated Treatment Fred Osher, M.D. Council of State Governments Justice Center 9

10 Evidence Base Practices for Justice Involved Persons with Mental Illnesses Housing with Appropriate Supports (Modified Therapeutic Communities) Integrated Dual Disorder Treatment Multidisciplinary Teams (ACT and FACT ) Supported Employment Illness Self Management Psychopharmacologic Medications Cognitive Behavioral Therapies Council of State Governments Justice Center 10

11 Housing as an EBP Council of State Governments Justice Center 11

12 The Evidence for Housing Multiple federal demonstration programs have shown: Persons with mental illnesses want their own homes Persons with mental illnesses are capable of maintaining residential stability with support No one housing model fits all Evidence for types of housing Supported Housing Modified Therapeutic Communities Council of State Governments Justice Center 12

13 Modified Therapeutic Community Key Modifications to structure more flexible activities shorter meetings & activities more staff guidance more staff responsibility as role models to process fewer sanctions engagement emphasis individually paced progress in program flexible criteria for moving to next stage live-out re-entry (aftercare) essential to elements accent on orientation & instruction individualized tasks engagement emphasis throughout activities proceed at a slower pace counseling to assist use of community

14 Integrated Co-occurring Disorder Treatment as an EBP Council of State Governments Justice Center 14

15 Hypothesis for Justice Involved Persons with COD Interventions (at the program or provider level) that reduce substance use (licit and illicit) and improve levels of functioning in persons with COD will reduce both their frequency of involvement with the justice system and their time spent in justice settings or under correctional supervision. Council of State Governments Justice Center 15

16 Heterogeneity of the Population with Co-occurring Disorders Alcohol and other drug abuse High severity III Substance abuse system IV State hospitals, Jails/prisons, Emergency Rooms, etc. I Primary health Care settings II Mental health system Low severity Mental Illness High severity Council of State Governments Justice Center 16

17 Challenges to Integrated Treatment for Justice Involved Persons Determining the appropriate clients for IDDT Identifying and training the appropriate multidisciplinary teams Finding the right community providers Understanding the separate community systems of care Defining and measuring desired client outcomes Council of State Governments Justice Center 17

18 CODs are Often Untreated Past Year Mental Health Care and Treatment for Adults Aged 18 or Older with Both Serious Mental Illness and a Substance Use Disorder Source: NSDUH, 2008 Council of State Governments Justice Center 18

19 Assertive Community Treatment as an EBP Council of State Governments Justice Center 19

20 Assertive Community Treatment Assertive community treatment is an intensive approach to the treatment of people with serious mental illnesses that relies on provision of comprehensive array of services in the community... Fueled by deinstitutionalization and the vital need for community-based services, a multidisciplinary team serving psychiatric inpatients adapted its role to patients in the community. For this reason, assertive community treatment often is likened to a hospital without walls. Source: Mental Health: A Report of the Surgeon General, Pg. 286 Council of State Governments Justice Center 20

21 ACT Basic Elements Multidisciplinary Staffing Primary responsibility In vivo services Small caseloads Team approach Flexible services 24/7/365 Service Provision Time unlimited Council of State Governments Justice Center 21

22 What is Fidelity? Fidelity is the degree of implementation of an evidence-based practice Programs with high-fidelity are expected to have greater effectiveness Fidelity scales assess the critical ingredients of an EBP Council of State Governments Justice Center 22

23 Percent in Remission Why Care About Fidelity? *** If current Figure & subsequent 1. Percent points of Participants = 1 then the current in Stable score Remission = 1 for High-Fidelity ACT Assessment Points Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo. Programs (E; n=61) vs. Low-Fidelity ACT Programs (G; n=26). Hi-Fidelity Low-Fidelity Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo. Council of State Governments Justice Center 23

24 What s the Evidence? Controlled ACT Research Number of Studies ACT better than Standard ACT not better than Standard ACT worse than standard Council of State Governments Justice Center 24

25 Forensic Assertive Community Treatment (FACT) Teams Key Features 100% of clients with criminal justice or forensic involvement active or history Clear focus on public safety outcomes seeks to reduce recidivism, re-arrest, reincarceration through legal risk reduction interventions Takes majority of referrals from jails, courts, state forensic hospitals, prisons, or all of the above Emphasizes housing access Mechanisms to facilitate communication with, or integrate criminal justice personnel on team developed. May, or may not, have high fidelity to the ACT model Source: Adapted from Morrissey et al, 2005 Council of State Governments Justice Center 25

26 Forensic Intensive Case Management (FICM) Teams Key Features Individual caseloads with focus on linking and coordinating, not treatment No team psychiatrist Less strict policies on when and if consumers transferred to other agency Less demand on 24/7 availability Maintains low case-loads Source: Adapted from Morrissey et al, 2005 Council of State Governments Justice Center 26

27 ACT, FACT, FICM, or not? Need for RCT of FACT Need to analyze C-J consumers on ACT to see if differential effects FACT may be critical to a subset of the population, but too expensive for many FICM might be applicable to the next tier of consumers Transition to usual care will always be an issue Council of State Governments Justice Center 27

28 Medications as EBPs Council of State Governments Justice Center 28

29 Psychopharmacologic Medications The most researched interventions Newer, more effective meds available Costs are increasingly an issue What can meds treat? What can t meds treat? Medications and justice involved persons Access Continuity Council of State Governments Justice Center 29

30 Cognitive Behavioral Treatments Council of State Governments Justice Center 30

31 Justice Involved Persons with MI Have Significantly More Central 8 Risk Factors LS/CMI Tot Persons with mental illnesses Persons without mental illnesses Dynamic Criminogenic Risks Antisocial Behavior Antisocial Personality Antisocial Peers Antisocial Thinking Family Discord School or Work Problems Few Leisure Activities Substance Abuse Source: Skeem, Nicholson, & Kregg (2008) Council of State Governments Justice Center 31

32 Cognitive-Behavioral Treatments Focus on skill-building (e.g., coping strategies) Self-control and self-management Problem-solving approaches Use of role play, modeling, feedback Repetition of material, rehearsal of skills Curriculum-based Council of State Governments Justice Center 32

33 The Bottom Line EBP Data for JI Impact Housing Integrated Tx ACT Supported Emp Illness Mgmt Trauma Int./Inf Medications CBT Council of State Governments Justice Center 33

34 Challenges to EBP Implementation Target population characteristics Staff attitudes and skills Facilities/resources (Physical environment, staff and staffing patterns, funding resources, housing, transportation) Agency Policies/Administrative Practices Local/State/Federal regulation Interagency networks Reimbursement Council of State Governments Justice Center 34

35 Too much emphasis on EBPs? There are not enough EBPs to cover the range of clinical circumstances Yet, if you only have a dime to spend. Hence, Evidence-Based Thinking The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individuals. Council of State Governments Justice Center 35

36 Contact Information Fred Osher, M.D. Director Behavioral Health Systems and Services Policy Council of State Governments Justice Center Council of State Governments Justice Center 36

Peer-to-Peer Connections http://consensusproject.

37 Peer-to-Peer Connections Council of State Governments Justice Center 37

38 Thank You! This material was developed by the presenters for this webinar. Presentations are not externally reviewed for form or content and as such, the statements within reflect the views of the authors and should not be considered the official position of the Bureau of Justice Assistance, Justice Center, the members of the Council of State Governments, or funding agencies supporting the work. Suggested Citation: Osher, Fred. Ask the Doctor Webinar Series: Evidence Based Practices - Myths and Realities. Webinar held by the Council of State Governments Justice Center, New York, NY, September 22, Council of State Governments Justice Center 38

Addressing Co-Occurring Disorders in Court-Based Programs

Addressing Co-Occurring Disorders in Court-Based Programs Roger H. Peters, Ph.D. Professor; Department of Mental Health Law and Policy at the Louis de la Parte Florida Mental Health Institute (FMHI), University