Improving Outcomes for Justice-Involved Individuals with Mental Health and Substance Use Disorders

Improving Outcomes for Justice-Involved Individuals with Mental Health and Substance Use Disorders Bree Derrick, Senior Policy Analyst May 2014!

Organiza4on and Funders Council of State Governments: National non-profit, non-partisan membership association of state government officials Engages members of all three branches of state government Justice Center provides practical, nonpartisan advice informed by the best available evidence Justice Reinvestment Funding Phase I Phase I / II Council of State Governments Jus4ce Center 3

Jus4ce Reinvestment in Kansas JR Policies Outlined in HB 2170: 1. Strengthen Proba4on by Increasing SwiK & Certain Responses to Viola4ons 2. Strengthen Proba4on by Providing Judicial Progressive Sanc4oning 3. Increase Reentry Success by Requiring Post- Release Supervision 4. Incen4vize Good Behavior & Focus Supervision on Higher- Risk Offenders 5. Reinvest in Evidence- Based Strategies Aimed at Enhancing Public Safety The Kansas Department of Correc4ons has allocated $2 million to support and strengthen behavioral health services for offenders on Community Supervision

Introduction to Behavioral Health: Learning Objectives Introduction to Behavioral Health Systems and Population Exploring What Works with Offenders Leveraging Resources to Achieve Positive Outcomes IDENTIFY!! The multiple components! of a comprehensive behavioral health service system and examine the population being served UNDERSTAND!! how evidence-based practices can help change offender behavior by addressing risk, needs, and responsivity!! DESCRIBE!! how providers and officers can effectively supervise and treat individuals with mental illnesses and cooccurring substance use disorders!

What is the Behavioral Health System? The Behavioral System in Your State The term behavioral health system is used to refer to programs and providers of mental health and/or addiction services. The system is actually quite fragmented, with services provided by an array of practitioners in a variety of settings, some of which aren t traditionally considered part of a health services system (e.g., jails, prisons). The Kansas Department for Aging and Disability Services has the responsibility for overseeing and, at times, providing services for adults with mental health and substance use disorders (funded by SAMHSA). For those with private health insurance, care can be accessed at general hospitals, and/or private group and solo practitioners. Examples of community-based treatment options supported by KDADS : Community Mental Health Centers Residential Care Facilities Private Psychiatric Hospitals Source: hwp://www.kdads.ks.gov/

Where Are Behavioral Health Services Provided and by Whom? Sector" Location" Providers" Specialty and behavioral health Outpatient setting; acute care in private, state, county hospital settings; outreach to schools, homes, shelters; in-reach to jails, prison Psychiatrists, psychologist, case managers, licensed counselors, certified alcohol and drug counselors, psychiatric nurses, social workers General medical/primary care Private and community clinics, hospitals, nursing homes Family practice physicians, internists, pediatricians, nurse practitioners Human services Faith-based institutions, public housing facilities Faith-based, criminal justice and vocational counselors; social workers, child care workers Voluntary support networks 12-step group meetings, drop-in centers Self-help groups, peer counselors

How are Behavioral Health Services Funded? 100! 80! 22% Even more complicated than how behavioral health service delivery is arranged is how it is funded. Administrators and providers must weave together funds from a large array of sources, each with different guidelines, fiscal years, and stated purposes. $ in Billions (in 2003) 60! 40! 20! 0! 78% Mental Health Services! 10% 90% Subtance Use Services! Private! Public! U.S. Department of Health and Human Services. Natural Expenditures for Mental Health Services and Substance Abuse Treatment: 1993-2003, Substance Abuse and Mental Health Services Administration. Maryland, 2007.

What are Behavioral Health Disorders? When we use the term, we are referring to: } Mental disorders (or mental illnesses) and/or substance use disorders = behavioral health disorders

What are Mental Disorders? } A syndrome characterized by clinically significant disturbances in a person s thinking, emotional state, and/or behavior that disrupt his/ her ability to work or carry out other daily activities, and engage in satisfying personal relationships } The diagnosis of a mental disorder should have clinical utility: it should help determine prognosis, plan treatment, and potential outcomes. } Individuals whose symptoms do not meet full criteria for a disorder may still need treatment or care.

Specific Diagnostic Categories Exact definitions of serious mental illness (SMI) and severe and persistent mental illness vary by state. While the same general criteria are used to determine eligibility for state-supported public mental health services, the variation in definitions state by state can affect a person s access to services. } } } } } } } } } } } } Neurodevelopmental Disorders Schizophrenia Spectrum and Other Psychotic Disorders Bipolar and Related Disorders Depressive Disorders Anxiety Disorders Obsessive-Compulsive and Related Disorders Trauma- and Stressor-Related Disorders Feeding and Eating Disorders Substance-Related and Addictive Disorders Disruptive, Impulse-Control, and Conduct Disorders Neurocognitive Disorders Personality Disorders (e.g. schizoid, schizotypal, borderline)

The Continuum of Substance Use Disorders Substance use disorders are best understood on a continuum, from no use to dependence on a particular agent (alcohol, medications, or illicit drugs). No Use Mild Moderate Severe Rates of substance abuse or dependence for individuals with criminal justice involvement are high. A 2004 Bureau of Justice Statistics survey estimated that over half of state and almost half of federal prisoners met the criteria for either substance abuse or dependence.

What Are Co-Occurring Disorders? SU Disorder CO- OCCURING MH Disorder If an individual has both a non-addiction mental health and substance use disorders, s/he is typically referred to as having co-occurring disorders. 1 Systemic Separation between Mental Health and Substance Use Substance use disorders and non-addictive disorders are addressed by separate administrative and programmatic structures with separate funding mechanisms. This separation can complicate responses to the needs of people with co-occurring disorders. 1. U.S. Substance Abuse and Mental Health Services Administration. Definitions and Terms Relating to Co-Occurring Disorders. Overview Paper 1. DHHS Publication No. (SMA) 06-4163. Maryland, 2006. 2. National GAINS Center for People with Co-Occurring Disorders in the Justice System (2001). The prevalence of co-occurring mental illness and substance use disorders in jails. Fact Sheet Series. Delmar, NY.

Behavioral Health Disorders by Population In the U.S. General Population: In the U.S. State Prison Population: 16% Meet criteria For mental illness 9% Meet criteria for substance use disorders 56% Meet criteria for Mental Health Problem 53% Meet criteria for Substance Abuse Disorders 5% Meet criteria for serious mental illness 17% Meet criteria for serious mental illness Source: Doris James and Lauren Glaze. Mental Health Problems of Prison and Jail Inmates. September 2006. Office of Jus4ce Programs hwp://gainscenter.samhsa.gov/pdfs/disorders/gainsjailprev.pdf On average, female inmates have a higher prevalence of MH and SU Disorders than male offenders

Serious Mental Illnesses (SMI) and Co- Occurring Substance Use Disorders (CODs) Prevalence of SMI and CODs in Jail Populations General Population Jail Population 95% 5% 83% 17% 28% 72% Serious Mental Illness No Serious Mental Illness Serious Mental Illness No Serious Mental Illness COD No COD 15

The Problem: Overrepresenta4on of Persons with Behavioral Disorders Arrested at disproportionately higher rates -Co-occurrence of SUD -Homelessness Low utilization of EBPs Stay longer in jail and prison High recidivism rates Limited access to health care More criminogenic risk factors 16

Research tells us X What does not work: ü What does work: Not a single study has found reductions in recidivism using punishment-oriented programs Supervision AND Treatment Punishment programs have actually made individuals worse Must incorporate programming targeted at specific risks and needs Punishment does not work for those who: History of being punished Under the influence Psychopathic risk takers Most effective interventions are: 1) Behavioral 2) Focus on current risk factors 3) Action-oriented 4) Behavior is reinforced Source:" What Works and What Doesn t in Reducing Recidivism: The Principles of Effec4ve Interven4on Presented by:edward J. Latessa, Ph.D. School of Criminal Jus4ce University of Cincinna4

Combining Treatment and Supervision Improves Outcomes Changes in Recidivism Rates for Adult Offenders Intensive Supervision: Surveillance Oriented Employment Training & Assistance Drug Treatment Intensive Supervision: Treatment Oriented 0% -4.8% -12.4% -21.9% Source: Steve Aos, Marna Miller, and Elizabeth Drake (2006). Evidence- Based Adult Correc4ons Programs: What Works and What Does Not. Olympia: Washington State Ins4tute for Public Policy

What Works in Reducing Recidivism? Risk principle Need principle Responsivity principle Human service (treatment) principle

Risk-Needs-Responsivity (RNR) Risk: criminogenic risk or the likelihood of reoffending. These are sta4c & dynamic factors. Dynamic Risk Factors Antisocial personality pattern Criminal thinking Criminal associates Substance Use problems Family and / or marital School and / or work Leisure and / or recreation Static Risk Factors Criminal history number of arrests number of convictions type of offenses Current charges Age at first arrest Current age Gender Council of State Governments Jus4ce Center 21

Essen4al to Target those Areas Demonstrated to Improve Outcomes for Offenders Central 8 Factors History of angsocial behavior AnGsocial personality paiern AnGsocial cognigon AnGsocial associates Substance Abuse Family and / or marital School and / or work Leisure and / or recrea4on The Big Four For most offenders with mental illness, the strongest criminogenic needs, or risk factors for criminal behavior are the same as those for offenders without mental illness. Match services to risk level Prioritize highest risk clients for services Source: Major Risk Factors for Recidivism Among Offenders with Mental Illness http://riskreduction.soceco.uci.edu/wp-content/uploads/2010/12/ CrimNeedsCSG_Revised_Clean.pdf

Criminal Jus4ce Risk on a Con4nuum Rates of Failure Across LSI-R Categorization: Kansas Department of Corrections Assessment Tools Can Accurately Identify Offender Risk 33% 41% 48% 21% Low Moderate Moderate / High Very High 0-18 19-24 25-31 32+ Source: Holsinger, Alex. Inves4ga4ng the Predic4ve Validity of the Level of Service Inventory Revised using a sample of releasees from the Kansas Department of Correc4ons

Risk Principle! Failing to adhere to the risk principle can increase recidivism LOW RISK + 3% Average Difference in Recidivism by Risk for Individuals in Ohio Halfway House Moderate Risk - 6% High Risk - 14% *Presentation by Latessa, What Works and What Doesn t in Reducing Recidivism: Applying the Principles of Effective Intervention to Offender Reentry

Risk-Needs-Responsivity (RNR) Need: dynamic factors that should be the focus of programming and treatment. Takeaways: Treat criminogenic needs (dynamic risk factors) Address highest need areas first Treat intrinsic needs first (attitudes, sub abuse, etc)

Addressing Criminogenic Risk Factors as Part of Sentencing and Supervision Dynamic risk factors and associated needs Dynamic Risk Factor History of antisocial behavior Antisocial personality pattern Antisocial cognition Antisocial attitudes Family and/or marital discord Poor school and/or work performance Few leisure or recreation activities Substance abuse Need Build alternative behaviors Problem solving skills, anger management Develop less risky thinking Reduce association with criminal others Reduce conflict, build positive relationships Enhance performance, rewards Enhance outside involvement Reduce use through integrated treatment Andrews (2006) 26

!! Risk- Needs- Responsivity (RNR) Responsivity: factors that will impact the effec4veness of treatment or may present barriers to treatment. INTERNAL RESPONSIVITY! FACTORS!! Motivation! Mental health: anxiety, psychopathy! Maturity Transportation! Cognitive deficiencies! Language barriers! Demographics! EXTERNAL REPONSIVITY! FACTORS! Program characteristics! Facilitator characteristics! Program setting!

Risk-Needs-Responsivity (RNR) Lack of Educa4on An4social Altudes An4social Personality PaWern Takeaways: Use methods which are effective for offenders Poor Employment History Lack of Prosocial Leisure Ac4vi4es Mental Illness Family and/ or Marital Factors Substance Abuse An4social Friends and Peers Adapt treatment to individual limits Consider those factors that may serve as barriers to program or supervision compliance (language barrier, illiteracy, etc.)

Human Service (Treatment) Principle: It is through human, clinical, and social services that the major causes of crime can be addressed (Andrews & Bonta 2010).!

Reduce Recidivism by Targe4ng Mul4ple Criminogenic Needs

Tailor Interven4ons Based on Risk & Need Identifying target populations by criminogenic risk and behavioral health need High Intensive treatment in collaboration with supervision Integrated supervision and Treatment Low Treatment and supervision coordinated as needed Behavioral Health Need Criminogenic Risk Intensive supervision in collaboration with treatment High Low

Creating Conditions to Beat the Odds According to a recent nationwide study, between 43% and 45% of individuals return to prison within three years of their release. Research shows that individuals with serious mental illnesses are 1.38 times more likely to have community supervision revoked than individuals without serious mental illnesses. Improving the odds for individuals with behavioral health problems requires collaboration between supervision and provider agencies.

The Behavioral Health Framework Council of State Governments Jus4ce Center 34

Applying the BH Framework: Step 1, Screening/ Assessment Key Decisions: What criminogenic risk tool will be used? ü LSI-R will be conducted by correctional staff on every probationer - How will LSI-R information be shared with community providers? What screening/assessments will be used to determine BH needs? - LSI-R may serve as initial flag for need but further screening needed - What criteria will triage people to a community provider? - Who will complete the screen? Probation? Community providers? Will additional assessments be used for MH/SUD? - How will different tools be used? - When will reassessments occur?

Applying the BH Framework: Step 2, Providing Tailored Services Based on Risk/Needs Key Decisions: What are the current services available for justice-involved populations? - What are the current services- and levels of service- available? How will BH reinvestment funds expand services in your area? - What new services/capacity will you have? - How will you determine who is eligible for which services? **What elements of programming address criminal thinking in addition to behavioral health needs? - Is programming proven to work with justice-involved populations?

Addi4onal Services Available Through BH Reinvestment Low Risk, Low / Mod Needs Mod / High Risk, Moderate Needs Mod / High Risk, High Needs Minimal supervision, Referral to Self-Help Groups Recovery Coaches and Peer Support Specialists housed in communitybased organizations Correctional Substance Abuse Program (SAP) Program Providers housed in correctional departments and community-based organizations Referral to Community Provider for treatment Care Coordinators serving as liaisons between jails, correctional departments, and providers

Applying the BH Framework : How Assessment and Referral May Work Low, Moderate, High Risk Assessed as Moderate & High Risk Assessed with Moderate & High Needs Referral needed Low Risk, Low / Mod Needs Mod / High Risk, Moderate Needs Mod / High Risk, High Needs Minimal supervision, Referral to Self-Help Groups Correctional Substance Abuse Program (SAP) Referral to Community Provider for treatment

Applying the BH Framework: Step 3, Moving Toward Collabora4ve Case Planning Key Decisions: What information is currently shared between agencies? - What additional information would be helpful? - Do releases currently cover relevant information? - Can releases of information be standardized? How can supervision and treatment requirements be integrated into one plan? - How can goals be tailored to the individual? - How can agencies work toward common goal of recidivism reduction?

Applying the BH Framework: Step 3, Moving Toward Collabora4ve Case Planning Research suggests that for adults with mental illnesses, combined supervision and treatment are more effective at reducing recidivism than supervision alone. The supervision plan outline the requirements that an offender must adhere to while on community supervision. Common goal of recidivism reduction. The treatment plan outlines how the offender will manage his/her illness(es) and identifies specific steps toward recovery. Ideally, behavioral health and community corrections stakeholders should come together to develop integrated treatment and supervision plans for offenders.

Applying the BH Framework: Step 4, Monitor Progress Key Decisions: All agencies receiving behavioral health reinvestment funds will be required to monitor service u7liza7on and report on aggregate u7liza7on periodically. What s important to measure? - Criminogenic risk/need informa4on - Behavioral health screening and/or assessment informa4on - Types and frequency of services received - Reasons for services ending (comple4on, nega4ve termina4on, etc.) - Funds spent by various services - Can we say that a certain service or group of services was related to beeer recidivism reduc4on outcomes?

Key Takeaways: ü Focus on the highest risk offenders. ü Target dynamic needs related to risk of criminal offending. ü Adapt interventions/strategies to an individual s style, limits, etc. ü Deliver interventions with fidelity. ü Integrate supervision and treatment services, whenever possible. ü Tailor case plans to the individual.

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Thank You For more information, please contact: Allison Berger, Program Associate at aberger@csg.org or Bree Derrick, Senior Policy Analyst at bderrick@csg.org!