integrating criminogenic risk into the mental health/criminal justice dialogue november 12, 2009...
TRANSCRIPT
Integrating Criminogenic Risk into theMental Health/Criminal Justice Dialogue
November 12, 2009
Fred C. Osher, MD
+
Overview1. The extent and nature of the problem2. Strategies to improve success for
offenders with mental illness3. Essential Elements of Specialized
Probation Responses4. Implications for Policy and Practice
Click icon to add picture
Burgeoning corrections population is now over 7.3 million
1980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520060
1000000
2000000
3000000
4000000
5000000
6000000
7000000
8000000
Source: Bureau of Justice Statistics (2008)
Total
3.2% of all adults in the United States
Most are supervised in the community
1980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520060
500000
1000000
1500000
2000000
2500000
3000000
3500000
4000000
4500000
Sources: Bureau of Justice Statistics (2007); Skeem, Emke-Francis, et al. (2006)
Probation
Prison
Parole
Jail
6October 5, 2006
Kansas Prison Population Projection
7000
7500
8000
8500
9000
9500
10000
10500
11000
11500
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
2016
9397
1834 bed shortfall
26%increase20%
increase
Impact of “off-grid” sentences and increase in probation condition violators
7October 5, 2006
Kansas Probation Revocations Rising
26%increase
17%increase
1,463
1,772
1,488
2,170
93%“Technical”Violations
1,857
Probation “conditions” violators admissions have increased from 111 a month in 2001 to 170 in 2006Probation revocation rate has stayed the same from FY 04 to FY 06 at about 27 revocations per 100 population
0
500
1,000
1,500
2,000
2,500
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
8October 5, 2006
Kansas Probation Revocations – Revocation rate unchanged since
FY04
– Lack of Consistent Supervision Strategies
– 19% of prison population
– Annual cost of $37.4 million
5 percent
29 percent
27 percent
Prison AdmissionsFY2006
36 percentProbation Violations
ParoleViolations, Conditions
Prob./Parole, New Sentence
New Court Commitments
Overrepresentation of Serious Mental Illnesses:General and Jail Populations
Steadman et al, 2009
% With Co-Occur-ring Substance Use
Disorders72%
% Without Co-Occurring Substance Use Disorders28%
Chart Title
Source: The National GAINS Center, 2004
Most have co-occurring substance abuse disorders
Compared to those without mental illness, community corrections supervisees with mental
illness are more likely…
• to be homeless• to be unemployed • to be psychologically impaired (including
extensive trauma histories)• to have prior criminal history
Those with serious mental illness often “fail” community supervision
• Vidal, Manchak, et al. (2009)– Screened 2,934 probationers for
mental illness; 13% screened in– Followed for average of two years
• No more likely to be arrested…
• But 1.38 times more likely to be revoked
See also: Eno Louden & Skeem, 2009; Porporino & Motiuk, 1995
Arrest Revocation0
10
20
30
40
50
60
70
Ps PMIs
*
Revolving door of justice involvement (Lamberti, 2007)
Supervision&
Treatmentnon-
adherence
Jail/Prison
Hospital
Problem behaviors
Arrest/revocation
Emergency room
Individual risk factors
Systemic risk factors
“Central Eight” risk factors for criminal recidivism (Andrews, 2006)
Risk Factor NeedHistory of Antisocial Behavior Build alternative behaviorsAntisocial Personality Pattern Problem solving skills, anger
managementAntisocial Cognition Develop less risky thinkingAntisocial Attitudes Reduce association with criminal
othersFamily and/or Marital Discord Reduce conflict, build positive
relationshipsPoor school and/or work performance
Enhance performance, rewards
Few leisure or recreation activities Enhance outside involvementSubstance abuse Reduce use
Offenders with mental illness have significantly more “central 8” risk factors for crime
Source: Skeem, Nicholson, & Kregg (2008)
….and these predict recidivism more strongly than risk factors unique to mental illness (e.g., diagnosis, symptoms, treatment compliance)
LS/CMI Tot
40
42
44
46
48
50
52
54
56
58
60
PMINon-PMI
**
System risk factors for criminal recidivism
• Inadequate service capacity• Lack of effective services• Lack of finances for existing services• Geographic barriers to care• Cultural or linguistic barriers to care• Lack of affordable housing• Lack of employment opportunities
Preventing criminal recidivism (adapted from Lamberti, 2007)
Decrease Jail/Prison
Days
Decrease Hospital
Days
FewerProblem
BehaviorsFewer
Emergency RoomVisits
FewerArrests/
Revocation
Adherence
Individual risk variables
System risk variables
Evidence-Based Supervision and Treatment Strategies
Economic Pressure44 States Face Budget Shortfalls
Source: Center on Budget and Policy Priorities (12/2008)
“The current situation not only exacts a significant toll on the lives of people with mental illness, their families, and the community in
general, it also threatens to overwhelm the criminal justice system.”
-Council of State Governments Criminal Justice/Mental Health Consensus Project (2002)
The perceived root of the problem
“People on the front lines every day believe too many people with mental illness become involved in the criminal justice system because the mental health system has somehow failed. They believe that if many of the people with mental illness received the services they needed, they would not end up under arrest, in jail, or facing charges in court”
The implicit model of “what works” for offenders with mental illness
Psychiatric treatment- Symptom reduction
Reduced recidivism
Assumption #1: Involved in crime solely because of mental illness
Arrest rarely is a direct product of mental illness; even for mentally ill
Junginger, Claypoole, Laygo, & Cristina (2006)
The implicit model of “what works” for offenders with mental illness
Psychiatric treatment- Symptom reduction
Reduced recidivism
Assumption #2: Providing mental health services will end involvement
Increased services often do not translate into reduced recidivism
• Specialty probation– Project IMPACT: RCT of 800
probationers – Specialty filled more
prescriptions and got more services…but had no fewer jail bookings
• Jail diversion– Multisite evaluation; includes
control groups – Increased rates of service use are
unrelated to rates of arrest
• “State of the art” – ACT- RCT of 203 DD patients
followed 3 years
ACT & TAU0
10
20
30
40
50
60
70
80
90
100
Arrest Contact
Caslyn et al., 2005; Clark, Ricketts, & McHugo, 1999; Skeem & Eno Louden, 2006; Steadman & Naples, 2005
Even for those “enrolled in state of the art treatment programs, arrests and
other encounters with the legal system are regular occurrences for persons with
dual disorders”
Clark, Ricketts, & McHugo (1999, p. 546)
PSYCHOPATHY AS A TAXON
Brid
Offenders Offenders with mental illness
The strongest risk factors for recidivism are shared by those with, and without mental
illness
+
Overview1. The extent and nature of the problem2. Strategies to improve success for
offenders with mental illness3. Essential Elements of Specialized
Probation Responses4. Implications for Policy and Practice
Click icon to add picture
Supervision style matters• Officers (and judges) often have lower thresholds for violating
mentally ill– Offenders with mental illness have greater needs; officers have little
incentive to meet them– Stigma affects officers, too
• Mental illness sensitivity to bad practices– “…what happens is you create more anxiety when you’re threatening
to send them to jail. They don’t want to go to jail—they’re not stupid—they’re a little bit crazy. And then they’ll stop coming in because they’re afraid”
“…anything additionally bad in my life contributes to the strain of a situation that is already teetering on the brink of suicide…it seems like it would make sense for him…to be very decent in his treatment of me”
Skeem, Encandela, & Eno Louden (2003)
Supervision Compliance Strategies
• Traditional– Trail ‘em, Nail ‘em, Jail ‘em– Threats of incarceration– Negative pressures
• Non-Traditional– “firm but fair”– Authoritative, but not authoritarian– Problem solving strategies
Negative pressure predicting failure at 6 months…bad is stronger than good
Arrested Revoked0
10
20
30
40
50
60
YesNo
**
**p<.01, ***p <.001. Source: Manchak, Skeem, et al., 2008
***
“Firm, but fair and caring” holds promise for all offenders
• Dowden & Andrews (2004): How an officer applies a model determines its effectiveness
• Paparozzi & Gendreau (2005): Within ISP parole
Revoked0
10
20
30
40
50
60
Surveillance Treatment Hybrid
Mental Health Treatment Symptom Reduction?Functioning Increase?
Program and Mandate Specialty v. Traditional
Reduced Recidivism
Arrests
Revocation
EBP in Correctionse.g., Firm but fair relationshipsCompliance strategies
Toward an evidence-based model of “what works, for whom”
+
Overview1. The extent and nature of the problem2. Strategies to improve success for
offenders with mental illness3. Essential Elements of Specialized
Probation Responses4. Implications for Policy and Practice
Click icon to add picture
Improving Responses to People with Mental Illnesses:
The Essential Elements of Specialized Probation Initiatives
Essential Elements
• Collaborative Planning and Administration• Define, Identify, and Assess the Target
population• Design the Initiative and Matching Individuals
to Supervision and Treatment Options• Set Conditions of Community Supervision
Heterogeneity of CC Population
Low
Risk Criminogenic Risk Criminogenic Risk
Fu
nc
tio
na
l Im
pa
irm
en
tsF
un
cti
on
alIm
pa
irm
en
ts
Low Functional Impairment
High Functional Impairment
High
Risk
Intensive supervision integrated with intensive mental health case management (e.g., specialized probation caseloads that integrate supervision and treatment)
Intensive mental health case management coordinated with good routine supervision (e.g., Forensic Assertive Community Treatment)
Intensive supervision coordinated with good routine mental health services (programs based on RNR principles)
Good routine supervision coordinated with good routine mental health services
36October 5, 2006
Change in Recidivism Rates for Adult Offenders
0%
-10%
-20%
-30%
-12.4
Drug Treatment
Intensive Supervision: Surveillance Oriented
0%
Intensive Supervision: Treatment Oriented
-21.9
Steve Aos, Marna Miller, and Eilzabeth Drake. (2006). Evidence-Based Adult Corrections Programs: What Works and What Does Not. Olympia: Washington State Institute for Public Policy.
Employment Training & Assistance
-4.8
Integration of Supervision and Treatment Strategies Likely to Have Largest Impact
Essential Elements
• Developing an Individualized Case Plan• Providing or Linking to Treatment and Services• Supporting Adherence to Conditions of
Community Supervision and Case Plans• Providing Specialized Training and Cross-
Training
Provisional: probation-recorded arrest or revocation, over 12 months
Revoked Arrested0
5
10
15
20
25
30
35
40
45
50
SpecialtyTraditional
*
**
* p= .05, ns, controlling for propensity scores **p <.001, <.01; controlling for propensity scores
%
+
Overview1. The extent and nature of the problem2. Strategies to improve success for
offenders with mental illness3. Essential Elements of Specialized
Probation Responses4. Implications for Policy and Practice
Click icon to add picture
What to do: Systems?
– Cross-agency collaboration• Info-sharing• Coordination of services
– Proper Program Implementation• Workforce Quality/Capacity• Organizational capacity/program fidelity• Outcome evaluations/performance measures
– Performance-based contracting/funding– Organizational culture and leadership
Example: Good
supervision + ACT
Example: RNR
supervision + ACT
Good supervision
+ good treatment
Example: RNR
supervision + good
treatment
What to do: Screening and assessment?
Screen and assess• Identify offenders with
mental illnesses, and substance use disorders, using a validated tool like the BJMHS and TCU-DSII– http
://gainscenter.samhsa.gov/HTML/resources/MHscreen.asp
– http://www.ibr.tcu.edu/pubs/
• Assess risk of recidivism, using a validated tool like the LS/CMI
Target criminogenic risk & clinical needs with EBPs
Clin
ical
Nee
ds
Criminogenic Risk
What to do: Services? – Mental health EBPs for persons with SMI
• Assertive Community Treatment (ACT)• Illness self-management and recovery• Integrated treatment• Supported employment• Psychopharmacology• Supported housing• Trauma interventions
What to do: Supervision? - use EBPs of correctional rehabilitation
• Focus resources on high RISK cases• Target criminogenic NEEDS like anger,
substance abuse, antisocial attitudes, and criminogenic peers
• RESPONSIVITY - use cognitive behavioral techniques like relapse prevention, thinking for a change, MRT
And the Maine Experience ??
