Transcript Addressing Treatment Needs of Kansas Offenders

Principles of Mental Health
and Drug Abuse Treatment for
Criminal Justice Populations
Association of Paroling Authorities International
Audio Conference Training
March 8, 2007
Fred C. Osher, MD
Director of Health Systems and Services Policy
Objectives of Presentation
• Overview of Issues and Common Definitions
• Principles of Effective Treatment for Criminal
Justice Populations
• Case Study
• Challenges and Opportunities
• Open Discussion
Skyrocketing Criminal Justice
Populations Bureau of Justice Statistics, 2005
What is the Problem ?
People with mental illnesses,
substance use disorders, and cooccurring disorders are
significantly over-represented in
the criminal justice system
Substance Abuse
•
A maladaptive pattern of substance use
leading to clinically significant
impairment or distress
– failure to fulfill obligations at work, school or
home
– use in situations in which it is physically
hazardous
– use-related legal problems
– persistent or recurrent social or interpersonal
problems caused or exacerbated by the
effects of the substance
Substance Dependence
•
A maladaptive pattern of substance use leading
to clinically significant impairment or distress
–
–
–
–
–
–
–
tolerance
withdrawal
taken in larger amounts or over a longer period than was
intended
persistent desire or unsuccessful efforts to cut down/control use
spending a great deal of time obtaining, using, or recovering
important social, occupational or recreational activities
abandoned or reduce because of substance use
continued use despite persistent /recurrent physical or
psychological problem substance is likely to cause or exacerbate
Mental Disorders
•
Clinically significant emotional, behavioral or
psychological syndrome or pattern
•
A diagnosable mental, behavioral, or emotional
disorder from the DSM-IV-R
•
Results in functional impairment that interferes
with at least one major life activity
•
Distinction between problems, serious mental
illnesses and severe mental illnesses.
Co-Occurring Disorders
•
One or more mental disorder[s] AND one or more
disorder[s] relating to alcohol and/or other drug
use
•
Must be established independently of each other
•
Very prevalent in specific environments
– Clinical settings
– Homeless settings
– Criminal Justice settings
Drug Addiction and Mental Illnesses are
brain diseases that affect behavior
(NIDA, 2006)
Source: EJ Nestler, “MOLECULAR BASIS OF LONG-TERM PLASTICITY UNDERLYING ADDICTION,” Nature Reviews Neuroscience 2, 119-128 (2001)
Drug
Related
Offenses
Drugs
Related
Offenses
(Bureau of Justice Statistics, 2005)
Substance Use Disorders Among Jail
Admissions
60
50
40
30
20
10
0
53.3
43.6
29.1
19.1
22.1
15.3
Jail - Males
Jail - Females
Alcohol Abuse/Dependence
Drug Abuse/Dependence
Either Substance Use Disorder
Serious Mental Disorders Among
General Population & Jail Admissions
14
12
10
8
6
4
2
0
12.2
10.5
6.4
0.1
0.9 1
1.8
General
Population Males
1.4
3.9
2.7
1.4
2
Jail - Males Jail - Females
Mania
Major Depression
Schizophrenia
Any Serious Disorder
Principles of Effective Treatment
1. Systematic and Comprehensive
Screening and Assessment is Essential
(NIDA, 2006)
Screening
• A formal process of testing to determine whether a
client does or does not warrant further attention at
the current time in regard to a particular disorder.
• The screening process for behavioral disorders
seeks to answer a “yes” or “no” question: Might the
offender have a mental illness, a substance use
disorder, or both.
• Note that the screening process does not
necessarily identify what kind of problem the person
might have, or how serious it might be, but
determines whether or not further assessment is
warranted.
Assessment
• An assessment for behavioral disorders consists of gathering
key information and engaging in a process with the offender
that enables the counselor to understand the client’s
readiness for change, problem areas, mental health and
substance use diagnoses, disabilities, strengths, and risks.
• An assessment typically involves a clinical examination of the
functioning and well-being of the offender, a record review,
and includes a number of written and oral tests.
• Assessment of the offender’s behavioral disorders is an
ongoing process that should be repeated over time to capture
the changing nature of the offender’s status.
Principles of Effective Treatment
2. Placement in treatment must be
individualized based on assessment
–
–
–
–
–
Clinical need
Motivation for Treatment
Risk Assessments
Availability of Treatment
Timing of Intervention
(NIDA, 2006)
Principles of Effective Treatment
Screening for Need
Objective and Comprehensive
Assessment
Secure
Residential
Residential
Day
Treatment
Intensive
Outpatient
Outpatient
(NIDA, 2006)
Efficient Use of Scarce Resources
Principles of Effective Treatment
3. Provide evidence based practices
whenever possible, evidence based
thinking after that
(NIDA, 2006)
Evidence Based Practices
The use of current and best research evidence
in making clinical and programmatic
decisions about the care of the offender.
Pyramid
of
Evidence Based
Practice Pyramid
Research Evidence
8
7
6
5
4
3
Expert
Panel
Review
of Research
Evidence
Meta-Anal ytic
Studies
ns
Clinical Trial Replicatio
s
ion
lat
pu
Po
nt
With Differe
Literature Reviews
Analyzing Studies
Clinical Trial
Single Study/Controlledental Studies
Multiple Quasi-Experimgle Group Design
Sin
Large Scale, Multi-Site,
Quasi- Experimental
2
Single Group Pre/ Post
1
Pilot Studies
Case Studies
(COCE, 2006)
Fidelity to Evidence Based
Practices
(McHugo et al, 1999)
Principles of Effective Treatment
4. When co-occurring mental and
addictive disorders exist, integrated
treatment strategies are to be used.
(NIDA, 2006)
Integrated treatment strategies
• Traditional models of treatment for persons with dual
disorders results in poor outcomes
• Integrated treatment associated with better outcomes
• Supported by integrated systems of care
• Need to bring in housing, health, and other service
arenas
• Integrated Dual Disorders Treatment is an evidence
based practice
Past Year Treatment among Adults Aged 18
or Older with Co-Occurring SMI and a
Substance Use Disorder: 2003 (NSDUH)
Treatment for Both
Mental Health and
Substance Use
Problems
Treatment Only
for Mental Health
Problems
39.8%
7.5%
3.7%
Substance Use
Treatment Only
49.0%
No Treatment
4.2 Million Adults with Co-Occurring SMI and
Substance Use Disorder
Principles of Effective Treatment
5. For the offender with behavioral
disorders, supervision + treatment is
more effective than either one alone.
(NIDA, 2006)
i
s
M
a
j
o
r
C
o
n
c
e
r
Principles of Effective Treatment
6. Coerced Treatment Can be Effective
7. Offenders Need Treatment that Includes
Cognitive Behavioral Therapies
8. No One Shot Solution: Treatment Must be
Continuous Over Time & Across Systems
9. Sticks + Carrots Are More Effective than
Either Alone
What Specific Intervention Works for Offenders?
(Faye Taxman, 2006)
Assertive Community Treatment
Modified Therapeutic Communities
Access to Medications
Kansas Probation Revocation Analysis:
Methodology
• Target Population:
– People admitted to prison in Kansas for probation
revocations (93% Technical)
• Extrapolated from sample of consecutive violators
• Screens utilized
– Substance Abuse Screen (TCUDS II)
– Mental Health Screen (NCCHC)
Kansas Probation Revocation Analysis:
Estimated Annual Service Demand
Probation Revocations
N = 2,168
Substance Abuse or Mental Health
Treatment Need?
No
Yes
42% N = 907
58% N = 1,261
Kansas Probation Revocation Analysis:
Substance Abuse
Substance Abuse
Treatment Need
N = 777 (508 SA Only)
Co-Occurring
269=High SA / Low MH
144=Low SA / High MH
Mental Health
Treatment Need
N = 483 (339 MH Only)
High Level of Need
Moderate Level of Need
N = 467
N = 310
Residential
Intensive Outpatient
Outpatient
Residential
w/ Integrated MH
Intensive Outpatient
w/ Integrated MH
Outpatient
w/ Integrated MH
Kansas Probation Revocation Analysis: Mental Health
Substance Abuse
Treatment Need
N = 777 (508 SA Only)
Co-Occurring
269=High SA / Low MH
144=Low SA / High MH
Mental Health
Treatment Need
N = 483 (339 MH Only)
High Level of Need
Moderate Level of Need
N = 386
N = 97
Residential
Intensive Case
Management
Outpatient
Residential
w/ Integrated SA
Intensive Case
Management
w/ Integrated SA
Outpatient
w/ Integrated SA
* 50% of high need and 25% of moderate need meet state definition for priority population and services will be reimbursed
Challenges
• Conducting Accurate Assessments
• Agreement on Matching Offenders to
Appropriate Placement
• Balancing Treatment in Custody vs.
Treatment in Community
• Accessing Evidence Based Treatment
Challenges
• Workforce Development and Collaboration
• Expanding Capacity Without Displacing NonCJ Population
• Treatment Completion Rates are Typically
Low
• Development of Performance Measures and
Evaluating Outcomes
Opportunities
• Increased interest in addressing jail and prison overcrowding through combined supervision and
treatment efforts
• Increased recognition that collaboration across
systems is required to achieve common objectives
– Mental Health and Substance Abuse Systems, then
– Behavioral Health and Criminal Justice Systems
• Increased cross-system dialogue (e.g. this audio
conference!)
THANK YOU !
Contact Information:
Fred C. Osher, M.D.
[email protected]
Council of State Governments Justice Center
www.justicecenter.csg.org