bh-framework-webinar_csgjc_9-6-2019

Criminal Justice Support for New Administrations Webinar The Behavioral Health Framework: Understanding How People with Behavioral Health Needs Interact with the Criminal Justice System David A. D’Amora, M.S., LPC, CFC, Senior Policy Advisor, State Initiatives, The Council of State Governments Justice Center September 6, 2019 Supported by

Overview Introduction The Criminogenic Risk and Behavioral Health Needs Framework Examples from States Questions and Answers

The Council of State Governments Justice Center Mission We develop research-driven strategies to increase public safety and strengthen communities.

Who We Are We are a nonprofit, nonpartisan organization that combines the power of a membership association, representing state officials in all three branches of government, with the expertise of a policy and research team focused on assisting others to attain measurable results.

Association of State Correctional Administrators Vision Excellence in corrections through exceptional leadership.

Mission We are united in our commitment of promoting the profession of corrections, supporting each other, and influencing policy and practices that affect public safety.

Objectives

Promote the profession of corrections Support ASCA members Influence policy and practices that affect public safety

National Criminal Justice Association (NCJA) NCJA promotes the development of justice systems that enhance public safety, prevent and reduce the harmful effects of criminal and delinquent behavior, adjudicate defendants and sanction offenders fairly and justly, and are effective and efficient. §

Maintains focus on the needs of the criminal and juvenile justice systems;

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Represents justice system concerns to the federal government;

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Supports development of criminal and juvenile justice policy for the nation’s governors and tribal leaders; and

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Coordinates education, community and social service systems, law enforcement and criminal justice measures to support all levels of government and achieve public safety goals.

National Governors Association (NGA)

About the Project Recognizing that newly elected governors must tackle many competing priorities, project partners are offering support to new administrations to help assess state criminal justice systems and create a concrete plan to achieve large-scale criminal justice reform.

This support enables states to build on past achievements, identify best practices and innovative approaches to address ongoing challenges, and lead new endeavors with messages that will resonate at local, state, and national levels.

Presenter David A. D’Amora, M.S., LPC, CFC, advises on risk and needs

assessment, correctional programming, and the intersection of behavioral health and criminogenic needs.

Prior to joining the CSG Justice Center, David worked in the criminal justice and behavioral health fields for more than 30 years. This included serving as the vice president of agency programs for a community-based agency providing multiple types of correctional and behavioral health treatment to formerly incarcerated people under community supervision. David was also a clinician at Somers State Prison and Meriden-Wallingford Hospital in Connecticut as well as a consultant with a national criminal justice technical assistance provider. A licensed professional counselor and certified forensic counselor, David earned his BA from Franklin College and his MS at Butler University.

Overview Introduction The Criminogenic Risk and Behavioral Health Needs Framework Examples from States Questions and Answers

The Problem: Overrepresentation of People with Behavioral Health Disorders in the Criminal Justice System Arrested at disproportionately higher rates • Co-occurring disorders • Homelessness Stay longer in jail and prison

Limited access to health care CSG Justice Center

Low utilization of EBPs

High recidivism rates

Many have criminogenic risk factors

What are behavioral health disorders?

When we use the term “behavioral health disorders,” we are referring to: § Mental disorders (or mental illnesses) + substance use disorders = behavioral health disorders However, the term “behavioral health” is not universally agreed upon in the field. § Historical context § Differences between mental health and substance use treatment communities/systems Terminology toss-ups § Disorders vs. illnesses § Serious vs. severe vs. severe and persistent § Substance use vs. substanceCSGabuse vs. addiction Justice Center

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Behavioral Health Needs Co-occurring substance use and mental illnesses: People are said to have co-occurring needs when at least one disorder of each type can be established independently of the other and is not simply a cluster of symptoms resulting from a single disorder.

In addition to behavioral health needs, people who have co-occurring disorders also tend to have higher prevalence of: Infectious diseases: e.g., hepatitis C, HIV Other chronic diseases: e.g., diabetes, obesity, asthma, heart disease, cancer

Source: Kessler RC, Chiu WT, Demler O,Walters EE. “Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication�

(NCS-R). Archives of General Psychiatry, 2005 Jun; 62 (6): 617-27

Illicit Drug Use and Substance Use Disorders Compared to the general population, people on community supervision have higher rates of substance use disorders.

Source: Substance Abuse and Mental Health Services Administration, National Survey on Drug Use and Health, 2009-2012

Prevalence of Substance Use Disorders Compared to the general population, people in jail and prison have higher rates of substance use and alcohol disorders.

Sources: Kessler, et al “The Epidemiology of Co-Occurring Addictive and Mental Disorders: Implications for Prevention and Service Utilization,” 17-31; Henry Steadman, Fred C. Osher, Pamela C. Robbins, Brian Case, and Steven Samuels,“ Prevalence of Serious Mental Illness Among Jail Inmates,” Psychiatric Services, 60 (2009)

Co-Occurring Substance Use Disorders and Serious Mental Illnesses Compared to the general population, people in the criminal justice system have higher rates of co-occurring substance use disorders and mental illnesses.

Source: “Co-occurring disorders among mentally ill jail detainees,” American Psychologist, 46 (10), 1036–1045.

What Accounts for the Problem?

Low utilization of EBPs Past Year Mental Health Care and Treatment for Adults Age 18 or Older with Both Serious Mental Illness and Substance Use Disorder

Source: NSDUH (2008)

Incarceration is not always a direct product of mental illness.

Continuum of Mental Illness Relationship to Crime

Number of Crimes

300

64.7%

250 200 150 100 50

7.5%

17.2%

10.7%

0 Completely Direct

Source: Peterson, Skeem, Kennealy, Bray, and Zvonkovic (2014)

Mostly Direct

Mostly Independent

CSG Justice Center

Completely Independent

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Criminogenic Risk and Mental Illness

Many people in the criminal justice system who have mental illnesses tend to have as many or slightly more criminogenic risk factors compared to people who do not have mental illnesses who are in the criminal justice system.

Source: Jennifer L. Skeem • Sarah Manchak •Jillian K. Peterson, Correctional Policy for Offenders with Mental Illness: Creating a New Paradigm for Recidivism Reduction, Law and Human Behavior, DOI 10.1007/s10979-010-9223-7

Criminogenic Risk

Criminogenic risk is the likelihood that a person in the criminal justice system will commit a new crime or violate the conditions of their supervision.

Criminogenic Risk

Criminogenic risk is NOT: Crime type Failure to appear Sentence to disposition Custody or security classification level Dangerousness

Risk-Need-Responsivity (RNR) Model as a Guide to Best Practices Principle

Impact on Practice

Risk Principle

Match the intensity of individual’s intervention to their risk of reoffending (WHO to target)

Focus resources on high-RISK cases

Needs Principle

Target criminogenic needs, such as antisocial behavior, substance abuse, antisocial attitudes, and criminogenic peers (WHAT to target)

Target criminogenic NEEDS, such as antisocial behavior, substance abuse, and antisocial attitudes

Responsivity

Tailor the intervention to the learning style, motivation, culture, demographics, and abilities of the offender (HOW to best target)

Address the issues that affect RESPONSIVITY (e.g., mental illnesses)

Principle

How do we Determine Criminogenic Risk?

Conditions of an individual’s behavior that are associated with the risk of committing a crime

Static factors – Unchangeable conditions Dynamic factors – Conditions that can change over time and are amenable to treatment interventions

CSG Justice Center

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Static Risk and Dynamic Risk Static Risk Factors (Unchangeable) 1. Criminal History ● Number of Arrests ● Number of Convictions ● Type of Offenses 2. Current Charges 3. Age at First Arrest 4. Current Age 5. Gender

Dynamic Risk Factors/Needs (Changeable)

1. Antisocial Attitudes 2. Antisocial Friends and Peers 3. Antisocial Personality Pattern 4. Substance Addiction 5. Family and/or Marital Factors 6. Lack of Education 7. Poor Employment History 8. Lack of Prosocial Leisure Activities

Andrews, D. A., & Bonta, J. (2017). The psychology of criminal conduct (6th ed.). Cincinnati, OH, US: Anderson Publishing Co

High-risk Individuals do not Improve with Limited Interventions.

•

Ineffective Intervention plan _________________________________________________________

û û û

Weekly AA/NA meetings Limited supervision Job placement program

• •

•

AA/NA meetings alone do not provide enough intensity of programming to address substance use issues.

Biweekly visits do not provide enough supervision/control to reduce recidivism.

Without addressing antisocial thinking and personality through cognitive behavioral interventions, the person is unable to maintain employment.

Conversely, without adequately addressing the substance use issues, the cognitive programs will be ineffective.

Responsivity: General and Specific Factors that Impact the Effectiveness of Treatment Use methods that are effective for people in the criminal justice system.

Antisocial Attitudes Antisocial Personality Pattern

Lack of Education

Poor Employment History

Lack of Prosocial Leisure Activities

Mental Illness Family and/or Marital Factors

Antisocial Friends and Peers

Substance Abuse

CSG Justice Center

Adapt treatment to individual limits (length of service, intensity).

Consider factors that may serve as barriers to program or supervision compliance (language barrier, illiteracy, etc.).

Non-Criminogenic Needs Related to Responsivity that May Need to be Targeted to Effectively Lower Criminogenic Needs

Self-esteem Anxiety Lack of parenting skills Medical needs Victimization issues

Learning disability

Receptive and Expressive Language Skills

Mental Illnesses

Learning style

Substance use (can be both)

Concrete thinking

Motivation Level

Trauma

principles

RNR

Respect for the person Theory Human service Crime Prevention

12. Dosage

13. Relationship skills 14. Structuring skills

8. Assess RNR 9. Strengths 10. Breadth 11. Professional discretion

15.

16.

17.

18.

Community-based Continuity of service Agency management Community linkages

Organizational

5. Risk 6. Need 7. Responsivity (general + specific)

Staff practices

Structural assessment

1.

2.

3.

4.

Program delivery

Overarching

Expansion of the RNR Model

There is a need for a shared framework to respond to the intersection of behavioral health and criminogenic risk and needs.

Adults with Behavioral Health Needs Under Correctional Supervision National publication released in September 2012 as a foundational report for policymakers, administrators, and service providers seeking to improve outcomes for the large number of adults cycling through the criminal justice system who have mental illnesses and substance addictions https://csgjusticecenter.org/mentalhealth-projects/behavioral-healthframework/

Creating Cross-System Collaboration

What Works in Mental Health Treatment What Works in Recidivism Reduction

What Works in Substance Use Treatment

Behavioral Health Framework

Framework for Addressing Population with Co-occurring Mental Illnesses and Substance Use Disorders

Alcohol and other drug abuse

High severity

Low severity Source: NASMHPD & NASADAD, 2002

IV

III Substance abuse system

State hospitals, Jails/prisons, Emergency Rooms, etc.

I

II

Primary health Care settings

Mental health system High

Mental Illness CSG Justice Center

severity

Highlights from the Behavioral Health Needs Framework The publication helps policymakers •

Develop a shared language about the risk of criminal activity and public health needs;

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Integrate best practices in mental health treatment, substance addiction treatment, and recidivism reduction;

•

Allocate scarce resources more wisely; and

•

Maximize the impact of interventions on public safety and public health.

Behavioral Health Needs Framework

What is the objective of treatment in justice-involved populations?

• To reduce symptoms so that the behavioral disorders minimally affect a person’s functioning • To reduce the risk of a person committing a new crime or violating conditions of release CSG Justice Center

Developing Effective Interventions for Each Subgroup

It is assumed these responses will: • Incorporate EBPs and promising approaches • Be implemented with high fidelity to the model • Undergo ongoing testing/evaluation CSG Justice Center

The “Next Generation:� Integrated Treatment for Criminogenic and Behavioral Health Needs Estimated Percentage Change in Recidivism Rates

0.0 Number of Studies

Combining supervision and treatment can improve outcomes.

Intensive Supervision: SurveillanceOriented Programs

Employment Training and Job Assistance in Community

Drug Treatment in the Community

Intensive Supervision: Treatment-Oriented Programs

0%

5.0

4.8%

10.0 12.4%

15.0 20.0

21.9%

25.0 Source: Aos, Steve, R. Barnoski, Marna Miller, and Elizabeth Drake (2001)

CSG Justice Center

EBPs for People in the Justice System Who Have Cooccurring Disorders For Persons with Substance Dependence and Less Serious Mental Disorders – Groups 3 and 7 • Cognitive Behavioral Therapeutic Techniques • Modified Therapeutic Communities • Medication Assisted Therapies • Contingency Management Techniques • Motivational Enhancement Therapy • Relapse Prevention • Trauma-Focused Treatment • Participation in Mutual Self-Help Groups

Adapted from COCE, 2005

For Persons with Serious Mental Disorders and Substance Dependence – Groups 4 and 8 • Integrated Dual Disorder Treatment • Supported Housing • Psychopharmacologic Interventions • Assertive Community Treatment • Forensic Assertive Community Treatment • Illness Management and Recovery Skills • Supported Employment • Trauma-Focused Treatment • Cognitive Behavioral Responses

Services and Supports Associated with Good Public Health and Safety Outcomes Evidence-Based Practices and Programs (EBPs)

Promising Practices and Programs

Assertive Community Treatment (ACT)

Forensic ACT (FACT); Forensic Intensive Case Management (FICM)

Supported Employment

Supportive housing

Integrated Dual Diagnosis Treatment (IDDT)

Peer support; Forensic Peer Specialists

Psychopharmacology

Modified Therapeutic Community (MTC)

Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Treatment (CBT) Targeted to Criminogenic Risk Factors (e.g., Reasoning or Rehabilitation; Thinking for a Change; Moral Reconation Therapy)

Overview Introduction The Criminogenic Risk and Behavioral Health Needs Framework Examples from States Questions and Answers

Key policy options to ensure that states are responding to the behavioral health drivers that can increase recidivism

1

2

Require substance use and mental health screens for individuals who enter into the criminal justice system.

3

Require that criminogenic risk and needs are assessed at the beginning of incarceration or community supervision.

+

4

Develop programs with the knowledge to treat or refer individuals for both behavioral health and criminogenic risk and need. +

Determine program placement and program type(s) needed utilizing the Behavioral Health Framework.

+

+

Arkansas: Investing in law enforcement training and Crisis Stabilization Units (CSUs) “We are cutting the ribbon on a new approach to law enforcement and the treatment of those in mental-health crisis. This is the grand opening of a second chance and a new life for the many people who will benefit from the care they will receive.”

—Governor Asa Hutchinson

$6.4M

Allocated $6.4M to open 4 CSUs across

the state and train officers to deal with people who have mental illnesses

Trained 495 law enforcement officers in 40-hour Crisis Intervention Training (CIT)

1,190 people will be served annually in the 4 CSUs

North Dakota: Investing in community-based behavioral health services instead of prisons “With this legislation, we can give those dealing with substance abuse and other behavioral health issues who become entangled in the legal system an opportunity to recover successfully and return to their communities.�

—Governor Doug Burgum

$7M

Invested $7M in an innovative behavioral health plan to improve health care outcomes and reduce recidivism by delivering highquality community behavioral health services linked with effective community supervision.

The Departments of Correction and Rehabilitation and Human Services partner with local organizations to deliver coordinated and comprehensive services to people in the program.

Community-based agencies provide a range of services, including comprehensive case planning, linking participants to services, peer recovery supports, and facilitating communication among treatment teams.

Bernalillo County, New Mexico: Utilizing the framework to prioritize treatment services Centurion medical staff conduct a screening of everybody who is booked at MDC. Part of this screening includes an assessment of criminogenic risks and behavioral needs, which places each person into a risk/need group ranging from 1 to 8. Initial screening is completed to determine what behavioral health need box someone fits in, with treatment services prioritized for those in boxes 6, 7, and 8

Overview Introduction The Criminogenic Risk and Behavioral Health Needs Framework Examples from States Questions and Answers

Thank You! Join our distribution list to receive updates and announcements: www.csgjusticecenter.org/subscribe For more information please contact David A. D’Amora at ddamora@csg.org The presentation was developed by members of The Council of State Governments Justice Center staff. The statements made reflect the views of the authors, and should not be considered the official position of The Council of State Governments Justice Center, the members of The Council of State Governments, or the funding agency supporting the work. Š 2019 The Council of State Governments Justice Center