Growing the Evidence for Specialty Mental Health Probation: Results from

an Experimental Study

Gary S. Cuddeback, PhD, MPH, MSW, UNC-CH

Tonya B. Van Deinse, PhD, MSW, UNC-CH

David Edwards, North Carolina Department of Public Safety

Anne Precythe, Missouri Department of Corrections

Academic and Health Policy Conference on Correctional HealthAcademic Consortium on Criminal Justice Health

March 16-17, 2017Atlanta, GA

Acknowledgements

• This project was supported by funding from the North Carolina Governor’s Crime Commission and the North Carolina Department of Public Safety.

• We would like to acknowledge the efforts of our many project partners including:

– NC Department of Public Safety– NC Department of Health and Human Services– Treatment Accountability for Safer Communities– Alliance Behavioral Healthcare Managed Care Organization– Eastpointe Managed Care Organization

• We would also like to acknowledge the work of our research team: Nathan Brunson, Stacey Burgin, Marilyn Ghezzi, Ashley Givens, Michelle Herman, Evan Lowder, Amanda Strott, Amy Blank Wilson

Criminal Justice and Mental Health

• The public mental health system has shrunk in past 50 years –now persons with severe mental illness (SMI) are impacted by a variety of policies and agencies over which mental health authorities have little control

• Where mental health and criminal justice connect … – The criminal justice system is the new frontier for mental health services

and research about interventions for mentally ill offenders … – Fates of persons with mental illness are intertwined with the policies of

the criminal justice system …– The criminal justice system is the place of last resort for dangerous and

hard-to-manage persons with mental illness …– The criminal justice system is a public health outpost for persons with

severe mental illness …

Daily Number of Persons with Mental Illness in the Criminal Justice System

4

31% of female jail inmates and 15% of male inmates have mental illness (Steadman et al., 2009)

24% of female and 16% of male prisoners have mental illness (Ditton, 1999)

About 27% of 5 million probationers have mental illness (Crilly et al., 2009) ~ 1.35 million probationers!

Approximately 35,000 in state hospitals

Prisons Jails Probation/Parole

# MI 276,994 130,140 1,350,000

Prevalence of Mental Illness in Corrections

5

Mental illness 5x higher

Psychotic disorders 10x higher

67%

33%

Corrections Census

Community supervision Incarerated

Vast majority in corrections are supervised in the community

7%-64% in corrections have MI

Those with MI have more infractions, arrests, violations

Crilly et al., 2009; Ditton, 1996; James & Glaze, 2006; Kaeble Glaze, Tsoutis & Minton, 2015; Lamberti, 2007; Teplin, 1990

Mental Illness and Community Supervision

6

16%-27% of the 4.7 million adults on community supervision have a mental illnessThey have:

- Difficulty meeting the terms of supervision

- More violations and recidivism

Probation officers face significant challenges: - Limited community resources- Complex probationer problems- Lack of medication adherence- Lack of health insurance- Limited officer training and expertise- High caseloads- Punishment vs. treatment orientation

Crilly et al., 2009; Ditton, 1996

Specialty Mental Health Probation and Statewide Training

• With a grant from the Governor’s Crime Commission and funding from DPS, principals from DPS, DHHS, TASC, and UNC-CH have led efforts to:

– Train and provide more information about mental health to all probation officers and other stakeholders across the state; and

– Launch two specialty mental health probation pilots in Wake (large urban) and Sampson (rural) Counties, North Carolina

Statewide Training

• To date, statewide mental health training modules have been disseminated to all probation officers, chiefs, district managers and other DPS stakeholders across the state, as well as to TASC employees and other stakeholders

• The six training modules cover the following topics:

– (1) using and interpreting the risk and needs assessment;

– (2) severe mental illness;

– (3) psychiatric medications;

– (4) PTSD, personality disorders and other disorders;

– (5) crisis response and local services for persons with mental illness; and

– (6) self-care for probation officers

Specialty Mental Health Probation

• Specialty Mental Health Probation (SMHP) is a promising practice for supervising probationers with mental illness

• Evidence suggests that SMHP improves MH and CJ outcomes

• Five elements of prototypical SMHP model

– Exclusive caseloads of probationers with mental illness

– Reduced caseload size (around 40 probationers)

– Ongoing mental health training for officers

– Interfacing with external resources to connect probationers to supports

– Problem-solving orientation

• More than 140 SMHP agencies across the country

9

Council of State Governments, 2002; Manchak, Skeem, Kennealy & Eno Louden, 2014; Skeem, Emke-Francis & Eno Louden, 2006; Skeem & Eno Louden, 2006; Wolff, Epperson, Huening, Schumann & Sullivan, 2014

Limitations in the Research Regarding SMHP

• Intervention implementation

– Lack of focus on implementation in criminal justice settings in general, and for SMHP in particular

– The challenges associated with implementing SMHP are unknown, which may limit fidelity and expansion of SMHP

• Efficacy of the intervention

– Results of SMHP are promising

– However, need RCTs

Alexandra, 2011; Gendreau, Goggin & Smith, 1999; Manchak, Skeem, Kennealy & Eno Louden, 2014; Skeem & Eno Louden, 2006; Wolff, Epperson, Huening, Schumann & Sullivan, 2014

Context of Specialty Mental Health Probation

• SMHP initiated by NC Department of

Public Safety (DPS)

• Planned by DPS, NC Department of Health

and Human Services, Treatment

Accountability for Safer Communities

(TASC), and the UNC Chapel Hill School of

Social Work (UNC-CH)

• Implemented the five elements of prototypical SMHP in one urban and one rural county, each with two officers

• DPS short term plans for expansion

TASC

Hybrid Efficacy-Implementation Design

12

Develop evidence base for SMHP

Explore and document implementation (challenges, facilitators, strategies)

Purpose/objective

Design elements

Efficacy/Effectiveness Implementation

RCT – SMHP vs. standard probation• Probationer-level data

(criminal justice & mental health outcomes)

Formative Evaluation• Stakeholder-level data from semi-

structured interviews examining implementation process, barriers, and facilitators

Curran et al., 2012

Hybrid Efficacy-Implementation Design

13

Develop evidence base for SMHP

Explore and document implementation (challenges, facilitators, strategies)

Purpose/objective

Design elements

Efficacy/Effectiveness Implementation

RCT – SMHP vs. standard probation• Probationer-level data

(criminal justice & mental health outcomes)

Formative Evaluation• Stakeholder-level data from semi-

structured interviews examining implementation process, barriers, and facilitators

Curran et al., 2012

Department of Public Safety (DPS; 3)

Treatment Accountability for Safer Communities (TASC; 1)

Department of Health and Human Services

(DHHS; 1)

DPS in Wake and Sampson Counties (9)

TASC Care Managers (3)

Local Managed Care Organizations (5)

UNC-CH Research and Implementation Team

(4)

Mental HealthCriminal Justice

State-level

Local-level

Inte

r-o

rg

an

iza

tion

al

Imp

lem

en

tatio

n S

tru

ctu

re

Implementation Study MethodsResearch questions Design and sample Measures Analysis

RQ1: What are the facilitators and challenges of implementing SMHP?

RQ2: What promising implementation strategies were used during the pilot phase?

Qualitative; n=26presenting all involved agencies: • Executive Committee

(23%)• Implementation Team

(12%)• CJ system (46%)• MH/CJ bridge

partners (15%) • MH system (23%)

Semi-structuredinterview guide consisting of 17 questions examining implementation of SMHP

Step 1: line-by-line open coding to identify challenges, facilitators, and strategiesStep 2: Deductive coding of challenges and facilitators using Consolidated Framework for Implementation Research (CFIR); deductive coding of strategies using Expert Recommendations for Implementing Change (ERIC)Step 3: open coding for statements that did not fit deductive coding frameworkStep 4: Identified strategies coded as facilitators

Damschroder et al., 2009; Miles, Huberman & Saldana, 2013; Powell et al., 2015

Relevant Frameworks and Taxonomies

Consolidated Framework For Implementation Research (CFIR)• Intervention characteristics (e.g.,

cost, complexity)• Inner setting (e.g., culture,

readiness)• Characteristics of individuals (e.g.,

knowledge, self-efficacy)• Outer setting (e.g., cosmopolitanism,

policies)• Process (e.g., planning, engaging)

Expert Recommendations for Implementing Change (ERIC)• A compilation of 73 discrete

implementation strategies associated with multiple domains, for ex:

– Using evaluative and iterative strategies– Providing interactive assistance– Tailoring strategies to context– Developing stakeholder

interrelationships– Training and educating stakeholders– Supporting clinicians

16Damschroder et al., 2009; Powell et al., 2015; Waltz et al., 2015

Implementation Facilitators of SMHP

17

Inner Setting

• Committed and engaged leaders

• Readiness for implementation

Outer setting

• Building rapport with MH agencies

Implementation process

• Having an implementation team

• Interdisciplinary engagement

Implementation Challenges

18

Inner Setting

• Existing workload of officer

• Caseload size• Vacancies

Outer setting

• Availability of resources

• Services• Transportation

Implementation process

• Interdisciplinary communication

• Agency role confusion

• Engaging standard officers

Facilitative Strategies

19

• Facilitative strategies are those that were cross-coded (in the qualitative data) as both ‘facilitators’ and ‘strategies’

Develop stakeholder interrelationships

• Develop relationships across agencies and stakeholders via stakeholder networking meetings and provider visits

Train and Educate Stakeholders

• Development of a statewide mental health training for probation officers

• Informational meetings for agency partners as well as other probation officers

Provide Interactive Assistance

• Provide clinical case consultation with licensed clinical social worker

• Provide system-level technical assistance via MCO

Hybrid Efficacy-Implementation Design

20

Develop evidence base for SMHP

Explore and document implementation (challenges, facilitators, strategies)

Purpose/objective

Design elements

Efficacy/Effectiveness Implementation

RCT – SMHP vs. standard probation• Probationer-level data

(criminal justice & mental health outcomes)

Formative Evaluation• Stakeholder-level data from semi-

structured interviews examining implementation process, barriers, and facilitators

Curran et al., 2012

CHARACTERISTICS OF SAMPLETotal

(n=99)

%(n)

Standard probation

(n=55)

%(n)

SMHP

(n=44)

%(n)

Age (M(SD)) 35.59 (12.40) 35.98 (12.82) 35.09 (11.98)

Race

White/Caucasian 39.80 (39) 38.89 (21) 40.91 (18)

Black/African American 42.86 (42) 46.30 (25) 38.64 (17)

American Indian/Alaskan Native 4.08 (4) 1.85 (1) 6.82 (3)

Other 13.27 (13) 12.96 (7) 13.64 (6)

Gender

Male 55.10 (54) 55.56 (30) 54.55 (24)

Female 44.90 (44) 44.44 (24) 45.45 (20)

Education

< High School 34.69 (34) 34.55 (19) 34.88 (15)

High school /GED 37.76 (37) 30.91 (17) 46.51 (20)

> High School 27.55 (27) 29.09 (19) 20.28 (8)

Employment

Unemployed 53.06 (52) 57.41 (31) 47.73 (21)

Part time 15.31 (15) 11.11 (6) 20.45 (9)

Full time 16.33 (16) 18.52 (10) 13.64 (6)

Disabled/unable 14.29 (14) 12.96 (7) 15.91 (7)

Student 1.02 (1) - 2.27 (1)

Health insurance 48.98 (48) 46.30 (25) 52.27 (23)

Total Sample

(n=99)

%(n)

Standard probation

(n=55)

%(n)

SMHP

(n=44)

%(n)

Probation

Previous sentence 70.41 (69) 70.37 (38) 70.45 (31)

Sentence length (M(SD)) 25.12 (13.24) 24.15 (11.44) 26.41 (15.40)

PPO-Offender relationship 172.00 (38.04) 166.65 (39.09) 178.47 (36.11)

Trust 27.01 (7.92) 25.81 (8.37) 28.47 (7.18)

Caring/Fairness 113.87 (16.45) 110.81 (27.03) 117.58 (25.56)

Toughness 31.12 (6.50) 30.04 (7.10) 32.42 (5.50)

Mental Health characteristics

Enrolled in MH services 56.84 (54) 62.26 (33) 50.00 (21)

Diagnosis

Depression 24.24 (24) 23.64 (13) 25.00 (11)

Bipolar 62.63 (62) 61.82 (34) 63.64 (28)

PTSD 6.06 (6) 7.27 (4) 4.55 (2)

Psychosis 7.07 (7) 7.27 (4) 6.82 (3)

Symptom Check List (SCL10-R) 19.89 (9.12) 19.22 (9.42) 20.70 (8.79)

CHARACTERISTICS OF SAMPLE (Cont’d)

Action Steps Initiated

0

20

40

60

80

100

SA action stepsinitiated

MH action stepsinitated

% O

F P

RO

BA

TIO

NE

RS

Action Steps Initiated

Total (n=91)

Standard probation (n=49)

SMHP (n=42)

SMHP officers had higher rates of initiating mental health and

substance abuse action items compared to standard probation

officers; however, this difference was only statistically significant for

mental health action steps.

Do probationers enrolled in SMHP have higher rates of mental health engagement compared to those on standard probation?

Action Steps Completed

0

20

40

60

80

100

SA action stepscompleted

MH action stepscompleted%

OF

PR

OB

AT

ION

ER

S

W/A

CT

ION

ST

EP

S

Action Steps Completed

Total (n=30)

Standard probation (n=13)

SMHP (n=17)

A higher percentage of probationers on SMHP caseloads completed their

mental health or substance abuse action steps. However, this difference was not

statistically significant.

Do probationers enrolled in SMHP have higher rates of mental health engagement compared to those on standard probation?

Percentage of Probationers with Violations

0

10

20

30

40

50

60

70

80

90

100

Any violation(n=51)

TechnicalViolations

(n=51)

Abscond (n=9) New (n=15)

% O

F P

RO

BA

TIO

NE

RS

Percentage of Probationers with Violations by Type and Group

Total (n=91) Standard probation (n=49) SMHP (n=42)

A higher percentage of probationers on standard caseloads

had technical violations and absconded compared to those on

SMHP caseloads. A higher number of probationers on SMHP

caseloads had violations due to new crimes. However, neither of these differences are statistically

significant.

Do probationers enrolled in SMHP have lower rates of violations compared to those on standard probation?

Percentage of Probationers with Violations

0

2

4

6

8

10

12

# of anyviolation(n=51)

# ofViolation

Count(n=51)

# ofTechnicalViolations

(n=51)

# Abscond(n=9)

# New(n=15)

ME

AN

# O

F V

IOL

AT

ION

S

Average Number of Violations by Type and Group

Total (n=91) Standard probation (n=49) SMHP (n=42)

Of the probationers who had violations, those on standard probation had a

slightly higher average number of any type of violations, a higher violation

count, more absconders, and more new violations, compared to those on SMHP

caseloads. However, the differences between the mean number of violations

between the two groups was not statistically significant.

Do probationers enrolled in SMHP have lower rates of violations compared to those on standard probation?

Current Status and Next Steps

27

• Wrapping up the pilot data analysis

• Active expansion into a multi-site RCT for 6 counties (4

urban, 2 rural)

• Continuation of the hybrid effectiveness-implementation

study

• Focus on implementation strategies to enhance

implementation

Current Status and Next Steps

28

Reduced caseloads

Exclusive MH caseload

Ongoing training

Problem-solving orientation

Interface with external resources

Develop stakeholder interrelationships

Provide interactive assistance

Train and educate stakeholders

Elements of SMHP

Specify Strategies to Facilitate

Implementation of Core SMHP Elements

Questions?

29

Gary S. Cuddeback, PhD, MSW, MPH919-962-4363; gcuddeba@email.unc.edu

Tonya Van Deinse, PhD, MSW919-962-6428; tbv@email.unc.edu

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ssw.unc.edu

Gary Cuddeback, PhD, MSW, MPH919-962-4363; gcuddeba@email.unc.edu

Tonya Van Deinse, PhD, MSW919-962-6428; tbv@email.unc.edu