rnr-based assessment and rehabilitation in corrections: severe mental illness, substance abuse, and...

RNR-Based Assessment and RNR-Based Assessment and Rehabilitation in Corrections: Rehabilitation in Corrections:

Severe Mental Illness, Severe Mental Illness, Substance Abuse, and TraumaSubstance Abuse, and Trauma

Kirk Heilbrun, Ph.D.Kirk Heilbrun, Ph.D.David DeMatteo, JD, PhDDavid DeMatteo, JD, [email protected]@drexel.edu

[email protected]@drexel.edu

Presented for the Pennsylvania Presented for the Pennsylvania DOC and Sponsored by DOC and Sponsored by

Community Education CentersCommunity Education Centers

DOC Training AcademyDOC Training AcademyElizabethtown, PAElizabethtown, PA

April 2011April 2011

AgendaAgenda

• Overview of RNR: Evidence and Implications (Heilbrun)Overview of RNR: Evidence and Implications (Heilbrun)

• RNR-Based Assessment & Treatment of Individuals w/ RNR-Based Assessment & Treatment of Individuals w/ •Substance Abuse (DeMatteo)Substance Abuse (DeMatteo)•Severe Mental Illness (Heilbrun)Severe Mental Illness (Heilbrun)•Trauma Histories (DeMatteo)Trauma Histories (DeMatteo)

•Small group exerciseSmall group exercise

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DetailsDetails

• Electronic version of handout available (RNR_ Electronic version of handout available (RNR_ DOC_CEC_4_28_11)DOC_CEC_4_28_11)

• Electronic version of slides available Electronic version of slides available (RNR_DOC_CEC_slides_4_28_11)(RNR_DOC_CEC_slides_4_28_11)

• See (See (http://www.drexel.edu/psychology/research/research/

labs/heilbrun/publicationslabs/heilbrun/publications/)/)

http://www.drexel.edu/psychology/

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RNR OverviewRNR Overview• What is risk-need-responsivity?What is risk-need-responsivity?– Model of correctional intervention based on the Model of correctional intervention based on the

factors of risk, need, and responsivityfactors of risk, need, and responsivity– Risk factorRisk factor• Risk principleRisk principle

– Need factorNeed factor• Need principleNeed principle

– Responsivity factorResponsivity factor• General and specific responsivityGeneral and specific responsivity

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RNR OverviewRNR Overview• Is there research supporting this model?Is there research supporting this model?– Evidence that adherence to the model results in a Evidence that adherence to the model results in a

35% reduction in recidivism35% reduction in recidivism– Meta-analysesMeta-analyses• RNR for adult, juvenile, violent, female, and sex RNR for adult, juvenile, violent, female, and sex

offendersoffenders

• Risk principleRisk principle

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RNR OverviewRNR Overview• Other research support onOther research support on– RNR for different populations/programsRNR for different populations/programs• Community-based electronic monitoringCommunity-based electronic monitoring

• Substance abusing populationsSubstance abusing populations

• Drug courtDrug court

• Prison-based programsPrison-based programs

– Benefits of targeting high risk offendersBenefits of targeting high risk offenders– Potential iatrogenic effects of interventions for Potential iatrogenic effects of interventions for

low-risk offenderslow-risk offenders

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RNR OverviewRNR Overview• How well are we doing with RNR?How well are we doing with RNR?– Studies of individual program adherence to RNR Studies of individual program adherence to RNR

show limited adherence in applied settingsshow limited adherence in applied settings

• Inconsistencies in the researchInconsistencies in the research– RNR more effective with certain populations (e.g., RNR more effective with certain populations (e.g.,

less supported among violent offenders in meta-less supported among violent offenders in meta-analysis)analysis)

– Some studies have failed to find significant effectsSome studies have failed to find significant effects

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RNR OverviewRNR Overview• Gaps in the researchGaps in the research– Lack of research examining RNR on an individual Lack of research examining RNR on an individual

levellevel– Studies have started to look at the risk principle, Studies have started to look at the risk principle,

and generally find support for matching service and generally find support for matching service intensity to risk levelintensity to risk level

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RNR OverviewRNR Overview• Gaps in the research (cont.)Gaps in the research (cont.)– Little research on “treatment fit,” or matching to Little research on “treatment fit,” or matching to

interventions based on needsinterventions based on needs– Little research on specific responsivityLittle research on specific responsivity• There is value in assessing individual factors that may There is value in assessing individual factors that may

influence how treatment succeeds, such as IQ, mental influence how treatment succeeds, such as IQ, mental illness, culture, motivation, and genderillness, culture, motivation, and gender

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RNR OverviewRNR Overview• Problems in implementing RNRProblems in implementing RNR– Not using up-to-date assessment toolsNot using up-to-date assessment tools– Failure to base interventions on assessment resultsFailure to base interventions on assessment results– Lack of any risk/needs tools in intervention Lack of any risk/needs tools in intervention

processprocess– When risk/need information is available, it is When risk/need information is available, it is

commonly not used effectivelycommonly not used effectively

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RNR OverviewRNR Overview• Guidelines for evidence-based RNRGuidelines for evidence-based RNR– Administer a good risk/needs tool to identify risk Administer a good risk/needs tool to identify risk

level and criminogenic needslevel and criminogenic needs– Match offender into programs based on the Match offender into programs based on the

present needspresent needs– Consider specific responsivity concerns, such as Consider specific responsivity concerns, such as

gender, mental illness, trauma historygender, mental illness, trauma history

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RNR OverviewRNR Overview

• RNR and Serious Mental IllnessRNR and Serious Mental Illness– Offenders with serious mental illness generally Offenders with serious mental illness generally

have the same risk factors as other offendershave the same risk factors as other offenders– Evidence that providing mental health treatment Evidence that providing mental health treatment

does not reduce recidivismdoes not reduce recidivism– Should focus on risk, need, responsivity factorsShould focus on risk, need, responsivity factors

Substance Abuse OverviewSubstance Abuse Overview

Scope of the Problem Scope of the Problem

• High rates of drug-involved criminal offendersHigh rates of drug-involved criminal offenders– Arrestees (Mdn: 67% of males & 68% of females)Arrestees (Mdn: 67% of males & 68% of females)– Inmates (80%) Inmates (80%) – Probationers (67%)Probationers (67%)– Parolees (80%)Parolees (80%)

• Strong relationship between drug use & crimeStrong relationship between drug use & crime

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Scope of the ProblemScope of the Problem

• 80% of offenders report prior drug use80% of offenders report prior drug use

• 50% of state inmates meet criteria for drug 50% of state inmates meet criteria for drug abuse/dependence (Karberg & James, 2005)abuse/dependence (Karberg & James, 2005)

• But only 40% participate in drug treatment But only 40% participate in drug treatment while incarcerated (Mumola & Karberg, 2006)while incarcerated (Mumola & Karberg, 2006)

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Relapse & RecidivismRelapse & Recidivism

• 95% relapse rate within 3 years of release95% relapse rate within 3 years of release

• 50% recidivism rate within 1 year of release 50% recidivism rate within 1 year of release

• Within 3 years of release – Within 3 years of release – – 68% re-arrested68% re-arrested– 47% re-convicted47% re-convicted– 25% re-sentenced for new crime 25% re-sentenced for new crime – 25% return to prison for testing drug-positive25% return to prison for testing drug-positive

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Public Safety vs. Public HealthPublic Safety vs. Public Health• Public SafetyPublic Safety– In-prison treatmentIn-prison treatment– Intermediate sanctionsIntermediate sanctions– Civil commitmentCivil commitment

• Public HealthPublic Health– InitiationInitiation– AttritionAttrition

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Substance Abuse Assessment Substance Abuse Assessment

Assessment ConsiderationsAssessment Considerations

• Brief screen vs. in-depth assessmentBrief screen vs. in-depth assessment

• Psychometrically soundPsychometrically sound

• Assessment of individual risks & needs Assessment of individual risks & needs

• Assessment of multiple domainsAssessment of multiple domains

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Substance Abuse Assessment Substance Abuse Assessment

Assessment ConsiderationsAssessment Considerations

• Ongoing assessmentOngoing assessment

• Administration timeAdministration time

• Interpretation by nonclinical staffInterpretation by nonclinical staff

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Substance Abuse AssessmentSubstance Abuse AssessmentAssessment ToolsAssessment Tools

• TCU Drug Screen TCU Drug Screen

• Level of Service/Case Management InventoryLevel of Service/Case Management Inventory

• Addiction Severity IndexAddiction Severity Index

• Global Assessment of Individual NeedsGlobal Assessment of Individual Needs

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Substance Abuse AssessmentSubstance Abuse AssessmentAssessment ToolsAssessment Tools

• Substance Abuse Screening Instrument Substance Abuse Screening Instrument

• Offender Profile IndexOffender Profile Index

• Substance Abuse Subtle Screening InventorySubstance Abuse Subtle Screening Inventory

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Substance Abuse TreatmentSubstance Abuse Treatment

Intervention ConsiderationsIntervention Considerations

• Client’s recognition of drug problemClient’s recognition of drug problem

• Motivation vs. coercion Motivation vs. coercion

• Matching services to needsMatching services to needs

• High-risk vs. low-riskHigh-risk vs. low-risk

• Recognizing diversityRecognizing diversity

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Substance Abuse Treatment Substance Abuse Treatment

Intervention ConsiderationsIntervention Considerations

• Comprehensive & evidence-based practices Comprehensive & evidence-based practices

• Medical care & medicationMedical care & medication

• Adaptive interventions Adaptive interventions

• Service integration & continuity of care Service integration & continuity of care

• Resources Resources

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Correctional-based InterventionsCorrectional-based Interventions

• Increasing motivation Increasing motivation

• Cognitive-behavioral therapyCognitive-behavioral therapy

• Substitution treatmentSubstitution treatment

• Contingency managementContingency management

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Correctional-based InterventionsCorrectional-based Interventions

• Case managementCase management

• Therapeutic communitiesTherapeutic communities

• Aftercare planning Aftercare planning

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Community-based InterventionsCommunity-based Interventions

• Restrictive Intermediate Punishment (RIP) Restrictive Intermediate Punishment (RIP)

– Outpatient, halfway house, short-term Outpatient, halfway house, short-term residential/detox, & long-term residentialresidential/detox, & long-term residential

– House offenders & monitor program compliance House offenders & monitor program compliance

• Diversion ProgramsDiversion Programs

– Examples: drug courts, mental health courts, veterans Examples: drug courts, mental health courts, veterans courts, re-entry courtscourts, re-entry courts

Gender Differences in Gender Differences in Substance Abuse TreatmentSubstance Abuse Treatment

• Increasing numbers of women are incarceratedIncreasing numbers of women are incarcerated– From 1995-2005, female inmate population From 1995-2005, female inmate population

increased 57%increased 57%– Since 1980, female inmate population has Since 1980, female inmate population has

increased 336% increased 336%

• Most growth in inmate population is due to Most growth in inmate population is due to drug-related offensesdrug-related offenses

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Female vs. Male OffendersFemale vs. Male Offenders

• Higher rates of (hard) drug useHigher rates of (hard) drug use

• More physical health problemsMore physical health problems

• Higher rates of mental health problemsHigher rates of mental health problems

• History of victimization/abuse/traumaHistory of victimization/abuse/trauma

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Female vs. Male OffendersFemale vs. Male Offenders

• Lower rates of employmentLower rates of employment

• Higher rates of financial difficultyHigher rates of financial difficulty

• Unhealthy social relationships Unhealthy social relationships

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Factors Influencing Re-arrest Factors Influencing Re-arrest

• Predictors of re-arrest within 1 yearPredictors of re-arrest within 1 year– Younger age Younger age – Fewer total days in aftercare Fewer total days in aftercare – Longer lifetime incarceration Longer lifetime incarceration – Co-occurring psychiatric disorderCo-occurring psychiatric disorder– Lower levels of education Lower levels of education – Unemployment (males)Unemployment (males)– Parental responsibilities (females)Parental responsibilities (females)

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Severe Mental Illness: Severe Mental Illness: AssessmentAssessment

• Assessment of mental health problemsAssessment of mental health problems

• Assessment of risk of violent and general Assessment of risk of violent and general reoffendingreoffending

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Mental Health AssessmentMental Health Assessment

• Screen for mental health problems generallyScreen for mental health problems generally

• Specifically, screen for psychiatric symptoms, Specifically, screen for psychiatric symptoms, substance abuse, and suicidalitysubstance abuse, and suicidality

• Incorporate information from a combination Incorporate information from a combination of records review, interview, and self-report of records review, interview, and self-report inventoriesinventories

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Risk AssessmentRisk Assessment

• Major predictors of general and violent Major predictors of general and violent recidivism comparable for mentally disordered recidivism comparable for mentally disordered and nondisordered offendersand nondisordered offenders

• Psychopathology important in managing Psychopathology important in managing mentally disordered offenders, butmentally disordered offenders, but

• In terms of risk assessment, these clinical factors In terms of risk assessment, these clinical factors are overshadowed by the more general factors are overshadowed by the more general factors identified in the criminological research (Bonta, identified in the criminological research (Bonta, Law, and Hanson, 1998)Law, and Hanson, 1998)

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• A few specialized risk assessment tools have been A few specialized risk assessment tools have been tested with mentally ill offenders, and perform tested with mentally ill offenders, and perform well enough to be used with this populationwell enough to be used with this population

• Some of the tools are prediction-only tools (Some of the tools are prediction-only tools (do not do not identify targets for intervention); others are risk-identify targets for intervention); others are risk-need tools (need tools (dodo identify intervention targets) identify intervention targets)

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• Psychopathy Checklist (PCL)Psychopathy Checklist (PCL)–measures psychopathy, but performs measures psychopathy, but performs

well in a risk assessment capacity well in a risk assessment capacity (prediction only)(prediction only)

• Violence Risk Appraisal Guide Violence Risk Appraisal Guide (VRAG)(VRAG)– prediction onlyprediction only

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• Level of Service (LS) inventoriesLevel of Service (LS) inventories– Risk-needRisk-need– ActuarialActuarial

• Historical, Clinical, Risk Management Historical, Clinical, Risk Management (HCR-20)(HCR-20)– Risk-needRisk-need– Structured professional judgmentStructured professional judgment

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• PCL, VRAG, and HCR-20 perform PCL, VRAG, and HCR-20 perform comparably with mentally disordered comparably with mentally disordered offenders (prediction)offenders (prediction)

• LS/CMI likely performs well with mentally ill LS/CMI likely performs well with mentally ill offenders (earlier LS tools have been found to offenders (earlier LS tools have been found to do so)do so)

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Severe Mental Illness: TxSevere Mental Illness: Tx

• Evidence-based InterventionsEvidence-based Interventions• Cognitive Behavioral TherapyCognitive Behavioral Therapy

• Dialectical Behavior TherapyDialectical Behavior Therapy

• Schema-focused TherapySchema-focused Therapy

• Group PsychotherapyGroup Psychotherapy

• Suicide Risk FactorsSuicide Risk Factors

• Critical Time InterventionCritical Time Intervention

• Forensic Assertive Community Treatment Forensic Assertive Community Treatment

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Cognitive Behavioral TherapyCognitive Behavioral Therapy• CBT is structured approach focused on CBT is structured approach focused on

symptoms, behavior and criminogenic needssymptoms, behavior and criminogenic needs

• Offenders w/SMI have criminogenic needs Offenders w/SMI have criminogenic needs associated with values, beliefs, thinking styles, associated with values, beliefs, thinking styles, and cognitive emotional statesand cognitive emotional states

• Identifying , disputing automatic thoughts that Identifying , disputing automatic thoughts that generate symptoms (e.g., anxiety, depression) generate symptoms (e.g., anxiety, depression) results in improvementresults in improvement

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CBT ExamplesCBT Examples

– Thinking for a Change Thinking for a Change – problem-solving approach – problem-solving approach using introspection, cognitive restructuring, and using introspection, cognitive restructuring, and social skills trainingsocial skills training

– Lifestyle Change Lifestyle Change – teaches cost-benefit analysis of – teaches cost-benefit analysis of choices and consequences; focuses on thinking choices and consequences; focuses on thinking styles associated with criminal activitystyles associated with criminal activity

– Reasoning & Rehabilitation Reasoning & Rehabilitation – targets cognitive – targets cognitive processing and pro-criminal thinkingprocessing and pro-criminal thinking

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CBTCBT• CBT reduced odds of recidivism by 1.5 in 12 CBT reduced odds of recidivism by 1.5 in 12

months after intervention months after intervention (Landerbergery & Lipsey, 2005)(Landerbergery & Lipsey, 2005)

• Important factors in reducing recidivism:Important factors in reducing recidivism:– Initial risk levelInitial risk level– How well treatment implementedHow well treatment implemented– Inclusion of anger control and interpersonal Inclusion of anger control and interpersonal

problem-solvingproblem-solving

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Dialectical Behavior Therapy Dialectical Behavior Therapy • Effective with behavioral dyscontrol (e.g., self-Effective with behavioral dyscontrol (e.g., self-

harm, violence, poor impulse control)harm, violence, poor impulse control)

• Goals:Goals:– Improve emotional modulationImprove emotional modulation– Increase awareness of consequences to othersIncrease awareness of consequences to others

• Skills training may emphasize emotional Skills training may emphasize emotional regulation and distress toleranceregulation and distress tolerance

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Schema-Focused TherapySchema-Focused Therapy

• SFT focuses on maladaptive schemas (fixed SFT focuses on maladaptive schemas (fixed patterns of thoughts, feelings, and behaviors patterns of thoughts, feelings, and behaviors from negative childhood experiences that from negative childhood experiences that continue into adulthood)continue into adulthood)

• Implemented in forensic settings for those with Implemented in forensic settings for those with severe APD and/or psychopathy severe APD and/or psychopathy (Bernstein, 2007)(Bernstein, 2007)

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Group PsychotherapyGroup Psychotherapy• May result in improvements in institutional May result in improvements in institutional

adjustment, anger, anxiety, depression, adjustment, anger, anxiety, depression, interpersonal relations, and self esteeminterpersonal relations, and self esteem

• Incorporation of cognitive and behavioral Incorporation of cognitive and behavioral approaches enhances resultsapproaches enhances results

• Improvements may not depend on whether Improvements may not depend on whether inmates were mandated or self-referredinmates were mandated or self-referred

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Suicide Risk FactorsSuicide Risk Factors

• Environmental Environmental – Being in isolation or segregation cellsBeing in isolation or segregation cells– Shifts with reduced staffingShifts with reduced staffing

• Distal Distal – Poor social and family supportPoor social and family support– Prior suicidal behavior (esp within last 1-2 years)Prior suicidal behavior (esp within last 1-2 years)– Hx of psychiatric illness, emotional problemsHx of psychiatric illness, emotional problems

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Suicide Risk Factors (cont.)Suicide Risk Factors (cont.)

• ProximalProximal

– HopelessnessHopelessness

– Narrowing of future prospectsNarrowing of future prospects

– Loss of options for copingLoss of options for coping

– Feeling of being bulliedFeeling of being bullied

– Suicidal intent or plansSuicidal intent or plans

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Critical Time InterventionCritical Time Intervention• Two main components:Two main components:– Strengthen long-term ties to community and Strengthen long-term ties to community and

family/friendsfamily/friends

– Provide emotional and practical support Provide emotional and practical support and advocacy during critical time of and advocacy during critical time of transitiontransition

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Critical Time Intervention (cont)Critical Time Intervention (cont)• Core elementsCore elements– small caseloads, individualized case managementsmall caseloads, individualized case management– community outreachcommunity outreach– psychosocial skills building, motivational coachingpsychosocial skills building, motivational coaching

• Context of reentry:Context of reentry:– Social ties (e.g., housing, employment, education)Social ties (e.g., housing, employment, education)– Makes use of existing social connectionsMakes use of existing social connections

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FACTFACT

• FACT (“Forensic ACT Team”) focuses FACT (“Forensic ACT Team”) focuses on keeping those with SMI out of on keeping those with SMI out of jails/prisonsjails/prisons

• Team of professionals provide services Team of professionals provide services based on consumer needsbased on consumer needs

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FACTFACT• ElementsElements– Goal : preventing (re)arrest and (re)incarcerationGoal : preventing (re)arrest and (re)incarceration– Those on team of service-providers may have Those on team of service-providers may have

criminal justice historiescriminal justice histories– Majority of referrals from justice agenciesMajority of referrals from justice agencies– Supervised residential tx component for high-risk Supervised residential tx component for high-risk

consumers, esp those with substance-use disordersconsumers, esp those with substance-use disorders

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Trauma HistoryTrauma History• Definition of TraumaDefinition of Trauma– Direct exposure to extreme stressorDirect exposure to extreme stressor– Actual or threatened death/serious injury/threat of Actual or threatened death/serious injury/threat of

injuryinjury– Witnessing death/injury/threat of injury to othersWitnessing death/injury/threat of injury to others– Learning about unexpected or violent death, Learning about unexpected or violent death,

serious harm or threat of death or injury to family serious harm or threat of death or injury to family member close friendmember close friend

– Marked by intense fear and helplessnessMarked by intense fear and helplessness

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Considering Trauma HistoryConsidering Trauma History

• Adverse Childhood Experiences (ACE) StudyAdverse Childhood Experiences (ACE) Study– Examined relationship between adult health risk Examined relationship between adult health risk

& exposure to childhood emotional/physical/sexual & exposure to childhood emotional/physical/sexual abuse & household dysfunction during childhood abuse & household dysfunction during childhood

– Those with four or more categories of childhood Those with four or more categories of childhood exposure had increased health risksexposure had increased health risks

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Considering Trauma HistoryConsidering Trauma History

• Messina & Grella (2006)Messina & Grella (2006)– Examined 500 women in Female Offender Examined 500 women in Female Offender

Treatment and Employment ProgramTreatment and Employment Program– Found similar results to ACE studyFound similar results to ACE study

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Trauma TriadTrauma Triad

• Re-living, re-experiencing, and intrusive Re-living, re-experiencing, and intrusive memoriesmemories

• Hyper-arousal, hyper-vigilance, intense Hyper-arousal, hyper-vigilance, intense physiological distress and reactivityphysiological distress and reactivity

• Dissociation avoidance and numbingDissociation avoidance and numbing

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Trauma Informed CareTrauma Informed Care

• Incorporates knowledge about trauma in all Incorporates knowledge about trauma in all aspects of serviceaspects of service

• Creates environment that is hospitable, engaging, Creates environment that is hospitable, engaging, & minimizes re-victimization& minimizes re-victimization

• Goals: empowerment and recoveryGoals: empowerment and recovery

• Recognize strengths of survivors & recovery/ Recognize strengths of survivors & recovery/ healing needs of survivorshealing needs of survivors

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Important Principles of Important Principles of Trauma Informed CareTrauma Informed Care

• SafetySafety

• TrustworthinessTrustworthiness

• ChoiceChoice

• CollaborationCollaboration

• EmpowermentEmpowerment

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Examples of Trauma Specific Examples of Trauma Specific Treatment ApproachesTreatment Approaches

• Seeking SafetySeeking Safety

• Trauma Recovery and Empowerment Trauma Recovery and Empowerment (TREM)(TREM)

• AtriumAtrium

• TriadTriad

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Small Group ExerciseSmall Group Exercise

• Considering your present unit(s) and caseload:Considering your present unit(s) and caseload:– How would you change current practice to reflect How would you change current practice to reflect

today’s material?today’s material?– If practice were changed in this way, how well If practice were changed in this way, how well

would it address the mental health needs of those would it address the mental health needs of those on your caseload? on your caseload?

– How well would it address the criminogenic needs?How well would it address the criminogenic needs?

rnr-based assessment and rehabilitation in corrections: severe mental illness, substance abuse, and...

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