specialty mental health vs. traditional probation
TRANSCRIPT
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Sarah Manchak, Jennifer Skeem, & Tracy Johnson Seattle, May 2008, MacArthur Research Network on Mandated Treatment
Specialty Mental
Health vs. Traditional Probation
+
Plan Background & Study Overview
Intermediate Outcomes (Services & Perceived Coercion/Adherence)
Clinical Outcomes (Symptoms, Functioning, QOL)
Criminal Justice Outcomes (Violence, Violations, Arrests, Revocation)
Statement of the problem
Persons with mental disorder grossly overrepresented in the criminal justice system
55-75% have co-occurring substance abuse disorder
CJS essential component of de facto mental health system Los Angeles County Jail Riker’s Island Jail 0
2
4
6
8
10
12
14
16
Pre
vale
nce
(%)
General population Incarcerated men Incarcerated women
Source: Teplin, 1990; Teplin, Abram, & McClelland, 1996
+ Corrections population now over 7.2 million
0
1000000
2000000
3000000
4000000
5000000
6000000
7000000
8000000
Source: Bureau of Justice Statistics (2007)
Total
3.2% of all adults in the United
States
+Probation the most common disposition
0
500000
1000000
1500000
2000000
2500000
3000000
3500000
4000000
4500000
Source: Bureau of Justice Statistics (2007)
Probation
Prison
Parole Jail
+Statement of the problem
Probationers with mental illnesses (PMIs) are highly likely to fail on supervision
Source: Dauphinot, 1999; see also Porporino & Motiuk, 1995
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“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)
+Statement of the problem
A staggering number of individuals with serious mental illness are placed on probation each year. Most fail.
Probation represents an unrealized opportunity to: engage and work with high risk individuals who otherwise
might be inaccessible;
facilitate these individuals’ exit from the criminal justice system and re-entry to the community
How do we get there?
+How do we get there?
Prepare conceptually and methodologically via: Focus group study (“best bets”)
National survey and follow-up survey (“lay of the land”)
Dual role relationship quality study (caring & controlling)
Specific aims of outcome study…
To assess the effect of ___________ on probationers’ perceived coercion, treatment adherence and outcomes POs’ strategies for monitoring and enforcing treatment mandates
the relationship between POs and probationers (mediation)
probation systems (specialty v. traditional)
+Method
Prospective design (2+? years) Interviews: Baseline, 6 mo, 12 mo Record follow-up: 18 mo (services) & 24 mo (c.justice)
Matched trial
Specialty & traditional sites Identified through national survey and follow-up visits
to 5 agencies Best match (size, ethnicity, proximity, resources)
Specialty: Dallas, TX Traditional: Los Angeles, CA
+Participants
Eligibility 18-65 years old, English-speaking, pass consent test Mental disorder
Dallas: specialty placement LA: Screened in or officer referral
On active supervision, completed > 1 initial meeting with officer, > 1 year remaining on term
Matching age, gender, ethnicity index offense (person/other) & time on probation (under/over 1
year)
Participants PMIs and their POs (30/Dallas; 120+/LA) Appx. 180 probationers per site (N=360)
+Specialty Recruitment (Dallas)
351 Enter MIMR
251 Eligible (72%)
183 Interviewed
(73%)
36 Refused (14%)
32 Expired (13%)
104 Ineligible
(28%)
Traditional Recruitment (Los Angeles)
861 Screened in or Referred
505 Eligible (59%)
312 Match (62%)
176 Interviewed
(56%)
115 Refused (37%)
21 Expired (7%)
193 Mismatch
(38%)
356 Ineligible
(41%)
Probationer Retention (5/08)
0 20 40 60 80 100 120 140 160 180
Specialty
Traditional
12 mo 6 mo Baseline
86%
90% (ongoing)
86%
90%
+Psychopathology (PAI)
0
10
20
30
40
50
60
70
80
90
100 Specialty Traditional Norm
Match Between Sites
0
10
20
30
40
50
60 Specialty
Traditional
No significant differences in all matching variables, including age
+
+Propensity Scores
Likelihood of traditional supervision, given 40+ criminal, psychiatric, substance use, & personality features
Nagelkerke R2 = .38; Classification accuracy=74%
+Events during follow-up
Still on probation At six months (90%) At twelve months (80%)
Same PO At six months(77%) At twelve months (66%)
Time in jail or prison At six months (25%) At twelve months (29%)
Less than 4% involved in MHC at any point
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Plan Background & Study Overview
Intermediate Outcomes (Perceived Coercion/Adherence & Services)
Clinical Outcomes (Symptoms, Functioning, QOL)
Criminal Justice Outcomes (Violence, Violations, Arrests, Revocation)
+Perceived coercion and adherence
Repeated measures MANCOVA with perceived coercion + procedural justice
Specialty probationers experience significantly*** more procedural justice than traditional probationers; no site x time interaction
Single-item self reports Appointment adherence,
mixed across time (favor specialty, neither, and traditional)
Medication adherence, favor specialty at follow-up (6 & 12)
BMQ medication adherence favors specialty across time Belief scale Regimen scale
Perceived coercion Treatment Adherence, no Site X Time
*** p <.001, controlling for propensity
+Medication adherence (six months, shown)
0 20 40 60 80 100
Specialty
Traditional
Missed 0
Missed 1-2
Missed more
* p <.05, controlling for propensity
+Service similarities, inpatient
0 10 20 30 40
Phys Inpt
Sub Inpt
Ment Inpt
Traditional
Specialty
6 months, shown
+Service similarities, outpatient
0 5 10 15 20 25 30
Phys Outpt
Sub Outpt
Traditional
Specialty
6 month shown
+Service differences
0 20 40 60 80 100
Specialty
Traditional
# Sig Discussions***
0 20 40 60 80 100
Specialty
Traditional
# Outpatient MH Sessions***
*** p <.001, controlling for propensity & jail time; #Sig Discussions 12 mo, p<.05
6 month shown
+Service differences
0
5
10
15
20
25
30
35
40
DualDxSame
Specialty
Traditional
*
* p <.05, controlling for propensity & jail time; Note: ns at individual follow-ups
Full follow-up shown
+
Plan Background & Study Overview
Intermediate Outcomes (Services & Perceived Coercion/Adherence)
Clinical Outcomes (Symptoms, Functioning, QOL)
Criminal Justice Outcomes (Violence, Violations, Arrests, Revocation)
+Change in symptoms (CSI) & functioning
35
40
45
50
55
60
65
CSI: No Site x Time GAF: Site x Time***
35
40
45
50
55
60
65
*** p <.001, controlling for propensity scores, in favor of Traditional
+Change in symptoms – PAI Cluster One***
0
5
10
15
20
25
30
35
40
ARD DEP* SCZ** SOM* BOR
Specialty1
Specialty2
Traditional1
Traditional 2
*** p <.001, multivariate, controlling for propensity scores, in favor of Traditional
+Change in symptoms – PAI Cluster Two*
0
5
10
15
20
25
30
35
40
ANT** AGG** PAR* MAN
Specialty1
Specialty2
Traditional1
Traditional 2
*p <.05, multivariate, controlling for propensity scores, in favor of Traditional
+Change in symptoms – PAI Cluster Three**
0
2
4
6
8
10
12
14
16
18
ALC** DRG*
Specialty1
Specialty2
Traditional1
Traditional 2
**p <.01, multivariate, controlling for propensity scores, in favor of Traditional
+Life satisfaction (“delighted-terrible” scale)
3
3.5
4
4.5
5
5.5
6
Base Six Twelve
Ns Site and Site x Time
+
Plan Background & Study Overview
Intermediate Outcomes (Services & Perceived Coercion/Adherence)
Clinical Outcomes (Symptoms, Functioning, QOL)
Criminal Justice Outcomes (Violence, Violations, Arrests, Revocation)
+Violence at 12 months
0
5
10
15
20
25
30
35
Minor Serious
Both Sites
Ns site differences, controlling for propensity scores and jail/prison days
+Recorded violations at 12 months
***p<.001; **p<.01, controlling for propensity scores
***
0 10 20 30 40 50 60 70 80 90
100
Specialty
Traditional
*** ***
**
+Self reported violations at 12 months
**p<.01; controlling for propensity scores
**
0 10 20 30 40 50 60 70 80 90
100
Traditional
Specialty
**
+Recorded arrests and revocation at 12 months
0
5
10
15
20
25
30
35
40
Arrested Revoked
Specialty
Traditional
***
*
***p<.001, ** p <.05; controlling for propensity scores; no diff in violation type by revocation
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Relative to traditional supervision, specialty supervision predicts Intermediately…
Greater procedural justice
More medication adherence
More mental health sessions & significant discussions with providers
Less improvement in functioning and symptoms over time
More recorded technical violations, but fewer arrests and revocations