Principles of Mental Health and Drug Abuse Treatment for Criminal Justice Populations

Fred C. Osher, MDDirector of Health Systems and Services Policy

Association of Paroling Authorities InternationalAudio Conference Training

March 8, 2007

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 co-

occurring 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)

Drugs Related Offenses

(Bureau of Justice Statistics, 2005)

Drug Related Offenses

19.115.3

29.122.1

43.6

53.3

0

10

20

30

40

50

60

Jail - Males Jail - Females

Substance Use Disorders Among Jail Admissions

Alcohol Abuse/Dependence

Drug Abuse/Dependence

Either Substance Use Disorder

0.10.9 1

1.8 1.42.7

3.9

6.4

1.4 2

10.512.2

02468

101214

GeneralPopulation -

Males

Jail - Males Jail - Females

Serious Mental Disorders Among

General Population & J ail Admissions

Mania Schizophrenia

Major Depression Any Serious Disorder

1. Systematic and Comprehensive Screening and Assessment is Essential

(NIDA, 2006)

Principles of Effective Treatment

• 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.

Screening

• 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.

Assessment

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

(NIDA, 2006)

Principles of Effective Treatment

Screening for Need

Objective and Comprehensive Assessment

OutpatientIntensive Outpatient

Day Treatment

ResidentialSecureResidential

Efficient Use of Scarce Resources

3. Provide evidence based practices whenever possible, evidence based thinking after that

(NIDA, 2006)

Principles of Effective Treatment

The use of current and best research evidence

in making clinical and programmatic

decisions about the care of the offender.

Evidence Based Practices

Pyramid of Research Evidence

8

6

4

2

1

3

5

7

ExpertPanelReview

of ResearchEvidence

Meta-AnalyticStudies

Clinical Trial Replications

With Different Populations

Literature ReviewsAnalyzing Studies

Single Study/Controlled Clinical Trial

Multiple Quasi-Experimental Studies

Large Scale, Multi-Site, Single Group Design

Quasi-Experimental

Single Group Pre/Post

Pilot StudiesCase Studies

Evidence Based Practice Pyramid (COCE, 2006)

Fidelity to Evidence Based Practices

(McHugo et al, 1999)*** If current & subsequent points = 1 then the current score = 1Assessment Points Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.Hi-Fidelity 0 19.67 26.23 29.51 37.7 42.62 55.74Low-Fidelity 0 3.85 3.85 7.69 7.69 15.38 15.38

Figure 1. Percent of Participants in Stable Remission for High-Fidelity ACT Programs (E ; n=61) vs. Low-Fidelity ACT Programs (G; n=26).

0

10

20

30

40

50

60

Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.

4. When co-occurring mental and addictive disorders exist, integrated treatment strategies are to be used.

(NIDA, 2006)

Principles of Effective Treatment

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)

Substance Use Treatment Only

4.2 Million Adults with Co-Occurring SMI and Substance Use Disorder

Treatment for Both Mental Health and Substance Use Problems

No Treatment

39.8%

49.0%

7.5%

3.7%

Treatment Only for Mental Health Problems

5. For the offender with behavioral disorders, supervision + treatment is more effective than either one alone.

(NIDA, 2006)

Principles of Effective Treatment

Prison Growth is Major Concern

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

Principles of Effective Treatment

What Specific Intervention Works for Offenders? (Faye Taxman, 2006)

Assertive Community TreatmentModified Therapeutic CommunitiesAccess 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)

Probation Revocations

N = 2,168

No

42% N = 907

Yes

58% N = 1,261

Substance Abuse or Mental Health Treatment Need?

Kansas Probation Revocation Analysis: Estimated Annual Service Demand

Substance Abuse Treatment NeedN = 777 (508 SA Only)

Mental Health Treatment Need

N = 483 (339 MH Only)

Co-Occurring269=High SA / Low MH144=Low SA / High MH

Kansas Probation Revocation Analysis: Substance Abuse

High Level of Need

N = 467

Moderate Level of Need

N = 310

Residential OutpatientIntensive Outpatient

Residentialw/ Integrated MH

Intensive Outpatientw/ Integrated MH

Outpatient w/ Integrated MH

Substance Abuse Treatment NeedN = 777 (508 SA Only)

Mental Health Treatment Need

N = 483 (339 MH Only)

Co-Occurring269=High SA / Low MH144=Low SA / High MH

Kansas Probation Revocation Analysis: Mental Health

Residential OutpatientIntensive Case Management

Residentialw/ Integrated SA

Intensive Case Management

w/ Integrated SA

Outpatient w/ Integrated SA

High Level of Need

N = 386

Moderate Level of Need

N = 97

* 50% of high need and 25% of moderate need meet state definition for priority population and services will be reimbursed

• 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 Non-CJ Population

• Treatment Completion Rates are Typically Low

• Development of Performance Measures and Evaluating Outcomes

Challenges

• Increased interest in addressing jail and prison over-crowding 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!)

Opportunities

THANK YOU !

Contact Information:

Fred C. Osher, M.D.fosher@csg.org

Council of State Governments Justice Centerwww.justicecenter.csg.org