1. Evidence-Based Guidelines, Evidence-Based Practices, and Evidence-Based Decision Making The Intersection of Research and CQI in the Quest to Change Offender Behavior Kimberly Sperber, PhD Talbert House

2. Evolution of Evidence-Based Decision Making Medicine –Physician as expert with little reliance on research –1970s document wide variation in physician practices –1980s document that number of physician practices are inappropriate –Increasing reliance on research led to development of evidence-based guidelines –Research starts to inform coverage, payment, performance measures Corrections –Practitioner as expert with little reliance on research –1970s document many programs ineffective and that “nothing works” –1980s find that punishing smarter programs also not effective –Increasing reliance on research led to development of evidence-based guidelines –Research starts to inform contracts, regulatory standards, performance measures

3. Corrections at a Crossroads Evidence-Based Guidelines –RNR Evidence-Based Practices –ORAS, LSI-R –CBT Role-Play –Dosage Evidence-Based Decision Making –Applying available evidence to specific client’s situation to make best possible choice for the client

4. Moving from Evidence-Based Guidelines to Evidence-Based Decision Making Evidence-Based Guidelines –Impact on care is indirect –Impetus for providing certain types of care to certain groups of people –Do not directly determine the care provided to a particular client. Evidence-Based Decision Making –Explicit and intentional use of current best evidence to make decisions about the care of individual clients. –Done by individual staff –Relies on EBG but also accommodates client issues not currently addressed by EBG

5. Example 1: Triaging Dosage by Risk Sperber, Latessa, & Makarios (2013): –100-bed CBCF for adult male felons –Sample size = 689 clients –Clients successfully discharged between 8/30/06 and 8/30/09 –Excluded sex offenders –Dosage defined as number of group hours per client –Recidivism defined as return to prison –All offenders out of program minimum of 12 months

8. Summary of Findings Overall, increased dosage reduces recidivism But not equally for all categories or risk levels Low / Moderate and Moderate Curvilinear relationship –Matters at the low ends of dosage, but effects taper off and eventually reverse as dosage increases High / Moderate Increases in dosage consistently result in decreases in recidivism, but Saturation effect at high dosage levels

9. Current Implications Optimal range for Low/Moderate risk = 100-149 hours Optimal range for Moderate risk = 150-199 hours Optimal range for High/Moderate risk = 250-299 Findings are specific to men

10. Unanswered Questions Laying out a comprehensive dosage research agenda: 1.Defining dosage 2.What counts as dosage? 3.Prioritization of criminogenic needs 4.Counting dosage outside of treatment environments

11. Unanswered Questions 5.Sequence of dosage 6.Cumulative impact of dosage 7.Impact of program setting 8.Low risk but high risk for specific criminogenic need

12. Unanswered Questions 9.Nature of dosage for special populations 10.Impact of skill acquisition 11.Identifying moderators of risk- dosage relationship 12.Conditions under which dosage produces minimal or no impact

13. Practice and Policy Implications Research clearly demonstrates need to vary services by risk Currently have general evidence-based guidelines Should not misinterpret to imply that 200 hours is required to have any impact on high risk offenders Not likely that there is a one-size-fits-all protocol for administering dosage Many questions still remain Need for evidence-based decision making

14. Requirements of Effective Execution Process for assessing risk for all clients Modified policies and curricula that allow for variation in dosage by risk Definitions of what counts as dosage and mechanism to measure and track dosage Formal CQI mechanism to: –monitor whether clients get appropriate dosage by risk –Monitor outcomes of clients receiving dosage outside of EBG

15. Example 2: Women’s Pathways to Serious and Habitual Crime Brennan, Breitenbach, Dieterich, Salisbury, and Van Voorhis (2012) –Quantitative exploration into identifying trajectories of offending for women –Relied on person-centered approach versus variable-centered approach –Found 8 trajectories

16. Female Trajectories “Normal Functioning” but Drug-Abusing Women 2 Paths –More vocational/educational resources, less poverty than other types. –Minimal abuse, few MH problems, minimal homelessness –Both chronic substance abusers with multiple arrests –Path 1 mostly single mothers, above average functioning, younger with more parenting anxiety than Path 2 –Path 2 older, functional in many areas, not currently parenting

17. Female Trajectories Battered Woman 2 Paths –Both with lifelong physical and sexual abuse, social marginalization. –Neither reflected MH problems, psychosis or antisocial personality. –Path 3 stressed single mothers with lifelong abuse, depression, AOD, abusive SO relationships. –Path 4 abused older women, conflicted relationships, chronic AOD, unsafe housing, chaotic lives. Most without children under 18.

18. Female Trajectories Socialized Subcultural with Less Victimization and Few Mental Health Needs 2 Paths Serious social marginalization, education/vocation deficits, high crime residences, stronger antisocial significant other influences. Little evidence of sexual/physical abuse. Path 5 younger, poor, stressed single mothers with low self- efficacy in conflicted but not violent relationships. All with children under 18. Path 6 addicted, older, isolated women with extreme marginalization, poverty, low self-efficacy, most without children under 18.

19. Female Trajectories Aggressive Antisocial Women 2 Paths Characterized by most extreme risk and need profiles. Lifelong sexual and physical abuse, antisocial families, hostile antisocial personality, MH, homelessness, antisocial significant others. Path 7 abused and aggressive, antisocial with hostility, MH/depression, homelessness, mostly single, most with children. Path 8 abused and addicted single mothers with serious MH, psychosis, suicide risk, aggressive, violent, and noncompliant.

20. Variable-Centered Findings on Women Offenders Evidence-Based Guidelines and Practices reflect generalized understanding of relationships among variables Therefore, women as a group are described as: –High in abuse and trauma –High in mental illness –High in parenting stress –High in economic marginalization –Low in self-efficacy Suggests similar approaches for women as a group

21. Heterogeneity Among Women 4 subgroups experienced repeated sexual and physical abuse (Pathways 3, 4, 7, 8) –Link between childhood abuse and adult criminal behavior not generalized 3 subgroups scored high on mental illness (Pathways 3, 7, 8) 5 subgroups characterized by parental stress (Pathways 1, 3, 5, 7, 8) 2 subgroups scored low on economic marginalization (Pathways 1 and 2) One group largely characterized by gender-neutral risk factors rather than gender-responsive risk factors (Pathway 2)

22. Policy and Practice Implications Need more than one “gender-responsive” approach to female offenders Need effective risk assessment and analysis systems to efficiently identify different subgroups Modified policies and curricula to address the different needs of the various groups CQI system to track that appropriate services were matched to each subgroup

23. Moving Forward to Achieve Effective and Efficient EBDM The Next Evolution of CQI –Data tied to individual clients –Ability to trend in the aggregate as well as at the individual client level –Data mining and data surveillance capabilities –Development of contextualized feedback systems

24. Contextualized Feedback Systems Characteristics: –Provides staff with real-time, pertinent, client-specific information –Information has been intelligently filtered –Delivered at the point of care –Offers actionable recommendation Evidence: –Systems have been shown to change staff behavior (i.e., better adherence to EBP) –One study showed that staff who viewed the information more frequently had clients who demonstrated greater improvements AND clients who demonstrated improvements more quickly

25. Conclusions Corrections has benefitted from a number of well-established Evidence-Based Guidelines and Evidence-Based Practices Next evolution will focus on bringing a more nuanced understanding and application of these EBG’s and EBP’s to the individual client level Practitioner-driven CQI needs to intersect with research to drive this process so that we continually move the field forward to maximize public safety outcomes