1. Principles of Mental Health and Drug Abuse Treatment for Criminal Justice Populations Fred C. Osher, MD Director of Health Systems and Services Policy Association of Paroling Authorities International Audio Conference Training March 8, 2007

2. Objectives of Presentation Overview of Issues and Common Definitions Principles of Effective Treatment for Criminal Justice Populations Case Study Challenges and Opportunities Open Discussion

3. Skyrocketing Criminal Justice Populations Bureau of Justice Statistics, 2005

4. What is the Problem ? People with mental illnesses, substance use disorders, and co- occurring disorders are significantly over-represented in the criminal justice system

5. 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

6. 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

7. 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.

8. 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

9. 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)

10. Drugs Related Offenses (Bureau of Justice Statistics, 2005) Drug Related Offenses

13. ■ % With Co-Occurring Substance Use Disorders ■ % Without Co-Occurring Substance Use Disorders Co-Occurring Substance Use Disorders among Jail Detainees with Serious Mental Illnesses (Teplin 1994)

14. 1. Systematic and Comprehensive Screening and Assessment is Essential (NIDA, 2006) Principles of Effective Treatment

15. 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

16. 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

17. 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

18. (NIDA, 2006) Principles of Effective Treatment Screening for Need Objective and Comprehensive Assessment OutpatientIntensive Outpatient Day Treatment ResidentialSecure Residential

19. Efficient Use of Scarce Resources

20. 3. Provide evidence based practices whenever possible, evidence based thinking after that (NIDA, 2006) Principles of Effective Treatment

21. The use of current and best research evidence in making clinical and programmatic decisions about the care of the offender. Evidence Based Practices

22. Pyramid of Research Evidence Evidence Based Practice Pyramid (COCE, 2006)

23. Fidelity to Evidence Based Practices (McHugo et al, 1999)

24. 4. When co-occurring mental and addictive disorders exist, integrated treatment strategies are to be used. (NIDA, 2006) Principles of Effective Treatment

25. 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

26. 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

27. 5. For the offender with behavioral disorders, supervision + treatment is more effective than either one alone. (NIDA, 2006) Principles of Effective Treatment

28. Prison Growth is Major ConcernPrison Growth is Major Concern

29. 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

30. What Specific Intervention Works for Offenders? (Faye Taxman, 2006) Assertive Community Treatment Modified Therapeutic Communities Access to Medications

31. 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)

32. 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

33. Substance Abuse Treatment Need N = 777 (508 SA Only) Mental Health Treatment Need N = 483 (339 MH Only) Co-Occurring 269=High SA / Low MH 144=Low SA / High MH Kansas Probation Revocation Analysis: Substance Abuse High Level of Need N = 467 Moderate Level of Need N = 310 ResidentialOutpatientIntensive Outpatient Residential w/ Integrated MH Intensive Outpatient w/ Integrated MH Outpatient w/ Integrated MH

34. Substance Abuse Treatment Need N = 777 (508 SA Only) Mental Health Treatment Need N = 483 (339 MH Only) Co-Occurring 269=High SA / Low MH 144=Low SA / High MH Kansas Probation Revocation Analysis: Mental Health ResidentialOutpatient Intensive Case Management Residential w/ 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

35. Conducting Accurate Assessments Agreement on Matching Offenders to Appropriate Placement Balancing Treatment in Custody vs. Treatment in Community Accessing Evidence Based Treatment Challenges

36. 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

37. 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

38. THANK YOU ! Contact Information: Fred C. Osher, M.D. fosher@csg.org Council of State Governments Justice Center www.justicecenter.csg.org