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					  Treating
Ex-offenders:
 Barriers to
 Treatment
       Tom Granucci, LCSW
 Supervisory U. S. Probation Officer
    United States District Court
    Central District of California

                 &

         Peter Getoff, LCSW
Supervising Psychiatric Social Worker
      California Department of
   Corrections and Rehabilitation
      Parole Outpatient Clinic
          Today’s Workshop
•   Overview of USPO and CDCR POC
•   Current Data on:
      •   The offender population
      •   Mentally ill offenders
      •   Substance Abuse in the offender population
      •   COD in the offender population
•   Trends in community supervision of offenders
              Today’s Workshop
•   Barriers to Treatment for Offenders:
    •       Offender Characteristics
    •       Lack of Motivated and Qualified Providers
        •     Evidence-based practice in:
                •   Mental Health, Substance Abuse,
                    Co-occurring Disorders, and Correctional
                    Treatment
    •       Underfunded Public Mental Health System
•   Collaboration: Integrated Treatment and Community
    Corrections
         U.S. Probation

• Established by Congress in 1925
• 94 Federal Districts
   • Central District of California
       • 7 Counties: Los Angeles,
         Orange, Riverside,
         San Bernardino, Ventura,
         Santa Barbara, San Luis Obispo
             CD-CA

• 12 Field Offices, 120 Supervision
  Officers, 40 Pre-sentence Officers, 3
  Federal Courthouses
• Crimes: Bank Robbery, Drug
  Trafficking, Credit Card Fraud,White
  Collar Fraud, Cyber Crime, Sex
  Offenses
• Diversity of Offenders
     Caseload/workload
• General Caseloads = 55-65
• Drug Specialists = 45
• MH Specialists = 35-40
• Sex Offender Specialists = 25
              U.S. Probation
                  Goals
•   Provide objective, verified information and
    recommendations to assist the court in making fair
    decisions
•   Ensure offender compliance with court-ordered conditions
    through community-based supervision and partnerships
•   Protect the community through the use of controlling and
    correctional strategies designed to assess and manage risk
•   Facilitate long-term, positive changes in offenders through
    proactive interventions
•   Promote the fair, impartial, and just treatment of offenders
         U.S. Probation
            Values
• Integrity
• Effective stewards of public resources
• Treat everyone with dignity and respect
• Fairness in process and excellence in
  service
• Work together to foster a collegial
  environment
• Responsible and accountable
• Parole abolished November 1, 1987

 • Supervised Release (76%)

 • Probation (22%)

 • Parole (<2%)

 • Military Parole (<1%)

 • Conditional Release (<1%)
• Federal Law Enforcement Officers and
  Officers of the Court
              Reentry

• in 2001, 1,600 state and federal
  prisoners released per day
• Residential Reentry Centers (RRCs)
California Department of Corrections
          and Rehabilitation

• State prison population is 174,000
  felons
• California: one of the highest recidivism
  rates in the country
     • 70% within 3 years
• Average yearly cost: $35,587 per
  inmate; $4,338 per parolee
• 33 state prisons
California Department of Corrections
          and Rehabilitation

• Los Angeles County - 40,000 parolees
   • Largest population of all counties
• 125,000 parolees statewide
   Parole Outpatient Clinic
           POC

• 1954: Established by the California
  Department of Corrections
   • To assist parolees with mental
     health problems
   • To reduce recidivism
               POC

• Caseloads: 80-200
         POC Outcomes
• UCLA Integrated Substance Abuse
  Program contracted by CDCR to
  conduct program evaluation
• The greater # of contacts a parolee has
  with clinic clinicians, the less likely to be
  returned to prison
• 17.4% of parolees with at least 9 POC
  contacts recidivated within 12 months
  vs. 70.6% of parolees w/ no POC
  contact
  Co-occurring Disorders at
         the POC

• Estimated at 75-85% at Region III’s
  POC
               Reentry

• Dr. Joan Petersilia proponent of
  prisoner reentry programs but only
  where practitioners and researchers
  work together to create services, both
  clinically and administratively effective
      The Offender Population
           The Numbers


• At midyear 2006: One in every 133 U.S.
  residents in prison or jail
         National State & Federal Prison
                   Population
        Source: Public Safety Performance Project. The Pew Charitable Trusts,
                                        2007




2,000,000
1,800,000
1,600,000
1,400,000
1,200,000
1,000,000
  800,000
  600,000
  400,000
  200,000
       00
        1980      1985      1990       1995      2000       2005      2010      2011
             Mentally Ill Offenders
                The Numbers



•   “There are three kinds of lies: lies, damned lies, and
    statistics”
    (Benjamin Disraeli)
          The Numbers


• 7% of Federal Inmates
• 16% in state prisons, local jails,
  and on probation
  Department of Justice, Bureau of
  Justice Statistics, 1999
        More Numbers

• DOJ, BJS 2006: 50%
• Change in Methodology
• Our current MH = 17%
    Mental Illness in the
    Forensic Population

• Psychotic Disorders and Major
  Depression 2-4x more common than in
  the general population
Personality Disorders in the
   Forensic Population

• Anti-social personality disorder 10x
  more common than in the general
  population
  Substance Abuse in the
   Forensic Population

• Across studies: 55% - 72%
  Co-occurring Disorders
      The Numbers
• General MH Population: 20-80% of
  severely mentally ill abusing
  substances
• Substance abuse treatment: 30-70% of
  addicts have a mental disorder
  Co-occurring Disorders
    Forensic Numbers

• Across studies: 56% - 75% (85% for
  alcohol)
           Trends
         Our Numbers
• MH doubled from 2000 to 2004
• Drug cases = 57%
• Co-Occurring = > 70%?
          More Trends

• More Sex Offenders: Internet Child
  Pornography and Lurers/Travelers
           More Trends
• More High Risk
• Axis I: Clinical Disorders, especially
  Psychotic Disorders and Mood
  Disorders +
• Axis I: Substance Abuse/Dependence
  +
• Axis II: Personality Disorders, especially
  Borderline, Narcissistic, and Antisocial
    My Forensic Formula

• Axis I + Axis II + Substance Abuse =
  Trouble
      Our Response:
   Specialized Caseloads

• Mental Health and Sex Offenders in
  2000
• Further Specialization of Sex Offenders
  in 2007
   Specialized Caseloads

• Council of State Governments,
  Criminal Justice/Mental Health
  Consensus Project in 2002
  www.consensusproject.org
  Specialty vs. Traditional
         Agencies
• Specialized Caseloads
• Reduced Caseloads
• Sustained Officer Training
• Integration of Internal and External
  Resources
• Problem Solving vs. Traditional
Barriers to Treatment
 The First Problem:
    The Offender
        Recidivism:
    Are they really “ex”?

• From Inmate to Offender to Inmate?
• Numbers are Frightening and
  Depressing: 50-70% Recidivism within
  3 years; 70% in California
                   or
• From Inmate to Offender to
  Ex-Offender: Law-abiding, drug free,
  productive, tax-paying citizen
• Federal Supervision Numbers:
  70% Succeeded, 30% Revoked

• Why? Speculation, no data.

 • Low risk/rehabilitation of some
   offenders

 • Sophistication of other offenders
             Outcomes
• My Snapshot: January 2007 -
  September 2007      n=13
• 31% Successful without violations
• 38% Revoked (1 for technical
  violations; 2 for drug use; 2 for new
  criminal conduct)
• 31% Violations without revocation
• 62% Overall success rate
      Mental Illness and
      Supervision Failure
• Research indicates mentally ill
  offenders are more likely to fail on
  supervision
• In my experience, due to substance
  abuse and new criminal conduct; not
  due to mental illness or mental health
  noncompliance
             Outcomes
• My Officers’ Snapshot:
  October 1, 2007 - January 14, 2008
• n= 33
• 55% Successful without violations
• 27% Revoked (1 for technical
  violations; 3 for drug use; 5 for new
  criminal conduct)
• 18% Violations without revocation
• 73% Overall success rate
   Characteristics of the
  Forensic MH Population
• Mandated/Involuntary = Unmotivated
• Deceptive
• Criminal Lifestyle
• Dangerousness
• Substance Abuse
• Co-occurring Disorders PLUS Antisocial
  Personality Disorder and/or
  Psychopathy
          Motivation:
       Stages of Change
• Pre-contemplation
• Contemplation
• Determination
• Action
• Maintenance
• Relapse
            Motivation

• A lot of precontemplation going on!
            Motivation

• My version of motivational interviewing:
  Prison or residential treatment?
• Move directly from precontemplation to
  action.
• Research: Drug treatment outcomes as
  good for mandated clients as voluntary
  clients
The Second Barrier: The Providers

• Lack of Integrated Co-Occurring
  Disorders Treatment and Lack of
  Qualified Forensic Mental Health
  Providers: Motivation, Training, and
  Experience
           History of
  MH Treatment vs. SA Treatment

• Two separate programs in the public
  health system
• Separate, unequal funding sources
• Treatment by providers with two
  different training backgrounds and
  treatment philosophies
• Treatment provided in two separate
  places
           History of
  MH Treatment vs. SA Treatment
• MH Diagnosis Primary vs. SA Dx
  Primary
• MH accepts limited recovery vs. SA:
  recovery and lifetime abstinence always
  possible
• MH: Medication accepted vs. SA: Clean
  and Sober required.
• MH: Supportive and Non-Directive vs.
  SA: Confrontive
           History of
  MH Treatment vs. SA Treatment

• MH: Professionals only vs. SA:
  Recovering clients and professionals
• MH: Scientific and process oriented vs.
  SA: Spiritual and outcome oriented
• MH: Prevent decompensation vs. SA:
  Hitting bottom OK
  Untreated Co-occurring
        Disorders
• In 2002, 52% of adults with co-
  occurring disorders did not receive
  mental health treatment or substance
  abuse treatment.
• Of the 48% who received treatment:
     • 34% received MH treatment only
     • 2% received SA treatment only
     • 12% received both MH and SA
       treatment
       Treatment of
   Co-occurring Disorders

• “The more things change, the more
  they remain the same” Jean-Baptiste Alphonse Karr, 1849
• "Those who cannot remember the past
  are condemned to repeat it." George Santayana,
   1905
      Treatment of
  Co-occurring Disorders

• Attitudinal Change:
  MH vs. SA providers and vice versa
• On MH side: Starts in the professional
  schools
  Forensic MH: Shortage of
    Motivated Providers
• Professional Prejudice
   • Resistance to change = untreatable
   • “Undignified” target population
• Countertransference
   • Fear
Forensic MH: Shortage of
   Qualified Providers


• Cross Training: MH-SA; SA-MH and
  Forensic
• Basic Competence and Teams
Evidenced-Based Practice

• Best Practices
• What Works
• EBP
   What Works in Mental
    Health Treatment
• The Relationship
• Cognitive Behavioral
• Medication
• Assertive Community Treatment (ACT)
  Models
  What Works in Substance
    Abuse Treatment
• Motivational Interviewing
• Cognitive-behavioral treatment: relapse
  prevention
• Contingency Management
• The Matrix Model
• Medication
• 90 days minimum effective dose
            What Works for
         Co-occurring Disorders
•   Integrated Treatment =
     •   Co-located
     •   Cross trained staff
     •   Adequate staffing: low staff to client ratios for
         intensive case management (ACT model)
     •   Individualized screening
     •   Flexible
     •   Peer support
     •   Comprehensive services: housing,
         employment, HIV/AIDS, Hepatitis
     EBP in Correctional
        Treatment

• Risk Principle
• Needs Principle
• Responsivity Principle
     EBP in Correctional
        Treatment

• Any other treatment is “correctional
  quackery”
   Dynamic Risk Factors
   Criminogenic Needs
• Antisocial Attitudes
• Antisocial Associations
• Antisocial Personality
• Substance Abuse
• Lack of Empathy
• Low Self-Control/Impulsive Behavior
• Dysfunctional Family Ties
• Employment/Education
EBP for Treating Offenders
• Cognitive-Behavioral Curriculum-Based
  Group Therapy
• Examples: Thinking For a Change
  (T4C) www.nicic.org and
  Moral Reconation Therapy (MRT)
  www. moral-reconation-therapy.com
       Evidence-Influenced
            Treatment
•   Address Instant Offense and Criminal History
•   Confront Anti-social Attitudes
•   Eliminate/reduce Anti-social Associations
•   Encourage Pro-social thinking and behavior
•   Abstinence from alcohol and drugs
•   Develop/increase empathy
•   Eliminate/decrease impulsive behavior
•   Develop/improve life skills
  Co-occurring Disorders
  Treatment at the POC
• Reality
• Dynamic
• Cognitive-behavioral
• Medication management
• Interactional
• Integrated team approach
     • Parole and Residential Treatment
 Therapeutic Confrontation
• Effectiveness
• Timing
• Empathy
• Feedback, not judgement
  Common Defense Mechanisms
         of Offenders


• Denial
  Common Defense Mechanisms
         of Offenders


• Rationalization
  Common Defense Mechanisms
         of Offenders


• Minimization
  Common Defense Mechanisms
         of Offenders


• Projection
• Sorry, no cartoon.
  What Does Not Work with
        Offenders

• Non-Directive
• Targeting Self-Esteem
   Sex Offender Specific
        Treatment

• Note: Even fewer qualified specialists
  in sex offender treatment
          The Third Barrier:
Limited Public Mental Health Resources


• State and Federal policy is to use
  community resources
         Collaboration
• Non-contracted:
  AB2034 Criteria:
     • Serious Mental Illness
     • Homeless
     • At risk of homelessness or
       incarceration
           Current
        Collaborations
• Contracted:
  Residential Co-Occurring Disorders
  Treatment: Tarzana Treatment Centers
  and BHS/Pacifica House
• Non-Contracted: DMH
The Case for Collaboration

• Mutual Clients:
   • Offenders are in the community
   • Severely Mentally Ill
   • Have SSI or SSI Eligible = Medi-Cal
The Case for Collaboration

• State and Federal have gaps in
  continuum of care; public mental health
  has a full continuum of care.
• Clients will require mental
  health/substance abuse services
  beyond the period of supervision.
    Future Collaborations

• Full Service Partnerships (FSPs)
 • Criteria:
   • Homeless
   • Criminal Justice contact
   • Frequent utilization
    Future Collaborations
• Staff training in forensic mental health
  needed
        Moving Forward
• If cannot co-locate, then collaborate
• Regional collaborations: mental health,
  substance abuse, and community
  corrections
                            References
•   Berman, G., Bowen, P., and Mansky, A. (2007). Trial and Error: Failure and Innovation in
    Criminal Justice Reform. Executive Exchange, Summer 2007.

•   Best, J.. Damned lies and statistics: untangling numbers from the media, politicians, and
    activists (2001). University of California Press, Berkeley and Los Angeles, California.

•   Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With Co-
    Occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication
    No. (SMA) 05-3992. Rockville, MD: Substance Abuse and Mental Health Services
    Administration, 2005.

•   Cohen, W. and Inaba, D. (1991). The Haight-Ashbury Training Series. Volume IV. Dual
    Diagnosis. The Mentally Ill Drug Abuser. Training Manual. CNS Productions.

•   DeMichelle, M. (2007). Probation and Parole’s Growing Caseloads and Workload Allocation:
    Strategies For Managerial Decision Making. The American Probation and Parole
    Association.

•   Ditton, P. M. (1999). U. S. Department of Justice, Office of Justice Programs. Bureau of
    Justice Statistics Special Report. Mental Health and Treatment of Inmates and Probationers.
                            References
•   Dual Diagnosis: Part I. The Harvard Mental Health Letter, Volume 20, Number 2, August
    2003.

•   Fazel, S. and Danesh, J. (2002). Serious Mental Illness in 23,000 Prisoners: A Systematic
    Review of 62 Surveys. The Lancet; 359(9306):545-550.

•   Flores, A. W., Russell, A. L., Latessa, E. J., and Travis III, L. F. (December 2005). Evidence
    of Professionalism or Quackery: Measuring Practitioner Awareness of Risk/Need Factors and
    Effective Treatment Strategies. Federal Probation.

•   Hills, H. A. (March 2000). Creating Effective Treatment Programs for Persons with Co-
    Occurring Disorders in the Justice System. The National GAINS Center for People with Co-
    Occurring Disorders in the Justice System.

•   Latessa, E. J. and Lowenkamp, C., What are Criminogenic Needs and Why are they
    Important? Community Corrections: Research and Best Practices, Ohio Judicial Conference,
    For the Record, 4th Quarter 2005.

•   James, D. J. and Glaze, L. E. (2006). U. S. Department of Justice, Office of Justice
    Programs. Bureau of Justice Statistics Special Report. Mental Health and Treatment of
    Inmates and Probationers
                            References
•   Latessa, E. J. (1999). What Works in Correctional Treatment, Southern Illinois University Law
    Journal Volume 23.

•   Massaro, J. (2004). Working with People with Mental Illness Involved in the Criminal Justice
    System: What Mental Health Service Providers Need to Know (2nd ed.). Delmar, NY:
    Technical Assistance and Policy Analysis Center for Jail Diversion.

•   Mendel, P. and Fuentes, S. (December 2006). Partnering for Mental Health and Substance
    Needs in Los Angeles: A Community Feedback Report. Summary of the Community
    Feedback Conference for the Health Care for Communities Partnership Initiative, Los
    Angeles, July 7, 2006.

•   National Institute on Drug Abuse. NIDA Notes, Court-Mandated Treatment Works as Well as
    Voluntary, Vol. 20, No 6. (July 2006)

•   National Institute on Drug Abuse. Principles of Drug Abuse Treatment for Criminal Justice
    Populations. A Research-Based Guide. NIH Publication No. 06-5316. July 2006.

•   Peck, J. A. (June 8, 2007). Evidence-Based Interventions for Substance Abuse. Advances in
    Addiction Treatment: Theory, Research, and Practice Conference, Bel Air, CA.
                             References
•   Petersilia, J. (2003). When Prisoners Come Home: Parole and Prisoner Reentry (Studies in
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•   Peters, R. H., Hills, H. A. Intervention Strategies for Offenders with Co-Occurring Disorders:
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    Justice System. December 1997

•   Public Safety Performance Project. A Project of the Pew Charitable Trusts.
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•   Sabol, W. J. and Harrison, P.M. (2007). U. S. Department of Justice, Office of Justice
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•   Skeem, J. L. and Louden, J. E. (March 2006). Toward Evidence-Based Practice for
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•   Skeem, J. L., Monahan, J., and Mulvey, E. P. (December 2002). Psychopathy, Treatment
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                               References
•   Taxman, F., Shephardson, E., & Byrne, J. (2004). Tools of the Trade: A Guide to
    Incorporating Science into Practice. National Institute of Corrections, U. S. Department of
    Justice, Office of Justice Programs.

•   Travis, J., Solomon A. L., and Waul, M. (2001). From Prison to Home - The Dimensions and
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•   U. S. Department of Health and Human Services, Substance Abuse and Mental Health
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•   U. S. Department of Health and Human Services, Office of Applied Studies, Substance Abuse
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•   U. S. Department of Justice, National Institute of Corrections. Crime & Justice Institute (April
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    Effective Intervention.

				
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