treating ex-offenders barriers to treatment.ppt

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 Barriers to
       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
    •       Underfunded Public Mental Health System
•   Collaboration: Integrated Treatment and Community
         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

• 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
• Diversity of Offenders
• General Caseloads = 55-65
• Drug Specialists = 45
• MH Specialists = 35-40
• Sex Offender Specialists = 25
              U.S. Probation
•   Provide objective, verified information and
    recommendations to assist the court in making fair
•   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
• Integrity
• Effective stewards of public resources
• Treat everyone with dignity and respect
• Fairness in process and excellence in
• Work together to foster a collegial
• 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

• 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
• 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

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

• 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
  Co-occurring Disorders at
         the POC

• Estimated at 75-85% at Region III’s

• 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
        Source: Public Safety Performance Project. The Pew Charitable Trusts,

        1980      1985      1990       1995      2000       2005      2010      2011
             Mentally Ill Offenders
                The Numbers

•   “There are three kinds of lies: lies, damned lies, and
    (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
  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
• Substance abuse treatment: 30-70% of
  addicts have a mental disorder
  Co-occurring Disorders
    Forensic Numbers

• Across studies: 56% - 75% (85% for
         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 =
      Our Response:
   Specialized Caseloads

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

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

• From Inmate to Offender to Inmate?
• Numbers are Frightening and
  Depressing: 50-70% Recidivism within
  3 years; 70% in California
• 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

 • Sophistication of other offenders
• 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
• In my experience, due to substance
  abuse and new criminal conduct; not
  due to mental illness or mental health
• 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
       Stages of Change
• Pre-contemplation
• Contemplation
• Determination
• Action
• Maintenance
• Relapse

• A lot of precontemplation going on!

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

• Lack of Integrated Co-Occurring
  Disorders Treatment and Lack of
  Qualified Forensic Mental Health
  Providers: Motivation, Training, and
           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
           History of
  MH Treatment vs. SA Treatment
• MH Diagnosis Primary vs. SA Dx
• MH accepts limited recovery vs. SA:
  recovery and lifetime abstinence always
• 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
• 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 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,
      Treatment of
  Co-occurring Disorders

• Attitudinal Change:
  MH vs. SA providers and vice versa
• On MH side: Starts in the professional
  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
• Basic Competence and Teams
Evidenced-Based Practice

• Best Practices
• What Works
   What Works in Mental
    Health Treatment
• The Relationship
• Cognitive Behavioral
• Medication
• Assertive Community Treatment (ACT)
  What Works in Substance
    Abuse Treatment
• Motivational Interviewing
• Cognitive-behavioral treatment: relapse
• 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

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

• Any other treatment is “correctional
   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) and
  Moral Reconation Therapy (MRT)
•   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

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

• 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
• Non-contracted:
  AB2034 Criteria:
     • Serious Mental Illness
     • Homeless
     • At risk of homelessness or
• 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
        Moving Forward
• If cannot co-locate, then collaborate
• Regional collaborations: mental health,
  substance abuse, and community
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