START NOW: Implementing and
Evaluating a Cognitive Behavioral
Intervention for Offenders
Susan Sampl, PhD
Robert L. Trestman, PhD, MD
Kirsten Shea, MBA
Malini Varma, MA
Walter Krauss, PsyD
Amy Houde, MSW, LCSW
Correctional Managed Health Care
University of Connecticut Health Center
Farmington CT USA
OBJECTIVES
1.Understand the theoretical and research background
of START NOW
2. Articulate recommendations for successfully
implementing a structured cognitive behavioral
intervention within corrections.
3. Identify methods and results of evaluating START
NOW in correctional settings.
DISCLOSURE
• No financial Conflicts of Interest
Using SCID II with 508 inmates in Connecticut jails in an IRB
approved National Institute of Justice Study:
(Trestman et al, 2007)
Personality Disorder
Male
(N=307)
Female
(N=201)
Total
(N=508)
Freq
%
Freq
%
Freq
%
Paranoid
29
9.6
20
10.1
49
9.8
Borderline
39
12.9
45
23.2
84
16.9
Antisocial
120
39.5
53
27.0
173
34.6
• Participants: English-speaking women (n=18)
and men (n=45)
• Results: Significant reduction in targeted
behavior was found from baseline to following
the16 week DBT-CM skills treatment groups.
Both case management and DBT coaching were
significant at 12month follow-up.
• Conclusions: The study supports the value of
DBT-CM for management of aggressive
behaviors in prison settings.
• PARTICIPANTS: 38 male adolescents
• RESULTS: Significant changes were
found in physical aggression, distancing
coping methods, and number of
disciplinary tickets for behavior.
• CONCLUSION: The study supports the
value of DBT-CM for the management of
incarcerated male adolescents with
difficult-to-manage aggressive behaviors.
CHALLENGES: TRANSITION FROM
RESEARCH TO PRACTICE
•
•
•
•
Costs of training
Staff turnover
Optimum language level
Costs and copyright issues
Background of START NOW:
Research
• START NOW is an evidence-informed coping
skills therapy designed to treat offenders with
behavioral disorders and associated behavioral
problems.
• START NOW grew out of National Institute of
Justice funded research at the University of CT
Health Center and the Connecticut DOC.
http://cmhc.uchc.edu/programs_services/startnow.aspx
Structure & Design of START NOW
• 32 CBT/Coping Skills group sessions
• Clinical Tools
– Participant workbooks
• 5th grade reading level
• Gender specific
• Spanish version available
– Facilitator manual
• Highly structured, detailed
• Basic scripts and examples provided
– Standardized protocol and tools for training and
fidelity monitoring
Background of START NOW: Theory
• An integrative skills training model informed by a
number of theoretical approaches & models– Primarily a cognitive behavior therapy (CBT) model
– Includes motivational interviewing principles &
practices to enhance motivation for change
– Infused with elements of cognitive neuro-rehabilitation,
in consultation with correctional neuro-cognitive
researcher, D. Fishbein (Fishbein et al., 2009).
– Theories of criminal behavior, including relevant
examples in participant workbooks.
CBT for a Correctional Population
• There is much support in the literature for the
use of CBT in the treatment of criminal conduct
(Thigpen, 2007; Wilson, Bouffard, & Mackenzie, 2005).
• Several meta analyses support the use of CBT to
reduce criminal recidivism (Pearson, Lipton, Cleland,
& Yee, 2002).
• Group oriented CBT was found to reduce
criminal behavior 20-30% compared to control
(Wilson, Bouffard, & Mackenzie, 2005).
CBT within START NOW
• CBT procedures during group:
–
–
–
–
Brainstorming
Role play
problem-solving
shaping of desired behaviors
• “Real life practice exercises” between group
sessions
• “ABC System” for functional analysis of behavior
Incorporating Motivational Interviewing
• Focuses on developing motivation for change (Miller
& Rollnick, 2002), including changing criminal behavior
(Chambers et al., 2008; Howells & Day, 2006).
• MI & CBT have been combined in other effective
interventions (Dennis et al., 2004; Diamond et al., 2002;
Steinberg et al., 2005).
• Research supports use of MI with offenders,
resulting in improved addictions treatment
compliance (Davis et al., 2003), reduced criminal
attitude and substance related problems (Harper &
Hardy, 2000), reduced reconviction rates (Antiss,
Polascek & Wilson, 2011), and reduced DUI behaviors
in adolescents (Stein et al., 2006).
Motivational Interviewing
Influence on START NOW strategies:
• Emphasis on accepting ambivalence about
change and “rolling with resistance”
• “Supporting self-efficacy” through focusing
on strengths
• Many opportunities to elicit change talk &
work through ambivalence are built into the
START NOW clinical materials
Offender Focused Interventions
Influence on START NOW strategies:
• Illustrative examples & coping behaviors are relevant to
forensic situations
• Concepts & language are simplified given cognitive
limitations of many offenders
• Numerous icons included in the participant workbookespecially useful with TBI or verbally limited participants
• Facilitator manual includes numerous tips for engaging
difficult-to-engage participants: eg, shaping by
reinforcing any movement toward the desired behavioral
change.
Standard CBT Session Structure
• Introduce any new members & review group rules
(5 min.)
• Review of real life practice exercise from previous
session (10 – 15 min.)
• Practice Focusing or ABC Skills (10 – 15 min.)
• Rationale & overview of new coping skill (10 min.)
• In-session practice exercise (15 min.)
• Assign new real life practice exercise (5 min.)
Unit 1- My Foundation:
Starting with Me
• Focuses on developing
increased self-control &
ability to cope with stressors
• Includes setting a treatment
goal, increasing wellness
skills, accepting yourself &
your situation, & enhancing
your spirituality, values &
personal boundaries.
Unit 2- My Emotions:
Dealing with Upset Feelings
Includes:
• Recognizing &
understanding emotions.
• Coping with emotions
through actions, or
through thoughts &
imagery.
• Coping with depression,
anger, anxiety & grief.
Unit 3- My Relationships:
Connecting with Others
• Focuses on developing
positive relationship skills
including:
–
–
–
–
–
Listening skills
Assertiveness
Setting boundaries
Asking for support
Avoiding destructive
relationships
– Responding to feedback
– Coping with rejection
Unit 4- My Future:
Setting & Meeting my Goals
• Focuses on preparing for a
positive future by:
– Developing hope
– Setting realistic goals &
breaking them down into
steps
– Learning problem solving
skills
– Learning to set & meet
educational & vocational
goals
Developing & Maintaining Fidelity
of Implementation
• Training, in absence of coaching, is insufficient.
(National Implementation Research Network- Fixsen et al., 2005)
• Network of START NOW Trainers developed
covering the entire CT DOC system
• START NOW Trainer Role:
– Serve as local expert & point of communication
– Provide centralized and local training
– Observe groups for fidelity monitoring & coaching
Supporting the Sustainability of
START NOW
• Enhanced by a standardized manual-guided
intervention
• Results in reasonable cost of training to allow for
staff turnover within corrections
• Requires a committed coordinating team, as well
as an organized system to track provision of
care
Creating an Information System
DATA!
• Repository for resources
• Internal
• External
• Program generated data
• Outcome Measures
• Methods to retrieve data/Reporting tools
http://cmhc.uchc.edu/programs_services/startnow.aspx
Program Generated Data
•
•
•
•
Group Data
Attendance Data
Program Outcomes
Satisfaction Questionnaires
Building a data set
• Identifying information
– Inmate name
– Inmate number
• Start date of group
• End date of group
• Number of sessions completed
Outcome Measures
• Identify available data
Outcome Measures
• Identify available and relevant data pieces
• Disciplinary Tickets
• Days spent as MH inpatient
• Psychological measure assessment (computerized)
• Buss-Perry Aggression Questionnaire
• Inventory of Interpersonal Problems
• Barrett Impulsiveness Scale
Outcome Measures
• Target new measures
•
•
•
•
Self-injurious behaviors
Medication adherence
Crisis encounters per month
Recidivism
Method to Retrieve Data / Reporting
• Canned reports through MS Access application
• Custom reports requested through IT
• Data Dashboards (coming soon)
START NOW Program
• 13 CDOC facilities have active START
NOW programs
• 57 clinicians are currently trained
• 215 individuals are in active treatment
Data as of February 28, 2013
START NOW
Participant Satisfaction Data
Through December 2012
Satisfaction Survey Procedures
•
•
•
•
N=619
10 questions; 8 Likert Scale, 2 open-ended
Completed at the end of every unit
Anonymous
START NOW Participant Satisfaction Data
Q1: How would you rate the quality of the START NOW unit
you just completed?
1=Poor, 2=Fair, 3=Good, 4=Excellent
Overall N: 619
U1 N: 210
U2 N: 158
U3 N: 127
U4 N: 124
START NOW Participant Satisfaction Data
Q5: How satisfied are you with the amount of help you have
received?
1=Quite Dissatisfied, 2=Indifferent or mildly dissatisfied,
3=Mostly satisfied, 4=Very satisfied
Overall N: 619
U1 N: 210
U2 N: 158
U3 N: 127
U4 N: 124
START NOW Participant Satisfaction Data
Q6: Has this START NOW unit helped you to deal more
effectively with your problems?
1=No, it seemed to make things worse, 2=No, it really didn’t help, 3=Yes, it helped, 4=Yes, it helped
a great deal
Overall N: 619
U1 N: 210
U2 N: 158
U3 N: 127
U4 N: 124
START NOW Participant Satisfaction Data
Q7: Has participation in this START NOW unit helped you
cope with daily life in prison/jail?
1=No, it seemed to make things worse, 2=No, it really didn’t help, 3=Yes, it helped, 4=Yes, it helped
a great deal
Overall N: 619
U1 N: 210
U2 N: 158
U3 N: 127
U4 N: 124
START NOW Participant Satisfaction Data
Q8: If you were to seek help again would you participate in
this START NOW unit?
1=No, definitely not, 2=No, I don’t think so, 3=Yes, I think so, 4=Yes, definitely
Overall N: 619
U1 N: 210
U2 N: 158
U3 N: 127
U4 N: 124
START NOW Participant Satisfaction Data
Q9: What were the activities or topics you liked the most about
this unit?
An open-ended question for which responses were categorized through qualitative analysis.
Frequencies of the top 6 responses are shown below:
Overall N: 615
START NOW Participant Satisfaction Data
Q10: What would you change about this unit to make it better?
An open-ended question for which responses were categorized through qualitative analysis.
Frequencies of the top 6 responses are shown below:
250
200
150
100
50
0
Overall N: 506
ADAPTATION of START NOW
Alternative to Incarceration (AIC)
Program
• DMHAS AIC program for Dually- Diagnosed SMI
clients (ASIST)
• Significant effect for START NOW on reduced
re-incarceration (b=-.024, S.E.=0.008, p=0.003,
OR=0.98); Cox regression, adjusted for illness severity
• Dose Response: Each START NOW session
yields a 2.0% reduction in the odds of reincarceration
•
Frisman LK, Lin H, Rodis E, & Grzelak J. Final Report: Evaluation of the ASIST Program. CT
Department of Mental Health & Addiction Services, internal document, 9/12/11
SUMMARY
• These interventions have a role to play in
empowering individuals to gain greater control
over their lives as they work toward recovery
and effective integration into the community
• Implementation of evidence-based or evidenceinformed treatment has many real world
challenges that can be met both in institutional
correctional and forensic settings