An Overview of the Continuum of Care
and Integrated Treatment Model
Presented by Kelly Dahl
North Sound Systems of Care Training Institute
Western Washington University
August 25, 2010
Presentation Overview
 Juvenile
 An
Justice in Washington State
Overview of JRA
Organizational Structure
Facts and Figures
 JRA’s
Integrated Treatment Model
Residential and Community Applications
CBT/FFP Basic Principles
2
Juvenile Justice in Washington State
 Juvenile Justice in Washington State is governed by Title 13 of the
Revised Code of Washington (RCW)
 The Juvenile Justice Act of 1977 (RCW 13.40) – Intent and Purpose
•Make the juvenile offender accountable for his or her criminal behavior
•Provide due process for juveniles alleged to have committed an offense
•Provide necessary treatment, supervision, and custody for juvenile offenders
•Provide for the handling of juvenile offenders by communities whenever
consistent with public safety
•Develop effective standards and goals for the operation, funding, and
evaluation of all components of the juvenile justice system and related services
at the state and local levels
•Encourage the parents, guardian, or custodian of the juvenile to actively
participate in the juvenile justice process
3
Continued: Juvenile Justice in Washington State
 Determinate Sentencing and Sentencing Guidelines - court sets
minimum and maximum sentence determined by offense
seriousness and criminal history
“The goal of a determinate sentencing system is to ensure that offenders
whose offenses and criminal histories are similar receive substantially
similar sentences.” (Juvenile Disposition Manual 2006)
 Manifest Injustice sentences – mitigating and aggravating factors
may result in sentencing outside of a standard range
“When a court finds that a presumptive sanction would amount to an
excessive penalty or would impose a serious and clear danger to society, it
may impose a disposition that departs from the standard range.”
(Juvenile Disposition Manual 2006)
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WASHINGTON STATE JUVENILE OFFENDER SENTENCING GRID - STANDARD RANGE
A+
CURRENT OFFENSE CATEGORY
A
AB+
B
180 weeks to age 21 for all category A+ offenses
103 - 129 weeks for all category A offenses
15-36
52-65
80-100
103-129
103-129
weeks
15-36
weeks
15-36
weeks
52-65
weeks
80-100
weeks
103-129
weeks
Local
weeks
weeks
15-36
weeks
15-36
weeks
52-65
weeks
weeks
15-36
weeks
15-36
weeks
weeks
15-36
Sanctions
LS
C+
LS
LS
LS
C
LS
LS
LS
LS
D+
LS
LS
LS
LS
LS
D
LS
LS
LS
LS
LS
E
LS
LS
LS
LS
LS
0
1
2
3
4 or more
PRIOR ADJUDICATIONS
weeks
5
Continued: Juvenile Justice in Washington State
 The Community Juvenile Accountability Act of 1997
CJAA is enacted into law “to provide a continuum of communitybased programs that emphasize the juvenile offender's
accountability for his or her actions while assisting him or her in the
development of skills necessary to function effectively and
positively in the community in a manner consistent with public
safety.” (RCW 13.40.500)
This established Evidence Based Practices funding for:
• Functional Family Therapy (FFT)
• Aggression Replacement Training (ART)
• Multi Systemic Therapy (MST)
• Coordination of Services (COS)
6
Evidence Based Practices Outcome Evaluations

Legislatively required evaluation was conducted to see if their
investment in Evidence Based Practices was effective.

Washington State Institute for Public Policy (WSIPP) conducted the
study

August 2002 interim outcome evaluation completed
• Competence in and adherence to an Evidence Based Practice is
critical to the effectiveness of the intervention
• $7.50 of cost benefit*
• 30% recidivism reduction
*Cost
Benefit = the savings from avoided crime costs for each tax dollar spent on the program.
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DSHS Mission
Improve the safety and health of
individuals, families and
communities by providing
leadership and establishing and
participating in partnerships.
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JRA Mission

Protect the public, hold juvenile
offenders accountable, and reduce
criminal behavior through a
continuum of preventative,
rehabilitative, and transition
programs in residential and
community settings

JRA’s overall goal is to enhance
public safety by preparing
delinquent youth to become
confident, competent, responsible
adults
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JRA Organizational Structure
Institution Programs
Oversees 4 institutions and 1 basic training camp.
Community Programs
Manages parole services, six community residential facilities
(group homes), and two contracted community programs .
Operations Support Services
Provides fiscal oversight and operational support to the JRA
divisions of Community Programs, Institution Services, and
Treatment and Intergovernmental Programs.
Treatment and Intergovernmental Programs
Responsible for developing treatment program policies and
standards. Oversees the Interstate Compact Program.
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JRA Youth Profile
Youth committed to JRA custody by local juvenile
courts have typically:

Committed a serious violent offense, or

Committed a series of minor offenses over time and
exhausted local sanctions and interventions, and

Have an average sentence of 40 weeks
JRA Youth Profile
(7/8/10)

3% of youth arrested in WA end up in JRA

Male:Female
11:1
(2004)

Ethnic Breakdown:
•
•
•
•
•

White/Non-Hispanic:
African American:
Hispanic:
Native American:
Asian:
Age range of incarcerated:
JRA
State (0-17)
45%
19%
20%
3%
4%
73%
5%
13%
2%
7%
8-20
• 40% (261) are 16 or younger
• 52% (343) are 17 and 18 years old
Residential Population Characteristics*








Mental Health:
Chemical Dependency:
Cognitive Impairment:
Sex Offender/Misconduct:
Medically Fragile:
62%
55%
43%
27%
3%
Two Issues:
Tri-Issue:
Quad-Issue:
46%
38%
5%
*January 26, 2010 Snapshot Data
Residential Offense Profile
Types of Current Offenses:
#
Robbery
154
Assault
142
Burglary
113
Other Sex Offense
60
Rape/Rape of a Child 46
Other Offense
26
Murder/Manslaughter 20
Theft
20
Motor Vehicle Theft
20
Weapon Offense
19
Drug Offense
19
Arson
9
Parole Revocation
6
Malicious Mischief
5
Poss. Stolen Prop.
3
Kidnapping
2
Escape
1
Forgery
1
Criminal Trespass
0
n=660
July 8, 2010
%
23.3
21.5
17.1
9.1
7.0
3.9
3.0
3.0
3.0
2.9
2.9
1.4
0.9
0.8
0.5
0.3
0.2
0.2
0.0
Youth in JRA care are at the very
deep end of the juvenile justice
system.
Their service and intervention needs
are both acute and complex.
61% are Violent Offenders
18% have 8 or more prior offenses
JRA Facilities and Programs
Institutions (598 Beds – actual pop. = 570, 7/8/10)
Green Hill School, Chehalis
Naselle Youth Camp, Naselle
Maple Lane School, Centralia
Camp Outlook, Connell
Echo Glen Children’s Center, Snoqualmie
State Community Facilities (92 Beds – actual pop. = 83, 7/8/10)
Canyon View, Wenatchee
Oakridge, Tacoma
Parke Creek, Ellensburg
Ridgeview, Yakima (female)
Twin Rivers, Richland
Woodinville, Woodinville
Contracted Programs (9 Beds – actual pop. = 7, 7/8/10)
Residential Treatment & Care, Spokane (6)
Benton/Franklin STTP (Short Term Transition Program) (3)
Functional Family Parole Services (433 Youth, 7/8/10)
Region 1, Spokane
Region 4, Seattle
Region 2, Yakima
Region 5, Tacoma, Bremerton
Region 3, Everett, Mount Vernon
Region 6, Olympia, Vancouver
JRA Continuum of Care
Residential Care:
669 youth (7/8/10)
Average Length of Stay:
44 Weeks (2010)
Institutions and Basic Training Camp
Community Facilities
Parole: 433 Youth (7/8/10)
Range = 4 to 6 months
Sex Offense = 24-36 months
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JRA Placement and Treatment Continuum
County
Juvenile Courts:
Youth w/ Criminal
offenses committed to
JRA
Residential
Placement in
JRA
JRA
Parole
No Longer
Under JRA
Jurisdiction
Screening, assessment, & testing for placement, treatment planning &
service delivery
(Diagnostic, Chemical Dependency/Abuse, Client History, GAIN-SS, Suicide & Self-Harm Screen,
Aggression/Vulnerability)
Residential Services
Parole Services
Integrated Treatment Model:
Dialectical Behavior Therapy (DBT/CBT)
Aggression Replacement Training ( ART)
Moral Reconation Therapy (MRT)
Residential Treatment and Care Program
(RTCP); aka Multidimensional Treatment
Foster Care (MTFC)
Family Integrated Transitions (FIT)
Individual and Group Therapy
Psychiatric & Psychological Services
Medication & Med. Management
Education/Vocational Training
Chemical Dependency/Abuse Treatment
Sex Offender Treatment
Recreation
Cultural Programs
Integrated Treatment Model
Functional Family Parole
Functional Family Therapy
Family Integrated Transitions
Connected to MH services
Medicaid Eligibility
Limited contracted MH
Transitional Services
Sex Offender Treatment
DASA CD Services
DDD Coordination
Aggression Replacement
Training (ART)
Mentoring
Community Connections
Community
Connections /
Resources
MHTP:
RSN's: Medicaid
Eligible
Private Insurance
No Insurance—
Private pay or are
unserved
Framework for working with youth and their family
Committed to
JRA/Placement
Determined
Youth
Discharged
from JRA
• Diagnostic Process
• Institution
• Youth Camp
• Basic Training Camp
• Community Facility
JRA Residential
Services
• Screening / Assessment
• School / Vocational
• CBT/DBT skills training and
coaching
• Medical services
• Specialized treatment
45 Days before
release—Transition
meeting w/Family:
• Parole or No Parole
• Living arrangements
• Service Connections
Functional
Family Parole
Engage & Motivate
Support and Monitor
Services
Generalize Skills
• Whole Family
Involved
OUTCOMES
JRA Integrated Treatment Model (ITM)
JRA implemented the Integrated Treatment Model (ITM) in 2003 to
address the acute and complex treatment needs of youth committed to
JRA care. The ITM incorporates best-practice and evidence-based
interventions to address the needs of youth and their families from the
point of admission through completion of parole aftercare.
Lessons Learned



Failure to adhere to and competently deliver evidence-based
intervention models can, in fact, be counter productive
Success requires strict model adherence with supporting quality
assurance and consultation
Environment is critically important to achieving positive outcomes.
JRA is working hard to establish residential environments that make
possible and support therapeutic intervention
JRA INTEGRATED TREATMENT MODEL
The 5 Critical Functions of Treatment
JRA Treatment Services

EVIDENCE BASED SERVICES:
Dialectical Behavioral Therapy
Cognitive Behavioral Therapy
Aggression Replacement Training
Family Integrative Transitions (FIT)

Functional Family Parole
Functional Family Therapy
Mentoring
MODES OF TREATMENT
Individual Counseling
Group Skills Training
Milieu Treatment

SPECIALIZED TREATMENT
OTHER SERVICES
Mental Health
Substance Abuse
Sex Offender
Vocational Training
Psychiatric
Medical/Dental
Education
Recreation
What the ITM Creates

A uniform set of skills

Behavioral targets that are clearly identified and
addressed in a systematic fashion

Addresses youth and family issues in the context in
which they occur

Identifies the role of staff across the continuum-of-care

Treatment approaches that vary based on the youth and
family needs

Treatment plans are individualized
Multidisciplinary Team approach across continuum

JRA Integrated Treatment Model

Principles – teaching, shaping, coaching, and reinforcing positive
behavior

Developing skills for socially responsible living
 Institutions:
Assess treatment needs
Begin process of adaptive skill development
 Community Residential Facilities:
Transition youth and practice skills in a community setting
 Parole Aftercare:
Support for generalization and maintenance of skills
Engagement of families in youth rehabilitation
Finding Treatment Priorities
Mental Health
Substance Abuse
Offense (Robbery)
Family Issues
T
R
E
A
T
M
E
N
T
H
I
E
R
A
R
C
H
Y
A. Recent (or Historic)
Parasuicidal Ideation,
Threats, or Behavior.
B. Recent (or Historic)
Aggressive Ideation,
Threats, or Behavior.
C. Recent (or Historic)
Escape Ideation,
Threats, or Behavior.
D. Recent or Current
Treatment-Interfering
Behaviors.
E. Significant Quality of
Life issues.
Analyze the chain of events
moment-to-moment over time
(Behavior Chain Analysis)
VULNERABILITIES
TARGET
BEHAVIOR
INITIAL CUE
LINKS
CONSEQUENCES
Understanding the Problem
Vulnerabilities
Substance
Abuse
B
C
A
Cue
Links
Target Behavior
Outcomes
Function and
Other Drivers
CBT/DBT Skill Modules

Mindfulness or Observing
Youth who are impulsive, Excessively judgmental, Easily distracted,
Rigid thinkers, Youth who have difficulty solving problems

Interpersonal Effectiveness
Unstable relationships, History of loss and grief issues, Poor peer
selection, Lack of respect, and Lack of social skills

Emotion Regulation
Intense anger, Intense shame, Emotional instability, and Low
tolerance to frustration

Distress Tolerance
Egregious suicide behavior, Acts of aggression, Impulsive self
destructive behavior, Substance abuse or addiction, and Compulsive
criminal behavior

Problem Solving
Anger, Aggression, and Social skills
Treatment Planning Summary
Mental Health
Substance Abuse
Robbery
Family Issues
T
R
E
A
T
M
E
N
T
Vulnerabilities
Substance Abuse
B
C
A
H
I
E
R
A
R
C
H
Y
Cue
Links
Function and
Other Drivers
Target Behavior
Outcomes
ITP
State the Target
Describe the Function
Pick Skills with Similar
Function
Identify Steps to Block
Outcomes
Identify Steps to Increase
Skillful Behavior
Identify Cue Management
Plan
Linked Processes
Determine Content for
Treatment Focus
Skill Selection Intervention Plan
Integrated Treatment Plan
Drives Content & Structure
of
Our Daily Interactions with our
Clients
Flow should be visible
Client History Review &
Behavior Chain Analysis
Functional Family Parole
CORE PRINCIPLES
 Working Alliance
 Relational (Family) Focus
 Strength Based
 Respect
 Matching
Advantages of Family Focus

Issues arise through family and can begin to be solved
there

With the family involved, changes can happen quicker...
IF we can engage and motivate them

Family can support youth more effectively than youth on
his/her own

Involvement is the first step toward persuasion…
MATCHING is a fundamental requisite for
effectively engaging and changing families

Match to the phase of your responsibility - Do the
right thing at the right time.

Match outcome goals to the family – Identify and
strategize steps to become functional and positive
within their own culture, communities, realities, etc.

Match to the clients - Do what it takes for them to feel
you are working hard to respect and understand
them, their language, norms, etc.
mismatch results in “resistance”
Engagement
ENGAGEMENT and
MOTIVATION GOALS
Motivation
Address and Reduce Negativity, Blame and Hopelessness
Create a Relational Focus
Maintain Balanced Alliance with all Participants
Help the Family see Different and More Productive Solutions
FFP Skills

Change Focus – from individual to relational
 Relationship building – humor, curiosity,
acknowledgement, strength based
statements
 Point processing
 Sequencing
 Interrupting/Diverting

Change Meaning – from blame and negativity
to noble but misguided intent
 Re-label
 Reframe
 Themes
What is Reframing?
Reframing is an Interpersonal Process in
which the you take the lead in suggesting
that a problem behavior may not
necessarily only have a malevolent motive;
instead it could also include a more
positive (but very misguided) intent.
How to do it…
1. Validate/ Acknowledge
The people involved and “the problem”
Validate the emotion/pain the “bad behavior” produced
2. Reframe
motive, intention, goal, underlying emotional state—it’s not giving reasons or excusing behavior
3. Assess acceptability/fit
4. Change/continue
Moving from Engagement and
Motivation to Support and Monitor
If we’ve consistently matched to, established a
balanced alliance, created a relational focus,
decreased negativity and blaming and created
a sense of hope…
We will also have created a motivational and
informational base, which results in having
the necessary credibility to match the
youth/family to a program or offer
recommendations that will help them make or
continue necessary changes
Support and Monitor
goals/activities
Goals:
•Move to less active role
•Support family and change agent
•Ensure program has effective
change process and element
•Eliminate barriers
Activities:
•Monitor and support change
•Structure supportive activities
•Encourage and reinforce family
members (and providers?)
•Be an advocate of effective
services/programs
Support and Monitor
Service and Activity Plans
Support Activities
Monitor Services



Employment
 Spiritual Related
 Youth oriented
recreation/leisure
 Family oriented
recreation/leisure
 Any significant, regularly
occurring activity that
impacts risk/protective
factors
Education
Treatment
Mental health, YSO,
Drug/Alcohol, FFT, FIT, MST,
ART


Mentoring
Employment Training
Generalization Phase
goals/activities/focus
Goals:
• become active again
• reinforce positive
change
• help generalize change
Activities:
• use the community
• maintain community contacts
• family case manager role
• target generalization change
based on relational assessment
Focus:
• relationships between the family and community
• using assessment knowledge
Linking to Change Program
Linking skills learned in facility to community context
P
R
E
R
E
L
E
A
S
E
P
R
E
P
Maintain Facility Treatment
Plan
(no additional services)
Engage &
Motivate
Support & Monitor
Evidence-Based or other
Change Program
P
O
S
I
T
I
V
E
T
E
Generalize R
M
I
N
A
T
I
O
N
Support and Monitor Program and Fit of Skills to Community Context
Relapse Prevention
1. Identify situations where problem may occur
2. Identify strategies to use when problem reoccurs
3. Predict the problem to reoccur (The best predictor of
future behavior is past behavior)
4. Repetitive skill use and reinforcement helps build
expectation that new skills will work in similar/different
situations over time
The Outcomes
Cognitive Behavioral Therapy in Residential Care Since implementing the
Integrated Treatment Model, JRA has seen a 60% reduction in assaultive behavior in
institutions and similar reductions in calls from living units for security staff
assistance, also reductions in self-harm behavior
Dialectical Behavioral Therapy (DBT) and it’s related skill sets is the primary
cognitive-behavioral intervention used with youth in JRA residential care. A 2002
WSIPP study of JRA youth involved in a DBT pilot-program at Echo Glen Children’s
Center shows a 15% reduction in 18 month felony recidivism. However, a future
study with a larger sample size is needed to determine conclusively if DBT reduces
recidivism
Family Integrative Therapy (FIT) is an intervention for youth with co-occurring
mental health and substance abuse disorders that uses a combination of evidencebased approaches involving youth and their families. The program begins in
residential care and continues when youth are released to parole supervision. A
2004 WSIPP study shows a 33.5% reduction in felony recidivism for youth involved
in FIT and future cost savings of $3.15 for each dollar spent
Functional Family Parole (FFP) In a recent study conducted by the University of
Indiana, 30 percent of youth who received FFP from highly adherent counselors were
convicted of a new felony within 12-months of release compared with 35 percent of
the matched control group. An 18 month post release study is being finalized
SPECIAL THANKS TO…
DAN SCHAUB, JRA Mental Health Program Administrator
LAURIE HART, JRA FFP Program Administrator
PAMALA SACKS-LAWLAR, JRA Substance Abuse Administrator
LISA MCALLISTER, JRA FFT Quality Assurance Administrator
DR. HENRY SCHMIDT, Former JRA Clinical Director
…FOR THEIR HELP AND INPUT INTO THIS PRESENTATION
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