The Complexity of Providing
Treatment in a Correctional Setting
2009 Fall Conference:
TREATING CRIMINOGENIC RISK
Presenters:
Bob Kingman, J.D., M.Ed., LCPC, CCS
Linda Wentworth, MSN, FNP-C, APRN BC
Objectives and Overview
• Components of integrated healthcare
-medical, mental health & substance
abuse services
• Integrated healthcare treatment Issues
• Role of criminogenic factors
• Differences between community-based
and correctional medical and behavioral
healthcare
• Treatment limitations and challenges
The Needs of Incarcerated Individuals
“For some, incarceration can be redemptive, a time for coming to terms and
reforming from harmful behaviors, addictions, dangerous environments, and
illicit activity. But for many, incarceration can be destructive, especially for
those removed from their fragile support network. Due to incarceration,
many lose jobs, housing, property, employability, reputation and/or family
and friend support. For these individuals, the release from jail or prison
where the basic needs of food, shelter, safety, and health are met, into
communities without structure, support, or resources can be overwhelming.”
-May, J. & Pitts, K. (1999), Building Violence: How
America’s rush to incarcerate creates more violence
Incarcerated Individuals’ Healthcare Needs
“ For non-incarcerated persons with complex health care needs, care is
frequently transferred and required in multiple settings. Incarcerated
persons with these needs are particularly vulnerable to experience
disruptions in quality of care and care fragmentation. Recognizing the risks
associated with these transitions, and delivering patient-centered care,
helps to mitigate the problem and bring better outcomes. “
- Coleman, E.A. (2003) Improving the quality of
transitional care for persons with complex care needs.
Integrated correctional healthcare
(does it matter?)
•
Integrate:
1. to bring together (parts) into a whole.
2. to make up or complete as a whole, as parts
do.
3. ‘The whole is greater than the sum of its
parts.’
Characteristics of the population
(Prins and Draper, Council of State Governments Justice Center, 2009)
• Prevalence of mental illness
– 5% of people in general population have a serious mental illness at any
given time.
(1999 study)
– 19% of adults under probation supervision had “psychotic disorders”,
i.e. schizophrenia, delusional disorder, NOS.
(2003 Illinois study)
– 13% of adults released to parole in California were classified (by
screening at time of release) to have a “mental disorder” (2004 study)
– 11% of individuals supervised by community corrections (probation)
were likely to have a serious mental illness
(2008 study)
– Prevalence estimates of mental illness in both jails and prisons range
from 7% to 16% [x4 higher for men; x8 higher for women than rates
found in the general population]
Characteristics (continued)
• Co-occurring Disorders
– 55% of individuals with one or more psychiatric disorders also were
dependent on 1 or more substances [vs. 37% of people without MI]
(2003 Illinois study of probationers)
– 52% of individuals on parole had a co-occurring substance use disorder
(2008 study)
– Surveys at KCCF indicate that approximately 60% of inmates have a
co-occurring disorder (self-reported)
Incarcerated Individuals and Medications
• Percentage of inmates on medications
• Average range
35% - 81%
46% - 60%
• Percentage on psychiatric medications
• Average range
25% - 55%
36% - 39%
• Percentage of total medication budget
expended on psychiatric medications
81%
Additional complicating factors
• Higher rates of victimization/trauma
– 39% of probationers with mental illness [vs. 12% without] report being
abused before their arrest
– 42% of female probationers with mental illness [vs. 20% without] report
being sexually abused (14%/2% for males)
-Also, increased percentages of homelessness
and unemployment (twice as likely if mentally ill)
Increased acuity of integrated health issues
and complexity of treatment challenges
• Is ‘de-institutionalization’ the culprit ?
• The economic crisis ?
• Change in social structure ?
Brief History of Mental Health Treatment “Philosophy’
1980-2010 (and parallels with correctional issues)
• Mental Health = major mental illness
(personality disorders not addressed/substance abuse is separate issue)
• Mental illness/substance abuse-which is primary?
(personality disorders are problematic/trauma is a separate issue)
• Dual-diagnosis assessment and treatment
(trauma=complicating factor/criminogenic element=separate issue)
• Co-occurring assessment and treatment
(trauma=gender responsive treatment/criminogenic issues = a complicating factor)
• Criminogenic Co-occurrence Treatment
(assessment and intervention with criminogenic factors for
sustainable pro-social change)
Evolving ‘philosophies’ of correctional (facilitybased) healthcare
•
‘You’ll get nothing and you’ll like it.’
• Medical problems are medical problems.
• A new ‘formula’: medical + behavioral = integrated care
• Ideal ‘formula’ : medical + behavioral (mental health &
substance abuse) + gender-specific/trauma-informed +
recidivistic & criminogenic risk factors= integrated
healthcare
Increased vulnerability and demands of the
population requires clearer definition and
implementation of services
•
Integrated correctional healthcare is the delivery of primary
medical care, substance abuse, mental health and crisis services to
incarcerated individuals by a single, unified care provider.
•
Respectful, timely, efficient and effective responses by a multidisciplinary team of care providers in a demanding institutional
environment to a wide spectrum of health needs and criminogenic
issues as presented by inmates with complex medical and
behavioral health histories.
Mission:
To offer standards-based
comprehensive and integrated
healthcare to incarcerated
individuals, to ensure their wellbeing while in custody and to
promote their successful transition
and re-entry to the community
after release.
Components of integrated care and summary of services
offered in correctional facilities:
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Screening and evaluation at admission
Risk assessment
‘Routine’ physical examination
Emergent medical assessment and referral as needed
Medication evaluation/consultation
Medication administration
Medical ‘sick call’
Psycho-educational & gender-specific groups
Treatment referrals and consultation (medical, dental, residential
rehabilitation, etc.)
• Individual interviews/appointments (behavioral health)
• Transition planning for medical and behavioral health needs upon
re-entry to the community
• Liaison with community healthcare providers, criminal justice and
community corrections (probation)
Evolution and adaptation to ever-changing needs
• Is there a possible parallel to the gradual modification of
the mental health treatment ‘system’ over the past forty
years?
• What lessons have been learned from mental health and
substance abuse providers’ response to increasingly
complex individuals and issues?
Lessons Learned (some of them):
• The combination of co-occurring disorders and
criminogenic factors can be highly treatment and
change-resistant.
• Medical care, in the community, is often an after-thought
or accessed only under emergent circumstances.
• Behavioral health and/or medical care , in the facility, can
be seen or experienced as a means to make the
incarceration experience ‘easier’ -- for the inmate .
• Treatment/pre-treatment interventions are highly
individualized, and often are only ‘planting a seed’ .
• Traditional treatment approaches can be ineffective.
Separate, but not equal (or effective)?
• “ There is nothing more unequal than the equal
treatment of unequal people. “
-Thomas Jefferson
Traditional Assessment and Programming
Behavioral Health
• Psychosocial format
• Symptom focus
• Contributing factors
• Standardized measures
• Diagnosis driven
• Financial
• Pathology based
• Medical Necessity
• Regulatory defined
• Categories
Criminal
Justice
• Classification
• Risk
• Corrections
• Pre-trial
• Probation
• LSI-R/LS-CM
Assessment Shapes the
Intervention
Traditional Psycho-Social Approach
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Presenting Concern
Current Mental Status
Risk of Harm to Self/Others
Family/Household Information
Employment
Social/Recreational History
Developmental History
Education/Military Service
Medical Health/Medications
Legal History**
Treatment History (mental health and substance abuse)
Treatment Planning and Intervention
What was, and still is, missing?
Recidivistic Risk Factors
Big Five
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Andrews and Bonta,
Criminal History
Anti-social Attitudes
Anti-social Associates
Anti-social Behaviors
Anti-social personality traits
Central Eight
• Substance Abuse
• Family/Relationship
• Recreation/Leisure
PERSPECTIVES: How does criminogenically informed,
integrated healthcare impact daily operations in a county
correctional facility?
• Delivery of medical and behavioral healthcare services.
• From risk assessments to referrals (and more).
• Facility administration and inmate management.
• Maximizing opportunities for change.
• Initiating/maintaining an ongoing dialogue with individual
inmates about wellness, recovery, and change.
Healthcare Delivery: Criminogenically informed
medical interventions in a facility-based setting
• Attitude
• Addictions
• Prescribing practices
• Coping skills
• Encourage appropriate referrals (counseling/self-help)
Enhance interventions and treatment opportunities by
expanding the view and sharpening the focus
• Shift psycho-social and ‘traditional’ medical
perspective/approach to:
- Include recidivistic risk factors
- Acknowledge history of disengagement
- Understand ‘value’ of criminal behavior
as a multi-dimensional coping skill (s)
- Incorporate trauma-informed & gender-responsive approaches
while continuing to address health issues in a respectful and
systemic manner.
• Train Providers/Clinicians/Correctional Staff
• Develop/utilize screening and evaluation tools to:
- Identify inmates/clients for follow-up
- Utilize information in medical and behavioral healthcare
interventions
Potential positive outcomes of criminogenically
informed integrated correctional healthcare:
1.
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Better care and improved well-being for inmates
Inmate (the care-recipient) is more informed of own health issues
Coordinated healthcare produces more effective care delivery
Jail administration and inmate management becomes more
efficient
Inmates can experience a better transition back into the
community
Community treatment interventions may be more successful
Reduced rates of recidivism
Summary:
• Dignity and respect (“be real” )
• Inclusive rather than exclusive (with information
and collaborating providers)
• Incorporate criminogenic issue-awareness
• Begin transition planning at time of admission
It’s about perception……
“ When you come to a fork in the road, take it.”
- Yogi Berra