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
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 cooccurring 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
•
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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 CoOccurring 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
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•
DeMichelle, M. (2007). Probation and Parole’s Growing Caseloads and Workload Allocation:
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•
Ditton, P. M. (1999). U. S. Department of Justice, Office of Justice Programs. Bureau of
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References
•
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2003.
•
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•
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•
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•
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•
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•
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•
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•
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•
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•
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•
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•
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•
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•
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