FADAA-FCCMH ANNUAL
CONFERENCE 2015
“BACK TO THE FUTURE:
DESIGNING TREATMENT PROGRAMS
FOR CRIMINAL JUSTICE POPULATIONS”
PRESENTERS:
Robert L. Neri, LMHC, CAP, Sr. VP, Chief Program/Service Officer,
WestCare Foundation, Inc.; robert.neri@westcare.com
Roger H. Peters, Ph.D., Professor, Department of Mental Health Law &
Policy, USF; rhp@usf.edu
Educational Learning Goals:
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Participants will be able to identify key steps to take
in the first 90 days of implementing offender
programs to build a therapeutic treatment culture
Participants will understand core evidence-based
interventions and models of treatment for criminal
justice populations
Participants will learn about important resources in
the field to help implement evidence-based treatment
services for offenders who have substance and/or
co-occurring disorders
Substance Use Disorder Evolution
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Separated vs. Integrated
Relapse Shame-Based vs. Relapse Analysis
Medication Shunned vs. Medication Valued
Confrontational Style vs. Motivational
Curriculum
Recovery Staff vs. Multi-Disciplinary
Substance Use Disorder Evolution cont’d…
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Instinct Based vs. Researched Based
Must “Hit Bottom” vs. Coercion Valued
Intermittent Clinical Supervision vs.
Planned Clinical Supervision
“One Size Fits All Approach” vs. Age,
Gender, Culture Specific
Intervention Considerations
Clinical
Process
Behavior
Shaping
Inside
Out
Outside
In
Clinical Process
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Tailored to Learning Style
Individualized Based on Core
Issues
Clinical Process cont’d…
How do you Identify a
Primary Learning Style?
 Audio
 Visual
 Kinesthetic
Clinical Process cont’d..
Do You Base Interventions That Consider:
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Age
Developmental Maturation
Gender
Culture
Risk / Needs
Clinical Process cont’d..
How Do You Structure Behavior Shaping?
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Use of Learning Experiences Opportunities
Considering Core Issues
Considering Risk / Needs
Considering Thinking Patterns
Considering Motivation
Motivational Matrix
Client Motivation is Dependent
Upon
Internal as Well As
External Pressures
Motivational Matrix cont’d..
Motivational Changes in Treatment
Treatment Dosage
Motivational Matrix
HIGH PAIN
HIGH HOPE
LOW PAIN
LOW HOPE
LEARNING EXPERIENCES
are Based on a
POSITIVE Discipline Philosophy
and the
“Response to Intervention Model”
Core Issues:
Power and Control
 Excitement / Crisis
 Compliance / Internalization
 Victim Stance / Entitlement vs.
Earned Privilege
 Isolation
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Continuum of Change
How WE Want Them to Change:
Hopeless
Indifference
No Learning
----------------------
Displacement --------
Hopeful
Industrious
Learning From
Experience
Belonging
Continuum of Change cont’d..
How WE Want Them to Change:
Numbness/Apathy
Learned Helplessness
Arrested Development
Unpredictable Adults
-----------------
Self Help
Mutual Help
Social Learning
Role Models
Continuum of Change cont’d..
How WE Want Them to Change:
Isolation
----- Connected to Self, Others,
Higher Power
Emotional
Deprivation ----- Comfort, Self Soothe
Emotional Literacy
Every Strategy is Based
on
Facilitating Personal Growth
Ratio of Rewards to Sanctions
and the Probability of Success
Support?
How Does your Clinical Supervision
Support This Tailored Model ?
and…
How does your Performance Appraisal
and Individual Development Plan for
Employees support this ?
Continuing Care
Considerations Regarding
Aftercare / Continuing Care
Planning
Research States:
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Discharge Planning Should Begin
at Intake
Aftercare is as Critical as Primary Care
Most Relapses are Situational
Successful Outcomes are Tied to Early
Progress in Treatment
Lets Take This Science and Ask:
Do You Use a Discharge
Planning Workbook?
Do Discussion Sessions Begin
Early in Treatment ?
Transition Points are Treated
as Cautious Times
Are Role Plays and Life Scripts
Used to Rehearse
Anticipate Clinical Challenges?
SOCIAL SUPPORT
Is Social Support Used to
Monitor Progress?
Network Mapping?
COMMUNICATION ALTERNATIVES
Are You Using Recovery Apps
and Recovery Check-ups to Enhance
Communication Throughout
Aftercare?
Do you Provide a Comprehensive
Screening/Intake and Assessment
Process?
Importance of Screening and Assessment

High rates of behavioral health disorders and related
problems in justice settings
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Persons with undetected problems are likely to cycle back
through the justice system
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Allows for treatment planning and linking to appropriate
treatment services
Offender programs using comprehensive assessment have
better outcomes
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Tips for Implementing Intake/Screening
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Outcome – develop a common vocabulary for
justice-based treatment teams
Avoid excluding from programs based on
serious mental illness
Adaptive functioning level more important for
placement than diagnoses
Don’t use screening in place of level-of-care
assessment
Identify persons needing special services
Goal – Provide Universal Screening
in Key Areas
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Mental disorders
Substance use disorders
Trauma/PTSD
Suicide risk
Motivation
Criminal risk
2015 Monograph: “Screening and Assessment of
Co-Occurring Disorders in the Justice System”
Alcohol, Smoking,
and Substance
Involvement
Screening Test
(ASSIST)
Substance
Use
Screening
Instruments
Simple
Screening
Instrument
(SSI)
Texas
Christian
University
Drug Screen V
(TCUDS V)
Brief Jail
Mental
Health
Screen
(BJMHS)
Correctional
Mental
Health
Screen
(CMHS)
Mental
Health
Screening
Instruments
Mental
Health
Screening
Form-III
(MHSF-III)
Trauma
History Screen
(THS)
Posttraumatic
Symptom Scale
(PSS-I)
Life StressorChecklist (LSCR) or Life
Events
Checklist for
DSM-5 (LEC-5)
Trauma and
PTSD Screening,
Assessment,
and Diagnostic
Instruments
Posttraumatic
Diagnostic
Scale (PDS)
Primary Care
PTSD Screen
(PC-PTSD)
PTSD Checklist
for DSM-5
(PCL-5)
Enhancing Accuracy of Screening
and Assessment
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Maintain high index of suspicion for mental and
other health disorders
Use non-judgmental approach and
motivational interviewing techniques
Gather substance use information before other
more intrusive information
Supplement self-report with collateral
information
36
Target Areas for Assessment - I
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Scope and severity of SU and other disorders
Pattern of interaction between the disorders
Conditions associated with occurrence and
maintenance of the disorders
Antisocial attitudes, peers, personality
features
Motivation for treatment
Family and social relationships
Physical health status and medical history
Target Areas for Assessment - II
Education and employment history
 Personal strengths and skills
 Areas of functional impairment:
 Cognitive capacity
 Communication and reading skills
 Capacity to handle stress
 Ability to participate in group
interventions
 Level of care required (e.g., ASAM)
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Do you Address Criminality and
Risk for Recidivism?
Risk Assessment
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Goals: Select offenders with “high risk/high need”
to engage in intensive services; identify low risk
offenders for less intensive services
‘Static’ factors (e.g., criminal history)
‘Dynamic’or changeable factors - targets of
interventions in the criminal justice system
Interventions should Target Dynamic
Risk Factors
“People involved in the justice system have many needs
deserving treatment, but not all of these needs are
associated with criminal behavior”
- Andrews & Bonta (2006)
Dynamic Risk Factors for Criminal
Recidivism
1. Antisocial attitudes
2. Antisocial friends and peers
3. Antisocial personality pattern
4. Substance abuse
5.
6.
7.
8.
Family and/or marital problems
Lack of education
Poor employment history
Lack of prosocial leisure activities
Risk Assessment Instruments
Historical-Clinical-Risk Management - 20 (HCR-20)
Level of Service Inventory - Revised – Screening Version (LSI-R-SV)
Ohio Risk Assessment System (ORAS)
Psychopathy Checklist - Screening Version (PCL-SV)
Risk and Needs Triage (RANT)
Short-Term Assessment of Risk and Treatability (START)
Violence Risk Scale (VRS): Screening Version
Monograph Reviewing Risk
Assessment Instruments
Desmarais, S. L., & Singh, J. P. (2013,
March). Risk assessment instruments
validated and implemented in
correctional settings in the United States.
New York: Council of State Governments
- Justice Center. Available at:
http://csgjusticecenter.org/wpcontent/uploads/2014/07/RiskAssessment-Instruments-Validated-andImplemented-in-Correctional-Settings-inthe-United-States.pdf
Using Risk Assessment to Guide
Implementation of EBPs
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Goal is to match level of services to risk level
Improved outcomes if focus on moderate to high
risk offenders
- Providing intensive treatment and supervision
for low risk offenders can increase recidivism
- Mixing risk levels is contraindicated
Higher risk offenders require greater structure, and
more intensive treatment and supervision
Translating Risk Assessment to
Service Planning
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Target areas of high need related to dynamic risk
factors
Treatment and supervision plans should be aligned
to focus on areas of high needs
Offenders with low severity problems may not
require treatment
Mixing persons with high and low treatment needs is
contraindicated
Readminister risk assessment
Criminal Thinking Curricula
 Criminal
Conduct and Substance
Abuse Treatment
 Reasoning and Rehabilitation
 Thinking for a Change
Do you Provide Specialized
Services for Co-Occurring Mental
Disorders?
Screening and Assessment of CODs
Don’t exclude persons based on serious mental illness,
severity of substance use problems, or active substance use
Screening
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Blended and routine
screening for MH, SA, and
trauma/PTSD
Identify acute symptoms
Focus on areas of
functional impairment that
would prevent effective
program participation
Assessment
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Examine longitudinal
interaction of disorders
Review participant motivation
over time
Periodic reassessment
(Peters, 2014; Council of State Governments Justice Center)
Evidence-Based COD Treatment
Interventions for Offenders
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Integrated MH and SA treatment
Cognitive restructuring – “criminal thinking”
Relapse prevention
Motivational interventions (MI/MET)
Contingency management
Behavioral skills training
Medications (for both disorders)
Trauma-focused treatment
Family interventions (psychoeducational)
COD Treatment Curricula
Integrated Treatment for CODs
 Illness
Management and Recovery (IMR)
 Integrated Group Therapy for Bipolar
Disorder and Substance Abuse
Substance Abuse and Trauma/PTSD
 Integrated
Cognitive Behavioral Therapy
 Seeking Safety
Models of Outpatient COD Services
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Enhanced services (e.g., COD group, medication
clinic)
Embed COD track within existing SA program
Specialized COD court docket (should include all
MH court programs)
Intensive case management (e.g., ACT/FICM,
specialized probation) - could augment
outpatient COD program
Program Adaptations for CODs
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Dually credentialed staff
Increased length of services
Slower pace of treatment
Emphasis on education and support vs.
compliance and sanctions
Enhanced motivational interventions
Cognitive and memory enhancement strategies
Focus on housing, employment, medication needs
Questions ?
Thank You!