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Transcript of audio from Co-Occurring Disorders and Justice-Involved People

Female voice

Ladies and gentlemen thank you for joining. The Co-occurring Disorders and Justice involved people conference call. Your host for today's call is Dr. Hank Steadman. Dr. Steadman, you may begin.

Dr. Hank Steadman

Oh, good afternoon or good morning depending on where you are. My name is Hank Steadman. I am President of Policy Research Associates and Director of the National GAINS Center. We welcome you to the Co-occurring Disorders Initiative webinar series. Today's webinar, which is focused on Co-occurring Disorder and Justice involved people, is the first webinar in a series of events that promote evidence based practice the individuals with Co-occurring mental health and substance use disorders. This event is sponsored by the Substance Abuse and Mental Health Services Co-occurring Disorders Initiative, known by the acronym CODI, C-O-D-I. CODI is a joint initiative of SAMHSA's Center for Mental Health Services and Center for Substance Abuse Treatment. To learn more about CODI, please visit our interim website, which is at the bottom of the screen that you're viewing if you're viewing this on your computer, its In the near future, this website will be revised and will feature CODI resources, events, trainings and learning tools to support and promote evidence based practice to improve the lives of individuals with co-occurring disorders. The other person who is presenting on this webinar with me today is Dr. Merrill Rotter. Merrill is Associate Clinical Professor of Psychiatry at Albert Einstein College of Medicine in New York City. He is a forensic psychiatrist with the New York State Office of Mental Health and with the New York Task Mental Health Diversion programs. We have approximately 840 people signed up for this conference, which means there's of cast array of expertise, and there's many people on this call who probably could do this webinar quite well with their expertise. We've tried to pitch this to get some common ground and some basic facts out and also, to present some relatively sophisticated clinical ideas, we hope. My job in the first 20 minutes or so will be to kind of provide a context and a frame of reference and review a couple of the major literary views that are out there in terms of what do we know about integrated dual disorder treatment particularly as it relates to persons with criminal justice involvement. Merrill, in the subsequent 30 minutes or so, will focus very specifically on treatment programs and treatment considerations in the context of justice involved people with co-occurring disorders. The PowerPoint that you'll be viewing, if you are viewing it, will be available to everyone who registered for the conference. That after the webinar, we will use those web addresses--your email addresses that you sent in when you registered and send you how to access the PowerPoints. So, that will be sent from our offices at the end of this webinar. So the format is I will present some content and then Merrill will go into his content. And then we hope that we have at least 30 minutes or so for question and answers, which may be frustrating for many people since we have so many people signed on and we'll only have time for a few questions.

So let me go forward. The first thing I wanted to do was talk about where the people are who are justice involved, and I think this is a basic piece of information that's just useful for framing our conversation.

These are the most recent data from the Bureau of Justice statistics and roughly the 750,000 people in jail, 1.5 maybe in a prison, which is 2 million out of 7 million people under correctional supervision in the United States. Five million of those 7 million people are in the community, mostly on probation and some on parole. So that as we talk about justice involved people with co-occurring disorder, the first thing to recognize is the vast majority of the people we're talking about relate to community based treatment. The second thing that I want to mention when it comes to the smallest number on that board, which is roughly 750,000 people in jail, is jail a very significant place because of the processing point that that is in the criminal justice system, and that when you look at the data from 2005 in terms of jail bookings, there were above 14 million bookings. So while there are only 750,000 people there in any given day, there are 14 million people, a duplicate account, booked into U.S. jails. So that as we think about where are people who are justice involved, 5 out of 7 million are in the community on any given day, and a large number are circulating through the jail which--to Stan Brodsky, a psychologist at University of Alabama--used a phrase that I first heard, I think, in 1972 of conceptualizing the jail as a public health outpost. So, the jail is a particularly important point when it comes to any behavioral health disorders even though it may not be the place where most people are any given day.

My next series of slides is to talk a little bit about some important characteristics of the people that we're talking about who are justice involved. The data on the slide that you see is from Cook County Jail, and this is data that Linda Teplin and her colleagues produced actually quite a while ago, but I still think it's just as relevant today as it was in the early '90s when she first collected it. And the take home message here is that when you look at both men and women who have serious mental disorder who are being booked into U.S. jails--and you can see schizophrenia and major depression or mania--and you look at what percentage of them have alcohol abusive dependence, for both men and women, it's approximately three quarters. So, of those 14 million people booked into U.S. jails every year, three quarters of those who have serious mental illness have a co-occurring substance use disorder. So, it's the norm, it's to be expected when we talk about justice involved people with serious mental illness; the co-occurring substance use disorder is tremendously prevalent.

The other characteristic, clinical characteristic, of these people that's so important is the next slide which is data taken from just under 1,000 people that are in a jail diversion program that the Center for Mental Health Services funded, and it relates to people who have physical or sexual abuse experiences in their life. And when you look at the sum of any physical or sexual abuse in a lifetime, there's 93%, and it's not separated by men and women because the number isn't different; it's only a couple percentage point differences, and that trauma history is almost universal in the people who are justice involved with co-occurring substance use disorder. So when thinking about the clinical interventions and the adaptations of standard evidence based practices are going to be necessary, it's important to recognize that trauma is a very significant factor.

The next thing about these folks that we're talking about, responding to their needs, is what happens in their lives. And this is a depiction you could depict at any number of ways of what happens in that when people get arrested, they go into jail for short periods of time, typically, or occasionally imprisoned, and then they bump back to the community. When they get into the community, a whole lot of different things happen to them in that they get some residential substance abuse treatments, some mental health inpatient or outpatient treatment, they may live in a private home or group residence, they may be in a shelter, they may be on the street, and they go back and forth in these settings. And typically, they don't do well in any of these settings because of the co-occurring disorders and vast trauma histories, and traditionally, the interventions that we've provided, the service programs, have not focused on the integrated nature that's necessary to be responsive.

And that one of the things that the people then pick up is they tend to pick up a label which is that they're treatment resistant. And that one of the things that we've thought about over the years is that maybe a more apt depiction is not that there are treatment resistant clients, but that there are client resistant services. And that when you look at what the clinical needs are and who these people are, that the service system that is set up and the programs that we have to offer, and particularly in these tight economic times, don't necessarily fit the profile of what their histories are and what their clinical profiles are.

So, that's kind of the background in terms of where people are, who they are, that the--approaching this, one of the tools that we've created that you see on the screen, if you have a screen in front of you, is something that we call the sequential intercept model. In the shift of schematic going from left to right, looking at what the key points are in the criminal justice system where person with co-occurring disorders might be intercepted as they travel through the system on any given detention. And it's just--it's a road map of thinking about, again, as we talk about what the clinical interventions are that a Merrill is going to focus on in the second half of this presentation. It's a way of thinking where might we identify people, where might the programs be set up to avoid deeper penetration at greater cost to the community, at greater cost to the individuals and that intercepts one, two, three, four and five, look at law enforcement, then initial detention as intercept two, jails and the courts as intercept three, reentry is intercept four, and intercept five, being the community corrections. And in many instances, particularly on probation, which is at the back end of this schematic, is actually the front door of the jail because of technical violations and as a way back into intercept two. But this is something that we offer and if you go subsequent to this webinar to the GAINS website, which I'll show you the actual website next slide, that it's--this is--there are some materials on the sequential intercept model as a way of conceptualizing and planning and strategizing about what gaps are in the system and where you might want to develop interventions.

Okay, now the next couple of slides that I'm going to do talk about what data we have, kind of a big overview of integrated dual disorder treatment as the evidence based practice that has been put forward for persons with co-occurring substance use disorders, and then how does that data on IDDT relate to justice involved people and maybe some special treatment needs and characteristics that this population has. The data that I have here, and there's kind of a small print at the bottom, is the paper that Fred Osher, as a consultant to the GAINS Center, put together in 2005 on the basis of expert panel meeting that we conducted in Washington, and it's called Integrated Mental Health Substance Abuse Responses Suggestive of Involved Persons with Co-occurring Disorders. It's available, hopefully, you can read it at the--our website which, and that's a PDF file that you can download the whole paper in. That's the best summary that we're aware of as it relates to linking the literature on integrated dual disorder treatment to justice involved people specifically. And I've just pulled out a few key points from that I think are important in framing the clinical material that Merrill will present in a little bit. The first thing that's important to recognize is that when we talk about integrated dual disorder treatment as an evidence based practice is that what it is it's conducting state of the art assessments, followed by a combination of individual group and family treatment modalities. It's not a single intervention; it's not like dialectical behavior therapy, it's not like cognitive behavior therapy. IDDT is--talks about a state of the art assessment and then integrating an array of appropriate clinical interventions as the service intervention. It's not a single intervention. In terms of what can we say about it, Bob Drake and his colleagues reviewed 36 studies that Fred goes over in this paper on the effectiveness of integrated treatment to people with serious mental illness and co-occurring disorder. And what did they find? And that's the third bullet on this slide. What they found in looking at the--a meta analysis of those 36 studies was that rates of stable remission of substance abuse were higher, rates of substance use in general were lower and some support for a reduced arrest were found in integrated programs as opposed to sequential or parallel programs.

The next thing that I've pulled out of Fred's paper, which I think is his conclusion, is that in integrated treatment, when delivered over sufficient length of time--and 18 months was what was proposed--to persons with serious mental illness results in significant reductions of substance use and an improvement in a range of other outcomes. So, generally, that's the literature in IDDT and obviously, there's a whole lot of studies out there and Bob Drake and colleagues have summarized them and Fred's summarized them plus some other work in the paper you can get from our website. But I think the next set of questions, that's data on IDDT and justice involved people.

How about integrated build disorder treatment and recidivism specifically? And you'll note there's a typo here. It's supposed to be IDDT and recidivism. And the first thing is--in Fred's paper, when he looked specifically at it as related to recidivism, he concludes that this little data to inform the discussion of the impact of IDDT of public safety outcomes through our justice involved persons with co-occurring disorders. Then--so that's his bottom line.

The next set of findings that I want to present is from a paper that Bob Drake, Joe Morrissey; Kim Mueser did in 2006 related specifically to forensic dual disorder clients and integrated treatment around jail recidivism or criminal justice recidivism. In the first observation that they make--we need to go back--is really important because I think it's something not many people have talked about, and I think Merrill will deal with.

And When Bob Drake, Joe Morrissey and Kim Mueser reviewed the literature, they felt that forensic dual diagnosis clients were different than the populations by and large that the evidence base by IDDT had developed. In the near view that forensic or justice involved clients are likely to have less psychosis, more depression, more trauma, more childhood conduct disorder, more adult antisocial personality disorder, more violent behavior, and more severe substance abuse than a typical dual disorder client. So, their first observation as it relates to recidivism is you're probably working with a different population of people on some very important characteristics as it relates to the clinical treatments.

The next finding of this is that, I think is specifically with recidivism and really mirrors the findings from Fred Osher's summary and from the earliest summary by Bob Drake and that is substance abuse treatment, integrated or not, has little effect on criminal behavior. These clients may need a specific intervention such as cognitive behavioral treatment that addresses their antisocial tendencies. And this is a general finding related to co-occurring disorder that's beginning to show up in some other work on--in probation studies that jet up a scheme at UC Irvine and that we on mental health courts looking at a mental health population with high rates of co-occurring disorder are also finding. And that is the traditional treatments that have been used may in fact produce positive behavioral health outcomes but they do not necessarily impact on recidivism.

And that's the next slide as just another way of saying that and that as Drake, Morrissey and Mueser said, "Merely extending integrated dual disorder or assertive community treatment to this population without focusing on an intervention specifically on criminal behavior is unlikely to succeed if the outcome you're striving for is reduced recidivism after people have initial criminal justice contact."

Now, I want to make one more point before I finish up and turn it over to Merrill. And this is, I think, a really important study when we go back to my first slide that talked about 5 million out of 7 million people under correctional supervision in the U.S. or in the community. Well, 2 million are in fact, on any given day, or at 2005 in any given day, were institutionalized and a lot the treatment programs in the last decade, the last five years, have been focused on persons in correctional settings, prisons, and to a much less extent, jails. And there's an important point that Stan Sacks and JoAnn Sacks and colleagues came up with of a study they did in Colorado that is a very important research finding in terms of conceptualizing if you go back and think about the sequential intercept model and the five intercepts, you think about institutional-based care while they're institutionalized. And this is, I think, a really important study. And this was done a sample of 185--you can see it on the slides here, if you have the slides--at the San Carlos Correctional Facility in Pueblo, Colorado.

And they did a modified therapeutic community and they did random assignment of 92 to the modified TC and 93 that got a straight mental health treatment program. The modified TC was cognitive based to change attitudes and lifestyle and substance abuse, mental illness, and criminal thinking. The mental health, it was intensive services of meds, therapy, counseling, and specialized group. And then, a subset of the MTC folks also got community-based treatment after prison and a 20-bed TC-oriented residential program. So what were the results when they looked at subsequent incarceration was what they were looking at in their study.

And what they found out is the people who got treatment in prison in the San Carlos Correctional Facility, 9% was subsequently arrested over the follow-up period compared to a third of those that just got mental health treatment, and clearly, that's a statistically significant difference. However, it really masked a terribly important difference within the modified TC group that the next table points out. And what--this taken again directly from Sacks, Stan and JoAnn and their data is it breaks the--MTC group, the modified therapeutic community and to those who got after care in their communities and those that didn't, and what you see is that's where the real difference is; that those who got treatment in prison and then got after care, 5% were subsequently arrested. Those that only got prison care got 16% and mental health group got 33% re-incarcerated. There's a statistically significant difference on subsequent incarceration, subsequent criminal activity, and subsequent criminal activity related to alcohol and drug use between the MTC plus after care, and the mental health. If you look at only those that got modified therapeutic community treatment while incarcerated, there's no statistically significant difference between them and those that got the mental health treatment. Now, if the trend is in the right direction but there's no statically significant relationship. So that the reason you find the difference and the point here is, yes, institutional care can be a good beginning point and it's important to think about, but if you don't provide after care and some continuity of care when people leave the correctional facilities, there's a little bit of gain but you aren't going to get much bang for your dollar. And that's the last point that I want to make and I've used my 20 minutes, so let me at this point, turn it over. I know there's a lot of information and Merrill's going to give you a ton more, but hopefully by--in the Q&A or looking at the PowerPoints afterwards, are going to some of the original resources through our websites that you'll be able to savor this a little bit more after the webinar. So, with that, let me turn it over to Merrill.

Merrill Rotter, M.D.

Okay. Thank you, Hank. I'm going to continue sort of this overview that Hank began but with the notion here that the specific focus that I'm going to continue on is his idea of dealing with this criminal justice recidivism, which is a primary, if not one of the primary focuses for other work that we do when we're trying to treat the co-occurring population who are also justice involved. So, that might, under the--back in almost 10 year--over 10 years ago now Lehamn Weinberger put together what was a really seminal article on principles of community forensic treatment, and you see them listed here on the slide. Many of them, we should recognize as good treatment principles overall, forensic or not, where treatment goes liaison with other agencies, in this context, criminal justice, be comfortable with authority, structure, supervision, outreach services, critical perhaps as per--as per Hank's earlier slides, violence risk management techniques are a little bit more important in this forensic population, supportive living environments for family involvement. Some of them are somewhat specific for forensics and not--certainly we need to be able to have a heightened awareness, but particularly, if we're talking about today, this true of treatment goals--the principle of clear treatment goal begs the question, what treatment? Next slide please.

And next slide. And as Hank suggested, you know, we--there are and SAMHSA has, you know, a number of evidence-based practices that have been targeted for the co-occurring population. These include--my slide didn't change--did with those--well there we go. Thank you. Including illness management and recovery integrated treatment, which Hank referred to already, as sort of community treatment, supportive employment, family cycle education, basically, all of which you can read about in the SANHSA website. The work, the tool kits are there to learn about these and perhaps you can implement some of these. What the critical issue as per the, you know, the introduction before, is that the primary focus of these interventions created not for forensic populations or criminal justice involved population but rather for general co-occurring population, the principal focus is to focus on mental illness, substance abuse, and better functioning in the community, not necessarily criminal justice contact. That said, the GAINS center had sponsored a number of forums for discussion of how to implement these in a forensic population and to see if--and indeed, that has been done--but again, the focus seems to continue to be not necessarily trying to prevent the recidivism that is an important, if not primary outcome or goal, but rather mental illness improvement, substance abuse improvement.

Next slide. That becomes problematic and this is the data that Hank referred to earlier. That both Jennifer Scheme (ph) out in California working with the probation population and Hanks Steven working nationally with jail diversion populations are finding very similarly that one can improve symptoms. One can improve even substance abuse, but that does not necessarily predict whether or not there's going to be a decreased re-arrest in the post treatment period or decreased revocation. That indeed, you can improve symptoms but symptom reduction isn't the decried, isn't tied to decreased criminal justice recidivism. And indeed, in Hank's work, as similar to other work, the most robust predictor of the future re-arrest is a history of arrest prior to the arrest for which the person became diverted into mental health services. Bottom line, we can do good work in terms of symptoms, in terms of substance abuse that may not deal with the justice involved part of this person's life history.

Next slide, please. That becomes, not surprisingly, when we look at some of the other recent data around the connection between criminal justice contact and mental illness. Gehringer (ph) in 2006 and Peterson in 2009 published somewhat similar studies where they looked at the instant offenses, the arrest offenses, for which some mentally ill offenders we're arrested, and coded them as to whether or not those related to mental illness specifically and in the 2006 study, divided between direct effect of mental illness and indirect. And even when you included both direct and indirect effects of mental illness on the--on the instant offense, we're still in the single digits, 8% in Gehringer's (ph) study and 7% in Peterson's study, that in which--in which the active symptom of mental illness were directly related to the instant offense. Leaving over 90% of the cases in which there wasn't a direct or indirect relationship between mental illness and the criminal behavior essentially. And equally interesting in Gehringer's (ph) study, even when they added in substance abuse as to whether or not that drove the criminal behavior in the particular offense that was only 25%. So, again, the vast majority of individuals getting in trouble with the law in these studies appeared to be not related to their mental illness or even their substance abuse directly, so something else is mediating this. A correlate to that--those studies was a study done by Fischer in 2000 where he looked at the prevalence of mentally ill in jail in two different Massachusetts counties; one that have received significantly increased mental health services. And arguably, if the criminalization hypothesis is correct that reason mentally ill are getting arrested in greater numbers than the general population is because of inadequate services while the place with more adequate services should have less mentally ill in jail, what Fischer found was that there was really no difference between the counties that had increased services and those that didn't. Again, arguing that this criminal-justice contact is about something other than just mental illness and substance abuse.

Next slide, please. So, we need to look at some other principles and there are principles within the criminal justice world that look at recidivism specifically and the watch words in that world are Risk-Needs-Responsivity, so-called RNR. Risk, the argument being one should focus on the highest risk individuals is being risked for recidivism. Responsivity, something to the last R, that treatment needs to be delivered in the setting and a manner to which clients can respond. And Need being the treatment focus has to be focused on recidivism issues directly. So, it's either a focus on what's getting this person in trouble in the community, that's the need in the RNR principle.

Next slide, please. That need has been broken out by various authors from both criminal justice such as Andrews (ph) and Lamberti (ph) in the--in the forensic mental health world as 8 big factors, the big eight, they call them here. History of antisocial behavior, antisocial personality pattern, antisocial cognitions or ideas, that is attitude support of a crime, antisocial associates, family support, leisure activities, school work--and substance abuse. You'll pardon me reading some of these. I know that some people can't--don't have access to the slides. So, those eight factors are seen as critical to look at as factors that explain criminal justice recidivism in not necessary in mentally ill offender populations. But the next slide is interesting because indeed, when Scheme (ph) looked at some of these factors within a recidivism focused risk assessment and when Carl looked at antisocial cognitions in a, say, hospital population, both of them found that in a mentally ill population, many of these factors were overrepresented particularly antisocial pattern, personality, and some of the antisocial ideas essentially. So that the big 8 which is clearly--are factors originally generated from factors associated with recidivism for a criminal justice population only appeared to be as or even more relevant for a mentally ill offender population.

Next slide, please. So what we clearly need to do to address this criminal justice population holistically or comprehensively, we have to integrate, I think, let the lamb (ph) consideration of community forensic treatment principles with the SAMHSA EBPs, Evidence Based Practices with this criminal justice needs assessment and the big 8, if you will. And in this slide, I'm sort of beginning to pull that together and looking again at the issue of treatment goals which is the focus of this webinar. There are two critical ones that I think we need to talk about a little bit further, one of which being treating the big 8. What can we do about this big 8 if we're going to treat the criminal justice involved co-occurring population comprehensively? And the other big one, which is not on the list of the Big 8 but I think ought to be there, is engagement because those of us working with this population over time know that engagement is a critical issue in this population, a critical challenge. And one that if we don't meet we could have the perfect treatment and it wouldn't make a difference because the person has to be engaged in order to take advantage of what we have to offer.

Next slide, please. For treating the Big 8, this is kind of run down the list again and look at what treatments we know already, maybe a useful, and what we need to think about perhaps in a novel way. Well, history and the social behavior isn't the treatment focus per se, it really just the historical factor that reflects, you know, as I said earlier, you know, Steadman's and others data that passed criminal justice jury is predictive of future criminal justice contacts. And the social associates, this is really a supervision issue. You know, the kind of--that watch where in substitute. This treatment has always been people, places and things and probation supervision and criminal justice supervision is all, often all about where the person is living and who they're hanging out with, who they can't hangout with. Family support, there's an EBP the family cycle education that's already part of all of the material that we have. Leisure activities, the force of the Big 8 is covered under illness management and recoveries, one of the SAMHSA's EBPs. School or work, these are the type that shouldn't say supportive housing, they're less important too, they should say support of employment. Another EBP, Evidence Based Practice, and certainly integrated treatment addresses the factor of substance abuse, the sixth factor among the Big 8. The last two factors though aren't really included anywhere in the above, that is the antisocial personality pattern and the antisocial cognition. And again, if we're going to deal with this part of this person's life we have to find a way that addresses those as well. And the way I want to shift into doing that is to really look to in many ways where the work has been done on this area, out of the criminal justice world. Really looking at and as Hank said earlier, cognitive behavioral treatment including, I guess, the Drake article, cognitive behavioral treatment to focus on criminal and justice recidivism. And once I--a quick detour just to make sure that we're on the same page because I know there's a varied audience, in terms of what we mean by cognitive behavioral treatment. Generally, before we talk about how to apply that specifically to the criminal justice involved co-occurring population. So cognitive behavioral treatment goes back 50, 60 years. And basically is a following--basically suggests number one, from a cognitive perspective, it's the principle that behavior follows thought. That indeed how you feel or how you--what you do is a result of how you think about the world, about your world, about particular situations. The behavioral of behavioral focus suggests that what we're all about in terms of treatment is changing behavior. And in fact at the most basic level, it doesn't matter what you think behavior is would say; that indeed changing your behavior somehow is what makes a difference and what you think may not matter as much essentially. Cognitive behavioral treatment attempts to blend both of those to use the principle of thought following--behavior following thought with behavioral reinforcement to insure that your behavior does indeed change or give you the best chance to change that behavior.

Next slide. So the cognitive interventions within traditional cognitive behavioral treatment are designed to change your thinking. And what they're really about is changing the automatic thoughts--recognizing the automatic thoughts that are leaving you to feel or behave in a particular way and then learning to challenge those automatic thoughts. Behavioral treatment is designed to build in skills training, role playing, exposure, desensitization in order to, independent of what you think, give you a chance to practice new kinds of behaviors. The traditional focus is for cognitive behavioral treatment has been anxiety and depression. And indeed--and where, for example, the automatic thought in a patient who is depressed is that if I said, "I failed this test and so I'm a bad person" and you learned to challenge that thought, that automatic thought, in a way that suggests that there's no logical connection between that test in my being a bad or good person. And in order to dispute that thought, I can begin to feel better about myself. The behavioral technique that will be used in that context would be some kind of homework to practice thinking differently about your situation to do journaling, to do writing diaries. Again, adding to some kind of actual action, behavioral action to the cognitive work that's being done in the psychotherapist's office. So this is traditional cognitive behavioral treatment.

Next slide please. In applying that note to a criminal justice population, it's a slight shift. The same techniques are applied, you know, the automatic thoughts, the disputation, the behavioral practicing, if you will. But instead of looking at symptom relief specifically, the focus really is on problem solving, integrating community responsibility, community rules into your thinking, recognizing the automatic thoughts that are getting you into trouble in the community. And so it's not about anxiety or depression but about the thoughts and behaviors that are getting you into trouble in the community. Indeed, you can look at engagement challenges and cognitive and the same kind of automatic thoughts that need to be challenged in a collaborative way in order to enhance somebody's engagement and treatment. So when you first look at the interpersonal skills building piece of this and then close with the engagement which, as I said, is I think is among the most critical issues because you don't have the engagement, you don't have any other treatment going on.

Next slide, please. So, in turn, general components for cognitive behavioral adaptations for criminal justice population and criminal justice thinking and behavior, there are a couple of general components I just want to emphasize from the this slide. One of which is this problem solving approach, identifying cognitions that are getting in the way of your problem solving without breaking the law, helping someone to begin to do a cost benefit analysis of their decision making, you know, what's the immediate cost, what's the immediate benefit, what are the risks and to do that in a more routine kind of way. Those are particularly unique to the criminal justice focus adaptation. The other one that's particularly relevant for the criminal justice population is this idea of moral reasoning. Again, to not only identify your automatic thoughts, not only identify the cost and benefits to you of behaving in a particular kind of way, but also to begin to integrate thinking about other people's needs, societal rules in a more routine way that will then serve you better in terms of avoiding such behavior in the community.

Next slide, please. There have been a number of studies that look at--and a variety of different kinds of adaptations. I'm going to focus on a couple of them just to give you a broad overview on meta-analysis including this one by (A) on 2006 show that cognitive behavioral treatment to address criminal justice behaviors and attitudes can decrease re-arrest. And in his meta-analysis, he came up with an 8.2% decrease in re-arrest among the studies that included this kind of an intervention. There are compounds that make these studies hard to compare or to look at. You know, among them whether they're controlled or naturalistic studies, how well they're done, how program fidelity, if you will. More importantly, what the outcome is, is an important variable between studies, make them hard to compare. Are we talking about re-arrest versus re-conviction on the crime versus just re-incarceration for a violation? Those may have different kinds of risk issues and different kinds of responses to this kind of treatment. With the offenders high or low risk, those vary from study to study. But the clinical variables I think are most important, particularly mental illness, to the extent that these behavioral adaptations weren't necessarily used in a population that also separate from mental illness, how they're--how well or poorly they may be adapted and may be useful is going to be questionable. So whether or not this same reduction will find in that population is a question, but I'll answer that a little bit later because I think we have some data that suggests that yes, indeed, it can be useful.

Next slide, please. Just to give you one of two examples of several examples of this kind of work. And one of the classic versions of criminal justice recidivism focused cognitive behavioral intervention is called, "Thinking for a Change." You can find it on the National Institute of Corrections website. And indeed, like any other cognitive behavioral treatment, the goal is to have somebody interrupt that cycle of having been stressed, having a problem in the community, having thoughts or feelings that might lead to an action that indeed is antisocial, illegal perhaps, that will lead to re-incarceration and to break that cycle. And so the point of entry, the point of intervention in this cognitive behavioral treatment is between feelings and thoughts and actions, if you will. And this is an understanding of the cycle as a whole and then the techniques and the skill building used to address that breaking point is what these treatments are all about.

Next slide, please. There are two places we can look for adaptations for mentally ill offenders of cognitive behavioral treatment for the purposes of recidivism reduction. There are adaptations of classic mental health interventions for criminal justice populations going in one direction. And the other direction, mental health adaptations of interventions developed in the criminal justice world. And I'll give you an overview of these two different set, these different areas. Again, it's beyond the scope and time of this webinar to go into great detail about how this gets done, but we want to give you kind of a road map to get a sense of, you know, what's out there and perhaps where to look for more information.

Next slide, please. So mental health adaptation for criminal justice populations really target a couple of different things, one of which is the frustration and tolerance, difficulty with social skills and perhaps misperception of the environment that leads the behavior that gets somebody in trouble. And that's kind of a generalized focus for these interventions. Two examples of them are a forensic adaptation of DBT, Dialectical Behaviors Therapy. Many of you may know about DBT, developed by Marsha Linehan for decreasing self-destructive behaviors among patients with borderline personality disorder. Several researchers have used this in incarceration populations to decrease untoward behavior in the criminal--in incarceration settings. Barry Rosenfeld in New York out of Fordham University and John Jay College have adapted forensic DBT for forensic population, people arrested for stalking and other illegal behavior. And what he was able to show was indeed a decreased re-arrest rate in a program focused on people arrested for stalking behaviors. Again, it's the general DBT kind of approach, general cognitive behavioral kind of approach but taking the bones, if you will, of the DBT program for a non-forensic population and applying it in a forensic population. A different but similar sort of pattern was developed by a forensic psychologist named David Bernstein, currently working actually in Holland. Schema Focused Therapy is a personality disorder focused version of cognitive behavioral therapy. And indeed, not developed for criminal justice population, David Bernstein has been using that with a forensic population in several Dutch Forensic Hospitals finding that indeed they can improve their behaviors at a point where indeed they're eligible for early release, early release into the community, essentially. Not quite directly criminal, this is recidivism focused, but the idea that this kind of cognitive behavioral focused intervention can be used in a mental health population is suggested by David's work as well.

Next slide, please. There are a number of criminal justice programs like "Thinking for a Change". Three of them have been used and begun to be written about in a mentally ill offender population; reasoning and rehabilitation, moral recreation therapy, and lifestyle change. I'll come to the first one last. Moral recreation therapy is being used currently in the Bonneville County Mental Health Court out in Idaho for the past five or six years already. There have not published outcome studies on that, but the report from both from the clients and from the providers is that it's a very well accepted and appreciated program by all. We're still waiting for the actual data to suggest that indeed it does support the decrease of recidivism, but anecdotally it appears to work very nicely in that population. Lifestyle change is another similar focused DBT intervention currently being used in New York City test in its Brooklyn Mental Health Diversion Program where the program there is using a journaling approach where clients there are forced to think about or are asked to think about the cost benefit analysis of their illegal behaviors, identify the cognitions that are getting--or cause them to repeat these behaviors and think of alternative strategies to avoid that essentially. Again, the data and outcome isn't available yet, but anecdotally it is a well accepted and appreciated program by both providers and clients creating a kind of dialogue that didn't exist before about all the needs, the comprehensive needs, of this mentally ill offender population. Reasoning and rehabilitation among other places currently being used in Manhattan Psychiatric Center here in New York City is part of a larger violence program at the State Hospital in Manhattan Psychiatric Center. I know I'd say a little bit more about that VSM data about that one.

All right, next slide please. So reasoning and rehabilitation, again focuses on some of the same areas for intervention; problem-solving, social skills, negotiation skills, values enhancement, moral reasoning, the same things you heard about before, the same, sort of general components.

Next slide, please. One study that we did a number of years ago on reasoning and rehabilitation looking at its application in the mentally-ill offender population came out of work done in Canada where this R&R, Reasoning and Rehabilitation was developed. A national study in Canada of over 1,400 inmates who received this program R&R while incarcerated found that they, you know, they could decrease their newly admission that is on--I'm sorry, that there was a lower readmission rate. That is to say, readmission to incarceration because of a violation and new conviction rate relative to the waiting list control, you'll see that in the first--46% versus 51% in new readmission, 21% versus 24% in the new convictions among the group that received this versus people who didn't receive this prior to getting out into the community. What we did, though, was look at a very small number, that is a small end but of individuals who received this program while in a forensic hospital, thereby being defined as mentally-ill offenders, they wouldn't be there but for their mental illness, to see if that group did as well as the group that indeed received it and who were not forensic hospital patients. And indeed, the forensic hospital--these 32 forensic hospital patients did better on both scores than the general population. The psychiatric population, in this slide, had a readmission rate of 30% rather than 51% and a new conviction rate of only 4.2% versus 24%; significantly lower than the other population. What's important to note is that like many individuals going into the community from incarceration, they received an actuarial risk rating as to where--as to the risk of recidivism. The actuarial risk of recidivism for the psychiatric population was the same as the general population and the waiting list control. All of which is to say that the mentally-ill offender population among this group did as well or better, in fact, than the general population who received this cognitive behavioral intervention addressing directly their antisocial cognitions.

Next slide, please. The Manhattan Psychiatric Center STAIR program published a study of their work essentially and found that, indeed, their six months re-arrest rate for the dischargers from their unit was only 20%, which is somewhat lower, perhaps half or so of the usual re-arrest rate for mentally-ill offender population. That said, that took the compounds of that study is that it wasn't a specific study of reasoning and rehabilitation but rather was a study, you know, of the program as a whole; which included a variety of things, including the token economy, new--some changes in medication, et cetera. So the real study of the STAIR program as a whole of which the reasoning and rehabilitation was a significant portion. But it at least supports the idea that this kind of work can be done with a mentally-ill offender population even though it was originally developed for an offender population alone.

Next slide, please. Shifting gear then, when I talk of--this is really close, by talking a bit about engagement because again, engagement is a critical part of the challenge that we face in working with the mentally-ill offender population. And I will argue the specific challenge for the specific challenge over and above the general challenge when you're with the critical consent of both mental illness and offending history. And what it suggests--I'll give you two possible ways of which one that gets--that's being addressed in the community now. One is dealing with the issue of, if you will, motivation and speaking about motivational interviewing specifically. And then look at the issue of incarceration called acculturation and the way in which one's adaptations to incarceration get in the way of adaptation and engagement in the community and what we can do about that as well.

Next slide, please. What they all--that is, the engagement approaches appear to be able to do, and this is sort of my synthesis if you will, is that what they do with this motivation interviewing whether it's suspect from WRAP group is take a holistic approach to the person on engaging the person not the patient, which is very much appreciated by the clients themselves. Maybe what is the most engaging that it's them as a person and their needs that are being engaged and not themselves as a patient or a client and meeting a client and where they are and that's true for both the spectrum approach and the motivational interviewing approach. Now expecting something at the front door of treatment that really is a goal for treatment and to kind of mean where they are and helping them to join with us collaboratively rather than tell them what we expect them to do Day 1. And any of that--the issue of collaborative problem-solving that also is common to both and seems to be perhaps one of the important aspects of what Jennifer Skeem studies in specialized probation when she compares probation officers in California and looking at the success with clients who are on probation. The more successful clients are those that received a more problem-solving approach to their community behavior rather than just an expectation approach, if you will, a directive approach. So that I think in general what engagement is about. Let's talk about motivational interviewing.

Next slide, please. This may be familiar to many of you, so just a quick, quick overview. The principle of motivational interviewing is that people aren't just motivated or not. It's not the economist yes or no thing but rather people go through stages of change. And what we do to help them, help patients through that stage of change is to express empathy with where they are now and avoid arguing. Don't argue with them about their position but help identify areas where they may feel ambivalent about their current circumstances or current thoughts. And problem-solve collaboratively with them around how to address their ambivalence, essentially, rather than expect them just to be motivated, if you will. This has been studied. Motivational interviewing developed actually largely for a substance abuse population only by having studied specifically in a criminal justice population, there seems to be some data that suggests that, indeed, retention can be enhanced--at an engagement--so retention can be enhanced in patients who receive emotional motivational interview as part of the package of services they receive in the community. There is even clearer data that it can be--you can improve their motivation to change and data as well that you can decrease people's substance abuse and decrease their reconvictions. Again, part of usually looking at outcomes for motivational interviewing within the criminal justice-involved population is again identifying and bring upon what outcomes you're looking for. And then they're being potentially three. Basically, changing their motivation to change, changing behavior and actually decreasing recidivism. And then they said what this data suggests is that motivational interviewing certainly is applicable in a criminal justice-involved population. And indeed, there is some suggestion that it does indeed help retention in services.

Next slide, please. Finally, the other interventions that I do want to mention is the work that my colleagues and I have done in the area of adaptation to incarceration and how that gets in the way of engagement in the community and what to do about that. The premise, the principle is really what's highlighted here out of an article by McKergie (ph) who studied prison population over the years, and that is that that an incarcerated population are people who are exposed to massive situation or implementers that are specifically designed to alter their attitudes, personality and behavior. So being aware of incarceration as this massive intervention is another way of approaching engagement.

Next slide, please. The second sort of foundation for the work is that indeed therefore, there are things that people do within the incarceration and learn to do in the incarceration environment that get in the way of their engaging in the community and in treatment, in particular; distrust of staff, hyper-vigilance, minding your own business are normal adaptive functions in incarceration. They may present as being anti-authoritarian, paranoid or depressed or resistant or noncompliant in the community. And research has shown recently that, indeed, measures of incarceration acculturation is negatively associated with working alliance. So even when we control for acute symptoms and personality differ like psychopathy, it's still has a negative effect on working alliance, therefore, suggesting that a more specific, direct intervention to address that is important for engagement.

Next slide, please. So one of the--among the ways we do that, you know, is both to increase our own awareness as providers that this is an issue, but we can also work in a cognitive behavioral approach with this--with our clients themselves to help promote their cultural re-adaptation, that is, adaptation to a clinical culture from the incarcerating culture by developing trust through shared experience, challenging their attitudes and giving them new problem-solving skills.

Next slide, please. Within the WRAP intervention specifically, there are three active ingredients, if you will, connecting. That is the sharing among the clients of, if you will, war stories of experience of incarceration. This helps develop trust between the members and trust between the members and the staff. Exploring, and this begins to move into both cognitive behavioral work, exploring, increasing awareness through cycle education of these differences and similarities between the incarceration and the clinical settings. And what if--what may be curing behavior that attitudes in the clients that they may or may not still need while they're back in the community. And finally, the most direct cognitive behavioral adaptation is helping the clients be aware of their automatic thoughts, here described as "script" and dispute them, challenge them, find new problem-solving ways of getting their needs met and have them be aware of the automatic, if you will, incarceration thoughts that is driving behavior. It's classic, again, cognitive behavioral therapy or cognitive behavioral techniques but is a--but with the content being the automatic thoughts, not being about depression or anxiety or at a social ideas, but rather incarceration-driven ideas.

Final slide. Again, this has been a bit of a rapid overview; lots of details, lots for us, lots for further discussion. Hopefully, we've given you a bit of a road map of what to look for and look at. The good news is that we can successfully, through other jail diversions, special observation, other interventions in the community, decrease people's symptoms, improve their functioning, decreases their substance abuse and even decrease re-arrest and arrest. However, as we said earlier, the success may not always translate to recidivism and merely treating the symptoms and the substance abuse may not lead to the recidivism decreases that we're looking for. And so what we should need to be thinking about a community forensic treatment model that is more comprehensive, that includes some of the additional interventions we've discussed today at some lengths and in general, share the bit of a problem-solving approach to the supervision and treatment that people receive as mentally-ill offenders in the community, one that engages the person, that's collaborative and finally that teaches them problem-solving skills in a specific and targeted way to decrease their criminal of justice skills that unfortunately they may have too well-ingrained from so many years. I'll stop there. Thank you.

Hank Steadman

Well, thank you so much, Merrill. And that is a ton of information. We've had a small technical glitch here that in front--related to the Q&A of which we have 30 minutes slot. And we can't take any via the telephone, but we can take them via the chat window and some people have already been reporting them in the chat window as we've been going along.


So let me go back into the chat window and the order that they came in and I'll read the question. So far, the questions I see Merrill, are all focused on you.

The first is from Judith Power (ph) and her question is "How do you suggest we get our agencies to allow us to add cognitive behavioral component within mentally-ill offenders if they insist that they are too fragile?"

Well, I guess the short answer is that I don't--that fragility--I mean, I think there are two points. One of which is the cognitive behavioral therapy actually, in my experience, is actually very good for--what it means by fragile can be very good for patients or clients who are "fragile" to the extent that it is structured. It is often manualized and our "more fragile" clients can often do better where the expectation within the group session, the therapy session is structured. So that shouldn't be a contraindication. Clearly, like any group work, like any group work, one--the client has to be stable enough to be able to attend to what's going on in the room, to be able to behaviorally maintain, you know, non-impulsive good behavior and sits through without being disruptive. But short of that, I think cognitive behavioral work has been used for years in all kinds of settings with very severely mentally ill individuals but have--but their fragility is only related to their ability to attend and sit through the group essentially. And the structured nature of it may be make it even better than an open-ended process group for people who are theoretically fragile.

Thank you. Our next question is from Marilyn Owl (ph), and her question is "Please clarify Moral Reconation Strategy."

OK. Again, it goes--I think it goes beyond the--my colleague, Eric Olson, who runs the clinical portion of the Bonneville County Mental Health Court talks about this, you know, in an hour to an hour and a half session at the least. Again, the principle of Moral Reconation Therapy, similar to some of the other therapies we've just been discussing, is to help in a--in a teaching and a practicing way and if clients integrate moral reasoning, moral problem solving into how they decide what they're going to be doing on a daily basis or what they're going to do when they're faced with a challenge, essentially. And the Moral Reconation Therapy, specifically, is their manual basically walks one through levels of moral thinking. Twelve would be, if you will, the highest in being, you know, in a Mother Theresa full altruism, which few of us get to, if at all, essentially. But integrating ruled other people's feelings, you know, throughout the different stages of the treatment, essentially. I think what's common to all of them, again back to what I said earlier, is this ability to be introspective about yourself, introspective of and aware of your thinking and to begin to fully integrate other kinds of problem-solving ideas, other kinds of thoughts which, in the Moral Reconation world, include societal rules, other people's feelings and the like, essentially. That's kind of a nutshell, if you will, but that's what it's about, essentially.

OK. The questions keep coming for you, Merrill. This one is from Pete Villani (ph) and it's "Do you have any comments or information regarding this approach to a juvenile justice population?"

Merrill Rotter

I'm thinking of--as I was doing some research for this, it's--I'm not a child and adolescent expert and majority of the work that I do is with for really forensic adults. Certainly, structured approaches are relevant. I think that to the extent that we're talking about a juvenile justice population, my experience with them is that a major issue that these kids have, you know, is in the area of impulsivity. A lot of the work, in general, that this is about is trying to create--I'm sorry--decrease impulsivity, create kind of a cognitive space for people to think about what they're before they do it, essentially. I don't know and I can't quote to you any specific outcome studies where this has been applied, but certainly it has been both--that is to say some cognitive behavioral strategies have been applied. I read an article in the past couple of days about motivational interviewing in the--in a juvenile justice population. I don't offhand recall the hard outcomes of those implementations, but I know it's been done.

Let me offer a location, Pete or anyone else interested in juvenile justice evidence based practices around these issues, a website that we operate at our policy research associates that's funded by the John D. and Catherine T. McArthur Foundation is the National Center for Mental Health and Juvenile Justice. And that website is N as in Nancy, C Charlie, So that's N-C, National Center; M-H, Mental Health and J-J, Juvenile and that could be a resource around the juvenile justice questions. OK. Our next question is from Paul Nagle-McNaughton (ph). And his question is "Where can we learn more about the rap model?"

You can write to me--let give you my--OK, I'll give you all my email address. You're welcome to write to me about that and I'll send you more information about that and the manual, et cetera. My email address is--what is it actually? Mrotter, M-R-O-T-T-E-R at OMH, M as in Mary; OMH dot state dot NY, New York, dot U.S. That's I'll be happy to send you more information.

OK. The next question is from Shallaine LaBrack (ph). And the question is "Are cultural and linguistic differences taken into consideration?"

Frankly, the studies that I've been looking at in this area have not broken this out in that kind of way. Clearly, that's an important issue anytime one takes any kind of treatment. And particularly when I'm talking about the issues on values and et cetera, behaviors, et cetera and it begins to move it beyond it's, you know, original source for intervention, you have to begin to wonder, "Are there other confounds?" I have not seen--and again, there may be other--technically may be aware of it--I have not seen these interventions broken out in terms of different culture or different language and it's an efficacy or lack thereof. I think the part of the reasons that--and obviously, my personal direct interest is mental health, obviously--and part of the reason that we specifically have been looking at this issue is because indeed, it wasn't necessarily a no-brainer that what works for general offenders should work for mentally ill offenders because mental illness is a special characteristic as well. So it's a very, very good question. The studies that I've reviewed didn't study those differences, certainly something that ought to be done.

And this is as an example to me (ph).

OK. Let me--there are couple of questions that are asking the same question. Amanda Goose (ph), Anne Perez (ph) asked is there any--does this information appear to imply the staff that will be best to help our former convicts based on their own personal relationships? And that very similar question was asked by Rosie Anderson Harper (ph) that says, "Has any of these approaches used peer support? If so, how do they work?"

Let me start that, Merrill and then I'll put it to you.


But peer support is probably--falls under the area of a promising practice. There is actually relatively little empirical data. I don't think there are any randomized clinical trials or strong comparison group studies. There is a lot of positive program experience that bringing in people with (lit) experiences that involve both substance abuse histories, mental illnesses and experience in the criminal justice system can be of tremendous value to complementing some of the other traditional approaches or the CPT approaches and can really have a lot of different roles in program planning and natural delivery of the interventions, providing additional types of supports in the form of case management. But there is a lot of optimism and the one nationally recognized peer--forensic peer specialist training program as Howie the Harp Peer Advocacy Center in Harlem in New York City that has been run and produced a number of graduates who are actively involved in a lot of different ways in communities' treatment and also institutional based treatment. So that from our perspective at the gang center and for persons with co-occurring disorders, the mental health culture which has peer specialists and then the active involvement on the substance abuse side historically of peer training counselors is coming together in the community based treatment as well as institutional based treatment and there's not the same level of empirical evidence that there is with some of the other things we've talked about. But it's a very cost effective, very powerful complement in mainstream optimistic practice. There's just isn't a research on it yet.

Merrill, which--you do have peer specialist in some of the programs you work in.


Yes, I think I would agree about the lack of randomization study going back out of the justice were involved with. A gentleman named--a psychiatrist named Peter Spazni (ph) out of New York is in a lot of work with peers going back into the early '90s. He published some study that suggested that peer involvement with intensive case managers can prove the outcomes for their clients who had an ICM if there was a peer--as part of the ICM team. That said, that was not a randomized kind of controlled study, of course. My study and my experience with peers echoes, you know, sort of Hank's. And certainly some of the information that we're talking about, you know, the WRAP group kinds of interventions, some of the cog via the social cognition, certainly when it comes from the peer rather than the staff, you know, is all the more powerful. And certainly it's been our experience. I will say that it is important that peers indeed be trained as well. They come, you know, with life experience that is really incalculable to the [INDISTINCT] of the process but to be able to also get more specific training in whether it's the intervention by cognitive behavioral interventions or whether it's a mental health issue, et cetera. Another very interesting program that's actually out of the Bronx is the Mike Internship where graduates of substance abuse treatment programs apply for a six-week, if you will, internship at a state hospital and with both lecturers as well as hands on doctors working on a mental health ward for the--for a six--or maybe more than six weeks--14 weeks, actually. And they really come out with, you know, a level of skill as well as knowledge that all demands their life skills. And so I would argue for that as well. But certainly, my experience with peers is such that from an engagement perspective, our clients--anything I can say to a client is doubly effective when it comes from a peer.

Thank you. Next question is from Santos Deleon. It says that it appears that there have been many ideas about implementing treatment but I don't see any actual tools for assessments. Let me give you a referral to our website where you can get a PDF file and download it for free. It's something that Roger Peters from the Florida Health Institute, the University of South Florida, wrote in. It's a screening and assessment manual that summarizes all the co-occurring disorders, all of the tools that are out there and the full title is "Screening and Assessment of Co-occurring Disorders in the Justice System." And if you go to our--the game center--what is it?

There's a list of all of the PDF file there and you can download it, no cost on the PDF file there. And that's the most comprehensive up-to-date piece that I'm aware of that's actually looks at each of the tools and talks about the strengths and weaknesses of each of the assessment tools.

Hank, pardon my ignorance, Hank but what they ought to add to that--and if this is included on that link, then you can certainly stop me--but just to note that as we're learning from the criminal justice world, there are tools that are used routinely and now begin to be implemented to the mentally ill world and mentally offender world as well that look at risk for recidivism; tools that have been used by probation and parole for many years. And they all have different acronyms. The one that's being used in New York is called the COMPASS, C-O-M-P-A-S-S. I believe Jennifer Skeem at California used one called the LOC or Level of Care. Those are tools that look at, in some ways, [INDISTINCT] the Big Eight, if you will, that I was talking about earlier. In a way, they're trying to drive the level of supervision that perhaps a type of intervention someone might need around the criminal justice needs, if you will; the end of the R and R that I talked about earlier, essentially. Again, those are tools, to my knowledge, are well studied in the offender--mentally ill offender except by Jennifer Skeem out in California. But that may be a novel area for assessment for the criminal justice involving co-occurring population because they more directly trough for the kinds of factor that are associated with recidivism.

Well, let me have a little conversation with you with the expense of a couple of questions here.


Because some of those instruments which are widely used sometimes are questionable, I think, in the context of the whole population of prisons with co-occurring substance use and mental health disorders. But the table that you showed on the out come, I forgot which of those two studies it was; it wasn't the Manhattan one, but the other one, that you showed that the risk score that the 32 psychiatric in-patients had was the same risk score on one of those instruments and yet they did substantially better. So that to some extent if you use those traditional, criminal justice recidivism risk scores for assessment purposes, might you be overestimating what the impact of actual, appropriate, clinical interventions can produce in this population?

Absolutely. I think that that is a kind (ph) found certainly in the slide that I showed them. I really appreciated that you're raising that. And what you're getting at--and again, what I was trying to suggest is that it's something to look at not necessarily--I wasn't trying to suggest to be prescriptive about using those at all. I hope I didn't come off sounding like that. But I was just suggesting that as we start getting into this area of criminal justice recidivism, maybe this--may begin to think about how those tools may be applicable or not, but anytime--I think you should [INDISTINCT] eight times, the one uses the tool, that would develop a different population, it doesn't necessarily extend to the new population and I think, your question about that slide involving the risk level in Canada versus the recidivism level may be a good example of that, that indeed the risk could overestimate it in the mental health population because the tool that was used shouldn't have been applied across mentally ill and non-mentally ill offender populations. I think that makes perfect sense. And well I think and I have--I do think that Jennifer Skeem is using that--using those to looking at her probation in population, using that as one of the measures in looking at success and failure and the differences between specialized and non-specialized probation groups, essentially. So it does--I think that they may be that they're starting--I will argue--I don't think there's enough data at all that suggests it's clinically applicable or should be used to drive decision making immediately for the mentally ill offender population. I'm suggesting as you look at the next generation of tools and this next generation of thinking about the criminal justice involved population is in a--there may be things we can learn from them as well and certainly the risks level ought to be studied.

Okay. Let me ask a--this is a fairly complex question, but it's related to the last few minutes of our conversations from Hartley Dowling (ph)--hot well (ph), excuse me Dowling (ph) says "Is there a category of otherwise relatively low risk individuals as a set on actual instruments like the LSIR but should be perceived as high risk to become high risk and thus should be the target of the intervention. The literature on correctional rehabilitation discourages too much intervention with low risk offenders."

That's a--it's a terrific question. I mean, I think, I mean--and unfortunate--I guess my perspective [INDISTINCT] I mean, this is, in many ways, a philosophical question, right? What was troubling about those kinds of statements and I think that in terms of--as they reflect the criminal injustice, this R and R philosophy and this [INDISTINCT] of philosophy, what's troubling to me always is that that's really a function of getting a bank for your buck, right? It's all a function of how much money you have and resources, right? And when we apply it to the mentally ill, we often need stuff that, you know, regardless of the level of risk, if you will, and the reason why we have to make choices about who gets the intervention. And part of it is driven by whether they have the resources to provide it to everybody or not, essentially. There's certainly a data I think, I should--there is data in the criminal justice world that the higher risk group gets more decreased recidivism than the lower risk group. There's some data and I can't think of the site right now, but where a violent--interventions for someone who has a violent defense is going to do and as a greater degrees, you know, recidivism than just property offenses. They don't get the same kind of bang from interventions. Again, I think it's a resource issue as much as it is just who's going to do well, eventually. Particularly to the extent that we're talking about intervention that are in themselves noxious, right? They're not--they don't have significant side effects, except the lapse in time, right?

Okay, let me--there's two questions up here that I see that might seem discrepant, but I think they're really getting at the same issue. The first is from Michael Brown (ph) that says, "Why do decreased treatments not prevent recidivism?" And then the other one that's somewhat related I think is from Ramulo Vilehas (ph), "Would you suggest that CBT be recommend in addition to substance abuse and mental health or would CBT alone suffice in treating at least some substance abuse and mental health issues, severe mental health issues not withstanding?" Let me start and then go back to you the coronation, Merrill. I think that the issue is that most of the evidenced-based practices that have been developed in the database to support them looked at whether they were effective at getting behavioral health outcomes, which was terribly important. So a sort of community treatment was developed, what 40, 50 years ago at this point, to keep people out of state mental high--in-patient hospitalization. It's tremendously effective at doing that. Then a lot of the family cycle social ads, supportive housing, is the keep people out of hospitals to improve their level of functioning to reduce symptoms. And those things are important in terms of life satisfaction. However, the whole array of factors that may relate to criminal behavior may or may not be related to those in the many instances at that. So that almost facetiously, someone could feel bad about themselves and fewer symptoms and become more effective at committing criminal activities because of where they live, who they hang out with, how they think you achieved likes, needs and so forth. So that it isn't to say you should stop treating those mental health things, but that if in fact your program is funded in part to achieve public safety outcomes, you can't assume that being effective at those public health outcomes is going to get you the public safety outcomes which isn't to say, you throw the baby out with the bathwater. So that--I think we're saying that you're--we're saying in this highly economic times where everything--if money is so scarce and treatment slots are just evaporating as we speak, but to figure out ways of developing CBT as a specific intervention and also developing case management capabilities of what it means to deal with criminogenic, which as a term some people resist, but it just simply means fact is associated with criminal behavior, that the criminogenic factors are part of the repertoire of things that they are thinking about. And often, case managers do that intuitively without any explicit training in that or any explicit terminology for what the intervention is. So then I would say CBT is something that we want to add on and integrate and make pattern. What we want trauma-informed care when 92% of people have a particular life experience, you want to take that into consideration in everything you do, not just necessarily have a trauma-specific intervention, you want trauma-informed care completely integrated. I think that's what we're saying, that you want a criminogenic appreciation, criminogenic factors and also have the capacity deliver some CBT programming. How does that sound to you, Merrill?

That sounds good. I mean I'm making a couple of quick things, one of which is for better or for worse you cannot--you can try to argue with the data, but the data is the data, right? So if the data--I don't know [INDISTINCT] the data [INDISTINCT] shop shows that you can decrease symptoms but that there is no tie between that in decreased criminal justice recidivism, that's the data. If the data shows that indeed when you study people's instant defenses that mental health--serious mental health only accounts for less than 10% of the cases of the instant defenses, then at least 90%, that's the data, right? So I think we can't argue with that, number one. Number two, one of the ways that my friend, out in Idaho, Eric Olsen described this is it's a three-legged stool, right? That we--that there is metal health, there's substance abuse and then there is this criminogenic or these added social cognition. It's a three-legged stool. And if we're going to treat our patients comprehensively and not have the stool tip over, you're going to be most successfully if you address all three legs of the stool, not just two out of the three. And then finally, just an engagement to note that it's been--it's my experience through the WRAP group predict predominantly but it's been my experience that in fact, our clients don't resent talking about this third leg, this third leg of the stool, but in fact, see that as perhaps the most engaging sometimes and indeed the most the affirming of who they are as people, essentially. That when talking about their criminal justice involvement or history, their incarceration, et cetera, that's where they are human. You know, the mental health is that's their patient is; their substance abuse, that's their substance abuse, you know, part of their lives. But who they often is more about what they think and how they behave in the community. And this third leg gets to it. So it's actually often a very engaging conversation and they feel that they're being talked to and dealt with comprehensively and holistically, as my experience with the WRAP group, as my experience with the lifestyle change journaling that we're doing in the Brooklyn Mental Health Diversion Office.

Okay. As a learning community form that we have here, there was--Cindy Mackenzie (ph) has offered a resource related to the questions that came up of juveniles that people might feel--might make--might find useful. I'm not familiar with them myself, but what she offers is something entitled "Pathways to Self Discovery and Change: Criminal Conduct and Substance Abuse Treatment for Adolescence". And the authors are Harvey Milkmand, M-A-N-D, Milkmand--if that's not a typo--and Kenneth Wanberg, W-A-N-B-E-R-G. That's the full citation there. So that may be something some people will use for. There's a question here related to the stand facts study I alluded too in my presentation and you made the answers to this--made come from you, Merrill. But it's "But did I hear you speak of evidence-based research that supports useful that's a modified PC as an effective treatment intervention in jails? If you agree, then what can we present to our department heads to advocate the use of MTC as opposed to substance abuse out-patient education textbook model of treatment for out-patient treatment?" What I said was not that it was an EBP factor and I don't know that literature. Maybe Merrill does. But there was a study that showed that modified PC in jail didn't give you a whole lot of effectiveness in terms of subsequent criminal behavior unless it was tied to after care. And in that case, it was a 20-bed out-patient, a TC based--cognitive based residential program. So I'm not sure what else you might add to that, Merrill.

No, I don't know the TC literature well enough to add, but I've heard Stan Sax (ph) and his colleagues from NDIR (ph) talk about, you know, integration of TC models into jails at the top for years. So certainly, I think from that perspective, both effective and--I mean, they believed in the TC and the modified TC model and they…

[INDISTINCT] there were sometime.


No, that's okay.

And certainly it's--and they've written about how, Colorado aside, for years of how it's potentially integratable into the jail setting. But the people in NDIR (ph) can obviously speak to that even better--well, way better than I could.

There's a specific question I have on Janet Nely (ph) about what trauma PTSD-based therapy is available for adult females and males? There's a number of traumas specific interventions related to that. And again, I think that you can find on the website, the National Game Center. Merrill, do you have any other suggestions in terms of where to go for trauma-specific interventions?

We need--among the most promulgated [INDISTINCT] is seeking safety which is least [INDISTINCT] model. And that's--I think I would start with the game center because I think you have the most comprehensive bibliography on that of the games. I do believe it's also on the Samson website right now. Maybe I'm mixing up my websites. But certainly, you can start with [INDISTINCT] and that would be the place to begin.

Yes, the other is tram which is the commuting connection that one--that Maxine Harris (ph) and Roger Fallot, Julian Ford has developed one. So there's a number out there. But I think that if you go to the website that that would be a good starting point.

Let's see. We've got time for about one more question here. Annie at Osborne mentions again in terms of this learning community. She said, "Roger Pete has also has a co-occurring disorder curriculum for incarcerated individual and that they used it in the Arizona COSIG." So that again is another resource and he's at the Florida Mental Health Institute. And I think they're or USF, and you'll probably get a lot there. And I think at this point we in fact are--have run out of time on this call. And I really appreciate this. And I know some of you--we had a glitch and some people were unable to get to the audio. I hope between using the chat window to explain where you can get the follow-up and the audio, there's a way you can get the power points that everyone will be able to have a reasonably satisfactory experience. And I appreciate you sticking with us. And I'm sorry we couldn't get to more questions. But with 500 or 600 people on at any one time, we just couldn't get all the questions. And please keep an eye out for the subsequent webinars that the Co-occurring Disorders Initiative will be offering and they'll all be advertised on the game's list serve and some of the other list serves that you got this on. So thank you very much and that's all for today. Bye.