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Daniel M. Blonigen, PhD
HSR&D Center for Innovation to Implementation (Ci2i), VA Palo Alto HCSAdjunct Professor, Palo Alto University
9th Annual Conference on the Science of Dissemination and Implementation in HealthWashington DC (Dec 15, 2016)
Disclaimer & Citation
No conflicts of interests
The views expressed in this presentation are those of the author and do not necessarily reflect the position or policy of the Department of Veteran Affairs.
Publication: Blonigen DM, Rodriguez AL, Manfredi L, Nevedal, Rosenthal J,
McGuire JF, Smelson D, & Timko C (in press). Cognitive-behavioral treatments for criminogenic thinking: Barriers and facilitators to implementation within the Veterans Health Administration. Psychological Services.
Outline
Policy shift in management of criminal offenders
Best practices for reducing risk for criminal recidivism: Treatments for antisocial cognitions and behaviors
(“criminogenic thinking”)
Implementation potential of treatments for criminogenic thinking in non-correctional settings.
Qualitative study: Barriers and facilitators to implementation of treatments for
criminogenic thinking in Veterans Health Administration (VHA)
Policy Shift: From Incarceration to Diversion
Behavioral health services increasingly called upon to treat offenders and reduce their risk for recidivism.
Samuels et al. (2013)
Best Practices for Reducing Recidivism Risk
Antisocial cognitions and behaviors (“criminogenic thinking”) is the strongest risk factor for recidivism.
e.g., impulsivity; blame externalization
Cognitive-behavioral treatments for criminogenic thinking are best practices for reducing recidivism risk:
Moral Reconation Therapy (MRT)
Thinking 4 a Change (T4C)
Reasoning & Rehabilitation
Andrews & Bonta (2010); Blodgett et al. (2013); Wilson et al. (2005)
Moral Reconation Therapy (MRT)
Manualized, cognitive-behavioral intervention
Group format (open enrollment)
Structured exercises and homework assignments aimed at modifying antisocial thought patterns.
Move participants through 12 steps of moral development: Completion requires 24-36 sessions, on average!
Little & Robinson (1988; 2013)
Implementation in non-correctional settings?
Treatments for criminogenic thinking were developed for use within correctional settings.
The implementation potential of these treatments in non-correctional settings is unknown.
VHA expanding implementation of Moral Reconation Therapy in behavioral health services:
No data to guide these efforts
Blonigen et al. (2016)
The current study
Identify barriers to implementation of treatments for criminogenic thinking in VHA, and facilitators that could serve as solutions to these barriers:
Qualitative methods
Funding: Department of Veterans Affairs (HSRD/QUERI)
RRP 12-507 (PI: Blonigen)
Partnership with the VHA’s Veterans Justice Programs (VJP):
Nationwide outreach and linkage service for veterans involved in the criminal justice system.
Veterans Justice Programs (VJP)
“…ensure access to exceptional care for justice-involved Veterans by linking each Veteran to VA and community services that will prevent homelessness, improve social and clinical outcomes, and end Veterans’ cyclical contact with the criminal justice system.”
Mission carried out by VJP Specialists (staffed at all VA Medical Centers)
Clark et al. (2010)
Sequential Intercept Model In
terc
ep
t 2
Initia
l d
ete
ntio
n/
Initia
l co
urt
he
arin
gs
Inte
rce
pt 4
Re
en
try
Inte
rce
pt 3
Ja
ils/C
ou
rts
Inte
rce
pt 5
Co
mm
un
ity
co
rre
ctio
ns/
Co
mm
un
ity
su
pp
ort
Inte
rce
pt 1
La
w
en
forc
em
en
t/
Em
erg
en
cy
Se
rvic
es
Local Law
Enforcement
Arrest
Initial Detention
First Appearance Court
Specialty Court
Jail - Pretrial
Dispositional Court
Jail - Sentenced Prison
Probation Parole
Community
Community
LAW ENFORCEMENT-
COURTS-JAILS:
VA Veterans Justice
Outreach (VJO)
PRISONS:
Health Care for Reentry
Veterans (HCRV)
Blue-Howells et al. (2013)
Study Design
A semi-structured phone interview with VJP Specialists to describe their practices regarding treatment of risk factors for recidivism among justice-involved veterans. N=63 (3 randomly selected from each of the VHA’s 21 networks)
35% of participants (n=22) had been trained in a treatment for criminogenic thinking: Moral Reconation Therapy (MRT) (n=19)
Thinking 4 a Change (T4C) (n=6)
Reasoning & Rehabilitation (n=0)
Interview guide included supplement to query on implementation potential of MRT and T4C in the VHA.
Interview Guide Supplement
RE-AIM framework: Reach, Effectiveness, Adoption, Implementation, Maintenance
Sample items:
[Reach]
“What are some things that would make a Veteran more likely to participate in Moral Reconation Therapy?”
[Adoption]
“What are the greatest barriers to VHA providers adopting Moral Reconation Therapy?”
Glasgow et al. (1999)
Qualitative Data Analysis
Audio-files of interviews transcribed and de-identified.
Interviews coded by two independent raters in ATLAS.ti
Thematic coding and pile-sorting techniques used to identify barrier and facilitator themes.
Results
Patient
Provider System
Barrier andfacilitator themes
Cucciare et al. (2015)
Patient-level themesBarriers Potential Solutions (i.e., Facilitators)
• Time-intensive curricula of MRT and T4C limit patient engagement in these treatments.
• Offer incentives and other acknowledgements to patients for reaching treatment milestones.
• Streamline the MRT and T4C treatment process.
• Implement them within long-term residential programs.
“There’s always a lot of compliance issues that they're actually doing the [MRT] homework. It’s just tough in outpatient – you won’t get great compliance. A long-term residential program where someone is in there for four months or so, that would be the right setting.” [Participant 14]
MRT = Moral Reconation Therapy; T4C = Thinking 4 a Change
Patient-level themesBarriers Potential Solutions (i.e., Facilitators)
• Insufficient attention to patients’ internal motivations for participation in MRT or T4C.
• Use veteran mentors and testimonials to increase patients’ engagement in MRT or T4C.
• Use motivational interviewing to help patients explore internal motivations to participating in MRT and T4C.
“I think through motivational interviewing, building rapport and trying to roll with that resistance of ‘oh, this is just another group, another thing being forced upon me by probation or by the judge.’ …Identifying what's important to them and what their goals are would be helpful in selling these groups.” [Participant 24]
MRT = Moral Reconation Therapy; T4C = Thinking 4 a Change
Provider-level themesBarriers Potential Solutions (i.e., Facilitators)
• Stigma and bias toward patients with “antisocial” tendencies.
• Market MRT and T4C as treatments for criminogenic “tendencies” rather than antisocial “personalities.”
• Organize national calls to provide education that MRT and T4C address problems that are common among veterans in behavioral health services(e.g., substance abuse; homelessness)
“We say [MRT] helps veterans stay in recovery. One of the providers did come up with a handout or brochure. I think that’s the sort of thing that has helped –saying that these veterans are more likely to avoid becoming homeless, more likely to stay connected to their families.” [Participant 44]
MRT = Moral Reconation Therapy; T4C = Thinking 4 a Change
Provider-level themesBarriers Potential Solutions (i.e., Facilitators)
• Time and resource constraints on VJP Specialists and behavioral health providers.
• Use peer support and other para-professional staff to assist with delivery of MRT and T4C.
• Establish partnerships between Justice Program Specialists and behavioral health services in the implementation and delivery of MRT and T4C groups.
“I think [MRT] ought to be a co-facilitated group. It would be nice to see partnership between substance abuse and maybe Veterans Justice Outreach on a project like that. I think it allows for continuity of care.” [Participant 59]
MRT = Moral Reconation Therapy; T4C = Thinking 4 a Change
System-level themesBarriers Potential Solutions (i.e., Facilitators)
• Stakeholders outside the criminal justice system are not familiar with the evidence base of MRT or T4C.
• Conduct formal and non-formal research studies.
• Leverage support from multiple stakeholders across the healthcare and criminal justice systems.
“I think working with your treatment court, enlisting our justice community. I’m just sitting here going through in my head the judges in my county and I know that if they knew that [MRT or T4c] was an option that they would ask that that be done.” [Participant 59]
MRT = Moral Reconation Therapy; T4C = Thinking 4 a Change
System-level themesBarriers Potential Solutions (i.e., Facilitators)
• Uncertainty of sustained funding to support ongoing costs of criminogenic treatments.
• Use a train-the-trainers model and establish facilitation groups led by national champions.
“A call of facilitators, a monthly call to talk about kind of how the group is going and get consultation from other group facilitators. Maybe identify some kind of superstars nationally who have been leading and facilitating the group for a while who have a good understanding and feel confident about their knowledge of Moral Reconation Therapy.” [Participant 46]
Summary
With rise of specialty courts, behavioral health services are increasingly called upon to treat criminal offenders.
Findings serve as a guide for various stakeholders in behavioral health services who seek to promote best practices for reducing recidivism among offenders.
Findings directly inform efforts to expand access to and implementation of Moral Reconation Therapy in VHA:
VJP and Mental Health Service training initiative
Limitations and Considerations Findings limited to perspectives of VJP Specialists:
VA-funded Hybrid 1 RCT of Moral Reconation Therapy will obtain patient and behavioral health provider input.
Many suggested facilitators require empirical validation prior to wider-scale implementation.
Moral Reconation Therapy and Thinking 4 a Change combined in analyses.
Value of evaluating implementation barriers concurrently with quantifiable measures of program feasibility: e.g., provider time; patient dropout rates
Acknowledgments
VHA operational partners:
Veterans Justice Programs:
Jessica Blue-Howells
Sean Clark
Jim McGuire (retired)
Joel Rosenthal
Office of Homelessness:
Thomas O’Toole
Mental Health Services:
Jennifer Burden
Research staff/collaborators: Jessica Britt Michael Cucciare Andrea Finlay Autumn Harnish Lakiesha Kemp Luisa Manfredi Andrea Nevedal Allison Rodriguez Joel Rosenthal David Smelson Jennifer Smith Christine Timko
Contact Information
• Email:
References Andrews, D. A., & Bonta, J. L. (2010). The psychology of criminal conduct (5th ed.). Cincinnati, OH: Anderson.
Blodgett, J. C., Fuh, I. L., Maisel, N. C., & Midboe, A. M. (2013). A structured evidence review to identify treatments needs of justice-involved veterans and associated psychological interventions. Menlo Park, CA: Center for Health Care Evaluation, VA Palo Alto Health Care System.
Blonigen, D. M., Rodriguez, A. L., Manfredi, L., Britt, J., Nevedal, A., Finlay, A. K., Rosenthal, J., Smelson, D., & Timko, C. (2016). The availability and utility of services to address risk factors for recidivism among justice-involved veterans. Criminal Justice Policy Review. [e-pub, Feb 10 , 2016]. DOI: 10.1177/0887403416628601.
Blonigen DM, Rodriguez AL, Manfredi L, Nevedal, Rosenthal J, McGuire JF, Smelson D, & Timko C (in press). Cognitive-behavioral treatments for criminogenic thinking: Barriers and facilitators to implementation within the Veterans Health Administration. Psychological Services.
Blue-Howells, J. H., Clark, S. C., van den Berk-Clark, C., & McGuire, J. F. (2013). The U.S. Department of Veterans Affairs Veterans Justice Programs and the sequential intercept model: Case examples in national dissemination of intervention for justice-involved veterans. Psychological Services, 10, 48-53.
Clark, S., McGuire, J., & Blue-Howells, J. (2010). Development of veterans treatment courts: Local and legislative initiatives. Drug Court Review, 7, 171-208.
Cucciare, M. A., Coleman, E. A., & Timko, C. (2015). A conceptual model to facilitate transitions from primary care to specialtysubstance use disorder care: A review of the literature. Primary Health Care Research & Development, 16, 492-505.
Glasgow, R. E., Vogt, T. M., & Boles, S.M. (1999). Evaluating the public health impact of health promotion interventions: The RE-AIM framework. American Journal of Public Health, 89, 1322-1327.
Little, G. L., & Robinson, K. D. (1988). Moral reconation therapy: A systematic step-by-step treatment system for treatment resistant clients. Psychological Reports, 62, 135-151.
Little, G. L., & Robinson, K. D. (2013). Winning the invisible war: An MRT workbook for veterans. Memphis, TN: Eagle Wing Books.
Samuels, J., La Vigne, N., & Taxy, S. (2013). Stemming the tide: Strategies to reduce the growth and cut the cost of the Federal Prison System. Washington, DC: Urban Institute.
Wilson, D. B., Bouffard, L. A., & MacKenzie, D. L. (2005). A quantitative review of structured, group-oriented, cognitive-behavioral programs for offenders. Criminal Justice & Behavior, 32, 172-204.
