Liam E Marshall, PhD Research & Academics Division and Provincial Forensics Waypoint Centre for Mental Health Care

Evidence-based interventions in forensic mental health and correctional settings

Introduction

• Rationale • Administrative Components • Therapeutic features • Evaluation • Future Directions

INTRODUCTION • Goals

– Provide evidence-based psychological treatments to reduce problems associated with mental illness

– Provide evidence-based psychological treatments to reduce risk and criminogenic needs

• Objectives – to meet these goals in empirically supported ways which are respectful toward the client and promote positive patient-staff relations

Rationale: RNR • RISK:

– Treating mental illness only, does not reduce risk for future offending

– Client’s risk for future offending and risk to cause harm to self and others, needs to be considered

• NEEDS: – Mentally ill offenders can profit from addressing empirically

identified criminogenic needs • RESPONSIVITY:

– There is typically less motivation for treatment in mentally ill offenders than in clients who seek treatment

– Skilled & supported facilitators are more effective

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Challenges • Choice of interventions • Choice of therapeutic style/model of

intervention • Staff to run interventions • Assessment procedures • Content and process • Over reliance on manuals • Infrastructure • Facility support

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Considerations

• Number of patients suitable for psychotherapy

• Range and skill of staff: choice of training • Other responsibilities of treatment staff • Who is the customer?

CDCP: Replicating Effective Programs (REP) project • Systematic and effective strategies to prepare HIV

interventions for dissemination • Four phases:

– Pre-conditions (e.g., identifying need, target population, and suitable intervention)

– Pre-implementation (e.g., intervention packaging and community input)

– Implementation (e.g., package dissemination, training, technical assistance, and evaluation)

– Maintenance and evolution (e.g., preparing the intervention for sustainability)

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How to Successfully Implement Evidence-Based Social Programs: A Brief Overview for Policymakers and Program Providers. (Gorman-Smith, 2006)

• Step 1: Select an appropriate evidence-based intervention

• Step 2: Identify resources that can help with successful implementation

• Step 3: Identify appropriate implementation sites • Step 4: Identify key features of the intervention that

must be closely adhered to and monitored • Step 5: Implement a system to ensure close

adherence to these key features

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Example of an Implementation Strategy in Forensic & Correctional Settings

• Oversight: intervention committee & 3 sub-committees • Required “core” interventions

– Criminogenic: emotional self-regulation & substance abuse (sexual self-regulation, prosocial cognition, domestic violence, relaxation/mindfulness, leisure awareness and skills, self-esteem)

– Others: illness related interventions (e.g., medication & symptom management, CBT for psychosis DBT for BPD)

• Assessments for interventions: only on issues actually addressed in interventions

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Suggestions for Implementation

• 1 staff member (psychologist) as over-seer of interventions

• Allocate according to interest and expertise • Empirical, collaborative, reflexive, approach to

program development • Ongoing support through weekly or bi-weekly

clinic meetings with each team and as a unit • Opportunities for immediate debrief when needed

Suggestions for Implementation

Recommended initial approach for groups • Closed format – move to open format when comfortable with

material and process • Minimum two facilitators – Primary & Secondary • Small groups (4+ participants) • Separate groups or individual counseling appropriate for

functioning level of clients (average, low, very low) • Number of sessions/week (min 2, max 3) dependent on risk

and needs • Length (# hours) of sessions – dependent of client

functioning level; i.e., shorter for lower functioning. • Completion criteria: Dependent on goals and objectives • Evaluation: Dependent on goals and objectives

1. Assessment & Triage – Choice of assessment tools – Assignment to intervention

2. Interventions & Reporting – Criminogenic & Mental Health needs – Therapist support & effective reporting

3. Tracking & Evaluation – Completions, dropouts, refusers – Targets of treatment, recidivism, client perspective

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Components of Intervention Implementation

ASSESSMENTS • RATIONALE:

– Need to identify each client’s personal Risk, Needs, & Responsivity, issues

– Need to be trauma-informed – Provides tracking of significant treatment-related

trends – Informs treatment decisions – Allows for measurement of treatment-related

progress – All of which, informs the improvement of clinical

services

Example Intake Assessments • All incoming patients:

– Psychology: – HCR-20, PCL-R, VRAG,

• Self-report – STAXI-II, URICA, SSEI, MAST, DAST, Shipley, PTSD-

CL-R, others – Social Work: Psychosocial history – Rec., O.T., Nursing, other

• Specialized – Any patient with an index offence of, or a history of, Sexual

Offending: STATIC-99R, STABLE-2007, and ACUTE-2007 – Any patient with an index offence of, or a history of, Domestic

Violence: ODARA or SARA

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2. Intervention & Reporting • Intervention design and implementation

– Theoretical orientation – Manuals – Training for facilitators

• Supervision – maintaining treatment focus and integrity – Depth & type of supervision

• Reporting results of interventions – Outcome of intervention – Consider stakeholders needs – Structure and length of reports

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DEGREE OF MANUALIZATION

No direction Guide Highly detailed manual

IMPLICATIONS OF THIS CHOICE

1) TARGETS

Lack of specification of targets

Choice of targets Fixed and specific targets

2) PROCEDURES FOR EACH TARGET

None specified Choice Single and specified

3) NUMBER OF TREATMENT SESSIONS

Unspecified Dependent on each client’s needs

Fixed number

4) STRUCTURE

Fully unstructured Treatment targets repeatedly addressed

Fully modularized

5) TREATMENT STYLE

Idiosyncratic Psychotherapeutic Psychoeducational

6) CLIENT INVOLVEMENT

Client choice only Collaboration Therapist choice only

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3. Tracking & Evaluation

• Successful completions, refusers, dropouts

• Pre & Post testing • Client satisfaction • Recidivism

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Sample Outcomes

Example outcomes: Facility “A”

Pre • Few programs running, no structure, no oversight,

outdated approach, conflict between medical and allied health staff

• Low staff morale and difficulty recruiting Strategy: provide training to interested staff members,

implement one intervention, then expand

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Example outcomes: Facility “A” Post • Every Allied Health team member running at least one

criminogenic need-related group intervention with evaluation and reporting processes in place

• Medical staff (physicians & nurses) also running groups • Clients’ perspectives canvassed • Achievement of targets of treatment

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Nursing run self-esteem program Social Self-Esteem Inventory (Lawson, Marshall, & McGrath, 1979)

N M SD

Pre-treatment 24 116.33 30.2

Post-treatment 24 128.33 28.7

t (23) = 2.34, p < .03, Norm Mean = 132, SD = 21

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Old Program Results: STAXI-II (N = 34) STAXI-II M SD %ile M SD %ile Diff t p.

State Anger 22.1 9.7 80th 20.1 7.1 75th 2 1.3 .20

Trait Anger 21.8 7.7 90th 20.3 6.2 75th 1.5 1.8 .09

Anger Expression - Out 18.1 5.1 90th 17.5 4.2 90th 0.6 0.8 .46

Anger Expression – In 19.5 5.3 90th 17.8 3.7 75th 1.7 1.9 .06

Anger Control – Out 21.7 6.2 25th 20.4 5.4 20th 1.3 1.4 .18

Anger Control – In 21.3 6.7 40th 19.7 5.7 35th 1.6 1.7 .91

Anger Index 42.5 17.1 80th 43.2 14.0 80th -0.7 -0.3 .78 26

Old New Program

STAXI-II M SD %ile M SD %ile t p. State Anger 22.1 9.7 80th 22.4 9.9 80th -.22 .83

Trait Anger 21.8 7.7 90th 23.5 7.6 95th -.83 .41

Anger Expression -

Out 18.1 5.1 90th 18.8 5.0 95th -.37 .71

Anger Expression - In 19.5 5.3 90th 20.0 5.7 90th -.5 .62

Anger Control - Out 21.7 6.2 25th 19.4 5.4 15th 1.6 .12

Anger Control - In 21.3 6.7 40th 21.0 4.9 30th 2.1 .06

Anger Index 42.5 17.1 80th 49.0 15.1 90th -1.6 .11

Old Program versus New Program

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STAXI-II M SD %ile M SD %ile t p

State Anger 21.3 8.3 80th 17.6 4.6 60th 2.7 < .01

Trait Anger 23.5 7.5 95th 19.9 7.7 75th 3.0 < .01

Anger Expression -

Out 19.2 5.4 95th 16.8 5.2 85th 2.9 < .01

Anger Expression - In 19.6 5.5 90th 17.3 4.9 60th 2.3 < .05

Anger Control - Out 19.2 5.8 15th 22.2 5.3 25th -2.6 < .01

Anger Control - In 19.0 5.0 30th 22.5 5.1 50th -3.1 < .01

Anger Index 48.5 14.8 90th 37.4 14.5 70th 3.7 < .001

STAXI-II RESULTS: NEW PROGRAM

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Results: Stage of Change (URICA)

6

14

1

23

2

14

0

5

10

15

20

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Pre-Contemplation Contemplation Action

Baseline After Treatment

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f Par

ticip

ants

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Clients’ Perspectives: Domestic Violence group (Group Evaluation Form-Revised, Marshall, Serran, & Cameron, 2010)

Scale Scale Alpha

Possible Range Mean SD Range %

Facilitator .88 4-20 18.59 1.74 15-20 92.5%

Group .87 6-30 27.59 3.25 19-30 91.9%

Total .92 10-50 46.18 4.88 35-50 92.4%

Overall Facilitator

Na 1-5 4.77 0.53 3-5 95.4%

Overall Group

Na 1-5 4.62 0.80 2-5 92.4%

Would you recommend this group to others? = 97% said Yes.

Factor Analysis of whole scale: 1 factor accounting for 59% of variance

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Therapist Post-Treatment Ratings - Domestic Violence Group

TRS-2* Mid

Treatment Post

Treatment t Sig Intellectual

Understanding 21.62 (3.07)

27.44 (3.58)

7.11 < .001

Acceptance / Demonstration

18.19 (2.86)

23.44 (3.78)

5.33 < .001

Total Score 39.81 (5.59)

50.87 (7.15)

6.67 < .001

*Marshall & Marshall, 2011

Outcome for Rockwood Psychological Services Sexual Offender Program - 2005

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Reoffence Treated* (N = 535)

Expected**

Sexual 3.2% 16.8%

General 13.6% 40.0%

*Mean follow-up = 5.4 years **Based on Static-99 and S.I.R.

Summary • Interventions for mentally ill and other offenders can

be effective • Proposed structure meets needs of clients, justice

system, and other stakeholders – Provides treatment needed to move through

system – Helps to reduce reoffending – Efficient use of resources

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Liam E Marshall, PhD Research & Academics Division and Provincial Forensics Division Waypoint Centre for Mental Health Care

Evidence-based interventions in forensic mental health and correctional settings

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