Henry Schmidt III, Ph.D.Henry Schmidt III, Ph.D.

Clinical DirectorClinical Director

Cory RedmanCory Redman

Substance Abuse Program AdministratorSubstance Abuse Program Administrator

Washington Juvenile Rehabilitation AdministrationWashington Juvenile Rehabilitation AdministrationCo-occurring Disorders ConferenceCo-occurring Disorders Conference

Yakima, WashingtonYakima, Washington

October 2, 2007October 2, 2007

JRA’s Integrated Treatment JRA’s Integrated Treatment Model: Working with Model: Working with

Complex Client PopulationsComplex Client Populations

Juvenile Rehabilitation Juvenile Rehabilitation Administration Administration Youth ProfileYouth Profile

3% of youth arrested in WA end up in JRA.3% of youth arrested in WA end up in JRA. Age range of incarcerated: 10-21Age range of incarcerated: 10-21 Male:Female Male:Female 8:18:1 (2002)(2002)

Ethnic Breakdown: Ethnic Breakdown: JRAJRA State State (0-17)(0-17) White/Non-Hispanic:White/Non-Hispanic: 59%59% 73%73% African American: African American: 21%21% 6% 6% Hispanic: Hispanic: 12%12% 12%12% Native American: Native American: 5%5% 2% 2% Asian: Asian: 3% 3% 7% 7%

Sex Offenders: Sex Offenders: 21%21% Violent Offenders: 46%Violent Offenders: 46%

Residential Population Residential Population Characteristics*Characteristics*

Mental Health:Mental Health: 62%62% Chemical Dependency:Chemical Dependency: 66%66% Sex Offender:Sex Offender: 21%21% Cognitive Impairment:Cognitive Impairment: 37%37%

Two Issues:Two Issues: 36%36% Tri-Issue:Tri-Issue: 19%19% Quad-Issue:Quad-Issue: 6%6%

*2006 Snapshot Data

JRA Continuum of CareJRA Continuum of Care850 Youth in Residential CareLength of Stay: Mode = 15-36 Weeks

Average = 1 year

3 Max Security Institutions, 3 Max Security Institutions, 1 Med Security Institution, 1 Med Security Institution, 1 Basic Training Camp1 Basic Training Camp

8 community facilities8 community facilities

750 Youth on ParoleMinimum = 6 monthsSex Offense = 24-36 monthsYouth with families, in foster care, or in group homes

Resources to implement Resources to implement treatmenttreatment

Mental health professionalsMental health professionals Institutions: Institutions:

Psychology: 6 Master’s/Ph.D. cliniciansPsychology: 6 Master’s/Ph.D. clinicians Psychiatry: Part-time at 3 institutions, Psychiatry: Part-time at 3 institutions,

telemedicine @ medium security telemedicine @ medium security institutioninstitution

Community Facilities: Contracted Community Facilities: Contracted servicesservices

Parole: Contracted services, FFTParole: Contracted services, FFT

Treatment ProgramsTreatment Programs Residential Mental Health UnitsResidential Mental Health Units

5 Residential Mental Health Units5 Residential Mental Health Units 1 Extended Care Mental Health Unit1 Extended Care Mental Health Unit

6 Programs for Youths who Sexually 6 Programs for Youths who Sexually OffendOffend

Chemical Dependency ProgramsChemical Dependency Programs 3 Intensive Inpatient Programs3 Intensive Inpatient Programs 1 Intensive Outpatient Program1 Intensive Outpatient Program 1 Outpatient Program1 Outpatient Program 1 Recovery House1 Recovery House All staffed by Chemical Dependency All staffed by Chemical Dependency

ProfessionalsProfessionals

ITM: Taking Advantage of ITM: Taking Advantage of ContextContextResidential SettingResidential Setting

Youth are separate from familyYouth are separate from family ‘‘Wake-up call,’ motivate youth to changeWake-up call,’ motivate youth to change Intensive focus on youth skill developmentIntensive focus on youth skill development Reinforce success, increase hopeReinforce success, increase hope

Families may gain ‘respite’, reliefFamilies may gain ‘respite’, relief Often have been struggling with youth’s Often have been struggling with youth’s

behavior in the communitybehavior in the community Relief that youth is safe, receiving treatmentRelief that youth is safe, receiving treatment Increase hope for future as youth behavior Increase hope for future as youth behavior

improvesimproves Collaborate with staff on youth effort toward Collaborate with staff on youth effort toward

goals (e.g., education, vocation, attitude)goals (e.g., education, vocation, attitude) ‘‘Reframe’ youth behavior, reduce labeling and Reframe’ youth behavior, reduce labeling and

blameblame

Taking Advantage of Taking Advantage of ContextContext

Community SettingCommunity Setting Youth and familyYouth and family

Increase motivation of family to work with Increase motivation of family to work with therapist, servicestherapist, services

Reduce negativity, blaming in familyReduce negativity, blaming in family Create a relational understanding of Create a relational understanding of

problems, solutionsproblems, solutions Increase positive interactionsIncrease positive interactions Work for “small, obtainable” change in Work for “small, obtainable” change in

family interactionsfamily interactions Link to services in communityLink to services in community Impact siblings of youthful offendersImpact siblings of youthful offenders

Typical Targets for Typical Targets for Forensic TreatmentForensic Treatment

RecidivismRecidivism Violent FelonyViolent Felony FelonyFelony OtherOther

Health and Safety in Residential Health and Safety in Residential ProgramsPrograms Self-injurious behaviorSelf-injurious behavior AssaultAssault EscapeEscape ContrabandContraband

Targeting – Balanced Targeting – Balanced ViewView

Reducing Dysfunctional BehaviorReducing Dysfunctional Behavior Reducing Risk Factors for Dysfunctional Reducing Risk Factors for Dysfunctional

BehaviorBehavior

Strengthening Pro-social Long-term Strengthening Pro-social Long-term GoalsGoals

Increasing Skills, Protective FactorsIncreasing Skills, Protective Factors Improving family communication and Improving family communication and

functioningfunctioning Increasing Hope, Creating a Life worth Increasing Hope, Creating a Life worth

LivingLiving

Working with Complex Working with Complex ClientsClients

Most clients have multiple targetsMost clients have multiple targets All clients have multiple risk factors for each All clients have multiple risk factors for each

targettarget Many clients have special treatment Many clients have special treatment

considerationsconsiderations

Across the Continuum of CareAcross the Continuum of Care Maximum, medium security institutions, Maximum, medium security institutions,

work camp, basic training campwork camp, basic training camp Community facilitiesCommunity facilities Parole, with family.Parole, with family.

Treatment DemandsTreatment Demands

Evidence-basedEvidence-based For deep-end adolescent delinquent For deep-end adolescent delinquent

populationpopulation Address multiple targetsAddress multiple targets In different contexts and settingsIn different contexts and settings Culturally sensitiveCulturally sensitive Strengths-basedStrengths-based

What works: High Risk What works: High Risk Offenders?Offenders?

CBT-Social Learning ApproachesCBT-Social Learning Approaches ModelingModeling ReinforcementReinforcement Graduated practice (“Shaping”)Graduated practice (“Shaping”) Role PlayRole Play ExtinctionExtinction Concrete Verbal Suggestions (“coaching”)Concrete Verbal Suggestions (“coaching”)

Family-based community interventions.Family-based community interventions.

National Institute of Corrections: CBT Strategiesto Change Offender Behavior Conference, 1997

JRA’s Integrated Treatment JRA’s Integrated Treatment ModelModel

Residential Program: DBTResidential Program: DBT School, GED and Vocational programmingSchool, GED and Vocational programming Aggression Replacement TrainingAggression Replacement Training Family Integrated TransitionsFamily Integrated Transitions

Community Program: FFPSCommunity Program: FFPS Family Integrated TransitionsFamily Integrated Transitions Functional Family TherapyFunctional Family Therapy Drug and Alcohol treatment (outpatient)Drug and Alcohol treatment (outpatient) Youth with Sex Offenses treatment Youth with Sex Offenses treatment

(outpatient)(outpatient)

Why Choose CBT?Why Choose CBT? The most empirically supported The most empirically supported

psychosocial treatment approachpsychosocial treatment approach Efficacious for symptoms of many Axis I, Efficacious for symptoms of many Axis I,

some Axis II disorderssome Axis II disorders Elements are able to be implemented by Elements are able to be implemented by

individuals w/o advanced degreesindividuals w/o advanced degrees Effective across levels of cognitive Effective across levels of cognitive

functioningfunctioning Principles of learning fit well with Principles of learning fit well with

behavioral management programsbehavioral management programs

Desired elements of CBT Desired elements of CBT ProgramProgram

Excellent at engaging, retaining Excellent at engaging, retaining clients (mandated population)clients (mandated population)

Skills-based (strengths-based)Skills-based (strengths-based) Addresses multiple targets Addresses multiple targets

comfortablycomfortably Modules for individual, group, family Modules for individual, group, family

workwork ManualizedManualized Results generalize to community Results generalize to community

settingssettings

Which CBT Program?Which CBT Program?Risk factors for dysfunctional behavior across Risk factors for dysfunctional behavior across

JRA youth:JRA youth: Poor problem-solving skillsPoor problem-solving skills Poor emotion regulationPoor emotion regulation Behaviorally dysregulated, low distress Behaviorally dysregulated, low distress

tolerancetolerance Poor interpersonal skillsPoor interpersonal skills Fluid definition of self (adolescence)Fluid definition of self (adolescence) Fluid or oppositional valuesFluid or oppositional values Over-interpretation of hostile intent in acts of Over-interpretation of hostile intent in acts of

othersothers

Dialectical Behavior Dialectical Behavior TherapyTherapy

Designed for difficult-to-treat, complex Designed for difficult-to-treat, complex clientsclients

Highly effective at retaining clientsHighly effective at retaining clients Addresses multiple targets in hierarchical Addresses multiple targets in hierarchical

fashionfashion Evidence for improvement of variety of Evidence for improvement of variety of

specific behaviors, symptomsspecific behaviors, symptoms Synthesizes practices from well-Synthesizes practices from well-

established cognitive-behavioral established cognitive-behavioral interventionsinterventions

Linehan, 1993

DBT AdaptationsDBT Adaptations Substance AbuseSubstance Abuse

Linehan et al. (1999)Linehan et al. (1999) AdolescentsAdolescents

Outpatient, Rathus & Miller (2002)Outpatient, Rathus & Miller (2002) Inpatient, Katz et al. (2004)Inpatient, Katz et al. (2004)

Residential settingsResidential settings Inpatient psychiatric, Swenson et al. (2001)Inpatient psychiatric, Swenson et al. (2001) Forensic inpatient - McAnn, Ball, Ivanoff Forensic inpatient - McAnn, Ball, Ivanoff

(2000)(2000) Washington State JRA – Trupin et al. (2002) Washington State JRA – Trupin et al. (2002)

Other Disorders: Batterers, couplesOther Disorders: Batterers, couples

Why DBT and Why DBT and Substance Use Disorder Substance Use Disorder

(SUD)?(SUD)? High co-occurrence of diagnosesHigh co-occurrence of diagnoses BPD with Substance Use Disorder (39%-BPD with Substance Use Disorder (39%-

84%)84%) Controlling for SUD BPD criterion (57%; Dulit et Controlling for SUD BPD criterion (57%; Dulit et

al, 1990)al, 1990) SUD with BPD (13% - 66%)SUD with BPD (13% - 66%) Substance users with BPD are more Substance users with BPD are more

disturbed than those w/o a personality disturbed than those w/o a personality disorderdisorder

Note: Linehan’s original studies eliminated subjects Note: Linehan’s original studies eliminated subjects meeting criteria for substance dependencemeeting criteria for substance dependence

Why DBT and Why DBT and Adolescent Substance Use?Adolescent Substance Use?

Behavioral DyscontrolBehavioral Dyscontrol Truancy, criminality, substance use, self-injury Truancy, criminality, substance use, self-injury

Emotional DyscontrolEmotional Dyscontrol Low-skilled in identifying and regulating Low-skilled in identifying and regulating

emotionsemotions Cognitive Rigidity Cognitive Rigidity (developmental)(developmental)

b/w thinking, oppositional, rule-governed b/w thinking, oppositional, rule-governed morals morals

Interpersonal IssuesInterpersonal Issues Socially isolated or shifting groups, deviant Socially isolated or shifting groups, deviant

peers, etc.peers, etc. Issues of Self Issues of Self (developmental)(developmental)

Unstable sense of self, low self-esteemUnstable sense of self, low self-esteem

Treatment Target Treatment Target HierarchyHierarchy

Decreasing:Decreasing:1. Suicidal, assaultive or AWOL behavior1. Suicidal, assaultive or AWOL behavior2. Treatment-interfering or program-2. Treatment-interfering or program-

destructive behaviordestructive behavior3. Quality-of-life-interfering behavior3. Quality-of-life-interfering behavior

Increasing:Increasing:1. Behavioral skill1. Behavioral skill2. Goal-directed behavior2. Goal-directed behavior3. Ability to structure own environment3. Ability to structure own environment4. Life worth living, Capacity for joy, 4. Life worth living, Capacity for joy,

connectionconnection

Structured Skill Structured Skill ModulesModules

Skill SetSkill Set ObservingObserving

Interpersonal Interpersonal EffectivenessEffectiveness

Emotion Emotion RegulationRegulation

Distress Distress ToleranceTolerance

Problem-solvingProblem-solving

Symptom Cluster Symptom Cluster B/W thinking, Impulsivity, B/W thinking, Impulsivity,

Values, MisinterpretationValues, Misinterpretation Social isolation, Deviant Social isolation, Deviant

Peers, HostilityPeers, Hostility Emotional Emotional

DysregulationDysregulation Behavioral Dysregulation, Behavioral Dysregulation,

Frustration/BoredomFrustration/Boredom Short-term solutions.Short-term solutions.

Basics of DBTBasics of DBT

JRA’s Inpatient DBT-SUD JRA’s Inpatient DBT-SUD ModelModel

Individual sessions with case Individual sessions with case managermanager

Skill acquisition groupsSkill acquisition groups Skill generalization groupsSkill generalization groups Milieu interventionMilieu intervention Family skills groupsFamily skills groups Staff meetingsStaff meetings Psychopharmacology (for mental Psychopharmacology (for mental

health symptoms)health symptoms)

Functions of Functions of Comprehensive CBTComprehensive CBT

Enhance Client MotivationEnhance Client Motivation Acquire SkillsAcquire Skills Generalize SkillsGeneralize Skills Structure Environment for Structure Environment for

TreatmentTreatment Enhance Therapist Motivation and Enhance Therapist Motivation and

SkillsSkills

Important ElementsImportant Elements

DIALECTICS - Balance of Acceptance v. DIALECTICS - Balance of Acceptance v. ChangeChange

BEHAVIORAL ASSUMPTIONSBEHAVIORAL ASSUMPTIONS Clients are doing the best that they canClients are doing the best that they can Maladaptive behavior occurs because of:Maladaptive behavior occurs because of:

Lack of skills to do otherwiseLack of skills to do otherwise History of it being reinforcedHistory of it being reinforced Strong contextual risk factorsStrong contextual risk factors

Thus, the behavior makes sense in Thus, the behavior makes sense in contextcontext

DBT Treatment DBT Treatment HierarchyHierarchy

DECREASEDECREASE Suicidal, Self-Injurious BehaviorSuicidal, Self-Injurious Behavior Treatment-Interfering BehaviorTreatment-Interfering Behavior Quality-of-Life Interfering BehaviorQuality-of-Life Interfering Behavior

Behaviors are targeted Behaviors are targeted sequentiallysequentially

Only one or two targets at a Only one or two targets at a timetime

DBT-SUDDBT-SUD Substance use is top quality-of-life Substance use is top quality-of-life

interfering targetinterfering target

DBT Assessment and DBT Assessment and Treatment PlanningTreatment Planning

Finding Treatment Finding Treatment PrioritiesPriorities

MentalMental HealthHealth

Substance AbuseSubstance Abuse

Offense (Robbery)Offense (Robbery)

FamilyFamily IssuesIssues

TTRREEAATTMMEENNTT

HHIIEERRAARRCCHHYY

A. Recent (or Historic) ParasuicidalParasuicidal Ideation, Threats, or Behavior.

B. Recent (or Historic) AggressiveAggressive Ideation, Threats, or Behavior.

C. Recent (or Historic) EscapeEscape Ideation, Threats, or Behavior.

D. Recent or Current Treatment-InterferingTreatment-Interfering BehaviorsBehaviors.

E. Significant Quality of Quality of LifeLife issues.

F.F. Significant Treatment Significant Treatment ConsiderationsConsiderations.

INITIAL CUE

VULNERABILITIESTARGET

BEHAVIOR

CONSEQUENCESLINKS

Analyze the chain of eventsAnalyze the chain of eventsmoment-to-moment over moment-to-moment over

time.time.

Function and Function and Other DriversOther Drivers

Understanding the Understanding the ProblemProblem

BBCCAA

VulnerabilitiesVulnerabilities

CueCue

LinksLinks

Target BehaviorTarget Behavior

OutcomesOutcomes

Substance Substance AbuseAbuse

Treatment Planning Treatment Planning SummarySummary

Mental HealthMental Health

Substance AbuseSubstance Abuse

Family IssuesFamily Issues

TTRREEAATTMMEENNTT

HHIIEERRAARRCCHHYY

Substance AbuseSubstance Abuse

State the TargetState the Target Describe the FunctionDescribe the Function Pick Skills with Pick Skills with

Similar FunctionSimilar Function Identify Steps to Block Identify Steps to Block

OutcomesOutcomes Identify Steps to Identify Steps to

Increase Skillful Increase Skillful BehaviorBehavior

Identify Cue Identify Cue Management PlanManagement Plan

ITPITP

BBCCAA

VulnerabilitiesVulnerabilities

CueCue

LinksLinks

Target BehaviorTarget Behavior

OutcomesOutcomes

Function and Function and Other DriversOther Drivers

RobberyRobbery

Linked ProcessesLinked ProcessesClient History ReviewClient History Review &&Behavior Chain AnalysisBehavior Chain Analysis

Flow

shou

ld b

e v

isible

Flow

shou

ld b

e v

isible

Our Daily Interactions with our Our Daily Interactions with our ClientsClients

Drives Content & Structure of

Integrated Treatment PlanIntegrated Treatment Plan

Determine Content for

Intervention PlanSkill Selection

Treatment Focus

Adapted Behavior Adapted Behavior ParadigmParadigm

Vulnerabilities

BoredLonelyFriends support the behaviorFamily members model behaviorHistory of behavior being reinforced

CueEmotion DysregulationCognitive Distortion

Target BehaviorOutcomes

DBT Treatment ApproachDBT Treatment ApproachVulnerabilities

BoredLonelyFriends support the behaviorFamily members model behaviorHistory of behavior being reinforced

CueEmotion DysregulationCognitive Distortion

Target BehaviorOutcomes

Block

Outcomes

Problem-solve the Cue

Block Targ

et

Behavior

Decrease Dysregulation

Functional Family Functional Family Parole ServicesParole Services

Generalize Monitor & Support

PRERELEASE

PREP

POS.

TERMINATION

Engage & Motivate

Link to…Gen

’liza

tio

nEvidence-Based or other

Change Program

Link

to…

Maintain Facility Treatment Plan (no additional services)

Gen’lization

Functional Family Parole Intervention Program

©FFTinc

Engagement/Motivation Phase Goal 1: Engagement/Motivation Phase Goal 1:

The Working AllianceThe Working Alliance

FFPS attempts to create a FFPS attempts to create a balanced alliancebalanced alliance with each with each family member whereby they family member whereby they ….….

•TrustTrust you, and believe you have the you, and believe you have the expertiseexpertise to to help themhelp them•Believe you are Believe you are working hardworking hard to to understandunderstand their their emotions, valuesemotions, values•Experience that you are Experience that you are working hardworking hard to to respectrespect and value them, [despite their (often) awful and value them, [despite their (often) awful behavior]behavior]

©FFTinc

FFPS Engagement/Motivation:FFPS Engagement/Motivation:

How Do We Move To A Positive How Do We Move To A Positive Alliance?Alliance?

- - Reduce Blaming and Negativity / Reduce Blaming and Negativity / HopelessnessHopelessnessChange…..

-meaning through Reframing & Themes

-intent /purpose-meaning

Interrupt….--negative interaction patterns

-blaming

Attempt to….--reduce blame and retain personal responsibility

-establish relational focus for the problem-open new possible solutions

In order to:Motivate to go to a resource

Hook up with resource/service

©FFTinc

Engagement/Motivation Interventions…Engagement/Motivation Interventions…

Reframing & ThemesReframing & Themes … …developing a relational threaddeveloping a relational thread

Presented ThemePresented Theme --causal attributions are individual/othercausal attributions are individual/other -emotional valence is negative-emotional valence is negative -blaming interactions-blaming interactions

Organizing Theme/FrameOrganizing Theme/Frame-problems are family/relationally -problems are family/relationally attributedattributed-non-blaming interactions-non-blaming interactions -emotional valence is positive, hopeful-emotional valence is positive, hopeful

ReframingReframing

©FFTinc

Relational “Functions”Relational “Functions” ““Space between”people can best be Space between”people can best be

explained by:explained by:

Goal..understand and use…Goal..understand and use…Attempting to change these basic motivational Attempting to change these basic motivational

components of human behavior in just a few sessionscomponents of human behavior in just a few sessionsis clinically impossible and ethically inappropriateis clinically impossible and ethically inappropriate

““When X relates to Y, the When X relates to Y, the typical relational typical relational patternpattern (behavioral sequence within the relationship (behavioral sequence within the relationship

)) is characterized by degrees of: is characterized by degrees of:RelatednessRelatedness….contact vs. distance ….contact vs. distance

(psychological intensity)(psychological intensity)HierarchyHierarchy….relational control/influence….relational control/influence

©FFTinc

Support/Monitor Change: Support/Monitor Change: Phase 2Phase 2

goals & activities (if services)goals & activities (if services)

Activities:•Refer to services•Monitor change •Structure supportive activities•Encourage and reinforce family

members (and providers?)•Be an advocate for effective services and programs

Goals:•Move to less active role•Support family and change agent•Ensure program has effective

change process and element•Eliminate barriers

©FFTinc

Select a change program that…Select a change program that… can impact “core” needs can impact “core” needs enhances/capitalizes on skills learned in facilityenhances/capitalizes on skills learned in facility best best matches tomatches to relational styles in family, relational styles in family, is one at which they can be successful, that won’t overwhelmis one at which they can be successful, that won’t overwhelm and is logistically possible. Don’t over-refer…and is logistically possible. Don’t over-refer…

Know the communityKnow the community Have current list of providers/agenciesHave current list of providers/agencies Know the transportation systemKnow the transportation system Know the school system/contactsKnow the school system/contacts

Use contacts and constantly develop new ones…Use contacts and constantly develop new ones… have specific referral persons in agencies (schools, mental have specific referral persons in agencies (schools, mental

health agencies, YMCA, boys/girls clubs)health agencies, YMCA, boys/girls clubs)

LINKING…LINKING…

©FFTinc

GeneralizationGeneralizationPositive Termination Phase…Positive Termination Phase…

goals/activities/focusgoals/activities/focus

Activities:•use the community•maintain/use community

contacts•target generalization based on relational assessment

Focus:•relationships between the family and community

Goals:•Become active again•Reinforce positive change•Help generalize change

©FFTinc