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An Overview of the Continuum of Care and Integrated Treatment Model Presented by Kelly Dahl North Sound Systems of Care Training Institute Western Washington University August 25, 2010. J uvenile R ehabilitation A dministration. Presentation Overview. Juvenile Justice in Washington State

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J uvenile r ehabilitation a dministration

An Overview of the Continuum of Care and Integrated Treatment Model

Presented by Kelly Dahl

North Sound Systems of Care Training Institute

Western Washington University

August 25, 2010

JuvenileRehabilitationAdministration


Presentation overview
Presentation Overview Treatment Model

  • Juvenile Justice in Washington State

  • An Overview of JRA

    Organizational Structure

    Facts and Figures

  • JRA’s Integrated Treatment Model

    Residential and Community Applications

    CBT/FFP Basic Principles


Juvenile Justice in Washington State Treatment Model

  • Juvenile Justice in Washington State is governed by Title 13 of the Revised Code of Washington (RCW)

  • The Juvenile Justice Act of 1977 (RCW 13.40) – Intent and Purpose

    • Make the juvenile offender accountable for his or her criminal behavior

    • Provide due process for juveniles alleged to have committed an offense

    • Provide necessary treatment, supervision, and custody for juvenile offenders

    • Provide for the handling of juvenile offenders by communities whenever consistent with public safety

    • Develop effective standards and goals for the operation, funding, and evaluation of all components of the juvenile justice system and related services at the state and local levels

    • Encourage the parents, guardian, or custodian of the juvenile to actively participate in the juvenile justice process


Continued: Juvenile Justice in Washington State Treatment Model

  • Determinate Sentencing and Sentencing Guidelines - court sets minimum and maximum sentence determined by offense seriousness and criminal history

  • “The goal of a determinate sentencing system is to ensure that offenders whose offenses and criminal histories are similar receive substantially similar sentences.” (Juvenile Disposition Manual 2006)

  • Manifest Injustice sentences – mitigating and aggravating factors may result in sentencing outside of a standard range

  • “When a court finds that a presumptive sanction would amount to an excessive penalty or would impose a serious and clear danger to society, it may impose a disposition that departs from the standard range.”

  • (Juvenile Disposition Manual 2006)


Continued: Juvenile Justice in Washington State Treatment Model

  • The Community Juvenile Accountability Act of 1997

  • CJAA is enacted into law “to provide a continuum of community-based programs that emphasize the juvenile offender's accountability for his or her actions while assisting him or her in the development of skills necessary to function effectively and positively in the community in a manner consistent with public safety.” (RCW 13.40.500)

  • This established Evidence Based Practices funding for:

    • Functional Family Therapy (FFT)

    • Aggression Replacement Training (ART)

    • Multi Systemic Therapy (MST)

    • Coordination of Services (COS)


Evidence based practices outcome evaluations
Evidence Based Practices Outcome Evaluations Treatment Model

  • Legislatively required evaluation was conducted to see if their investment in Evidence Based Practices was effective.

  • Washington State Institute for Public Policy (WSIPP) conducted the study

  • August 2002 interim outcome evaluation completed

    • Competence in and adherence to an Evidence Based Practice is critical to the effectiveness of the intervention

    • $7.50 of cost benefit*

    • 30% recidivism reduction

      *Cost Benefit = the savings from avoided crime costs for each tax dollar spent on the program.


Dshs mission
DSHS Mission Treatment Model

Improve the safety and health of individuals, families and communities by providing leadership and establishing and participating in partnerships.


Jra mission
JRA Mission Treatment Model

  • Protect the public, hold juvenile offenders accountable, and reduce criminal behavior through a continuum of preventative, rehabilitative, and transition programs in residential and community settings

  • JRA’s overall goal is to enhance public safety by preparing delinquent youth to become confident, competent, responsible adults


JRA Organizational Structure Treatment Model

  • Institution Programs

    • Oversees 4 institutions and 1 basic training camp.

  • Community Programs

    • Manages parole services, six community residential facilities (group homes), and two contracted community programs .

  • Operations Support Services

    • Provides fiscal oversight and operational support to the JRA divisions of Community Programs, Institution Services, and Treatment and Intergovernmental Programs.

  • Treatment and Intergovernmental Programs

    • Responsible for developing treatment program policies and standards. Oversees the Interstate Compact Program.


Jra youth profile
JRA Youth Profile Treatment Model

Youth committed to JRA custody by local juvenile courts have typically:

  • Committed a serious violent offense, or

  • Committed a series of minor offenses over time and exhausted local sanctions and interventions, and

  • Have an average sentence of 40 weeks


Jra youth profile 7 8 10
JRA Youth Profile Treatment Model(7/8/10)

  • 3% of youth arrested in WA end up in JRA

  • Male:Female 11:1

    (2004)

  • Ethnic Breakdown: JRAState (0-17)

    • White/Non-Hispanic: 45% 73%

    • African American: 19% 5%

    • Hispanic: 20% 13%

    • Native American: 3% 2%

    • Asian: 4% 7%

  • Age range of incarcerated: 8-20

    • 40% (261) are 16 or younger

    • 52% (343) are 17 and 18 years old


Residential population characteristics
Residential Population Characteristics* Treatment Model

  • Mental Health: 62%

  • Chemical Dependency: 55%

  • Cognitive Impairment: 43%

  • Sex Offender/Misconduct: 27%

  • Medically Fragile: 3%

  • Two Issues: 46%

  • Tri-Issue: 38%

  • Quad-Issue: 5%

*January 26, 2010 Snapshot Data


Residential offense profile
Residential Offense Profile Treatment Model

Youth in JRA care are at the very deep end of the juvenile justice system.

Their service and intervention needs are both acute and complex.

61% are Violent Offenders

18% have 8 or more prior offenses

Types of Current Offenses:

# %

Robbery 154 23.3

Assault 142 21.5

Burglary 113 17.1

Other Sex Offense 60 9.1

Rape/Rape of a Child 46 7.0

Other Offense 26 3.9

Murder/Manslaughter 20 3.0

Theft 20 3.0

Motor Vehicle Theft 20 3.0

Weapon Offense 19 2.9

Drug Offense 19 2.9

Arson 9 1.4

Parole Revocation 6 0.9

Malicious Mischief 5 0.8

Poss. Stolen Prop. 3 0.5

Kidnapping 2 0.3

Escape 1 0.2

Forgery 1 0.2

Criminal Trespass 0 0.0

n=660 July 8, 2010


Jra facilities and programs
JRA Facilities and Programs Treatment Model

Institutions (598 Beds – actual pop. = 570, 7/8/10)

Green Hill School, Chehalis Naselle Youth Camp, Naselle

Maple Lane School, Centralia Camp Outlook, Connell

Echo Glen Children’s Center, Snoqualmie

State Community Facilities (92 Beds – actual pop. = 83, 7/8/10)

Canyon View, Wenatchee Oakridge, Tacoma

Parke Creek, Ellensburg Ridgeview, Yakima (female)

Twin Rivers, Richland Woodinville, Woodinville

Contracted Programs (9 Beds – actual pop. = 7, 7/8/10)

Residential Treatment & Care, Spokane (6)

Benton/Franklin STTP (Short Term Transition Program) (3)

Functional Family Parole Services (433 Youth, 7/8/10)

Region 1, Spokane Region 4, Seattle

Region 2, Yakima Region 5, Tacoma, Bremerton

Region 3, Everett, Mount Vernon Region 6, Olympia, Vancouver


Jra continuum of care
JRA Continuum of Care Treatment Model

Residential Care: 669 youth (7/8/10)

Average Length of Stay: 44 Weeks (2010)

Institutions and Basic Training Camp

Community Facilities

Parole: 433 Youth (7/8/10)

Range = 4 to 6 months

Sex Offense = 24-36 months


JRA Placement and Treatment Continuum Treatment Model

County

Juvenile Courts:

Youth w/ Criminal offenses committed to JRA

Residential Placement in

JRA

JRA

Parole

No Longer Under JRA Jurisdiction

Screening, assessment, & testing for placement, treatment planning & service delivery

(Diagnostic, Chemical Dependency/Abuse, Client History, GAIN-SS, Suicide & Self-Harm Screen, Aggression/Vulnerability)

Community Connections / Resources

MHTP:

RSN's: Medicaid Eligible

Private Insurance

No Insurance—

Private pay or are unserved

Residential Services

Integrated Treatment Model:

Dialectical Behavior Therapy (DBT/CBT) Aggression Replacement Training ( ART) Moral Reconation Therapy (MRT) Residential Treatment and Care Program (RTCP); aka Multidimensional Treatment Foster Care (MTFC) Family Integrated Transitions (FIT)

Individual and Group Therapy

Psychiatric & Psychological Services

Medication & Med. Management

Education/Vocational Training

Chemical Dependency/Abuse Treatment

Sex Offender Treatment

Recreation

Cultural Programs

Parole Services

Integrated Treatment Model

Functional Family Parole

Functional Family Therapy

Family Integrated Transitions

Connected to MH services Medicaid Eligibility

Limited contracted MH Transitional Services

Sex Offender Treatment

DASA CD Services

DDD Coordination

Aggression Replacement Training (ART)

MentoringCommunity Connections


Framework for working with youth and their family
Framework for working with youth and their family Treatment Model

  • Committed to JRA/Placement Determined

    • Diagnostic Process

    • Institution

    • Youth Camp

    • Basic Training Camp

    • Community Facility

Youth Discharged from JRA

  • Functional Family Parole

  • Engage & Motivate

  • Support and Monitor Services

  • Generalize Skills

    • Whole Family Involved

  • JRA Residential Services

    • Screening / Assessment

    • School / Vocational

    • CBT/DBT skills training and coaching

    • Medical services

    • Specialized treatment

OUTCOMES

  • 45 Days before release—Transition meeting w/Family:

    • Parole or No Parole

    • Living arrangements

    • Service Connections


Jra integrated treatment model itm
JRA Integrated Treatment Model (ITM) Treatment Model

JRA implemented the Integrated Treatment Model(ITM) in 2003 to address the acute and complex treatment needs of youth committed to JRA care. The ITM incorporates best-practice and evidence-based interventions to address the needs of youth and their families from the point of admission through completion of parole aftercare.

Lessons Learned

  • Failure to adhere to and competently deliver evidence-based intervention models can, in fact, be counter productive

  • Success requires strict model adherence with supporting quality assurance and consultation

  • Environment is critically important to achieving positive outcomes. JRA is working hard to establish residential environments that make possible and support therapeutic intervention


Jra integrated treatment model the 5 critical functions of treatment
JRA INTEGRATED TREATMENT MODEL Treatment ModelThe 5 Critical Functions of Treatment


Jra treatment services
JRA Treatment Services Treatment Model

  • EVIDENCE BASED SERVICES:

    Dialectical Behavioral Therapy Functional Family Parole

    Cognitive Behavioral Therapy Functional Family Therapy

    Aggression Replacement Training Mentoring

    Family Integrative Transitions (FIT)

  • MODES OF TREATMENT

    Individual Counseling

    Group Skills Training

    Milieu Treatment

  • SPECIALIZED TREATMENT OTHER SERVICES

    Mental Health Psychiatric

    Substance Abuse Medical/Dental

    Sex Offender Education

    Vocational Training Recreation


What the itm creates
What the ITM Creates Treatment Model

  • A uniform set of skills

  • Behavioral targets that are clearly identified and addressed in a systematic fashion

  • Addresses youth and family issues in the context in which they occur

  • Identifies the role of staff across the continuum-of-care

  • Treatment approaches that vary based on the youth and family needs

  • Treatment plans are individualized

  • Multidisciplinary Team approach across continuum


ITM Treatment Model

CBT/DBT

FFP

Parole

Residential

Family Focus

Youth Focus

Emphasis on Engagement & Motivation

Validation

Reframing

Connecting Treatment to Goals

Reducing Blame & Negativity

Functions of Behavior are Examined

Relational & Hierarchical Assessment

Behavior Chain Analysis

Skill Generalization is the Ultimate Goal


Jra integrated treatment model

Principles – teaching, shaping, coaching, and reinforcing positive behavior

Developing skills for socially responsible living

Institutions:

Assess treatment needs

Begin process of adaptive skill development

Community Residential Facilities:

Transition youth and practice skills in a community setting

Parole Aftercare:

Support for generalization and maintenance of skills

Engagement of families in youth rehabilitation

JRA Integrated Treatment Model


Finding treatment priorities
Finding Treatment Priorities positive behavior

T

R

E

A

T

M

E

N

T

H

I

E

R

A

R

C

H

Y

  • Recent (or Historic) Parasuicidal Ideation, Threats, or Behavior.

  • Recent (or Historic) Aggressive Ideation, Threats, or Behavior.

  • Recent (or Historic) Escape Ideation, Threats, or Behavior.

  • Recent or Current Treatment-InterferingBehaviors.

  • Significant Quality of Life issues.

MentalHealth

Substance Abuse

Offense (Robbery)

FamilyIssues


Analyze the chain of events moment to moment over time behavior chain analysis
Analyze the chain of events positive behaviormoment-to-moment over time (Behavior Chain Analysis)

VULNERABILITIES

TARGET

BEHAVIOR

INITIAL CUE

  • LINKS

CONSEQUENCES


Understanding the problem

Vulnerabilities positive behavior

B

C

A

Cue

Function and Other Drivers

Links

Target Behavior

Outcomes

Understanding the Problem

Substance

Abuse


Cbt dbt skill modules
CBT/DBT Skill Modules positive behavior

  • Mindfulness or Observing

    Youth who are impulsive, Excessively judgmental, Easily distracted, Rigid thinkers, Youth who have difficulty solving problems

  • Interpersonal Effectiveness

    Unstable relationships, History of loss and grief issues, Poor peer selection, Lack of respect, and Lack of social skills

  • Emotion Regulation

    Intense anger, Intense shame, Emotional instability, and Low tolerance to frustration

  • Distress Tolerance

    Egregious suicide behavior, Acts of aggression, Impulsive self destructive behavior, Substance abuse or addiction, and Compulsive criminal behavior

  • Problem Solving

    Anger, Aggression, and Social skills


Treatment planning summary

T positive behavior

R

E

A

T

M

E

N

T

H

I

E

R

A

R

C

H

Y

Mental Health

Vulnerabilities

B

C

A

Cue

Substance Abuse

Function and Other Drivers

Links

Substance Abuse

Target Behavior

Outcomes

State the Target

Describe the Function

Pick Skills with Similar Function

Identify Steps to Block Outcomes

Identify Steps to Increase Skillful Behavior

Identify Cue Management Plan

ITP

Family Issues

Treatment Planning Summary

Robbery


Linked processes

Determine Content for positive behavior

Integrated Treatment Plan

Treatment Focus

Skill Selection

Intervention Plan

Drives Content & Structure

of

Our Daily Interactions with our

Clients

Linked Processes

Client History Review&

Behavior Chain Analysis

Flow should be visible


Functional family parole
Functional Family Parole positive behavior

CORE PRINCIPLES

  • Working Alliance

  • Relational (Family) Focus

  • Strength Based

  • Respect

  • Matching


Advantages of family focus
Advantages of Family Focus positive behavior

  • Issues arise through family and can begin to be solved there

  • With the family involved, changes can happen quicker...

    IF we can engage and motivate them

  • Family can support youth more effectively than youth on his/her own

  • Involvement is the first step toward persuasion…


Matching is a fundamental requisite for effectively engaging and changing families
MATCHING positive behavioris a fundamental requisite for effectively engaging and changing families

  • Match to the phaseof your responsibility - Do the right thing at the right time.

  • Match outcome goals to the family – Identify and strategize steps to become functional and positive within their own culture, communities, realities, etc.

  • Match to the clients- Do what it takes for them to feel you are working hard to respect and understand them, their language, norms, etc.

    mismatch results in “resistance”


ENGAGEMENT and positive behavior

MOTIVATION GOALS

Engagement

Motivation

  • Address and Reduce Negativity, Blame and Hopelessness

  • Create a Relational Focus

  • Maintain Balanced Alliance with all Participants

  • Help the Family see Different and More Productive Solutions


Ffp skills
FFP Skills positive behavior

  • Change Focus – from individual to relational

    • Relationship building – humor, curiosity, acknowledgement, strength based statements

    • Point processing

    • Sequencing

    • Interrupting/Diverting

  • Change Meaning – from blame and negativity to noble but misguided intent

    • Re-label

    • Reframe

    • Themes


  • What is reframing
    What is Reframing? positive behavior

    Reframing is an Interpersonal Processin which the you take the lead in suggesting that a problem behavior may not necessarily only have a malevolent motive; instead it could also include a more positive (but very misguided) intent.


    How to do it… positive behavior

    1. Validate/ Acknowledge

    The people involved and “the problem”

    Validate the emotion/pain the “bad behavior” produced

    2. Reframe

    motive, intention, goal, underlying emotional state—it’s not giving reasons or excusing behavior

    3. Assess acceptability/fit

    4. Change/continue


    Moving from engagement and motivation to support and monitor
    Moving from Engagement and Motivation to Support and Monitor positive behavior

    If we’ve consistently matched to, established a balanced alliance, created a relational focus, decreased negativity and blaming and created a sense of hope…

    We will also have created a motivational and informational base, which results in having the necessary credibility to match the youth/family to a program or offer recommendations that will help them make or continue necessary changes


    Support and monitor goals activities
    Support and Monitor positive behaviorgoals/activities

    • Goals:

      • Move to less active role

      • Support family and change agent

      • Ensure program has effective

        • change process and element

      • Eliminate barriers

    • Activities:

      • Monitor and support change

      • Structure supportive activities

      • Encourage and reinforce family members (and providers?)

      • Be an advocate of effective

        • services/programs


    Support and monitor service and activity plans
    Support and Monitor positive behaviorService and Activity Plans

    Support Activities

    • Employment

    • Spiritual Related

    • Youth oriented recreation/leisure

    • Family oriented recreation/leisure

    • Any significant, regularly occurring activity that impacts risk/protective factors

      Monitor Services

    • Education

    • Treatment

      Mental health, YSO, Drug/Alcohol, FFT, FIT, MST, ART

    • Mentoring

    • Employment Training


    Generalization phase goals activities focus
    Generalization Phase positive behaviorgoals/activities/focus

    • Goals:

      • become active again

      • reinforce positive change

      • help generalize change

    • Activities:

      • use the community

      • maintain community contacts

      • family case manager role

      • target generalization change based on relational assessment

    • Focus:

      • relationships between the family and community

      • using assessment knowledge


    Linking to Change Program positive behavior

    Linking skills learned in facility to community context

    POS I T I VE

    TERMI NAT I ON

    Generalize

    PRERELEASE

    PREP

    Maintain Facility Treatment Plan

    (no additional services)

    Link to…

    Gen’lization

    Engage & Motivate

    Support & Monitor

    Link to…

    Gen’lization

    Evidence-Based or other Change Program

    Support and Monitor Program and Fit of Skills to Community Context


    Relapse prevention
    Relapse Prevention positive behavior

    1. Identify situations where problem may occur

    2. Identify strategies to use when problem reoccurs

    3. Predict the problem to reoccur (The best predictor of future behavior is past behavior)

    4. Repetitive skill use and reinforcement helps build expectation that new skills will work in similar/different situations over time


    The outcomes
    The Outcomes positive behavior

    Cognitive Behavioral Therapy in Residential Care Since implementing the Integrated Treatment Model, JRA has seen a 60% reduction in assaultive behavior in institutions and similar reductions in calls from living units for security staff assistance, also reductions in self-harm behavior

    Dialectical Behavioral Therapy(DBT) and it’s related skill sets is the primary cognitive-behavioral intervention used with youth in JRA residential care. A 2002 WSIPP study of JRA youth involved in a DBT pilot-program at Echo Glen Children’s Center shows a 15% reduction in 18 month felony recidivism. However, a future study with a larger sample size is needed to determine conclusively if DBT reduces recidivism

    Family Integrative Therapy (FIT) is an intervention for youth with co-occurring mental health and substance abuse disorders that uses a combination of evidence-based approaches involving youth and their families. The program begins in residential care and continues when youth are released to parole supervision. A 2004 WSIPP study shows a 33.5% reduction in felony recidivism for youth involved in FIT and future cost savings of $3.15 for each dollar spent

    Functional Family Parole (FFP) In a recent study conducted by the University of Indiana, 30 percent of youth who received FFP from highly adherent counselors were convicted of a new felony within 12-months of release compared with 35 percent of the matched control group. An 18 month post release study is being finalized


    SPECIAL THANKS TO… positive behavior

    DAN SCHAUB, JRA Mental Health Program Administrator

    LAURIE HART, JRA FFP Program Administrator

    PAMALA SACKS-LAWLAR, JRA Substance Abuse Administrator

    LISA MCALLISTER, JRA FFT Quality Assurance Administrator

    DR. HENRY SCHMIDT, Former JRA Clinical Director

    …FOR THEIR HELP AND INPUT INTO THIS PRESENTATION


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