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RNR-Based Assessment and Rehabilitation in Corrections:  Severe Mental Illness, Substance Abuse, and Trauma. Kirk Heilbrun, Ph.D. David DeMatteo, JD, PhD Presented for the Pennsylvania DOC and Sponsored by Community Education Centers.

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RNR-Based Assessment and Rehabilitation in Corrections:  Severe Mental Illness, Substance Abuse, and Trauma

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RNR-Based Assessment and Rehabilitation in Corrections:  Severe Mental Illness, Substance Abuse, and Trauma

Kirk Heilbrun, Ph.D.

David DeMatteo, JD, PhD

presented for the pennsylvania doc and sponsored by community education centers

Presented for the Pennsylvania DOC and Sponsored by Community Education Centers

DOC Training Academy

Elizabethtown, PA

April 2011



Overview of RNR:  Evidence and Implications (Heilbrun)

RNR-Based Assessment & Treatment of Individuals w/

Substance Abuse (DeMatteo)

Severe Mental Illness (Heilbrun)

Trauma Histories (DeMatteo)

Small group exercise

  • Electronic version of handout available (RNR_ DOC_CEC_4_28_11)
  • Electronic version of slides available (RNR_DOC_CEC_slides_4_28_11)
  • See (


rnr overview
RNR Overview
  • What is risk-need-responsivity?
    • Model of correctional intervention based on the factors of risk, need, and responsivity
    • Risk factor
      • Risk principle
    • Need factor
      • Need principle
    • Responsivity factor
      • General and specific responsivity
rnr overview1
RNR Overview
  • Is there research supporting this model?
    • Evidence that adherence to the model results in a 35% reduction in recidivism
    • Meta-analyses
      • RNR for adult, juvenile, violent, female, and sex offenders
      • Risk principle
rnr overview2
RNR Overview
  • Other research support on
    • RNR for different populations/programs
      • Community-based electronic monitoring
      • Substance abusing populations
      • Drug court
      • Prison-based programs
    • Benefits of targeting high risk offenders
    • Potential iatrogenic effects of interventions for low-risk offenders
rnr overview3
RNR Overview
  • How well are we doing with RNR?
    • Studies of individual program adherence to RNR show limited adherence in applied settings
  • Inconsistencies in the research
    • RNR more effective with certain populations (e.g., less supported among violent offenders in meta-analysis)
    • Some studies have failed to find significant effects
rnr overview4
RNR Overview
  • Gaps in the research
    • Lack of research examining RNR on an individual level
    • Studies have started to look at the risk principle, and generally find support for matching service intensity to risk level
rnr overview5
RNR Overview
  • Gaps in the research (cont.)
    • Little research on “treatment fit,” or matching to interventions based on needs
    • Little research on specific responsivity
      • There is value in assessing individual factors that may influence how treatment succeeds, such as IQ, mental illness, culture, motivation, and gender
rnr overview6
RNR Overview
  • Problems in implementing RNR
    • Not using up-to-date assessment tools
    • Failure to base interventions on assessment results
    • Lack of any risk/needs tools in intervention process
    • When risk/need information is available, it is commonly not used effectively
rnr overview7
RNR Overview
  • Guidelines for evidence-based RNR
    • Administer a good risk/needs tool to identify risk level and criminogenic needs
    • Match offender into programs based on the present needs
    • Consider specific responsivity concerns, such as gender, mental illness, trauma history
rnr overview8
RNR Overview
  • RNR and Serious Mental Illness
    • Offenders with serious mental illness generally have the same risk factors as other offenders
    • Evidence that providing mental health treatment does not reduce recidivism
    • Should focus on risk, need, responsivity factors
substance abuse overview
Substance Abuse Overview

Scope of the Problem

  • High rates of drug-involved criminal offenders
    • Arrestees (Mdn: 67% of males & 68% of females)
    • Inmates (80%)
    • Probationers (67%)
    • Parolees (80%)
  • Strong relationship between drug use & crime
substance abuse overview1
Substance Abuse Overview

Scope of the Problem

  • 80% of offenders report prior drug use
  • 50% of state inmates meet criteria for drug abuse/dependence (Karberg & James, 2005)
  • But only 40% participate in drug treatment while incarcerated (Mumola & Karberg, 2006)



substance abuse overview2
Substance Abuse Overview

Relapse & Recidivism

  • 95% relapse rate within 3 years of release
  • 50% recidivism rate within 1 year of release
  • Within 3 years of release –
    • 68% re-arrested
    • 47% re-convicted
    • 25% re-sentenced for new crime
    • 25% return to prison for testing drug-positive



substance abuse overview3
Substance Abuse Overview

Public Safety vs. Public Health

  • Public Safety
    • In-prison treatment
    • Intermediate sanctions
    • Civil commitment
  • Public Health
    • Initiation
    • Attrition



substance abuse assessment
Substance Abuse Assessment

Assessment Considerations

  • Brief screen vs. in-depth assessment
  • Psychometrically sound
  • Assessment of individual risks & needs
  • Assessment of multiple domains
substance abuse assessment1
Substance Abuse Assessment

Assessment Considerations

Ongoing assessment

Administration time

Interpretation by nonclinical staff



substance abuse assessment2
Substance Abuse Assessment

Assessment Tools

TCU Drug Screen

Level of Service/Case Management Inventory

Addiction Severity Index

Global Assessment of Individual Needs



substance abuse assessment3
Substance Abuse Assessment

Assessment Tools

Substance Abuse Screening Instrument

Offender Profile Index

Substance Abuse Subtle Screening Inventory



substance abuse treatment
Substance Abuse Treatment

Intervention Considerations

Client’s recognition of drug problem

Motivation vs. coercion

Matching services to needs

High-risk vs. low-risk

Recognizing diversity



substance abuse treatment1
Substance Abuse Treatment

Intervention Considerations

Comprehensive & evidence-based practices

Medical care & medication

Adaptive interventions

Service integration & continuity of care




substance abuse treatment2
Substance Abuse Treatment

Correctional-based Interventions

Increasing motivation

Cognitive-behavioral therapy

Substitution treatment

Contingency management



substance abuse treatment3
Substance Abuse Treatment

Correctional-based Interventions

Case management

Therapeutic communities

Aftercare planning



substance abuse treatment4
Substance Abuse Treatment

Community-based Interventions

Restrictive Intermediate Punishment (RIP)

Outpatient, halfway house, short-term residential/detox, & long-term residential

House offenders & monitor program compliance

Diversion Programs

Examples: drug courts, mental health courts, veterans courts, re-entry courts



gender differences in substance abuse treatment
Gender Differences in Substance Abuse Treatment
  • Increasing numbers of women are incarcerated
    • From 1995-2005, female inmate population increased 57%
    • Since 1980, female inmate population has increased 336%
  • Most growth in inmate population is due to drug-related offenses
gender differences in substance abuse treatment1
Gender Differences in Substance Abuse Treatment

Female vs. Male Offenders

  • Higher rates of (hard) drug use
  • More physical health problems
  • Higher rates of mental health problems
  • History of victimization/abuse/trauma



gender differences in substance abuse treatment2
Gender Differences in Substance Abuse Treatment

Female vs. Male Offenders

  • Lower rates of employment
  • Higher rates of financial difficulty
  • Unhealthy social relationships



factors influencing re arrest
Factors Influencing Re-arrest
  • Predictors of re-arrest within 1 year
    • Younger age
    • Fewer total days in aftercare
    • Longer lifetime incarceration
    • Co-occurring psychiatric disorder
    • Lower levels of education
    • Unemployment (males)
    • Parental responsibilities (females)
severe mental illness assessment
Severe Mental Illness: Assessment
  • Assessment of mental health problems
  • Assessment of risk of violent and general reoffending
mental health assessment
Mental Health Assessment
  • Screen for mental health problems generally
  • Specifically, screen for psychiatric symptoms, substance abuse, and suicidality
  • Incorporate information from a combination of records review, interview, and self-report inventories
risk assessment
Risk Assessment
  • Major predictors of general and violent recidivism comparable for mentally disordered and nondisordered offenders
  • Psychopathology important in managing mentally disordered offenders, but
  • In terms of risk assessment, these clinical factors are overshadowed by the more general factors identified in the criminological research (Bonta, Law, and Hanson, 1998)
risk assessment1
Risk Assessment
  • A few specialized risk assessment tools have been tested with mentally ill offenders, and perform well enough to be used with this population
  • Some of the tools are prediction-only tools (do not identify targets for intervention); others are risk-need tools (do identify intervention targets)
risk assessment2
Risk Assessment
  • Psychopathy Checklist (PCL)
    • measures psychopathy, but performs well in a risk assessment capacity (prediction only)
  • Violence Risk Appraisal Guide (VRAG)
    • prediction only
risk assessment3
Risk Assessment
  • Level of Service (LS) inventories
    • Risk-need
    • Actuarial
  • Historical, Clinical, Risk Management (HCR-20)
    • Risk-need
    • Structured professional judgment
risk assessment4
Risk Assessment
  • PCL, VRAG, and HCR-20 perform comparably with mentally disordered offenders (prediction)
  • LS/CMI likely performs well with mentally ill offenders (earlier LS tools have been found to do so)
severe mental illness tx
Severe Mental Illness: Tx
  • Evidence-based Interventions
    • Cognitive Behavioral Therapy
    • Dialectical Behavior Therapy
    • Schema-focused Therapy
  • Group Psychotherapy
  • Suicide Risk Factors
  • Critical Time Intervention
  • Forensic Assertive Community Treatment
cognitive behavioral therapy
Cognitive Behavioral Therapy
  • CBT is structured approach focused on symptoms, behavior and criminogenic needs
  • Offenders w/SMI have criminogenic needs associated with values, beliefs, thinking styles, and cognitive emotional states
  • Identifying , disputing automatic thoughts that generate symptoms (e.g., anxiety, depression) results in improvement
cbt examples
CBT Examples
  • Thinking for a Change – problem-solving approach using introspection, cognitive restructuring, and social skills training
  • Lifestyle Change – teaches cost-benefit analysis of choices and consequences; focuses on thinking styles associated with criminal activity
  • Reasoning & Rehabilitation – targets cognitive processing and pro-criminal thinking
  • CBT reduced odds of recidivism by 1.5 in 12 months after intervention (Landerbergery & Lipsey, 2005)
  • Important factors in reducing recidivism:
    • Initial risk level
    • How well treatment implemented
    • Inclusion of anger control and interpersonal problem-solving
dialectical behavior therapy
Dialectical Behavior Therapy
  • Effective with behavioral dyscontrol (e.g., self-harm, violence, poor impulse control)
  • Goals:
    • Improve emotional modulation
    • Increase awareness of consequences to others
  • Skills training may emphasize emotional regulation and distress tolerance
schema focused therapy
Schema-Focused Therapy
  • SFT focuses on maladaptive schemas (fixed patterns of thoughts, feelings, and behaviors from negative childhood experiences that continue into adulthood)
  • Implemented in forensic settings for those with severe APD and/or psychopathy (Bernstein, 2007)
group psychotherapy
Group Psychotherapy
  • May result in improvements in institutional adjustment, anger, anxiety, depression, interpersonal relations, and self esteem
  • Incorporation of cognitive and behavioral approaches enhances results
  • Improvements may not depend on whether inmates were mandated or self-referred
suicide risk factors
Suicide Risk Factors
  • Environmental
    • Being in isolation or segregation cells
    • Shifts with reduced staffing
  • Distal
    • Poor social and family support
    • Prior suicidal behavior (esp within last 1-2 years)
    • Hx of psychiatric illness, emotional problems
suicide risk factors cont
Suicide Risk Factors (cont.)
  • Proximal
    • Hopelessness
    • Narrowing of future prospects
    • Loss of options for coping
    • Feeling of being bullied
    • Suicidal intent or plans
critical time intervention
Critical Time Intervention
  • Two main components:
    • Strengthen long-term ties to community and family/friends
    • Provide emotional and practical support and advocacy during critical time of transition
critical time intervention cont
Critical Time Intervention (cont)
  • Core elements
    • small caseloads, individualized case management
    • community outreach
    • psychosocial skills building, motivational coaching
  • Context of reentry:
    • Social ties (e.g., housing, employment, education)
    • Makes use of existing social connections
  • FACT (“Forensic ACT Team”) focuses on keeping those with SMI out of jails/prisons
  • Team of professionals provide services based on consumer needs
  • Elements
    • Goal : preventing (re)arrest and (re)incarceration
    • Those on team of service-providers may have criminal justice histories
    • Majority of referrals from justice agencies
    • Supervised residential tx component for high-risk consumers, esp those with substance-use disorders
trauma history
Trauma History
  • Definition of Trauma
    • Direct exposure to extreme stressor
    • Actual or threatened death/serious injury/threat of injury
    • Witnessing death/injury/threat of injury to others
    • Learning about unexpected or violent death, serious harm or threat of death or injury to family member close friend
    • Marked by intense fear and helplessness
considering trauma history
Considering Trauma History
  • Adverse Childhood Experiences (ACE) Study
    • Examined relationship between adult health risk & exposure to childhood emotional/physical/sexual abuse & household dysfunction during childhood
    • Those with four or more categories of childhood exposure had increased health risks
considering trauma history1
Considering Trauma History
  • Messina & Grella (2006)
    • Examined 500 women in Female Offender Treatment and Employment Program
    • Found similar results to ACE study
trauma triad
Trauma Triad
  • Re-living, re-experiencing, and intrusive memories
  • Hyper-arousal, hyper-vigilance, intense physiological distress and reactivity
  • Dissociation avoidance and numbing
trauma informed care
Trauma Informed Care
  • Incorporates knowledge about trauma in all aspects of service
  • Creates environment that is hospitable, engaging, & minimizes re-victimization
  • Goals: empowerment and recovery
  • Recognize strengths of survivors & recovery/ healing needs of survivors
important principles of trauma informed care
Important Principles of Trauma Informed Care
  • Safety
  • Trustworthiness
  • Choice
  • Collaboration
  • Empowerment
examples of trauma specific treatment approaches
Examples of Trauma Specific Treatment Approaches
  • Seeking Safety
  • Trauma Recovery and Empowerment (TREM)
  • Atrium
  • Triad
small group exercise
Small Group Exercise
  • Considering your present unit(s) and caseload:
    • How would you change current practice to reflect today’s material?
    • If practice were changed in this way, how well would it address the mental health needs of those on your caseload?
    • How well would it address the criminogenic needs?