specialty mental health vs. traditional probation

+

Sarah Manchak, Jennifer Skeem, & Tracy Johnson Seattle, May 2008, MacArthur Research Network on Mandated Treatment

Specialty Mental

Health vs. Traditional Probation

+

Plan Background & Study Overview

Intermediate Outcomes (Services & Perceived Coercion/Adherence)

Clinical Outcomes (Symptoms, Functioning, QOL)

Criminal Justice Outcomes (Violence, Violations, Arrests, Revocation)

Statement of the problem

 Persons with mental disorder grossly overrepresented in the criminal justice system

  55-75% have co-occurring substance abuse disorder

  CJS essential component of de facto mental health system   Los Angeles County Jail   Riker’s Island Jail 0

2

4

6

8

10

12

14

16

Pre

vale

nce

(%)

General population Incarcerated men Incarcerated women

Source: Teplin, 1990; Teplin, Abram, & McClelland, 1996

+ Corrections population now over 7.2 million

0

1000000

2000000

3000000

4000000

5000000

6000000

7000000

8000000

Source: Bureau of Justice Statistics (2007)

Total

3.2% of all adults in the United

States

+Probation the most common disposition

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

4000000

4500000

Source: Bureau of Justice Statistics (2007)

Probation

Prison

Parole Jail

+Statement of the problem

 Probationers with mental illnesses (PMIs) are highly likely to fail on supervision

Source: Dauphinot, 1999; see also Porporino & Motiuk, 1995

+

“The current situation not only exacts a significant toll on the lives of people with mental illness, their families, and the community in general, it also threatens to overwhelm the criminal justice system.”

-Council of State Governments Criminal Justice/Mental Health Consensus Project (2002)

+Statement of the problem

 A staggering number of individuals with serious mental illness are placed on probation each year. Most fail.

 Probation represents an unrealized opportunity to:   engage and work with high risk individuals who otherwise

might be inaccessible;

  facilitate these individuals’ exit from the criminal justice system and re-entry to the community

 How do we get there?

+How do we get there?

  Prepare conceptually and methodologically via:   Focus group study (“best bets”)

  National survey and follow-up survey (“lay of the land”)

  Dual role relationship quality study (caring & controlling)

  Specific aims of outcome study…

  To assess the effect of ___________ on probationers’ perceived coercion, treatment adherence and outcomes   POs’ strategies for monitoring and enforcing treatment mandates

  the relationship between POs and probationers (mediation)

  probation systems (specialty v. traditional)

+Method

 Prospective design (2+? years)  Interviews: Baseline, 6 mo, 12 mo  Record follow-up: 18 mo (services) & 24 mo (c.justice)

 Matched trial

 Specialty & traditional sites  Identified through national survey and follow-up visits

to 5 agencies  Best match (size, ethnicity, proximity, resources)

 Specialty: Dallas, TX  Traditional: Los Angeles, CA

+Participants

 Eligibility   18-65 years old, English-speaking, pass consent test   Mental disorder

  Dallas: specialty placement   LA: Screened in or officer referral

  On active supervision, completed > 1 initial meeting with officer, > 1 year remaining on term

 Matching   age, gender, ethnicity   index offense (person/other) & time on probation (under/over 1

year)

 Participants   PMIs and their POs (30/Dallas; 120+/LA)   Appx. 180 probationers per site (N=360)

+Specialty Recruitment (Dallas)

351 Enter MIMR

251 Eligible (72%)

183 Interviewed

(73%)

36 Refused (14%)

32 Expired (13%)

104 Ineligible

(28%)

Traditional Recruitment (Los Angeles)

861 Screened in or Referred

505 Eligible (59%)

312 Match (62%)

176 Interviewed

(56%)

115 Refused (37%)

21 Expired (7%)

193 Mismatch

(38%)

356 Ineligible

(41%)

Probationer Retention (5/08)

0 20 40 60 80 100 120 140 160 180

Specialty

Traditional

12 mo 6 mo Baseline

86%

90% (ongoing)

86%

90%

+Psychopathology (PAI)

0

10

20

30

40

50

60

70

80

90

100 Specialty Traditional Norm

Match Between Sites

0

10

20

30

40

50

60 Specialty

Traditional

No significant differences in all matching variables, including age

+

+Propensity Scores

  Likelihood of traditional supervision, given 40+ criminal, psychiatric, substance use, & personality features

  Nagelkerke R2 = .38; Classification accuracy=74%

+Events during follow-up

  Still on probation   At six months (90%)   At twelve months (80%)

  Same PO   At six months(77%)   At twelve months (66%)

  Time in jail or prison   At six months (25%)   At twelve months (29%)

  Less than 4% involved in MHC at any point

+

Plan Background & Study Overview

Intermediate Outcomes (Perceived Coercion/Adherence & Services)

Clinical Outcomes (Symptoms, Functioning, QOL)

Criminal Justice Outcomes (Violence, Violations, Arrests, Revocation)

+Perceived coercion and adherence

  Repeated measures MANCOVA with perceived coercion + procedural justice

  Specialty probationers experience significantly*** more procedural justice than traditional probationers; no site x time interaction

  Single-item self reports   Appointment adherence,

mixed across time (favor specialty, neither, and traditional)

  Medication adherence, favor specialty at follow-up (6 & 12)

  BMQ medication adherence favors specialty across time   Belief scale   Regimen scale

Perceived coercion Treatment Adherence, no Site X Time

*** p <.001, controlling for propensity

+Medication adherence (six months, shown)

0 20 40 60 80 100

Specialty

Traditional

Missed 0

Missed 1-2

Missed more

* p <.05, controlling for propensity

+Service similarities, inpatient

0 10 20 30 40

Phys Inpt

Sub Inpt

Ment Inpt

Traditional

Specialty

6 months, shown

+Service similarities, outpatient

0 5 10 15 20 25 30

Phys Outpt

Sub Outpt

Traditional

Specialty

6 month shown

+Service differences

0 20 40 60 80 100

Specialty

Traditional

# Sig Discussions***

0 20 40 60 80 100

Specialty

Traditional

# Outpatient MH Sessions***

*** p <.001, controlling for propensity & jail time; #Sig Discussions 12 mo, p<.05

6 month shown

+Service differences

0

5

10

15

20

25

30

35

40

DualDxSame

Specialty

Traditional

*

* p <.05, controlling for propensity & jail time; Note: ns at individual follow-ups

Full follow-up shown

+

Plan Background & Study Overview

Intermediate Outcomes (Services & Perceived Coercion/Adherence)

Clinical Outcomes (Symptoms, Functioning, QOL)

Criminal Justice Outcomes (Violence, Violations, Arrests, Revocation)

+Change in symptoms (CSI) & functioning

35

40

45

50

55

60

65

CSI: No Site x Time GAF: Site x Time***

35

40

45

50

55

60

65

*** p <.001, controlling for propensity scores, in favor of Traditional

+Change in symptoms – PAI Cluster One***

0

5

10

15

20

25

30

35

40

ARD DEP* SCZ** SOM* BOR

Specialty1

Specialty2

Traditional1

Traditional 2

*** p <.001, multivariate, controlling for propensity scores, in favor of Traditional

+Change in symptoms – PAI Cluster Two*

0

5

10

15

20

25

30

35

40

ANT** AGG** PAR* MAN

Specialty1

Specialty2

Traditional1

Traditional 2

*p <.05, multivariate, controlling for propensity scores, in favor of Traditional

+Change in symptoms – PAI Cluster Three**

0

2

4

6

8

10

12

14

16

18

ALC** DRG*

Specialty1

Specialty2

Traditional1

Traditional 2

**p <.01, multivariate, controlling for propensity scores, in favor of Traditional

+Life satisfaction (“delighted-terrible” scale)

3

3.5

4

4.5

5

5.5

6

Base Six Twelve

Ns Site and Site x Time

+

Plan Background & Study Overview

Intermediate Outcomes (Services & Perceived Coercion/Adherence)

Clinical Outcomes (Symptoms, Functioning, QOL)

Criminal Justice Outcomes (Violence, Violations, Arrests, Revocation)

+Violence at 12 months

0

5

10

15

20

25

30

35

Minor Serious

Both Sites

Ns site differences, controlling for propensity scores and jail/prison days

+Recorded violations at 12 months

***p<.001; **p<.01, controlling for propensity scores

***

0 10 20 30 40 50 60 70 80 90

100

Specialty

Traditional

*** ***

**

+Self reported violations at 12 months

**p<.01; controlling for propensity scores

**

0 10 20 30 40 50 60 70 80 90

100

Traditional

Specialty

**

+Recorded arrests and revocation at 12 months

0

5

10

15

20

25

30

35

40

Arrested Revoked

Specialty

Traditional

***

*

***p<.001, ** p <.05; controlling for propensity scores; no diff in violation type by revocation

+

Relative to traditional supervision, specialty supervision predicts Intermediately…

Greater procedural justice

More medication adherence

More mental health sessions & significant discussions with providers

Less improvement in functioning and symptoms over time

More recorded technical violations, but fewer arrests and revocations