Wednesday, January 8, 2014

Homelessness and contact with the police

During the holidays, we often reflect on those in our community without housing and suffering from mental illness or other disabling conditions.  We wanted to use this opportunity to highlight the challenges that the justice system faces in dealing with the chronically homeless; the actions being taken in Portland, Oregon to address these challenges; and a number of resources that offer guidance for justice practitioners. 

As a society, we have made some progress in the past decade to reduce the national number of chronically homeless individuals, yet the numbers still remain high. The U.S. Department of Housing and Urban Development (HUD) 2013 Annual Homeless Assessment Report to Congress indicates that since 2012, the population of chronically homeless individuals in the United States has declined by more than 7,000, or 7%, to approximately 92,000 individuals in 2013.  Among this population of chronically homeless, more than two-thirds of individuals were considered unsheltered at the time of the study.  It is important to note that these estimates do not include chronically homeless individuals in families.

Portland, Oregon was identified by the 2013 HUD report as being among the top ten major cities with large chronically homeless populations.  The impact on the justice system in Portland, as in other cities and counties across the country, is notable—frequent contact with police, often resulting in arrest, booking and custody in jail, charges filed, court hearings and, frequently, warrants resulting from failure-to-appear in court.  A study conducted by Portland Police Bureau highlights the broader implications of chronic homelessness on the justice system, noting that while individuals with mental illness are not predisposed to violence, homelessness and substance abuse can exacerbate mental health issues and, ultimately, increase the likelihood of contact with law enforcement.  Indeed, a monograph produced by Rutgers University Center for Behavioral Health Services and Criminal Justice Research suggests a strong connection between chronic homelessness and criminal justice involvement. Further, the monograph makes the case that homelessness can be considered a factor contributing to increased criminogenic risk resulting from the individual’s decreased family support, increased proximity to crime,  criminal culture and victimization. 

The criminal justice response to chronic homelessness is an example of the expanding and widely varied roles law enforcement is expected to perform in our communities.  Portland’s experience provides a compelling example that law enforcement officers require new skillsets, including Crisis Intervention Training (CIT) and engagement techniques that build trust and legitimacy with homeless populations, to be effective in this expanding mission. Indeed, Portland’s approach incorporates several themes for improving the criminal justice response to chronically homeless and mentally ill individuals discussed in the Rutgers monograph.  In particular, Portland’s approach seeks to closely integrate and coordinate services toward a holistic, person-centered, approach to the chronically homeless, while recognizing that the response to the individual needs to be flexible and tailored to their specific needs.  In addition to implementing a bureau-wide CIT training for officers, Portland recently created a Behavioral Health Unit which combines CIT trained officers with mental health professionals and its Service Coordination Team.  Further, Portland has improved the way it tracks data related to interactions with individuals in crisis and dedicated analyst staff to monitor and report performance.

The Center for Problem Oriented Policing (POP) is a helpful resource for communities that are working to address many of the challenges associated with chronic homelessness as well as providing examples from communities that are having success in improving the ability of law enforcement to respond effectively to chronically homeless individuals and to break the cycle of chronic homelessness.  POP identifies several strategies to guide communities in developing responses to the chronically homeless that include increasing public awareness of the underlying issues associated with chronic homelessness, changing law enforcement culture and attitudes toward homelessness and collaboration with service providers, and providing alternatives to homeless encampments.  Specifically, POP identifies a strategy of ‘housing first’ to get the chronically homeless into housing and then engage them in mental health and addictions services.

Housing first is a widely known approach to providing alternatives to emergency and shelter care by providing housing and services to chronic users of these traditional systems.  Housing First-type programs first emerged in the 1990s in New York and Toronto and have since been implemented in many communities in the United States and internationally.  Unlike some traditional strategies to address chronic utilizers of emergency services, jails, and shelters, Housing First programs typically do not require participants to be sober before entering into housing.  However, program participants are paired with a case manager and an interdisciplinary Assertive Community Treatment (ACT) team.  A substantial volume of research and evaluation relating to Housing First is available from HUD’s Office of Policy Development and Research and the Pathways to Housing research library.  New research on Housing First suggests that the strategy can produce significant public health and safety outcomes while saving taxpayers money.  These savings include substantial reductions in the use of hospital emergency rooms, jails, and police.  

The recent web documentary, Here At Home, produced by the Canadian National Film Board, presents the findings from a study released by the Mental Health Commission of Canada on the impacts and outcomes of the Housing First model.  The study was the largest of its kind to implement a randomized controlled trial of Canada’s national Housing First strategy and included a total of 2,235 individuals, 1,265 of which were selected for the Housing First program.  Researchers tracked service utilization and related costs for these study groups, finding that for the top 10% of study participants (defined as the high service user group), Housing First helped to avoid over $26,000 in costs per individual.  In other terms, for every dollar spent on these chronic users, Canadians saved $1.50, reinforcing the strategy of prioritizing housing for individuals who are high utilizers of hospital emergency rooms, social services, and jails.  Jail costs alone were reduced by over 35% for the high use group in the Canadian study while the largest aggregate cost reduction occurred in hospital emergency room utilization. Further, the perceptions of safety among program participants increased dramatically due to reductions in use of emergency shelter care and interactions with police and security guards.


Video diaries and interviews presented in the documentary provide additional insight into the challenges and successes of the program participants, including some truly impactful testimonials from the program participants, service providers, and property managers. Combined with the statistical findings from the study, the Here At Home documentary makes a unique and compelling case that addressing chronic homelessness with housing and services can improve public safety and health outcomes. Additionally, Portland’s experience demonstrates that providing officers with additional training in Crisis Intervention techniques and building collaboration with service providers can help to ensure we are using our criminal justice dollars to their best effect to mitigate the impacts of chronic homelessness to local justice systems. 

Wednesday, November 20, 2013

Judge John C. Uhler in York County, PA distinguishes between juveniles and adults when it comes to sex offender registration

On November 4th, Judge Uhler of the Court of Common Pleas in York County, PA ruled that the Sexual Offender Registration and Notification Act (SORNA) is unconstitutional as it applies to juveniles. It has been less than a year since Pennsylvania instituted the requirement that juvenile sex offenders become listed on a sex offender registry for life. This law complies with the federal Adam Walsh Child Protection and Safety Act. (Read the PennLive article about this decision.)

Yet, in his opinion, Judge Uhler stated that the SORNA requirement for juveniles, in fact, violates the United States Constitution and the Pennsylvania Constitution. He cited Pennsylvania’s Juvenile Court Act of 1901 and its subsequent Juvenile Court Act of 1972, both of which described the commonwealth’s goals in juvenile justice to be far more rehabilitative than punitive. He also referenced the unique ability of juveniles to reform and their low recidivism rate as sex offenders.

Certainly, this case will stir quite a controversy. As stated on the website of the Office of Sex Offender Sentencing, Monitoring, Apprehending, Registering, and Tracking (SMART), a component of the U.S. Department of Justice, “SORNA aims to close potential gaps and loopholes that existed under prior law and generally strengthens the nationwide network of sex offender registration and notification programs.” For many proponents, the sex offender registry is critically important for holding offenders accountable, deterring future sexual offenses, and ensuring public safety.  As such, the legal status of the offender, whether considered an adult or a juvenile, is of less concern when the offense merits registration.

On the other hand, studies have shown that juvenile sex offenders do not often become adult sex offenders. (For one such study, click here.) There is a substantial body of scientific research that demonstrates how impulsivity and irresponsibility are most pronounced in the adolescent stage of brain development. This research has been cited in major Supreme Court decisions, such as Roper v. Simmons, Graham v. Florida, and Miller v. Alabama, to lighten punishment standards for juveniles. (Read Dr. Laurence Steinberg’s article about these decisions here.)

Critics of SORNA registration requirements, particularly with regard to juveniles, point to the very issues cited in Judge Uhler’s ruling and the potential for other long-term collateral consequences of registration. Juvenile sex offenders face difficulties in procuring employment and attending college. They also lose access to public housing and oftentimes must move to comply with laws that prohibit them from living within a certain distance from schools and other public facilities. These restrictions can make matters even more complicated if they have children of their own later in life. Furthermore, even though juvenile sex offender registries are not released to the public like adult sex offender registries, law enforcement officials and school administrators who do have access to them are not prohibited from sharing the information. Juvenile sex offenders can face stigmatization and harassment from peers if their names get leaked.  

Regardless of where you stand with regard to Judge Uhler’s decision, it raises an issue that is likely to elevate SORNA and appropriate sanctions for juvenile sex offenders to a national debate. The facts of the case and Judge Uhler’s ruling are offered below as food for thought.

The case involved 7 juvenile petitioners, who had all been adjudicated before the SORNA juvenile provision went into effect on December 20, 2012. According to the new version of the law, these 7 juveniles had to retroactively register as sex offenders. Represented by the Juvenile Law Center, the Defender Association of Philadelphia, and the public defender’s office, they challenged this requirement. (Read the Juvenile Law Center’s blog about this decision.)

Judge Uhler ruled that the lifetime sex offender registration requirement for the 7 petitioners is unconstitutional. While not binding statewide, the decision against the SORNA juvenile provision both “retroactively and prospectively” sets a precedent for future cases in York County.

The York County District Attorney’s office is considering appealing Judge Uhler’s ruling to the Pennsylvania Supreme Court. Prosecutors should reach a decision within the next two weeks.

To read Judge Uhler’s opinion in full, click here.

Tuesday, November 5, 2013

Civil Citations for Juvenile Misdemeanants in Florida

On October 30, 2013, the Florida Department of Juvenile Justice (DJJ) issued a press release celebrating Walton County as the 50th county in the state to implement a civil citation program for juveniles. Civil citation programs have grown rapidly in Florida over the past two years. As outlined in Margie Menzel’s Orlando Sentinel article “State seeking major overhaul of juvenile justice system” (10/10/2013), they are a crucial part of the DJJ’s larger effort to shift the juvenile justice system away from a punitive model based on incapacitation and deterrence towards a model that focuses more on changing behavior.
 
Wansley Walters, who was appointed as Secretary of the Florida DJJ in January 2011, has drafted a new system improvement agenda that uses risk-assessment tools and aims to avoid placing low- and moderate-risk juveniles in detention centers.  The new juvenile justice agenda also calls for alternatives to arrest—the most notable of which is the expanded use of civil citations throughout the state.
 
In certain cases, the DJJ may issue civil citations to youth instead of processing them through the juvenile justice system. Only first-time, non-violent misdemeanants can receive these citations, which may mandate community service, intervention services, or both.
 
Civil citations begin with a law enforcement official taking one of two alternatives to arresting a juvenile. The law enforcement official can either issue the juvenile who has committed a misdemeanor a field citation or send him or her to a juvenile assessment center. The DJJ then decides whether it will grant a civil citation and if it does, the juvenile undergoes an assessment to determine the specific outlines of his or her sanctions and services.
 
Civil citations can include family counseling and treatment for substance abuse and mental health disorders. The DJJ often relies on established community programs to provide these services. The community service requirement of a civil citation can require the youth to perform up to 50 hours of community service. Civil citations may also require juveniles to write formal apologies to victims and in some cases, pay remuneration of damages. If juveniles do not successfully complete the requirements of their civil citation, the DJJ reports their misdemeanor to the state attorney.
 
The county of Miami-Dade has the largest civil citation system in Florida. Here, civil citations are uniformly available for any juvenile who fits the predetermined criteria of being between the ages of 8 and 17 and committing a minor, first-time misdemeanor offense. As of 2011, the recidivism rate in Miami-Dade for juveniles who had been given a civil citation instead of going through formal adjudication in the juvenile justice system was 3%. The county has saved an estimated $5,000 per child.
 
Since Walters became Secretary of the Florida DJJ, civil citation programs have expanded from 17 counties to 50, with 5 more in process, and the goal is to continue until the remaining 12 counties are up and running (Map of Civil Citation Implementation in Florida by county).
 
Certainly this shift in Florida is in line with what we know about what works in reducing recidivism among juveniles and adults alike.  Studies have shown that confinement or intensive intervention designed for high-risk offenders increases recidivism for low-risk offenders, whether juvenile or adult.  Furthermore, low-risk youth who spend time in formal detention have an increased likelihood to reoffend as adults.  What is exciting about the statewide implementation of the civil citations is that according to Florida DJJ’s own studies, only 6% of youth who were issued a civil citation went on to commit another crime within the year, compared to 41% of those who were sent to residential centers and 17% of those on probation (DJJ Presentation, January 2013, slide 10).
 
So, why do civil citations seem so promising?  First, they align with research-based practices by expediting the response to juveniles’ misdemeanors (i.e., swift, certain, and proportional responses). After a youth commits an offense, traditional juvenile justice system procedures can take longer than a year. Within two months of their offense and issuance of a civil citation, juveniles have often completed the requirements of their citation.  Second, civil citations are also a strategy for mitigating the negative, collateral consequences of youth having criminal records, by diverting them outside of formal adjudication.
 
Finally, the benefits have also translated into tax savings.  A report that Florida TaxWatch released in April 2011 calculated that if all communities in the state had civil citation programs, costs to taxpayers would decrease anywhere from $44 million to $139 million annually (Florida TaxWatch Report).  Civil citation programs average $386 per youth, while traditional juvenile justice system costs average $5,000 per youth (DJJ Presentation, May 2012, slide 7).  These costs do not include the costs of the adult criminal justice system, where low-risk juveniles who have been arrested and formally adjudicated are more likely to end up than their peers who have been diverted.
 
Walters’ proposed plan is to reinvest these savings into enhanced evidence-based programming for youth involved in the juvenile justice system.  Yet, as the program and opportunities for reinvestment have grown, so has the need to standardize the program.  The 2011 Florida TaxWatch report recommended that the civil citation system should be standardized, even as it is expanded statewide. Different counties continue to have different criteria for program eligibility. In most counties, individual law enforcement officers have great discretion over whether a youth offender should receive a civil citation or be arrested.  Structured decision-making protocols can help to mitigate disparities that would inevitably arise from such variation across programs.  As the DJJ seeks to expand this promising practice, it will need to continue to grapple with these implementation issues.
 
Yet, the opportunities for reinvestment make the challenges of the civil citation system seem quite worthwhile. As the use of civil citations increases, so do the DJJ’s savings. It will be interesting to see what other system reforms may emerge in Florida.
 
For more information:

Wednesday, October 16, 2013

Promoting Court Leadership in Juvenile Justice

On October 1-2, 2013, the Justice Management Institute hosted a Court Leadership Symposium in Washington, DC.  The John D. and Catherine T. MacArthur Foundation’s Models for Change Initiative sponsored the event that brought together over 30 representatives from the country’s leading court leadership organizations and associations with judges on the cutting edge of juvenile justice reform.  Yesterday, we released the summary of proceedings from the two-day meeting.

The sense of possibility and urgency among the invited participants was palpable.  This meeting was perhaps the first of its kind among national court leadership organizations, calling for unified action to elevate juvenile justice in the United States.

Participants heard from practitioners and experts in the field about some of the gaps in juvenile justice, the best practices that have emerged, and the opportunities to promote further system change.    The meeting focused on five core reform areas: 1) Racial and Ethnic Fairness in Juvenile Justice; 2) Juveniles with Behavioral Health Needs; 3) High Quality Juvenile Defense Services; 4) Dual Status Youth and Fragmented Child-Serving Systems; and 5) Over-Involvement of Non-Delinquent Youth in Juvenile Courts.  Within each, we considered together how national court leadership organizations (and in turn judges and court administrators) could take action to address critical gaps in juvenile justice.

By the end, the leaders of these national organizations were offering ideas for not only how their specific groups could elevate juvenile justice as a national priority but also how they could work together and synergistically.  It set the stage for ongoing work by Models for Change through its new Resource Center Partnership (RCP) and through the National Center for State Courts (NCSC), a strategic ally of the RCP.  Over the next year, NCSC will build on the Symposium through a series of regional meetings of state teams to develop strategies for juvenile justice system improvement.

The judges, court administrators, and other leaders present at this Symposium developed three major recommendations for the group to consider pursuing after the meeting:

       Pursue a common vision of juvenile justice as a national priority and endorse a shared statement of principles or national strategy.
       Promote a specialized, high quality profession in juvenile justice by
·         defining and implementing standards of practice and
·         providing specialized, multidisciplinary, and ongoing training in juvenile justice as an area of law.
        Engage a broader audience –in particular, judges and court administrators who work with juvenile cases on a day-to-day basis but who do not typically attend national conferences focused on juvenile justice issues.

The Symposium marked the end of JMI’s second year as part of the Models for Change Initiative.  Yet, it was also the product of the work we will continue to do over the next two years with the Initiative.  Since the spring, JMI has coordinated the Resource Center Partnership, an extension of the MacArthur Foundation’s nearly 20-year, $150 million investment in supporting juvenile justice reform.  The Partnership is based on research, practice, and reform efforts that have reached more than 35 states, much of which was made possible by the Foundation.  This Symposium featured the RCP and laid the groundwork for meaningful partnerships between them and state and local judiciaries as well as national court leadership organizations and associations.

Launched this past summer, the Partnership will provide juvenile defenders, judges, policymakers, advocates, probation officers, and mental health and social service agencies with much needed technical assistance, trainings, tools, and resources to help advance juvenile justice reform across the country. 

The Resource Centers include:

       The Mental Health and Juvenile Justice Collaborative for Change: A Training, Technical Assistance and Education Center: Led by the National Center for Mental Health and Juvenile Justice at Policy Research Inc., the Center is a training, technical assistance, and education center designed to promote and support adoption of new resources, tools, and program models to help those in the field better respond to youth with mental health needs in the juvenile justice system.

       The National Juvenile Defender Center: The Center improves access to counsel and quality of representation for children in the justice system and bolsters juvenile defense by replicating field-driven innovations, facilitating adoption of new juvenile justice defense standards, and developing a corps of certified juvenile indigent defense trainers.

       The Robert F. Kennedy National Resource Center for Juvenile Justice: Led by the Robert F. Kennedy Children’s Action Corps, the Center uses proven models, frameworks, tools, resources, and the best available research to serve local, state, and national leaders, practitioners, and youth-serving agencies.  The Center’s work focuses on improving system performance and outcomes for youth involved with the juvenile justice system. The Center focuses primarily on youth with prior or current involvement in the child welfare and juvenile justice systems (known as dual-status youth) and on the review and improvement of juvenile probation systems.

       The Status Offense Reform Center: Led by the Vera Institute of Justice, the Center serves as a resource clearinghouse and assistance center for practitioners and policymakers in juvenile justice, with a focus on encouraging and showcasing strategies to safely and effectively divert non-delinquent youth and their families from the formal juvenile justice system.

In addition to our extensive work with the new Resource Center Partnership, JMI will continue to be part of the work of supporting local juvenile justice system leadership, including but not limited to local judges.  The work over the next two years brings together our long-time work with our networks – the Criminal Justice Coordinating Council, Urban Court Managers, and Rural Court Improvement Networks – with the juvenile justice system change work of Models for Change.  Our vision is that the work at the local level will complement and reinforce the great work that we have already helped to kickstart at the national and state level with this Symposium.

To learn more about the Resource Center Partnership and Models for Change in general, visit the Models for Change website.  I would also strongly encourage you to visit our website to review the meeting summary and the resources that were shared during the Symposium.

Tuesday, October 15, 2013

Smarter Sentencing and Special Offender Populations

As justice practitioners begin to fully grasp the possibilities for adopting evidence-based practices, there is inevitably a series of questions that emerge about what the most effective, research-based strategies are for dealing with special populations.  Two of these populations – individuals who sexually abuse children and clinically-diagnosed psychopaths—have fewer gold standard studies that offer guidance on what works, until now.  In this posting, we are sharing two new studies that may offer some long-need insight into strategies to effectively deal with sex offenders and psychopaths.

With respect to men who sexually abuse children, Dr. Karen Franklin has posted on the subject (9/22/13), reviewing a recent article in the British Medical Journal, “Preventing sexual abusers of children from reoffending: systematic review of medical and psychological interventions“ by Niklas Långström, Pia Enebrink, Eva-Marie Laurén, Jonas Lindblom, Sophie Werkö, and R Karl Hanson (2013).  Her review is reposted below, but the major lessons regarding sexual abusers of children are:

·       Very few well-designed or “gold” or “silver” standard research exists in this area.  As the authors of the study explain, “After review of 1447 abstracts, we retrieved 167 full text studies, and finally included eight studies with low to moderate risk of bias.”  This finding is consistent with previous reviews in this area.

·       Treatment effects are modest at best, but because there are so few studies, it is not clear yet how to generalize from them.  This finding does not mean that “nothing works,” but it does mean that we still are not sure what does work.

·       Despite the popular debate about the use antiandrogen drugs (i.e., chemical castration) as treatment for these offenders, Långström et al. found no “minimally adequate” studies about their effectiveness.

·       Treatment works best for a small minority of very high-risk offenders, yet it may increase risk for men at lower risk of recidivism.

On this last point, of course, the initial findings seem consistent with the risk and need principles we discuss in smarter sentencing.  Långström et al. explain that “…prolonged or intense interventions for offenders at low risk of relapse, or grouping low risk offenders with those at high risk for reoffending, could result in adverse outcomes.” (Långström et al., 2013, 4)  Touching on another special population that has been the source of much debate, the authors caution that treatment of juvenile sex offenders should be carefully considered.  Unnecessary treatment of children, whom are often at low risk of reoffending, may lead to “unjustified stigmatisation and could negatively affect the child’s development.  Hence, risk should be balanced against the relatively low base rate of future sexually abusive behaviour among children with sexual behavioural problems. If these children are subjected to excessively intense or inappropriate therapy, this could increase the risk for future antisocial behaviour. An important evidence based alternative to treating such children would be to provide structured training or education for the primary caregivers to improve their parenting skills, as has been successful with parents of children with conduct disorder.” (Långström et al., 2013, pp. 3-4)

Again, to read more on this subject, see the re-post below and certainly take a look at the source article.

On the issue of psychopaths, Dr. Franklin has more recently reviewed another research article on the subject, “Predicting future violence among individuals with psychopathy” by Jeremy W. Coid, Simone Ullrich and Constantinos Kallis in the British Journal of Psychiatry.  Her post is brief, but the article itself describes recent work by the authors looking at a variety of tools that predict violence when used with offenders who present with a range of mental health disorders.  The most serious of these disorders is psychopathy.  Coid et al. found that none of the three commonly used risk assessments studied – HCR-20, VRAG, OGRS-II – were any more effective at predicting future violence among psychopaths than flipping a coin. 

All three instruments are used in research and clinical practice in Canada and the United States, among other parts of the world.  The Violence Risk Assessment Guide (VRAG) is a 12-item actuarial instrument; the 20-item Historical, Clinical, Risk Management-20 (HCR-20) is a structured professional judgment tool; and the Offenders Group Reconviction Scale-II (OGRS-II) produces a statistical risk of reoffending score, but it has also been found to predict future violent offending among men.

Of course, psychopathy is very rare, found in less than 0.5% of the population.  Even so, these individuals have a disproportionate impact on violence and have extremely high levels of criminal recidivism.  The authors caution, “Our findings do not explain whether failure of three risk assessment instruments to predict violence in individuals with psychopathy was due to inherent limitations in their construction and standardisation or the inherent and unpredictable behaviour of these individuals, characteristic of their life course.” (Coid et al., 2013, 2)  Nonetheless, there are some implications for practice here.  Certainly, we need more research to understand psychopathy and how to best address it in the criminal justice context.  Yet, today, criminal justice systems can use this information to structure risk and needs assessment processes in their systems.  “Taken together, our findings emphasise that the first step in any assessment should be a comprehensive diagnostic assessment before assessing risk of future violence” explain Coid et al (pg. 2).  In other words, determination of risk of violence cannot be effectively determined without assessing psychopathy or similarly severe mental disorders.  It is important to note here that the authors are discussing risk of future violence, which is not the same as risk of future offending.

While these two populations present significant challenges for criminal justice systems attempting to rehabilitate offenders, many of the basic premises of smarter sentencing hold true.  Objective, validated assessments of risk and criminogenic need are critical components on any intervention, even if to identify populations who are difficult to treat.  Low and high risk offenders require different interventions.  More research is necessary to understand the drivers of criminal behavior among these populations, but certainly there is still room for experimenting and exploring new approaches that may have an impact and evaluating them.

###

REPOST: Efficacy of sex offender treatment still up in the air
Sunday, September 22, 2013
http://forensicpsychologist.blogspot.com/2013/09/efficacy-of-sex-offender-treatment.html

“Did he complete treatment?”

That is a front-burner question for judges and jurors in sexually violent predator trials. Understandably, before they decide to release someone who has been convicted of sexually molesting a child, they want reassurance that he is sincerely remorseful and has acquired the tools to turn his life around. In short, they want a certificate of rehabilitation attesting to his low risk.

But does formal sex offender treatment really lower risk?

A systematic review found no scientifically rigorous studies that establish a link between treatment completion and a reduced risk of reoffending among men who have sexually abused children.

This isn't altogether fresh news. We knew from earlier research reviews that:

·         Any effect of treatment was modest, at best
·         Treatment works best for the tiny minority of very high-risk offenders, while possibly aggravating risk for the broad majority of men at lower risk of recidivism
·         Older offenders, due mainly to their very low risk, derive no tangible benefits from treatment

But considering both the prevalence and the harm of child sexual abuse, there is surprisingly little high-quality research on effective interventions. Partly, this is because of the lock-'em-up-and-throw-away-the-key mentality of policy makers. And partly it is because of the ethical difficulties in implementing random-design procedures, a hallmark of the scientific method, because men assigned to a control group would be denied treatment that could reduce their risk and in some cases shorten their prison terms.

Scouring research databases, a six-member, international research team was able to locate only three well-designed experimental studies. These included one with adults, one with adolescents and one with children. In only the study with adolescents was treatment shown to reduce recidivism. That project used multisystemic therapy, a very promising approach that integrates the family and larger community in the treatment. 

Even broadening the search to include observational studies that lacked experimental designs, the research team found only five studies with a low enough risk of research bias to be deemed reliable. None of the five observational studies demonstrated that formal treatment -- primarily cognitive behavioral therapy with relapse prevention -- impacts sexual reoffending.

High-bias studies, in which the study design introduced a high probability of unreliable findings, were excluded. An example of such research bias would be a study in which treated and untreated offenders differed on a variable known to affect risk. When subjects are  not randomly assigned to treatment or control groups, any observed differences between groups may be due to factors outside of the treatment itself.

Treatment in most formal sex offender programs is cognitive behavioral, and relies primarily on manual-based group therapy. For example, group exercises challenge distorted thinking, denial and minimization.

The research team found no  minimally adequate studies whatsoever on the efficacy of pharmacological treatment with antiandrogen drugs, more popularly known as “chemical castration.” They found this omission “particularly striking,” in light of the prominence of this method in public debates. 

Can treatment cause harm?

Given “the overall unimpressive treatment effects” that were found, the researchers cautioned clinicians working with sex offenders to consider the potential negative effects of treatment:

“Under certain circumstances, with some people and some interventions, treatment could increase the risk of sexual reoffending. For instance, prolonged or intense interventions for offenders at low risk of relapse, or grouping low risk offenders with those at high risk for reoffending, could result in adverse outcomes.”

They especially cautioned against unnecessary treatment of children. With recidivism risk very low among untreated children, treatment may lead to “unjustified stigmatization and could negatively affect the child’s development…. If these children are subjected to excessively intense or inappropriate therapy, this could increase the risk for future antisocial behavior.”

The team was headed up by prominent researcher and professor Niklas Långström and included Canadian researcher R. Karl Hanson, psychologist Pia Enebrink, forensic psychiatrist Eva-Marie Laurén and researchers Jonas Lindblom and Sophie Werkö. The research was commissioned and partially funded by the Swedish government.

The Convention on the Protection of Children against Sexual Exploitation and Sexual Abuse, ratified by 27 countries so far, mandates effective treatment to sexual abusers of children, individuals at higher risk of committing such offences, and children with sexual behavior problems.

This mandate is a bit of a problem, given the inconclusive evidence that the dominant treatment approach works.

Manualized, one-size-fits-all approach

My own belief is that the one-size-fits-all approach of manualized group therapy, driven in part by a shortage of highly qualified and talented clinicians in bureaucratic institutions, can never meet the needs of a heterogeneous population of offenders. Indeed, in the hands of poorly trained technicians, much of what passes for “treatment” is actually punishment in disguise. As anthropology professor Dany Lacombe noted in her insightful ethnographic study,  sex offender treatment can paradoxically cement deviance through its obsessional fixation on sex. As an 18-year-old patient told Lacombe:

“They want to hear that I always have fantasies and that I have more bad ones than good ones. But I don't have bad ones that often. I make up the bad ones. I make them really bad because they won’t leave me alone.”

Genuine treatment, as we all should remember from our graduate school training, is all about the empathic relationship -- not the technique. Indeed, although more and more psychologists have internalized the insurance industry's mantra that cognitive-behavioral therapy (CBT) is the “evidence-based” treatment of choice for a variety of conditions, this is not actually true. For example, in a new randomized clinical trial published in the American Journal of Psychiatry, psychodynamic therapy performed just as well in the treatment of depression.

The research team cautioned that their failure to find significant effects of treatment should not be interpreted to mean that treatment as currently implemented is ineffective. The low base rates of recidivism among sex offenders make it difficult to find treatment effects without very large sample sizes and long follow-up periods, they point out.

Additionally, an early study out of California provided some evidence that it was not the formal completion of treatment per se that reduced risk but, rather, the internalization of treatment messages and a desire to change -- something that is harder to measure. 

The research team issued a call for large-scale, multinational randomized controlled trials. In the meantime, in the absence of solid proof that manualized cognitive-behavioral group therapy works as intended, they recommend a shift to more individualized assessment and treatment.

That's a solid, and very welcome, recommendation.

Saturday, September 7, 2013

Drug-Involved Individuals, A Road Trip through a Southern State, and A Book by Faye Taxman: Matching the Right Treatment to Right Substance Abuser

Over the past two weeks, two colleagues and I have been traversing a Southern state working on a project to pilot research-based criminal justice system responses to the needs of drug-involved defendants and offenders.  (In our last newsletter, we highlighted the report that provides the basis for this work.)  Our trip took us to three very different judicial circuits all sharing a need and desire to address the intersection of addiction and criminal conduct in their communities.  Yet, even as the three circuits were so different – rural versus suburban, low income versus affluent, conservative versus progressive – they shared many of the same significant challenges.

What struck me right away was that almost universally there was a huge gap between the number of individuals in need of services and the capacity of service providers to meet those needs.  Much of our discussion also centered around the varying degrees to which the circuit courts and their partners were able to identify whether an individual had a substance use disorder and the its severity.

Serendipitously, I happened upon a recent book that fit hand in glove with what I witnessed on our trip and my subsequent reflections on that experience.  Simulation Strategies toReduce Recidivism: Risk Need Responsivity (RNR) Modeling for the CriminalJustice System, eds. Faye S. Taxman and April Pattavina (2013) is the first book I have purchased in a while that did not get beamed into some sort of device, but it was well worth the price of a hardcover.  In Chapter 2, A Case Study in Gaps in Services for Drug-Involved Offenders, Taxman and co-author Matthew L. Perdoni describe a model to estimate the number of individuals in our prisons, jails, and community corrections with varying levels of substance use disorder and which of them actually use available services.  The table below summarizes some of their findings:

Correctional setting
Total Population
Subtotal Needing SA Treatment
(Any Level)
Subtotal Needing Medium to High Intensity Treatment
Annual Participation Rate (Liberal Estimate)
Prisons
1,233,867
874,170 (70.8%)
635,207 (72.7%)
180,826 (20.7%)
Jails
745,765
531,080 (71.2%)
391,706 (73.8%)
90,046 (17.0%)
Community corrections
5,864,152
4,208,489 (71.8%)
3,172,917 (75.4%)
338,834 (8.1%)
Adapted from Taxman & Perdoni, 2013.

Taken together, the data paint a somber picture of treatment in our criminal justice system.  Out of 5.6 million people under some form of correctional supervision, who have some degree of diagnosable substance use disorder, only 11 percent or just under 610,000 are ever provided treatment by jails, prisons, probation, or other correctional settings.  As a result, a staggering 5 million people in need of treatment are left without services – treatment that could not only address their substance use but reduce their likelihood to commit new crimes in the future.

This gap is certainly daunting but likely unsurprising to many of us who have worked or still work in the criminal justice system.  What did give me particular pause in my trip over the past two weeks – and what I was glad to see addressed at length in Taxman and Pattavina’s book – is the lack of focus on individual treatment needs and differentiation in the treatment provided even when it is available.  We met a number of treatment providers as we traveled, and while there were some modest efforts to individualize treatment plans, generally the approaches were very similar across different levels of risk and need among their clients.  The reasons varied of course – from lack of resources, to insufficient assessments and diagnostic tools, to mismatches between treatment and criminal court policies and goals.  Nonetheless, the net effect remains the same: many of those receiving treatment may not be  getting the right treatment for their needs.

By way of an extensive exploration of the Responsivity Principle (of the Risk-Need-Responsivity Principles), the contributors to Simulation Strategies to Reduce Recidivism not only affirm the prevalence of this “cookie cutter” approach but present new paradigms and models to guide criminal justice leaders and practitioners in matching the right people to the right treatment and services.

In Chapter 4, The Empirical Basis for the RNR Model with an Updated RNR Conceptual Framework, Taxman, Pattavina, Michael S. Caudy, James Byrne, and Joseph Durso suggest a number of “refinement” to the Risk-Need-Responsivity Principles as they relate to substance use (pg.92).  Based on their review of the research, they affirm that not all drugs impact criminal behavior in the same way, and some may not impact criminal behavior at all.  Opiate, cocaine, and methamphetamine use are more likely to than other drugs to influence criminal conduct.  For alcohol, the major connection to criminal conduct is drunk driving.  On the other hand, marijuana use comparatively has a minor impact on criminal conduct and its use should not be considered a criminogenic need.

Furthermore, the offense should not be the determinant of a substance use disorder, because many individuals with moderate to severe substance use disorder are arrested for non-drug crimes.  Furthermore, many of those who are arrested for drug crimes do not have substance use disorders and would contraindicated for treatment.

These refinements to the RNR Model present a more nuanced view of “substance abuse” as a criminogenic need.  Referencing prior work by Belenko and Peugh (2005), as well as the recent revision to the Diagnostic Statistical Manual (DSM-V), this chapter’s authors suggest that drug-involved individuals be divided into three categories:
  • Those who have used drugs in the past with current use of “soft drugs” (i.e., marijuana);
  • Those who have used hard drugs in the past; and
  • Those who used hard drugs just prior to arrest.

In Chapter 6, The Responsivity Principle: Determining the Appropriate Program and Dosage to Match Risk and Needs, Erin L. Crites and Taxman build further on these categories and are inspired by the LOCUS to create a model of six primary targets and approaches for programming based on risk of recidivism, criminogenic needs, clinical destabilizers, and lifestyle destabilizers and stabilizers*.  The LOCUS is a tool developed by the American Association of Community Psychiatrists (AACP) that helps clinicians evaluate individuals based on six dimensions, which in turn feed into six treatment levels.  Consistent with the Responsivity Principle’s call to match interventions and services to the specific strengths and needs of the individual, the LOCUS looks at an individual from a wide variety of perspectives, albeit with a singular focus on one problem behavior, substance abuse.  Crites and Taxman graft this model onto the criminal justice system response to substance abuse.  In the final chapter of the book, their model is summarized as follows:

“Group A: drug dependence on opiates, cocaine, or amphetamines.  Offenders with drug dependence disorders, particularly on substances that are linked to criminal behavior (see Bennett, Holloway, & Farrington, 2008), should receive cognitive restructuring treatments focused on their drug dependence. The programs may offer cognitive-based treatments to improve decision-making, interpersonal skills, and social skills of the clientele.  Once this primary criminogenic need (substance dependency) has been stabilized, other dynamic needs can be addressed.

“Group B: criminal thinking/ lifestyle.  Offenders with a spectrum of criminal lifestyle needs (several dynamic needs relating to antisocial attitudes, values, behaviors, and social networks) should receive an emphasis on criminal thinking using cognitive restructuring techniques. These programs may also focus on building interpersonal and social skills.

“Group C: substance abuse and mental health needs.  Offenders who abuse drugs and alcohol but have other stabilizer-related need factors (e.g., employment issues, mental health) should be linked to programming that addresses these specific clinical needs.  Once these needs have been addressed, programming should focus on interpersonal and social skill development.

“Group D: social and interpersonal skill development.  Offenders with few dynamic needs but other social needs (e.g., mental health, housing instability) should be linked to programming that focuses on social and interpersonal skill development.  This focus is intended to address the multiple destabilizing issues.

“Group E: life skills. Lower risk offenders with only stabilizer-related needs (e.g., employment issues, low educational attainment) should be linked to programming that will enhance their ability to improve their overall functioning.

“Group F: punishment only. Low-risk or low-need individuals who do not require any direct services should be designated for punishment/supervision only.  These individuals do not have specific needs that can be addressed through programming. They should not be placed into programming that overly intensive or unnecessary. Also, when programming is not available within specific jurisdiction, it may be necessary to place offenders with certain dynamic needs in this category instead of using poorly matched programming that may exacerbate their underlying treatment needs.  Punishment in this sense may include a number of options with the use of incarceration reserved for higher-risk offenders.” (Taxman, Caudy & Pattavina, 2013, 288-289)

Although this guide for treatment does not resolve the issues of funding and capacity, which present significant barriers, Taxman, Pattavina, and their colleagues present a compelling and thoughtful framework for criminal justice leaders and practitioners to use as they structure their system responses.  They present as clear a protocol as any I have seen for judges, prosecutors, defense counsel, and corrections to define what they need to know about the people they see go through the criminal justice system and to have focused discussions with treatment providers about the appropriateness of the services they provide.  Precisely because we do have so many treatment programs that do not provide individualized or responsive services, Simulation Strategies to Reduce Recidivism should be required reading for anyone working in criminal justice systems and supporting services and interventions for individuals with substance use disorders.


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* NOTE:  In Chapter 4, Taxman et al. define stabilizers as factors that can serve to protect the individual from criminal involvement (such as stable housing) or that may contribute to the opportunity or desire to commit crimes (such as untreated, severe mental illness).  While these factors may not be criminogenic (or may not have significant criminogenic effects), they are critical to consider and address in the treatment context (as per the Responsivity Principle) because they inevitably impact the choices and decisions people make and their capacity and desire to change their behavior.